Apertura y Evaluación de las Ofertas

Value or Style Guiding Questions

Family composition Who are the members of the family?

How many family members live in the same house?

Is there a hierarchy in the family based on gender or age?

Decision making Who makes the decisions for the family?

Primary caregiver Who is the primary caregiver?

Is this role shared?

Independence/

interdependence

Do family members value independence?

Is reliance on each other more important than independence?

Feeding practices Who feeds the infant or child?

What are the cultural rules or norms about breast feeding, mealtime, self-feeding, eating certain foods?

When is independence in feeding expected?

Sleeping patterns Do children sleep with parents?

How do parents respond to the infant during the night?

What are appropriate responses to crying?

Discipline Is disobedience tolerated?

How strict are the rules governing behavior?

Who disciplines the child?

How do the parents discipline their child?

Perception of disability

Do the parents believe that a disability can improve?

Do they feel responsible for the disability?

Do family members feel that they can make a difference in improving the disability?

Are spiritual forms of healing valued?

Help seeking From whom does the family seek help?

Does the family actively seek help, or do the family members expect help to come to them?

Communication and interaction

Does the family use a direct or an indirect style of communication?

Do family members share emotional feelings?

Is most communication direct or indirect?

Does the family value socializing?

Adapted from Wayman, K. I., Lynch, E. W., & Hanson, M. J. (1990). Home-based early childhood services: Cultural sensitivity in a family systems approach.Topics in Early Childhood Special Education, 10, 65-66.

other disciplines (e.g., psychology); however, often research studies and clinical trials in other disciplines have relevance to occupational therapy practice. Research evidence is readily available and accessible through Internet sources. A list of links to health care research databases can be found on the Evolve website. The steps in applying evidence-based practice are listed in Box 1-2.

Using evidence is part of the occupational therapist’s scien-tific reasoning. In scienscien-tific reasoning,⁷⁸the occupational ther-apist uses research evidence, science-based knowledge about the diagnosis, and past experience in all steps of the assessment and intervention process. For example, in the case of Rebecca, a 5-year-old with autism, the occupational therapist noted that developmental play-based approaches that incorporate peers have evidence for moderate treatment effects,^49,50 and that social interactive strategies⁴⁶have been found to be effective.

Because Rebecca attends a preschool in which application of these interventions is supported by the team, the occupational therapist decided to use a developmental play-based, interac-tive approach.

In another example, Aaron, who has arthrogryposis, has limited upper extremity range of motion and difficulty holding utensils or opening packages. He is unable to carry his books during school transitions. Armed with research about arthro-gryposis demonstrating that range of motion and strength do not significantly improve over time,⁸⁵ the therapist selects a compensatory/adaptation approach to increase Aaron’s inde-pendence in activities of daily living. In the case of Claire, who has a diagnosis of developmental coordination disorder and poor handwriting, the occupational therapist accessed research by Sullivan, Kantuk, and Burtner.⁸⁷Based on this evi-dence and her past success in using motor learning strategies with children with developmental coordination disorder, the therapist selected a motor learning approach to increase Claire’s

handwriting performance. The therapist reasoned that Claire would need 100% feedback about her performance until new skills were learned.⁸⁷Because the therapist found making holi-day cards to be engaging for other girls Claire’s age, she selected this activity to practice and reinforce correct letter formation.

In searching for research to inform a clinical decision, the occupational therapist weighs the strength or importance of each study. Studies that provide the most important research evidence are meta-analyses or systematic reviews of clinical trials. The findings of these studies generally have good appli-cability to practice because they combine the findings of stud-ies that have met a rigorous standard established by the authors. Findings from a rigorous randomized clinical trial also provide strong evidence for practice, followed by results from studies using quasi-experimental designs. Cohort studies and descriptive designs can provide information relevant to clinical decision making; however, their findings are not as strong and should be applied with caution. Outcome research can help practitioners establish benchmarks or standards for perfor-mance and client programs; however, descriptive outcome studies do not provide strong evidence for the effectiveness of a specific intervention. The parts summarized next describe some of the evidence for specific occupational therapy inter-ventions or models of practice used in occupational therapy.

Examples of interventions and models that have growing evi-dence of positive effects on children and families are presented.

Sensory Integration

The original studies that compared sensory integration inter-vention with no treatment^3,4demonstrated significant positive effects. These studies used samples of children with learning disabilities and compared sensory integration intervention with a control group. Although the effect sizes in Ayres’ original studies were high, the sample sizes were small.

Recent studies have found that the effects of intervention using a sensory integration approach are equivalent to the effects of alternative treatment approaches. Polatajko, Kaplan, and Wilson analyzed seven randomized clinical trials of sensory integration treatment that used two or more groups and included a comparison or control group.⁶⁷ All studies were of children with learning disabilities between the ages of 4.8 and 13 years. The outcome variables in seven clinical trials did not provide any statistical evidence that sensory integration intervention improved academic performance. Several of the studies found that sensory and motor performance improved with sensory integration intervention. Most of the findings for children who received sensory integration intervention were similar to the findings for the children who received a perceptual motor intervention. A limitation cited by Polatajko et al. was that sensory integration intervention in a research context is quite different from sensory integration intervention in a clinic, where therapists can individualize each session to the needs of the child.⁶⁷

A meta-analysis of sensory integration intervention by Vargas and Camilli showed small treatment effects,⁹⁶ substan-tiating the earlier findings of Polatajko et al.⁶⁷ Using a criterion-based selection process, Vargas and Camilli found 14 studies of sensory integration compared with no intervention and 11 of sensory integration compared with an alternative intervention (usually perceptual motor activities).⁹⁶Effect sizes were calculated and weighted for sample size. For comparisons BOX 1-2 Steps in Evidence-Based Practice

STEP 1

Convert the need for information (about intervention effects, prognosis, therapy methods) into an answerable question.

STEP 2

Search the research databases using the terms in the research question.

Track down the best evidence to answer that question.

STEP 3

Critically appraise the evidence for its:

○ validity (truthfulness)

○ impact (level of effect)

○ clinical meaningfulness STEP 4

Critically appraise the evidence for its applicability and usefulness to your practice.

STEP 5

Implement the practice or apply the information.

Evaluate the process.

of sensory integration with no treatment, the average effect size was .29, which is a low effect size. When sensory integration is compared with an alternative treatment, the effect size was .09, which means that the effects of sensory integration were not significantly different from those of other treatments. The authors reported that the average effect size for earlier studies (before 1982) was higher (.60) than the average effect size for studies after 1982 (.03). The skill areas that improved were psychoeducational and motor performance areas. Although the effects of sensory integration appear to be small, findings of significant improvement in motor performance following sensory integration intervention are consistent.

Recent studies of sensory integration intervention have shown positive effects. In a randomized clinical trial, Miller, Coll, and Schoen examined the effects of occupational therapy using a sensory integration approach on children’s attention, cognitive/social performance, and sensory processing and behavior.⁵⁷ Children with sensory modulation disorders and co-occurring diagnoses such as attention deficit hyperactivity disorder (ADHD) and learning disabilities were randomized into three groups, occupational therapy (n¼7), activity proto-col (n¼10), and no treatment (n¼7). Children in the occupa-tional therapy group received 10 weeks of two-a-day sensory integration intervention sessions using the protocol developed by these authors.⁵⁸ Following the 10-week intervention, the children who received occupational therapy sensory integra-tion made gains greater than those in the other two groups in intervention goals (using Goal Attainment Scaling) and on the Cognitive/Social composite of the Leiter International Performance Scale. The occupational therapy group also made gains in sensory processing and child behavior, but these were not statistically significant when compared with the other two groups. It is probable that the gains in sensory processing behaviors would have been significant if a larger sample size had been used. Although this trial provides evidence for sensory integration intervention effects, the strength of the findings is limited by the small sample size.

An important step in enhancing the rigor of sensory inte-gration trials is the development of a fidelity measure⁶⁵and a manual of procedures for sensory integration interven-tion.^57,58 Use of standardized intervention protocols will improve the fidelity of sensory integration intervention when administered in future trials and will improve both internal and external validity of the findings. Parham and Mailloux (Chapter 11) further discuss fidelity issues in sensory integration intervention trials.

Sensory Modalities

Application of sensory modalities has also been studied, gener-ally in small samples and with positive results. These studies investigate the application of a specific sensory modality to achieve specific behavioral/performance outcomes in a group of children with the same diagnosis or similar problems. The efficacy of using touch pressure to gain behavioral changes in children with autism or ADHD has been researched.^28,30,94 Edelson and his colleagues investigated the efficacy of the Hug Machine, a device that provides touch pressure through the sides of the body. Using a sample of children with autism, participants who received the Hug Machine treatment twice a week were compared with a control group. The participants who used the Hug Machine exhibited a significant reduction

in tension and a slight change in anxiety. Physiologic measures were not significantly different between groups.

Two studies have examined the effect of pressure through wearing a weighted vest. Fertel-Daly and colleagues investi-gated the effects of a weighted vest on five preschool children with pervasive developmental disorders.³⁰ Using an ABA single-subject design, vests were worn for 2 hours per day, 3 days a week, for 5 weeks, with baseline (wearing no vest) data collected before and after the intervention. Attention, number of distractions, and duration of self-stimulation beha-viors were measured. All participants demonstrated increased attention and decreased distractibility, and four of five showed decreased self-stimulation behaviors. VandenBerg also exam-ined the effects of a weighted vest on four children diagnosed with ADHD.⁹⁴ The children demonstrated greater on-task behaviors when wearing the vests. The summary of the studies using small samples found that touch pressure and deep pres-sure, applied intermittently, can decrease tension and anxiety, improve attention, and increase on-task behavior.

Another study of sensory modalities examined the effects from children sitting on therapy balls on in-seat behavior and legible word productivity.⁸⁰ Occupational therapists some-times recommend that students sit on therapy balls in the classroom to give them additional vestibular and propriocep-tive input while sitting. The children can bounce to stay atten-tive and alert and receive additional vestibular/propriocepatten-tive feedback when they shift their weight through the ball’s move-ment. Using a multiple-baseline single-subject design, all parti-cipants (n¼3) improved in in-seat behavior and legible word productivity.⁸⁰The balls seemed to help in sensory mod-ulation with the participants, and they represent a nonintrusive method to promote academic-related outcomes, staying in one’s seat, and legible word productivity.

Randomized clinical trials of touch-based interventions, such as massage, have shown positive effects on attention and behavior. In two randomized clinical trials, Field and collea-gues completed two trials with children with autism.^29,32In each the children were massaged (circular application of deep touch on trunk and extremities 1 to 2 times per day) by either parents or therapists. The children who received the month-long treatment demonstrated decreased aversion to touch, off task behaviors, stereotypical behaviors, and impulsivity.

Interventions that involve intensive tactile input applied in sys-tematic ways may reduce impulsive, hyperactive, or nonpurpo-seful behaviors.

Sound-based interventions have been applied to children with autism. Occupational therapists sometimes use modu-lated music through head phones as an adjunct modality (e.g., Therapeutic ListeningW).³³ Research of auditory inte-gration training, generally a 10-day program in which children listen to modulated music through headphones twice a day, shows mixed evidence of benefit.⁸³ It appears that auditory integration training can improve behavior (decrease aberrant behaviors), but it does not improve auditory reception, lan-guage, or adaptive behaviors.^6,62Hall and Case-Smith used a single-group design to study the effects of Therapeutic Listen-ing³³ in conjunction with a sensory diet.⁴⁰ Ten children received a sensory diet for 1 month and then received the Therapeutic Listening program with a sensory diet for 8 weeks.

Measures of sensory processing, visual motor skills, and hand-writing were used to compare the control and treatment

phases. Children’s gains in sensory processing included a decrease in irritability, fewer temper tantrums, and less hyper-activity and improvement in affect, interaction, and emotional responding (as measured by the Sensory Profile).

In summary, studies have demonstrated that sensory-based interventions can improve behavior, attention, and activity levels in children with autism, sensory processing disorders, and ADHD. However, these studies were generally of brief intervention duration and did not follow the participants long term. Baranek⁵and Parham and Mailloux (Chapter 11) recommend that therapists pair sensory-based interventions with more holistic and comprehensive interventions. The evi-dence suggests that when sensory modalities are paired with functional or play-based interventions, children are likely to demonstrate gains in performance and improved adaptive behaviors.¹⁴

Play-Based, Relationship-Focused Interventions Occupational therapists often implement a play-based interac-tive intervention with a goal of engaging the child in a just right challenge to his or her skill set. When these intervention episodes are repeated, practiced, and generalized, children exhibit increased social interaction and cognitive skills. Play-based relationship–focused interventions are frequently imple-mented with children with autism, who universally have delays in social participation and communication.³⁸ These interven-tions allow children to choose activities, provide them with multiple examples of behavior, and systematically reward the child using natural reinforcement. Greenspan and Weider cre-ated a relationship-based play intervention similar to occupa-tional therapy play-based interventions.³⁸ Their floor time intervention emphasizes the child’s social-emotional growth and symbolic play as fundamental to learning language and cognitive skills. Greenspan and Weider evaluated the effects of their relationship-based intervention and reported that 58% of the children who had received the intervention (an average of 2 years) had achieved strong positive outcomes (e.g., performance improved to within the normal range).³⁸ Wieder and Greenspan analyzed 16 of the children whose out-comes immediately after a course of intervention were good to outstanding.⁹⁸ These children were evaluated 10 to 15 years after they had participated in the relationship-based interven-tion. At this follow-up point, the children had become socially competent, responsive, and interactive. Although they exhib-ited some symptoms of mental illness (depression and anxiety), they did not exhibit the primary characteristics of autism.

Similar interventions focused on encouraging interactions and play have been applied and researched, particularly with children with autism.^69,71 Rogers created comprehensive, interdisciplinary preschool program, the Denver Model, that integrates developmental, relationship-based, and applied behavioral analysis approaches. Components of the Denver Model Intervention for Children with autism are listed in Box 1-3.

Application of the Denver Model with children with autism spectrum disorder has been researched. In a cohort study (one group), Rogers, Herbison, Lewis, Pantone, and Rels measured play and developmental skills before and after a 6-month preschool program.⁷¹ The children who participated (n¼26) demonstrated positive change in cognition, communication, and social emotional skills beyond their developmental

trajectory. Rogers and DiLalla completed a retrospective analy-sis of children’s change in developmental rate before and after 8 to 12 months of intervention.⁷⁰Following this intervention period, the children had improved more than was expected in all development areas, making gains comparable to children without autism. This model was applied to a 9-month-old using a version adapted for younger children and combining this approach with behavioral interventions.⁹⁷ In this case study, the 9-month-old made substantial gains in social com-municative behaviors and attention.

Relationship development intervention (RDI) is a third relationship-based intervention for children with autism similar to occupational therapy play-based interventions.³⁹In a recent evaluation of RDI using a one group pre-post design, 16 chil-dren (who completed an average of 18 months of treatment) made significant gains, and by the end of the treatment, 10 were functioning in regular education classroom without an aide.

Almost all of the studies of play-based, relationship-focused interventions have used a single group design to analyze the children before and after participation. Therefore, although the results have been universally positive, the findings are weak and the studies need to be replicated to reach definitive conclusions about play-based, relationship-focused interven-tions. Nevertheless, these studies do provide evidence for pos-itive effects when applying playful interventions focused on social interactions and engaging children in play that targets specific developmental goals. Intervention components that seem to be important to obtaining positive effects include (1) selecting activities of interest to the child, (2) allowing child choice, (3) encouraging or modeling higher level beha-viors, (4) promoting engagement, (5) providing natural rein-forcers, and (6) encouraging peer interactions.^49,86,97 Family-Centered Care

Family-centered care is a model advocated in the literature and the legislation for individuals with disabilities. Although it is well described in the literature, efficacy studies investigating the outcomes of family-centered care are few. Rosenbaum, King, Law, King, and Evans reviewed clinical trials of family-centered

BOX 1-3 Components of the Denver Model Intervention for Children with Autism

1. A playful environment is established where learning opportunities are plentiful.

2. One-on-one interaction is used.

3. Taking turn in play interaction is emphasized.

4. The activities incorporate children’s interests and preferences with learning opportunities.

5. The task sequence is varied and previously mastered tasks are interspersed with not yet mastered tasks.

6. Children are rewarded for attempting new skills as well as performing them successfully.

7. Reinforcers are employed that are directly and inherently related to children’s responses.

8. Immediate and contingent reinforcement is given when children demonstrate an appropriate response.

Adapted from Vismara, L. A., & Rogers, S. J. (2008). The Early Start Denver Model: A case study of an innovative practice.Journal of Early Intervention, 31, 91-108.

health care. They identified five clinical trials, published from 1983 to 1995, most of which used a parent education model as part of intervention for chronically ill children. When compared with child-focused models, the positive outcomes of the family-centered interventions included improved child skills, increased

health care. They identified five clinical trials, published from 1983 to 1995, most of which used a parent education model as part of intervention for chronically ill children. When compared with child-focused models, the positive outcomes of the family-centered interventions included improved child skills, increased