Towards a better understanding of sensory approaches

[00:00:00]hello and thank you for the invitation to speak today about sensory approaches and how best to implement them my name is sally payne and my pronouns are she and her i'm a professional advisor at the royal college of occupational therapists and i've worked for more years than i care to mention in the community as a children's occupational therapist i continue to do a small amount of work in the nhs alongside my rcot role one of the most interesting aspects of my work and an issue that's frequently raised by parents caregivers occupational therapists commissioners and others is how best to support children and young people whose sensory needs affect their daily lives at home at school and during their leisure time in preparation for this session i asked people on twitter to tell me how differences in the way that they notice process and respond to sensory information affected their lives at school an environment in which young people spent a lot of time these were a few of the things that they said i'm going to read the quotes from the bottom of this page i have trouble filtering out auditory information when i would take tests if a student near me had a cold every time they sniffed i got distracted i began to just sit and wait until everyone was finished and only then would i take my test it affected my grades any lesson that followed pe was a write-off for me as i couldn't focus on anything thanks to having to dress quickly after showering all i could feel was my damp skin all i could smell was spray deodorant even worse after swimming when the chlorine smell surrounded me her sensory needs impact her ability to wear the uniform required she can't tolerate the shirt won't wear anything around her waist doesn't like socks coats jumpers uniform issues will literally stop my child from attending education there is no doubt that being different in the way that everyday sensory stimulation is noticed processed and responded to can have a real impact on a person's participation learning achievements interactions and well-being at school and elsewhere but what is the best approach to ensure children and young people with sensory needs realise their potential and can lead full and happy lives first a reminder about our approach as occupational therapists as occupational therapists we're interested in the roles routines and activities that occupy children that keep them busy during the day we want to find out what children do well and what they find hard we then explore the personal environmental and occupation-based factors that support or limit the child's occupational performance their participation development and well-being sensory differences are one of many factors that we consider when working with children and young people but we aren't sensory therapists although that's not always clear to parents and caregivers my recommendation is that commissioners whether parents schools or commissioners of statutory services should be clear about what they are commissioning a sensory assessment for example will not necessarily cover all factors that might influence a person's occupational performance i can think of at least one case where it became clear that physical and learning factors were also affecting a young person's engagement at school but the provider had only been commissioned to provide sensory input so wasn't able to explore these physical and learning factors in detail this led to a breakdown in relationships between all three parties which wasn't at all helpful for the young person my suggestion is that we commission and provide occupational therapy rather than sensory therapy commissioning an occupational therapy assessment that includes sensory factors would enable providers to consider all factors that affect occupational performance reducing the potential for misunderstandings later on and now a note about terminology i often read reports and information referring to sensory processing disorder and it's really important to note that sensory processing disorder or spd is not recognized as a separate and unique diagnosis sensory processing disorder wasn't included in the last revision of the diagnostic and statistical manual because it was unclear whether children who present with sensory-based problems have a specific disorder of sensory processing or whether sensory differences are symptoms of other disorders such as autism as there's no universally accepted framework for diagnosis it is the rcot view and that of many other organizations that the term spd should not be used however it is critically important that a person's sensory needs are identified so this adjustments and support can be provided we will all i'm sure be familiar with the tiered model of intervention and this can be applied to sensory approaches too there is sometimes a perception that the tiered approach is used as an excuse to save costs by providing a watered-down service but this is not the case this is about providing the right help at the right time it's about intervening early to prevent difficulties from escalating and becoming more complex it's about skilling up young people and the adults who support them to use appropriate strategies in context so children and young people can take part in the daily activities that are important to them wherever they are a tiered approach to sensory interventions prioritizes independence and self-management it helps people identify tools and strategies that they can use in a variety of situations not just as children but throughout their lives it also helps to use resources wisely enabling them to support services to support more children and young people to fulfill their potential the model enables enables services to free up capacity to provide in a timely way specialist direct support needed by the small number of children and young people with the most complex needs and circumstances and now i think it's time to talk about the elephant in the room that is sensory integration therapy this is the intervention approach that i receive most inquiries about from parents and carers commissioners occupational therapists and others it's also mentioned frequently in sen tribunals and their equivalents in the devolved nations even as someone who knows a bit about sensory approaches understanding what is meant by sensory integration therapy is challenging possibly because people use the term in different ways so let's try to unpick this a little first what is clear is that sensory integration therapy or air sensory integration therapy asi is a trademarked intervention delivered by people occupational therapists physiotherapists speech and language therapists who have undertaken specific training it's a trademarked approach a bit like mavis beacon or pittman our trademark to pro approaches to learning to type s.i therapy is one way of treating children with sensory needs like the pittman approach is one way of teaching typing but it is not the only way we should also be clear that the health and care professions council hcpc which is the regulatory body for therapists in the uk does not require occupational therapists have a particular type or level of qualification in sensory integration therapy if this is written in a report then there should be clear clinical justification for the statement we'll come back to this point in a moment so what is sensory integration therapy si therapy is traditionally understood as an individualized intervention that aims to change a child's neurophysiological processing of sensation through direct intensive therapeutic input the intervention is usually delivered in a therapy setting using specialist equipment such as the swing illustrated the theory behind si is that over time the brain will adapt and allow a person to process and react to sensations more efficiently the descriptions on this slide are how to uk-based si training orgasm organizations describe si therapy a number of research studies have been undertaken to examine the efficacy of si interventions the si community has developed a fidelity tool to ensure that the si interventions being evaluated are true to the ideas and therapy principles developed by jean-aires and her successors jean as being the creator of si therapy we'll come back to the evidence base in a little while but many therapists are using the term si therapy more broadly to include sensory diets caregiver education and environmental accommodations this is confusing because while these border approaches are informed by sensor integration theory they are not the classic si interventions described on the previous slide it will help everyone if we are much clearer in our use of terminology when recommending or commissioning sensory interventions we should clarify when we are talking about sensory integration therapy an intervention involving individually tailored graded exposure to sensory input delivered in a specific therapy space and when we're talking about sensory approaches and interventions including those described on this slide that are embedded into children's everyday lives routines and contexts of course we also need to be explicit in our clinical reasoning for the approaches that we recommend request or commission and take account of the evidence base so what training is required as i mentioned before hcpc does not require occupational therapists to have a particular type or level of qualification in sensory interventions rcot and the hcpc do however require occupational therapists to practice safely and effectively within their scope of practice and in accordance with their professional standards occupational therapists and others may choose to expand their knowledge about sensory processing and there are many ways that this can be done for example attending a course critically reading research papers attending webinars working with experienced practitioners and so on i think we need to be very careful about recommending or accepting a recommendation that a particular type or level of qualification is required to deliver sensory interventions a practitioner would need to make a strong case for sensory integration therapy to justify a requirement for the practitioner to have a particular level of sensory integration training i would question the requirement for a practitioner to have a particular level or type of sensory integration training if recommendations are for environmental accommodations or task adaptation because our core training as occupational therapists enables us to deliver this type of intervention and support so to return to the evidence base earlier this year rcot published an informed view about sensory integration therapy and sensory-based interventions this concluded that the evidence base for asi and sensory-based interventions such as the use of weighted vests was limited and inconclusive to expand a little the evidence is limited in scope often focusing on children of a particular age with a particular diagnosis and no overlapping conditions which may not reflect a clinical population it is also limited in quality few papers apply the si fidelity tool many studies have significant methodological weaknesses and the number of participants is often small there is also limited evidence of a positive impact on occupational performance practitioners have a responsibility to access understand and critically evaluate research and its outcomes we mustn't assume that research is high quality just because it has been published earlier this year rcot published an evidence spotlight to help practitioners critically appraise the evidence around sensory interventions it's really important that we are open and honest with families about the evidence base for sensory interventions and that we add to the evidence where we can we await with interest the findings of an nihr funded pragmatic randomised controlled trial of s.i compared to usual care for autistic children aged 4 to 11 years which is being carried out in the uk the study is due now to report in june 2022 in the meantime it's recommended that interventions are regularly reviewed for effectiveness at an individual level and that intervention audits are systematically conducted to inform local evidence so what does this tell us from a commissioning and recommendations perspective well there is evidence that occupational therapy improves children's activities of daily living which will be a relief for the occupational therapists in the room and you might like to see the paper by novak and homan published in 19 2019 for more information however the evidence for si therapy is much weaker we suggest that sensory intervention should be included as part of a wider occupational therapy approach and that a range of universal targeted and specialist sensory interventions should be offered if recommending or commissioning direct intervention consider the cost by that i mean not just the cost of providing training and maintaining equipment although these are factors but the educational social and economic cost to the individual and family of taking time off school or work for the intervention clear criteria should be established for access to support at universal targeted and specialist levels and intervention goals should be agreed monitored and reported outcomes should be measured in terms of impact on occupational performance rather than changes in body functions such as balance and proprioception and importantly when commissioning specialist interventions the aim should be to develop independence and self-management rather than dependence on specialist services this is important because people's intervention experiences and expectations influence the way that they will access and use health services across the lifespan and so in summary sensory differences do affect children's participation their education and personal achievements their development health and well-being effects also extend beyond the individual to include their family too whilst we should avoid using the term spd it is critical that we recognize a person's sensory challenges and strengths so that we can identify appropriate adjustments accommodations and support to enable them to realize their potential and lead full and happy lives children should be offered occupational therapy which includes consideration of their sensory strengths and needs where these impact on their occupational performance and participation sensory approaches are part of occupational therapy and not a separate identity services should offer a range of sensory interventions and support at universal targeted and specialist levels so children can access the support they need at the right time if we get this right fewer children will require direct specialist intervention we need to be clear what we mean by sensory integration therapy when commissioning services and when making or accepting therapy recommendations and we need to challenge where appropriate the recommendation that intervention should be delivered by someone with a particular type or level of sensory qualification and finally we should be confident in our understanding and use of the evidence not all published research is good quality and not all is relevant to local populations evidence should be critically considered and we need to be honest when sharing information with parents commissioners and others to conclude i'd like to return to these quotes illustrating the impact that sensory differences have on a person's health development and well-being which approach do you think is best to address these sensory needs focusing on these everyday challenges will help us identify appropriate interventions to enable children and young people who notice process and respond to sensory input differently to enable them to realize their potential and to lead full and happy lives i hope you found this information useful please do explore these additional rcot resources and get in touch if you have any further queries or comments