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08/09/2015

Evidence for Ayres Sensory Integration®
Roseann C. Schaaf, PhD., OTR/L, FAOTA
Thomas Jefferson University
Philadelphia PA

What Constitutes an Evidence Based
Practice?

•According to 3 separate sources Occupational
Therapy using Ayres Sensory Integration
meets the criteria for an evidence-based
practice

1

Remedial and Special Education. • Identified Quality Indicators (QUI’s) and standards for classifying EBP in special education Cook.1177/0741932514557271 2 . or – A combination of one high quality randomized or quasiexperimental group design study and three high quality single subject design What is an Evidence-Based Practice? Available at http://autismpdc. 36(4). high-quality studies that use experimental research designs and demonstrate robust effects • Council of Exceptional Children (CEC) created an EBP Workgroup charged with creating and vetting a revised set of EBP standards for special education.fpg. et al (2015).G.edu/content/evidence-based-practices Council for Exceptional ChildrenGuidelines for Identifying Evidencebased Practices in Special Education • Effective practices should be based on multiple. DOI: 10. B.08/09/2015 The National Professional Development Center on Autism Spectrum Disorders To be considered an evidence-based practice for individuals with ASD. or – Five high quality single-subject design studies by three different investigators or research groups. CEC’s standards for classifying the evidence base of practices in special education.unc. efficacy must be established through peer-reviewed research in scientific journals using: – Two high quality randomized (experimental) or quasi-experimental group design studies. 220 – 234.

demographics. disability and methods for determining – Interventionists – training. • Sufficient information must be presented on: – Context or setting – Participants (e. and at least 60 total participants across studies.08/09/2015 Standards for classifying Evidence-based Practices (CEC) • Two methodologically sound group comparison studies with random assignment to groups. materials. and at least 120 total participants across studies. positive effects. positive effects. • Four methodologically sound group comparison studies with non-random assignment to groups. interventionists actions – Implementation and measurement of fidelity 3 . replicable. qualification – Intervention – describes features of the practice. or • Five methodologically sound single-subject studies with positive effects and at least 20 total participants across studies Quality Indicators for EBP (CEC) • QIs were identified to examine methodological soundness of studies.g.

effect size is reported or can be calculated U.htm 4 . clearly defined. Note that some inconsistency of findings across individual wellconducted studies could preclude a classification of strong evidence and result instead in a designation of moderate evidence. Insufficient evidence indicates that the number and quality of studies are too limited to make any clear classification http://www. Mixed evidence indicates that the findings were inconsistent across studies in a given category. applied • Data Analysis – Appropriate. and some inconsistency in the findings across individual studies.org/uspstf/grades.S. described. Limited evidence indicates few studies.uspreventiveservicestaskforce. flaws in the available studies. usually at least two randomized controlled trials (RCTs).08/09/2015 Quality Indicators • Internal Validity – Description of services provided and comparison conditions and phases including attrition – That the researcher controls and systematically manipulated the independent variable – Describes group assignment or randomization • Outcome Measures/dependent variable – Appropriate. • Moderate evidence indicates one RCT or two or more studies with lower levels • • • of evidence. clear. Preventative Services Task Force Guidelines for Evidence Reviews • Strong evidence includes consistent results from well-conducted studies.

Copyright © 1996 by the British Medical Association. Preferred Reporting Items for Systematic Reviews andMeta-Analyses: The PRISMA Statement. Please refer to http://www. M. Altman DG. British Medical Journal. pretest & posttest) Descriptive studies that include analysis of outcomes (singlesubject design. A. before & after. cohort.g.org/statement.1. J.1371/journal. nonrandomized studies (e..prisma-statement. 312. Sackett. 71–72.08/09/2015 PRISMA Guidelines for Evidence-based Reviews (Adopted by AJOT) Moher D. B. PLoS Med 6(6): e1000097.org/2.g.2%20-%20PRISMA%202009%20Checklist.pdf. 1996. Tetzlaff J. randomized controlled trials Two groups. Haynes. S. case-control) One group. 5 .pmed1000097 • The American Journal of Occupational Therapy (AJOT) uses the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines as a basis for systematic reviews. Muir Gray. Richardson. doi:10. & W. nonrandomized (e. R. pp. The PRISMA Group (2009). case series) Case reports and expert opinion that include narrative literature reviews and consensus statements From “Evidence-Based Medicine: What It Is and What It Isn’t. Liberati A. meta-analyses. Adapted with permission.htm • The PRISMA checklist is available at http://www.. Rosenberg.” by D. W. L. • PRISMA Transparent Reporting of Systematic Reviews and Meta-Analyses Levels of Evidence • Level I • Level II • Level III • Level IV • Level V Systematic reviews.prismastatement.

3 X per week showed statistically significant improvements in primary measure of Goal Attainment. Mailloux. Hunt. 2014 11 11 Effectiveness of SI for children with ASD Schaaf. et al. as well as secondary outcome measures showing statistically significant decreases in caregiver assistance needed for self-care and social activities.08/09/2015 ASI – Now Evidence-based Schaaf. van Hooydonk. the group who received OT-SI for 10 weeks. Leiby. Freeman. 12 6 . & Kelly JADD.. (2014) In a randomized trial of 32 children with autism. Sendecki. Faller. Benevides.

ADIr. Fragile X. CP) – Demonstrate difficulty processing and integrating sensory information as measured by the Sensory Profile and/or the SIPT Interventionists – Occupational Therapists certified in sensory integration (USC/WPS courses) – Additional training on manualized approach Design & Methods Children who do not meet inclusion criteria excluded Referral & Screening Phenotypic evaluation for eligibility ADOS.e.08/09/2015 Meets Quality Indicators for Evidencebased Practice • • • • Funded by the Autism Speaks Foundation Context: Outpatient setting. Clinic setting Participants – well characterized sample – 4-8 years of age – Diagnosed with ASD using ADOS and ADI-R – Developmental Quotient: Non-Verbal IQ >65 – No other co-morbid genetic or developmental conditions (i. SEQ. SIPT Informed Consent Pre-treatment Assessments Analysis of Assessment Data Goal writing with Parent: GAS PEDI. QOL. PEDI. IQ. 10 weeks n = 15 Post Test SIPT. PDDBI WHO-QOL SEQ Vineland. SSP. Vineland.II Data Driven Decision Making Hypothesis generation Randomization Experimental Group OT/SI 30 sessions/10 weeks N= 17 Manualized Protocol Control Group Usual Care. PDDBI Post GAScale Interview 7 .

2006) 8 .08/09/2015 Comprehensive Assessment • History and occupational profile/Parent Interview • Sensory Motor Assessment – Sensory Integration and Praxis Tests – Sensory Profile – Sensory Experiences Questionnaire (SEQ – Baranek.

• 10 weeks 3X/weeks • Follows manualized protocol • Fidelity was tested with validated measure (Parham. Coster.08/09/2015 Outcome Measures (dependent Variables) •Primary Outcome Measure: Goal Attainment Scales •Secondary Measures • Pediatric Evaluation of Disability Inventory • • (Haley. et al 2011) 9 . Replicable. et al . Intervention • Active.PEDI) Pervasive Developmental Disorder Behavior Inventory (PDDBI) Vineland Adaptive Behavior Scales (Vineland-II) Manualized. individuallytailored sensory motor activities designed to address underlying factors affecting participation.

– Proximal (sensory motor) and distal (participation-based) outcomes identified and measured. DDDM 10 . 2015) – Uses data to guide assessment and intervention – Analysis and interpretation of assessment data to identify the sensory motor factors hypothesized to impact participation.08/09/2015 Use Data Driven Decision Making: A systematic approach for reasoning and decision making (Schaaf and Mailloux.

2015) Findings 11 .08/09/2015 Clinician Guide for Implementing Ayres Sensory Integration® (Schaaf and Mailloux.

69 0.6856 0.53 GAS T-score 60 50 43 40 30 t= -3.23.5 0 0.0394* 0.3 Treatment Median Change Median Change Functional Skills Self Care 1.0968 0.08/09/2015 Primary Outcome Primary Outcome: Parent-Rated Goal Attainment Scale: Goal Attainment Scale Group Comparisons 80 70 56.1 Caregiver Assistance Self Care 1.0 4 0.9 Mobility 0 0 0. n=17 23 PEDI Control p value Effect Size 3.3 12.2 20 10 0 Usual Care.1976 0.003** E. df=23 p = .0076** 0.2 0. = 1.7 0.7 Mobility Social Function 0 1. n=14 OT/SI Treatment.5 0.S.7 12 .2 Social 0 13.

4442 -0.8192 -3 -6 0.6 PDDBI 13 .4321 -2 -2 0.4 -0.5 -5 0.4 -0.3859 Specific Fears Ritualism/ Resistance to Change Semantic/Pragmati c Problems Sensory/Perceptual approach Behaviors -1 -3 0.5758 1 -1 0.0637 Effect size -0.08/09/2015 PDDBI Median change from pre-intervention Control Treatment p value Aggressiveness Arousal Regulation Problems -2 -3 0.

2038 Daily Living1 0 4 0.2928 0.1763 Socialization Skills1 Motor Skills -2 -3 3 0 0.4814 Adaptive Behavior Composite1 0 2 0.08/09/2015 PDDBI Graphs Vineland Adaptive Behavior Scales II Control Treatment p value (Change Score) (Change Score) Communication1 1 1 0.3130 1Standard Score 14 .

ES size 0. randomized • 18 tx sessions over 6 weeks • Used ASI Fidelity Measure • RESULTS: Children with ASD had greater gains on GAS and a significant decrease in autistic mannerisms in comparison with the fine motor intervention 29 Pfeiffer. 2011 • Comparative Effectiveness Study: OT ASI vs Fine Motor • 37 children with ASD aged 6-12. et al.360) 15 . ES 0.125) and teachers (p < ..05. et al..01.08/09/2015 Additional Evidence for ASI Pfeiffer. 2011 (continued) •Both SI and FM groups demonstrated significant improvements toward goals on the GAS •The SI group demonstrated more significant improvement than the FM group in the attainment of goals as rated by parents (p < .

53. American Journal of Occupational Therapy. T.. 2007 • Case-Smith. 207–213 16 . B. & Stewart. (1999). 69 subjects total. The effects of occupational therapy with sensory integration emphasis on preschool-age children with autism. K.. meet quality indicators of CEC • Two methodologically sound group comparison studies with random assignment to groups.08/09/2015 Conclusions – Meets CEC Criteria ASI meets the criteria for an evidence-based intervention by CEC: 2 RCT’s. positive effects. (1999). M. Sensory integrative-based occupational therapy and functional outcomes in young children with pervasive developmental disorders: A single-subject study. T. American Journal of Occupational Therapy. & Bryan. 1999 • Watling & Dietz. 1999 • Linderman & Steward. 53. J. and at least 60 total participants across studies Single Subject Studies Provide Further Support • Five methodologically sound single-subject studies with positive effects and at least 20 total participants across studies • Case-Smith & Bryan. 489–497. • Linderman.

& Vertes. J.. S. A. Lessons Learned: Be Clear and Systematic! • Devlin. S.. J. Schoen. M. 6 times/day 17 . 228–238 • Miller.. A.1300/J006v10n03_01 • Miller. American Journal of Occupational Therapy. K. T. J. R.08/09/2015 Additional Studies • Humphries. – SI: 15 minute access to equipment provided during school day for approx. Lessons learned: A pilot study on occupational therapy effectiveness for children with sensory modulation disorder. L. 1–17. R. American Journal of Occupational Therapy.. & Schoen. doi:10. C. Coll.. The efficacy of sensory integration therapy for children with learning disability. et al 2010 – JADD • Comparison of the effects of sensory integration and behavioral intervention for addressing problem behaviors • N = 4 boys with challenging behaviors • Conclusion: behavioral interventions effective in reducing problem behaviors but SI was not. A randomized controlled pilot study of the effectiveness of occupational therapy for children with sensory modulation disorder. 61. (2007). Physical and Occupational Therapy in Pediatrics. (1990). Wright. (2007). J. James.. 10. 61... B. McDougall. & Schaaf. L. 161–169.

Volkmar Book 2011) Subtype studies: Miller. et al. et al) • Each of you can participate – we need more – 1. Schoen. Parush. Test Hypotheses by charting outcomes – 5. Davies. publish. assess • Use theory to generate hypothesis and underlying mechanisms • Identify outcomes – 4. Publish. publish 18 .08/09/2015 Analysis (Schaaf & Blanche. Be systematic in your approach – 2. et al 2001. 2010) Physiological studies (Schaaf & Benevides. 2011) • “Sensory Integration Therapy” – not an accurate representation of the sensory integrative approach (OT/SI) – Did not use ASI Fidelity Measure • Failure to conduct a systematic assessment to guide intervention • Inaccurate use of literature – Does not include contemporary or classic literature We Need to Continue to Generate Evidence! • Progress made – – – – – Studies of OT/SI ASI Fidelity Measure (Parham. assess. Reichow…. 2011) Evidence Reviews (AJOT. Miller. et al. Use systematic clinical reasoning based on theory – 3. Articulate hypothesis • Identify participation limitations • Obtain a history to guide systematic assessment • Assess.

edu/occupational therapy http://www.08/09/2015 Thank you! For more information on Jefferson’s Programs go to Jefferson.jefferson.edu/university/health_professions/depart ments/occupational_therapy/programs/certificates.html 19 .