1. Sensory Regulation in Children with Intellectual Disability or Mental Health Diagnoses Emily Bantz, OTS Chatham University

2. Introduction  PICO Question: How do sensory regulation interventions impact behavior and academic success of children with intellectual disability or mental health diagnoses compared to no intervention?  Why does it matter?  High % of individuals in the United States with mental health diagnoses  Future social and academic success of students  Self-esteem of child  Parent and teacher frustration  OT scope of practice http://pixgood.com/question-mark-border.html

3. Evidence Based Practice and Sensory  Why is this topic of interest?  High frequency of children with sensory processing disorder  Desire to work with pediatric population  Community Fieldwork: Friendship Academy (students with mental health diagnoses)  Further understanding of sensory integration and its impact on an individual’s success http://ptcne.org/services/occupational-therapy/

4. Research  Data bases: CINAHL, AJOT, OT Search, MEDLINE  Search terms : sensory integration, sensory regulation, sensory integration processing disorder, classroom sensory integration, children with mental diagnoses (dx) and sensory integration deficits https://www.southern.edu/News/DispForm.aspx?ID=755

5. Research Continued  Inclusion criteria: school- age children with mental health dx or intellectual disability, sensory integration, sensory processing disorder, sensory regulation, peer reviewed  Exclusion criteria: children younger than school-age, children without intellectual disability or mental health dx, articles older than ten years, not peer reviewed http://research-methodology.net/research-methodology/research- design/

6. Nature of Evidence  Number of studies examined: 10  Level I evidence:  Systematic Reviews of Randomized Control Trials: 3  Level II evidence:  Randomized Controlled Trials: 0  Level III evidence:  Controlled trial without randomization: 1  Level IV evidence:  Case control or cohort study: 4  Level VI:  Qualitative Study: 1  Level VII:  Expert Opinion: 1 http://www.projectrenaissance.com/education/6-important-sales- marketing-books

7. Review of Best Evidence (Smith, Press, Koenig, & Kinnealey, 2005) Article 1  Title: Effects of Sensory Integration Intervention on Self- Stimulating and Self-Injurious Behaviors (Smith, Press, Koenig, & Kinnealey, 2005)  Study objectives:  Examine impact on self- injurious behavior of children with developmental delay and intellectual disability as a result of OT using an SI approach vs. tabletop activities http://autism.lovetoknow.com/Self_Injury_and_Autism

8. Review of Best Evidence (Smith, Press, Koenig, & Kinnealey, 2005) Article 1  Methods:  Videos recorded daily of subjects for 15 minutes prior to, immediately after and one hour following SI or tabletop intervention  Alternating SI or tabletop interventions by week for four weeks  Investigators observed video and determined frequency of self-harming behaviors http://muautismrepetitiveplaypatterns.blogspot.com

9. Review of Best Evidence (Smith, Press, Koenig, & Kinnealey, 2005) Article 1  Outcome:  Self-harming behaviors reduced by 11% one hour following SI intervention as opposed to tabletop intervention  Sensory integration approach found to be effective in reducing self injurious behavior http://news.bbc.co.uk/2/hi/uk_news/scotland/8476703.stm

10. Review of Best Evidence ( Review of Best Evidence (Barnes, Schoenfeld, Garza, Johnson, & Tobias, 2005) Article 2  Title: Preliminary: Alert Program for Boys With Emotional Disturbance in the School Setting (Barnes, Schoenfeld, Garza, Johnson, & Tobias, 2005)  Study objectives:  Examine the use of the Alert Program with children who have emotional disturbance and sensory integration problems  Is the Alert program feasible with this population?  Ways to document the Alert Program’s effect on academic success http://thegrio.com/2012/01/26/state-of-the-union-can-obama-really-stop- high-school-dropouts/

11. Review of Best Evidence ( Review of Best Evidence (Barnes, Schoenfeld, Garza, Johnson, & Tobias, 2005) Article 2  Methods:  Pilot the Alert Program in public school with students ranging in age from 6 to 11 with emotional disturbance dx  Participants: three boys ranging from nine to ten years of age with emotional disturbance, observed sensory processing difficulties and IQs in the low to normal range  Intervention: Alert Program used for 30-minute individual sessions for 7 weeks http://blog.charactercounts.org/boys-lagging-academically- character-development

12. Review of Best Evidence ( Review of Best Evidence (Barnes, Schoenfeld, Garza, Johnson, & Tobias, 2005) Article 2  Methods continued:  Tools used to assess behavior:  Classroom Behavioral Checklist: Utilized during the study in classrooms 3 days a week during one hour periods to monitor effects of the Alert Program on in-class behavior  Utilized prior to and following the study:  Piers-Harris Children’s Self- Concept Scale (Piers, 1986): how one feels about one’s own behavior and qualities  Devereux Behavior Rating Scale-School Form (Naglieri, LeBuffe, & Pfeiffer, 1993): measures inappropriate behaviors, feelings, depression  Sensory Profile (Dunn, 1999): sensory effects on ADLs in children 3-10 years of age http://loveandlifetoolbox.com/parenting-look-listen-and-learn-to- get-a-handle-on-child-misbehavior-by-dr-lynne-kenney-psy-d/

13. Review of Best Evidence ( Review of Best Evidence (Barnes, Schoenfeld, Garza, Johnson, & Tobias, 2005) Article 2  Outcomes  Small improvement in students 1 and 2 behavior  Student 1 showed significant improvement from the Devereux Behavior Rating Scale-School Form while students 2 and 3 did not  Student 2 showed significant improvement on the Piers- Harris Children’s Self- Concept Scale while students 1 and 3 did not  Sensory Profile: filled out by parents and found to be inconclusive in all three cases http://www.kidsoncolor.com/tag/black/

14. Review of Best Evidence ( Review of Best Evidence (Barnes, Schoenfeld, Garza, Johnson, & Tobias, 2005) Article 2  Limitations:  Preliminary study: Number of students examined  Possible bias in scales utilized to assess progress  Students pulled-out from classroom as opposed to in- class intervention http://www.rainbowrehab.com/sensory-integration- classroom/

15. Review of Best Evidence (Lima, Silva, Amaral, Magalhães, & de Sousa, 2013) Article 3  Title: Beyond Behavioural Observations: A Deeper View through the Sensory Reactions of Children with Profound Intellectual and Multiple Disabilities (Lima, Silva, Amaral, Magalhães, & de Sousa, 2013)  Study objectives:  Examine behavior and physiological response of children with with profound intellectual and multiple disabilities to sensory input http://thechart.blogs.cnn.com/2011/10/24/labeling-tantrums-a-mental-illness- doesnt-help/

16. Review of Best Evidence (Lima, Silva, Amaral, Magalhães, & de Sousa, 2013) Article 3  Methods:  18 common intervention items deemed appropriate by therapists used to determine response through:  Behavioral and electrodermal reactions  Changes in heart rate  Outcome:  Frequent physiological reactions, but rare changes in behavior  All subjects showed change in heart rate  Conclusion:  Despite unobservable differences in behavior, physiological changes result from appropriate sensory stimuli http://www.24parent.com/ 一個人的失敗 98 死於脾氣 /

17. Review of Best Evidence (Vlaskamp & Cuppen-Fonteine, 2007) Article 4  Title: Reliability of assessing the sensory perception of children with profound intellectual and multiple disabilities: A case study (Vlaskamp & Cuppen- Fonteine, 2007)  Study Objectives:  Beginning stages of developing a checklist to determine response of children with intellectual and multiple disabilities to sensory input  Reliability of current tools is low and is based on sensory integration instead of perception http://laskintherapygroup.com/sensoryprocessing.htm

18. Review of Best Evidence (Vlaskamp & Cuppen-Fonteine, 2007) Article 4  Methods:  Inter-rater reliability of one checklist was examined  Adjustments to the checklist made to increase reliability http://www.ncas.rutgers.edu/pre-healthtimeline

19. Review of Best Evidence (Vlaskamp & Cuppen-Fonteine, 2007) Article 4  Results:  Decrease in reliability for all components of checklist after adjustments  Effect of familiarity of teachers examined  Teachers who knew the child well were able to assess behavior more accurately  Reliability of checklist continues to be a problem http://laughjooks.com/funny-jokes-teachers.html

20. Limitations of Current Studies  Limited number of participants per study  Difficult to consistently measure effectiveness of sensory stimuli with behavior  Numerous studies on Autism Spectrum Disorder (ASD), but limited number of studies on children with mental health dx and sensory processing deficits  Minimal randomized controlled trials applicable to sensory integration  Further studies need to be conducted in order to generalize to the population

21. Clinical Implications of Findings  Considerations when working with children with intellectual disability or mental health dx:  Sensory needs  Reliability of current sensory evaluation materials  Integration of sensory activities throughout daily routine  May require increased time to complete task http://www.pdresources.org/blog_data/tag/occupational- therapist/

22. References Barnes, K., Schoenfeld, H., Garza, L., Johnson, D., & Tobias, L. (2005). Preliminary: Alert Program for boys with emotional disturbances in the school setting. American Occupational Therapy Association School System Special Interest Section Quarterly, 12, 1-4. Cohn, E. S., Kramer, J., Schub, J. A., & May-Benson, T. (2014). Parents’ Explanatory Models and Hopes for Outcomes of Occupational Therapy Using a Sensory Integration Approach. American Journal Of Occupational Therapy, 68(4), 454-462. doi:10.5014/ajot.2014.010843 Davies, P. L., & Tucker, R. (2010). Evidence Review to Investigate the Support for Subtypes of Children With Difficulty Processing and Integrating Sensory Information. American Journal Of Occupational Therapy, 64(3), 391-402. doi:10.5014/ajot. 2010.09070 Jirikowic, T., Olson, H., & Kartin, D. (2008). Sensory processing, school performance, and adaptive behavior of young school-age children with fetal alcohol spectrum disorders. Physical & Occupational Therapy In Pediatrics, 28(2), 117-136. Lima, M., Silva, K., Amaral, I., Magalhães, A., & de Sousa, L. (2013). Beyond behavioural observations: a deeper view through the sensory reactions of children with profound intellectual and multiple disabilities. Child: Care, Health & Development, 39(3), 422-431. doi:10.1111j1365-2214.2011.01334.x

23. References May-Benson, T. A., & Koomar, J. A. (2010). Systematic Review of the Research Evidence Examining the Effectiveness of Interventions Using a Sensory Integrative Approach for Children. American Journal Of Occupational Therapy, 64(3), 403-414. doi:10.5014/ajot.2010.09071 Moro, C. (2007). A comprehensive literature review defining self-mutilation and occupational therapy intervention approaches: dialectical behavior therapy and sensoryintegration. Occupational Therapy In Mental Health, 23(1), 55-67. Smith, S., Press, B., Koenig, K., & Kinnealey, M. (2005). Effects of sensory integration intervention on self-stimulating and self-injurious behaviors. American Journal Of Occupational Therapy, 59(4), 418-425. Vlaskamp, C., & Cuppen-Fonteine, H. (2007). Reliability of assessing the sensory perception of children with profound intellectual and multiple disabilities: a case study. Child: Care, Health & Development, 33(5), 547-551. Wheble, J., & Hong, C. (2006). Apparatus for enhancing sensory processing in children. International Journal Of Therapy & Rehabilitation, 13(4), 177-181.

24. Questions? Contact me with any questions at ebantz@chatham.edu or bantzemily@gmail.com ebantz@chatham.edu