Adolescents’ and Adults’ Perceptions of Sensory-Based Interventions: A Qualitative Analysis

Abstract

Importance: Adolescents and adults report that their sensory integration and processing differences affect their occupational performance and quality of life, thus requiring effective sensory-focused interventions. Researchers have yet to investigate this population’s experience of occupational therapy interventions designed to remediate these challenges.

Objective: To explore the perceived experience of adolescents and adults with respect to (1) response to intervention, (2) strategies offered to manage sensory differences, and (3) need for services on completion of an intervention.

Design: Retrospective, qualitative study.

Setting: Zoom or phone call.

Participants: Eleven adolescents and adults with sensory integration and processing differences who had previously completed occupational therapy interventions.

Intervention: Sensory-based intervention based on the principles of Ayres Sensory Integration^® (ASI) and the Sensory Therapies and Research Frame of Reference.

Outcomes and Measures: A semistructured interview to obtain data, followed by an in-depth analysis using an inductive coding process to group initial open codes into themes and common subthemes

Results: Open codes were grouped into three core themes: (1) therapist-related factors (what the therapist did in treatment); (2) client-related factors (what the client experienced); and (3) follow-up (future needs of the clients). Four main subthemes of the client–therapist relationship emerged: (1) therapeutic alliance; (2) education and knowledge; (3) strategies, tools, and resources; and (4) future needs.

Conclusions and Relevance: This study provides a perspective on the experience of adolescents and adults specific to the impact of a sensory-focused occupational therapy intervention on their daily lives. This will help occupational therapists when designing interventions for current and future clients.

What This Article Adds: This study highlights the need for further research addressing effective sensory-based interventions for adolescents and adults. It also captures which components of intervention clients deemed helpful and identifies potential targets for future intervention.

This study highlights the need for further research that addresses effective sensory-based occupational therapy interventions for adolescents and adults. It also captures which components of intervention clients deemed helpful and identifies potential targets for future intervention.

Ayres (1972) defined sensory integration as a neurological process that organizes sensations from the body so one can act effectively within the environment. When differences in sensory integration exist, people report challenges modulating and discriminating sensory stimuli (McMahon et al., 2019; Miller et al., 2009). Sensory processing and integration differences negatively affect occupational performance and participation in social activities as well as the completion of daily life tasks (Bailliard & Whigham, 2017; Costa-López et al., 2021; Kinnealey et al., 2011). Although much of the literature primarily focuses on the pediatric population (Ahn et al., 2004; Gouze et al., 2009) or specific diagnoses with sensory processing features, such as autism spectrum disorder (American Psychiatric Association, 2013; Crane et al., 2009) or attention deficit hyperactivity disorder (ADHD; Kamath et al., 2020), research suggests that sensory integration and processing challenges in children can persist into adulthood, affecting overall functional performance throughout the life course (Goodman-Scott et al., 2020; May-Benson et al., 2021; McMahon et al., 2019; Neufeld et al., 2021). The adolescent and adult population is underrepresented in the relevant literature. As such, addressing the unique sensory processing and integration challenges present in this population has become a priority (American Occupational Therapy Association [AOTA], 2017; May-Benson, 2009).

Goodman-Scott et al. (2020) examined the concerns of adult clients with sensory challenges seeking mental health support through counseling. They found that clients were seeking support for the physical, psychological, and interpersonal impact of their sensory differences. However, mental health professionals report limited knowledge and resources related to sensory integration. The impact of these sensory differences align with the client factors occupational therapists are trained to address (AOTA, 2020). Example areas affected by the secondary negative impact of sensory difference include self-concept, emotion regulation, attention, problem solving, skill performance, and the capacity to develop and maintain interpersonal relationships (AOTA, 2017; Kotsiris et al., 2020). As a result, occupational roles, routines, and rituals are affected, including parenting, working, engaging in home management, and participating in social and leisure activities (AOTA, 2017). An inability to participate fully in these roles could lead to occupational deprivation and a diminished quality of life.

Occupational therapy practitioners provide direct services, accommodations, and emotional support to adolescents and adults with sensory integration and processing challenges (Kinnealey et al., 2011 ; May-Benson & Kinnealey, 2012). Examples of sensory integration treatment activities described in the literature for adults include remedial intervention, accommodations, adaptations, sensory diet programs, environmental modifications, and education (AOTA, 2017; Kinnealey et al., 2011; May-Benson, 2009; May-Benson et al., 2021). Although there is a growing body of research regarding the effectiveness of treatment within pediatrics using Ayres Sensory Integration^® (Schaaf et al., 2018; Schoen et al., 2019), there is insufficient information and research on the experience of adolescents and adults engaged in sensory-based interventions (Brown et al., 2020; DuBois et al., 2017; Watling & Hauer, 2015). Thus, in this research we aimed to explore the personal experiences and possibly illuminate the needs of adolescents and adults with sensory differences.

The overarching objective of this study was to use a retrospective approach to understand the lived experiences of a small group of adolescent and adult clients previously engaged in occupational therapy intervention for sensory integration and processing challenges. We sought to answer three research questions:

What components of intervention do adolescent and adult clients identify as being helpful and meaningful?

What changes in daily life do adolescent and adult clients report experiencing after completing an intervention focused on sensory integration/processing, regulation, and relationship?

What do clients identify as a need after participating in an intervention program?

The insights gained by considering adolescent and adult clients’ lived experiences will enable practitioners to be better able to design sensory-based interventions to meet their clients’ needs.

Method

Research Design

This retrospective, qualitative study focused on reviewing responses that were initially deemed of interest in a quality assurance project. A questionnaire was developed for use as a semistructured interview guide with former occupational therapy clients. This interview guide was designed as part of a program evaluation and then examined retrospectively in the present study. The Rocky Mountain University of Health Professions institutional review board assigned this study the status of exempt.

Participants

Thirty-one former clients were sent an email asking them to participate in a brief phone interview. Of these 31 clients, 33% responded, and 11 agreed to be interviewed. The two inclusion criteria included (1) being a previous client at a small therapy and research center in a metropolitan, western city in the United States and (2) previous participation in a 1-wk extended evaluation or an intensive intervention program. Initially designed as a quality assurance project, this was converted into a qualitative study, and data were deidentified. There were 3 adolescent (ages 13, 17, and 19 yr) and 8 adult participants. Thirty-three percent (n = 3) of participants identified as male, 63% (n = 7) identified as female, and 1 preferred not to answer. The youngest participant was age 13 yr, and the oldest was 50. Of the 11 participants, 9 took part in an in-person, 5-day extended occupational therapy evaluation; 1 had an extended evaluation over Zoom; and 1 took part in an in-person, 20-session intensive program. Ten of the participants were from the United States, and 1 was from out of the country. Table 1 lists the participants’ demographic characteristics. No information regarding race/ethnicity or socioeconomic status was collected. Parents were present for two of the adolescent interviews (the 13-yr-old and the 17-yr- old). Although adolescent interviews were generally shorter and less detailed in content, the procedures were identical to those in the other interviews, and none of the parents answered questions for their child.

Table 1.

Participants’ Demographic Characteristics

Characteristic	% (n)
Age, yr
13–21	33 (3)
22–50	72 (8)
Gender
Male	33 (3)
Female	63 (7)
Chose not to answer	9 (1)
Type of program
In-person extended evaluation	81 (9)
Virtual extended evaluation	9 (1)
Intensive 20-session program	9 (1)
Location
In the United States	90 (10)
Outside the United States	9 (1)

Note. N = 11.

Intervention

The sensory integration intervention used in this study was based on the principles of ASI (Schaaf & Mailloux, 2015) and the Sensory Therapies and Research Frame of Reference (STAR FOR; Miller et al., 2018). This intervention builds on ASI by adding an intentional focus on regulation, and relationship, reflecting principles rooted in the DIR^® (Developmental, Individual-differences, and Relationship-based/Floortime model; Greenspan & Wieder, 2009). A key premise of this multifaceted intervention is that regulation and relationship are foundational to development and have a bidirectional influence on integrating the sensory features. Intervention consists of sensory and motor exploration, emotion and arousal regulation, engagement in meaningful activities, and collaborative problem solving, within a strengths-based approach. This manualized approach is consistent with the ASI Fidelity Measure as well as the STAR FOR Fidelity Measure. Clients often seek occupational therapy services after a referral from a physician, mental health specialist, or self-referral based on their own awareness of sensory struggles that are affecting their daily lives. The next step is to contact the therapy clinic through a services inquiry form. On the basis of the therapist’s recommendations generated in an intake process and a comprehensive occupational therapy evaluation, clients were offered the option to participate in a week-long extended evaluation or an intensive intervention program of 15 or more sessions.

Interviewer

Dana Miller was the interviewer. At the time of the study, she was an occupational therapy doctoral student completing her capstone project. She completed Collaborative Institutional Training Initiative training, reviewed education modules, and was trained by a supervisor in administering the interview questions. She was blind to each participant’s experience and had no previous connection to participants or therapists. She took detailed handwritten notes and was able to capture exact phrases of participants’ responses to the interview questions.

Team

The research team was led by Sarah A. Schoen, who is Director of Research at the STAR Institute and has advanced training in and knowledge of sensory integration and processing. The team also included the adolescent and adult team supervisor and a qualitative research expert with expertise in ASI and the STAR FOR.

Interviews

Interviewees responded via email to indicate their willingness to participate. They were sent the interview questions via email 1 day before the scheduled meeting. Participant interviews began with introductions and ranged from 20 min to 60 min. The interview included eight semistructured questions, which are listed in the Appendix. Wording was modified and additional explanations were provided as needed to clarify or explore information pertaining to the participant’s responses. Of 11 interviews, 10 were completed by phone; 1 was completed via Zoom for scheduling convenience. Field notes were completed by Miller on a handwritten document that included the interview questions, which provided the content for data analysis. In addition, reflective questions were asked to elicit initial impressions of the accuracy of the interviews. The reflective commentary was completed to monitor the researchers’ constructs as well as ensure credibility and trustworthiness (Shenton, 2004).

Instruments

The eight open-ended questions were designed by the adolescent and adult team supervisor to assess participants’ level of satisfaction and response to intervention. In addition, the quality-improvement project served to identify the potential future needs of participants who had completed an intervention program. To ensure quality and rigor, member checks were completed during the interviews; Miller read notes back to the participants about what she had heard to obtain feedback and validate their responses. Moreover, an audit trail (Lincoln & Guba, 1985) was kept throughout the process; specifically, the research team met on several occasions to share their coding process. They discussed the progression from individual codes to themes and the rationale for what codes clustered together to form the basis of a theme. This process ensured that the analysis followed a logical path and was based on the participants’ narratives.

Data Analysis

To ensure trustworthiness, a qualitative thematic analysis using multiple inductive approaches was conducted (Merriam & Tisdell, 2015). Two researchers reviewed data, which consisted of field notes from all 11 interviews, and performed open coding using handwritten visual mapping to identify repeated themes (Thomas, 2006). Miller, using color-coded concept mapping, performed the initial coding. She, Schoen and Carolyn Schmitt then completed axial coding, or grouping of open codes, during multiple coding meetings. A fourth researcher, Lisa M. Porter, independently performed open coding using ATLAS.ti (Friese, 2020), a data management software used for coding, sorting, and managing qualitative data. Interviewer field notes were entered verbatim into ATLAS.ti and analyzed separately to provide a form of triangulation (Merriam & Tisdell, 2015). After these independent analyses, the team met to consolidate codes into themes and subthemes through axial coding, which involved extensive discussions of the interview responses reported in the field notes, to reach agreement among the team members (Merriam & Tisdell, 2015). Credibility was addressed through frequent team meetings, conducted via Zoom, in which categorization of themes and subthemes were discussed. ATLAS.ti was used throughout the data analysis process to visually track and organize codes into themes and subthemes.

Results

Overall, the participants expressed a positive experience with occupational therapy intervention. Twelve descriptive codes, identified during the iterative analysis process, were used to classify findings and support theme and subtheme development. These codes, themes, and subthemes, based on the nature of the interview questions and the participants’ responses, are depicted in Figure 1.

Figure 1.

Codes, themes, and subthemes, based on the interview questions and participants’ responses.

There were three primary themes:

Therapist-related factors, which reflect what the therapist did in treatment.

Client-related factors, which reflect what the client experienced.

Follow-up, which captures the future needs of the clients.

Four subthemes were then proposed to organize the data into specific therapeutic components common across themes: (1) therapeutic alliance; (2) education and knowledge; (3) strategies, resources, and tools; and (4) future needs. These themes and subthemes are described in the sections that follow.

Therapist-Related Factors

Throughout the interviews, participants discussed the importance of validation (i.e., the therapist upholding the client’s experience) during the intervention process. One participant described this as “getting [empathic] understanding that others are going through the same thing.” Another disclosed that “A big component was validation for what I was experiencing.” A third participant stated, “There was validation and a sense of confirming that everything discussed was shown in the final report,” and a fourth said, “It was definitely so nice to feel that I’m not alone.”

Participants also indicated that the therapeutic environment felt safe and allowed them to openly express their emotions, ask questions, and explore difficult topics. One participant reported appreciating a therapist who was patient and actively listened. Another participant stated that they “felt cared for and comfortable” with the treating therapist.

Participants recognized that the education provided by the therapist was a valuable component of intervention. Information was conveyed regarding sensory integration and processing (e.g., sensory triggers, auditory sensitivity) and evaluation information (e.g., explaining the visual system, providing a referral to a developmental optometry specialist). One participant stated that, through this education, the therapist helped her learn a different way to interpret sensory challenges. She learned how to adapt in different situations and determine what strategies help her manage her sensory sensitivities and self-regulation as well as achieve a better understanding of what is happening to her. One participant noted that “Education was extremely helpful—[such as] learning about the arousal curve” (handout based on Hebb, 1949) and that “Education changed my perspective and empowered me.”

Last, participants discussed how the therapist provided many useful tools, strategies, and resources. Most participants discussed specific tools. For example, one participant spoke of buying noise-reduction earplugs to accommodate auditory overresponsivity, and another participant bought special sunglasses to help with visual overresponsivity. Other types of strategies participants identified were designed for application in daily activities, such as incorporating more sensory breaks (e.g., fidget devices, cold showers) into daily life or engaging in a daily exercise routine. One participant stated they used “fifty to seventy-five percent of strategies daily from the implementation plan.”

The therapeutic alliance subtheme describes the relationship between the participant and the therapist. This relationship is described as a safe, trusting, and positive one that developed between the participant and treating therapist that supported participants being vulnerable and able to openly expose themselves during the intervention process.

Client-Related Factors

A key area of change reported by participants was knowledge. Specific gains in knowledge reflected the importance of increased self-awareness. Some participants reported a better understanding of their body and their sensory challenges. One participant disclosed that learning about herself and her sensory differences helped her find the words to express her struggles and needs to others. Another participant stated that “it was a learning curve for me and my parents” and that once she became more aware of her body, she was able to catch her sensory struggles before they escalated. Another participant described an “awareness for taking care of myself.” Feedback sessions were another source of knowledge. These sessions offered a general knowledge of sensory integration and processing and supported an understanding of the sensory systems. Knowledge was gained about regulation, in particular as it relates to arousal and the association between arousal and performance. In addition to general knowledge, clients identified gaining individual knowledge of their own sensory needs, with one client stating that “knowledge replaced fear.”

Application of strategies, tools, and resources were highlighted by participants. They indicated that daily body-based activities were helpful. One said that the “physical part of obstacle courses are a good way to get active and move my body.” A specific tool valued by participants was sensory exploration. One participant pointed out that “testing out swings, chairs, [fidget devices], [and] resistance bands to experience different sensory experiences was helpful to find what is most beneficial for my body and brain.” Establishing routines was identified by participants as beneficial for their daily lives. One participant specifically stated that she purchased some of the suggested equipment (e.g., a chair swing and resistance bands) for use at home and was able to start her day with input to help her feel regulated. Integrating strategies into daily life activities and routines was reflected in several comments, such as “I am more focused by using putty in meetings,” “I have improved [my] visual attention after installing special light filters in my office,” and “I feel calmer after adding more breaks into [my] day.”

Advocacy was the last change identified by participants, revealing that the intervention allowed them to learn how to advocate for themselves. One participant said, “I showed up at my last job interview and said I was autistic.” Another participant said she now recognizes the need to communicate her struggles to others. Participants also reported seeking additional education on how to advocate for themselves in social roles and professional situations.

Subtheme: Education and Knowledge

The subtheme of education and knowledge reflects two related and complementary components: Education is defined as the therapist instructing the participant, and knowledge is defined as the information the participant acquired through the education process. This theme was discussed various times throughout the interviews. Participants discussed the benefits of education for sensory integration and processing, the nervous system, and their own sensory differences while describing how this knowledge enhanced their understanding of their challenges in daily life.

Subtheme: Strategies, Tools, and Resources

The subtheme of strategies, tools, and resources reflects what the therapists did and offered to participants during the intervention and what gains were achieved through application of these strategies, resources, and tools. Clinicians collaborated with participants and problem-solved a range of individualized strategies, resources, and tools; participants then reported being able to apply the knowledge they had gained to help with functional participation in daily activities.

Follow-Up

The majority of participants stated they would be interested in participating in follow-up group sessions. Many expressed interest in a support group to hear others’ experiences and strategies used for their sensory integration and processing challenges. In addition, participants stated they would appreciate obtaining additional resources for daily life. One participant stated they “wanted more at-home exercises,” “more body-based activities,” and “more reading options for dyspraxia.” Participants also requested more information on comorbidities with sensory integration and processing challenges, such as misophonia and ADHD. One participant requested further information on the similarities and differences between ADHD and sensory integration and processing challenges.

Some participants specifically requested further follow-up to address continued challenges in daily life. One participant reported she was “struggling with parenting” and “intimacy with my partner.” Another disclosed “struggling with [sympathetic nervous system] freeze symptoms and wanting more resources to better address this challenge.” Other topics for which participants reported needing further support included social interaction skills, sleep, and daily motivation.

The subtheme of future needs contains content similar to that of the follow-up theme, which reflects comments made by participants related to continuing needs for intervention. Participants described specific areas of concern requiring further consultation or assistance from the therapist after the completion of their occupational therapy intervention.

The data from the themes of therapist-related factors, client-related factors, and follow-up were valuable in highlighting the participant’ experiences, thoughts, and desires. Thematic analysis was used to identify the four core subthemes (Figure 2).

Figure 2.

The four subthemes as derived through thematic analysis.

Discussion

The purpose of this study was to conduct a retrospective analysis of interview data initially collected for a quality-improvement project on client satisfaction and follow-up needs. Positive experiences from the intervention were expressed by all participant who took part in interviews. Several important themes emerged from this analysis that will be helpful to shape future studies and intervention planning.

Therapeutic Alliance

The therapeutic alliance was a primary and overarching theme identified by the participants, who discussed its importance to their experiences with sensory challenges and the sensory-based intervention. This was not surprising given that a therapeutic alliance is central to the practice of occupational therapy (Kornhaber et al., 2016). A wealth of literature highlights the importance of the therapeutic relationship both within and outside of the occupational therapy profession (Ardito & Rabellino, 2011; Kornhaber et al., 2016). Although much of the sensory integration literature describes a strong therapeutic relationship as critical to progress during interventions with children (Holland et al., 2018), this study shows the importance of the therapeutic alliance for adolescents and adults engaged in a sensory-based occupational therapy intervention as well. This finding is supported by other research that has also emphasized the importance of adult clients creating and maintaining a close, trusting relationship with their therapist during occupational therapy (Cole & McLean, 2003; Palmadottir, 2006; Solman & Clouston, 2016).

Education and Knowledge

The second most common theme was the importance of education and knowledge translation during the therapeutic process (AOTA, 2020). Participants in this study emphasized the importance of gaining knowledge regarding sensory integration and processing, their unique sensory profiles, and understanding the nervous system’s connection with arousal regulation. Recommendations from the therapist consisted of concrete strategies, specific tools and equipment, and discussing the nervous system’s relationship to sensory integration and processing challenges. Knowledge of sensory differences influenced the participants’ ability to perform their daily occupational roles and routines, similar to that reported by AOTA (2020). This also helped with self-awareness, the need for self-advocacy, and the relationship to overall health.

Education was effective in this study; however, little has been reported in the occupational therapy literature as supporting individuals and families regarding underlying impairments in sensory processing that are affecting occupational performance (AOTA, 2020; DeCleene et al., 2013; Lawler et al., 1997; Paterick et al., 2017). This study adds to the literature on the benefits of education and training for adolescents and adults, and the results are consistent with the increasing evidence for the impact of education and training of parents of children with a range of disabilities (Miller-Kuhaneck & Watling, 2018). As this study shows, knowledge can affect engagement and performance in the therapeutic process as well as motivation and outcomes (AOTA, 2020).

Strategies, Tools, and Resources

This study also gives insight into the value of strategies, tools, and resources these participants received and used throughout the intervention and afterward to assist with daily life challenges (Guidetti & Tham, 2002). This is consistent with literature that has focused on the need to carry over therapeutic gains to the home environment (May-Benson & Kinnealey, 2012). Strategies, tools, and resources allow clients and families to address daily challenges with a battery of activities that have been successful in intervention (Guidetti & Tham, 2002). Some programs may provide at-home plans and care, whereas in this study’s program participants were given individualized self-regulation strategies and recommendations for specific tools (i.e., equipment) as well as community resources to use after completion of the program (i.e., follow-up with an occupational therapist in their area or recommendation of another specialist). Participants in this program identified being able to effectively incorporate individualized sensory and motor strategies into their daily routines as well as alerting them to difficulties and learning calming strategies. This is different from programs reported in the literature that teach specific skills (Hebert, 2016).

Future Needs

The follow-up subtheme suggests that individuals who participated in this short-term intensive intervention might need additional support after its completion. We found that the adults and adolescents who participated requested follow-up with the therapeutic team. This is not surprising given that many of the participants were seen only for an extended evaluation over a 5-day period. In addition, some of the participants had completed their program 1 to 2 yr before their interview, suggesting that a booster intervention program might be beneficial (May-Benson & Kinnealey, 2012). This is consistent with other literature suggesting that adults with sensory integration and processing challenges may continue to struggle with interpersonal skills and relationships after the time they are in therapy (AOTA, 2017; Goodman-Scott et al., 2020; May-Benson & Kinnealey, 2012). Participants specifically discussed the importance of additional follow-up focused on role performance (i.e., parenting self-efficacy, sleep, motivation). In addition, participants indicated that they would be open to a group intervention instead of individual therapy. Although some research has focused on specific leisure groups, such as art therapy or gardening (Udovicich et al., 2020), this study suggests that sensory support groups or sensory education groups may be valuable to adolescent and adult clients. As the literature suggests, groups are a cost-effective method of service delivery across disciplines as well as a way to provide clients with a support network for dealing with challenges in the future (McConachie et al., 2014; Udovicich et al., 2020).

Limitations

This study has several limitations. First, it had procedural limitations because the interviews were not recorded, and hence all direct quotes were based on the interviewer’s field notes. Another limitation, which is due to the nature of the phone interviews, is that the interviewer was unable to observe nonverbal communication, such as body language and facial expressions. This study also used only interviews, and as a result the data are exclusively based on self-report. This sample was largely homogeneous, lacking specific data on ethnicity and social economic diversity, and we recognize that in future studies more diversity will be needed.

Implications for Occupational Therapy and Future Research

The results of this study have the following implications for current occupational therapy practice:

▪ Occupational therapy practitioners can benefit from first-person accounts of the sensory integration and processing challenges identified by adults and adolescents so as to better design targeted interventions.

▪ Occupational therapists should consider the value of providing support and interventions to the adult and adolescent population while also building awareness of how to address the needs of this population.

▪ Sensory support groups may be a beneficial means of follow-up for adolescent and adult clients after individual therapy.

▪ Further research regarding the effectiveness of adolescent and adult sensory-based interventions is needed.

Conclusion

Sensory integration and processing challenges are present throughout the life course. Little has been written about the experience of adolescent and adult clients and how occupational therapists evaluate and treat their sensory differences. This study is a first step toward understanding what components of their intervention program were meaningful and what needs remain after participation. Building knowledge of individuals’ lived experiences with sensory integration and processing challenges will give therapists better tools for designing effective and appropriate interventions.

Footnotes

Acknowledgments

The authors acknowledge the support of capstone faculty advisor Dr. Stacy Caplan at Wingate University, as well as Abby Mucklow, OTD, OTR/L, and Gina Grites, OTR/L, MFTC, at STAR Institute, who tirelessly supported clients of the Adult– Adolescent Team on a daily basis at the time of this study.

Appendix. Client Interview Questions

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