Abstract
Children with challenges in sensory processing and integration made significant changes related to occupational performance following OT intervention, and goal achievement was sustained over time.
Between 5% and 13% of children ages 4 to 6 yr and 16% of children ages 7 to 11 yr have challenges with sensory processing and integration (Ben-Sasson et al., 2009). Children with these challenges are less able to efficiently process and integrate sensory information to produce adaptive behaviors (Miller et al., 2007). Challenges with sensory processing and integration can affect a child’s participation in everyday activities, including in self-care, education, play activities, and social participation, as well as the child’s overall quality of life (Costa-López et al., 2021; Jones et al., 2020). Given the potential impact sensory challenges can have on many aspects of children’s daily life, it is important to identify interventions that increase children’s participation in everyday activities and have a lasting effect. It is also important to understand parent–caregiver perspectives of the benefits of occupational therapy (OT) intervention for children with challenges in sensory processing and integration.
Despite an increasing body of evidence showing the effectiveness of OT sensory integration intervention, little research exists regarding the long-term impact of OT intervention on children following the intervention and whether progress made during OT intervention is sustained after intervention is over. Literature reviewing the effectiveness of OT months or years following intervention is outdated or examines different diagnostic populations, such as children with developmental coordination disorder who may or may not have underlying challenges with sensory processing and integration. There is little information on parents’ perspectives of OT intervention.
Studies have reported statistically significant results showing that children made improvements immediately after completing OT intervention three or more times per week. Pfeiffer et al. (2011) used a randomized controlled trial to examine the effectiveness of sensory integration interventions compared with fine-motor interventions among 37 children with autism spectrum disorder (ASD). The results demonstrated that children in both groups made significant improvements toward goals; however, the sensory integration group demonstrated more significant improvements (p < .05) in each of the goal areas for Goal Attainment Scaling (GAS; Kiresuk et al., 2014) as identified by the children’s parents (Pfeiffer et al., 2011). Another randomized controlled trial explored the impact of sensory integration intervention on goal attainment among 32 children with ASD (Schaaf, Benevides, et al., 2014). After 10 wk of intervention for an average of 30 treatment sessions, the treatment group achieved significantly higher GAS scores compared with the usual treatment group (Schaaf, Benevides, et al., 2014). In a retrospective study of 179 children with sensory processing challenges who received OT intervention, assessments before and after intervention showed statistically significant results in the children’s sensory processing (Schoen et al., 2018). Significant changes were demonstrated before and after intervention on the Sensory Processing 3-Dimensions Scale (SP–3D; Mulligan et al., 2019) assessment (p < .001) on all sensory modulation scales (Schoen et al., 2018; the SP–3D is an objective measure under development but is not yet standardized or available for widespread use in OT practice). Significant changes were also noted in motor scales on the Miller Function and Participation Scales (Miller, 2006), including visual–motor (p < .001), gross motor (p < .001), and fine motor (p < .001), and the Bruininks–Oseretsky Test of Motor Proficiency, Second Edition (Bruininks & Bruininks, 2005) in the areas of fine motor (p < .04) and manual dexterity (p < .03; Schoen et al., 2018). None of these studies followed up with the participants after the intervention was completed, making it difficult to determine whether improvements were sustained following intervention.
In reviewing studies with a longer follow-up period to assess whether changes were sustained following OT interventions for children with challenges in sensory processing and integration, we found notable limitations, including a dated study (Wilson & Kaplan, 1994) and a study exploring the lasting impact of OT combined with perceptual–motor intervention for children with developmental coordination disorder (Davidson & Williams, 2000). The most relevant study that examined the effects of sensory integration therapy on children with autism used a 2-mo follow-up period after the intervention (Khodabakhshi et al., 2014). The results of that study found that the OT group showed significant improvement in social interaction (p = .001) and motor (p < .001) and tactile (p < .001) performance immediately after intervention, and these changes were maintained 2 mo postintervention (Khodabakhshi et al., 2014); however, it is unclear whether these changes were sustained for a longer period.
We found only one qualitative research study on parents’ perception of OT sensory integration intervention. This study explored 28 parents’ perspectives of OT services provided to their child approximately 1 mo to 2 yr after intervention (Cohn, 2001). All parents reported an observed increase in various abilities in their children following OT intervention (Cohn, 2001). Parents also reported that OT improved their child’s self-efficacy, confidence, and happiness because their child was better able to engage in meaningful play occupations (Cohn, 2001).
Given the gaps identified in OT intervention for children with sensory challenges, additional research is needed to determine whether changes made during OT are sustained over time and what aspects of OT intervention are perceived as most beneficial for children with sensory challenges. Therefore, the purpose of this study was twofold. The first was to determine whether there were changes immediately after children participated in an intensive OT program and, if so, whether the changes were sustained over time. The second was to determine what parts of the intensive OT program parents perceived to be the most valuable in helping their children achieve identified goals as well as opportunities for improving the OT program.
Method
Study Design
This study followed a mixed, cross-sectional, single-group follow-up design. We implemented a one-group repeated-measures quasi-experimental design to evaluate differences in occupational performance and related goal achievement at three time points: pre- and postintervention and 6- to 12-mo follow-up. Data from measures taken pre- and postintervention were extracted from the medical records of children with sensory processing challenges who completed about 20 OT intervention sessions that applied sensory integration principles over a 6- to 7-wk period. We collected follow-up data by conducting a one-time phone interview with the parent–caregiver that involved the readministration and scoring of the outcome measures, including GAS and the Canadian Occupational Performance Measure (COPM; Law et al., 2019) scores. We completed analyses to determine statistical differences between the time points and explored clinical significance by comparing changes in mean COPM scores over time with established standards. The qualitative component involved asking questions during the phone interview to understand parent–caregiver perspectives and experiences of the OT intervention provided to their child and family. The interviews were transcribed verbatim, and the data underwent a thematic analysis to explore parent–caregiver satisfaction and components of the intervention that they felt were most effective, as well as to gather and summarize feedback on ways for improving the OT intervention experience.
Participants
The sample included children with sensory challenges who participated in the OT intervention at an outpatient pediatric hospital in the Midwest between July 2019 and January 2020 and their parents–caregivers, who were interviewed by phone in July and August 2020 to allow for a 6- to 12-mo follow-up period. Children were referred to the OT program on the basis of reported and observed challenges with sensory processing and integration, particularly sensory modulation challenges, that affected the child’s and family’s ability to participate in daily activities. Children were able to participate in the OT intervention with or without a medical diagnosis, such as ASD or attention deficit hyperactivity disorder (ADHD), if they were exhibiting challenges with sensory processing and integration that were affecting daily living. For the follow-up study with parents–caregivers, individuals who were non–English speaking were excluded; there were no additional inclusion or exclusion criteria. Potential participants were identified through electronic medical records. Once participants were identified, the parents of the children who completed the OT program were contacted by phone. Once the study was explained to potential participants by a member of the research team, parents provided verbal consent to be interviewed for the study as well as for the recording of the interview for data collection. Following consent, we conducted the interviews immediately unless the participants scheduled an interview for a later date.
Intervention
The OT intervention occurred three times per week for 1-hr sessions over the course of 6 to 7 wk. The OT intervention focused on using the STAR Frame of Reference (Schoen et al., 2019) and Ayres Sensory Integration® (ASI; Schaaf & Mailloux, 2015) principles; in addition, other components, frames of references, or approaches were incorporated to meet the needs and goals identified by children or their caregivers. Key components of the STAR Frame of Reference include focusing on arousal and regulation before building skills, building relationships, and educating and coaching parents (STAR Institute, 2022). Occupational therapists used ASI components to facilitate rich multisensory experiences, incorporating vestibular, proprioceptive, and tactile input and promoting success by providing the just-right challenge while increasing the complexity of the task (Schaaf & Mailloux, 2015). Occupational therapists delivering the intervention (Shannon Teeters, Anna Ramstetter, and Sara-Ruth Strain-Riggs) had advanced training in working with children with challenges in sensory processing and integration. All occupational therapists delivering the intervention completed the STAR Institute Level 1 mentorship program, and three of the four occupational therapists received their sensory integration certification through Western Psychological Services.
Children participating in the OT intervention received individually tailored play-based intervention that focused on improving overall sensory integration and processing. During the goal-setting process, clinicians used caregiver-reported outcome measures and standardized assessments to create family-centered goals related to the child’s participation in activities of daily living (ADLs). Throughout the program, occupational therapists encouraged caregivers to become “play partners” by being actively involved with their child in therapy sessions. This active engagement facilitated caregiver understanding, education, and hands-on practice under guidance from the occupational therapist on how to apply sensory principles with their child. Therapists focused on supporting appropriate arousal and regulation through coregulation with the child and by making environmental modifications. Relationships were built through engagement in preferred activities and establishing trust, which is supported by providing the just-right challenge. In addition to providing the just-right challenge, occupational therapists providing the intervention used other tools or approaches such as the interoception curriculum (Mahler, 2019), self-regulation curriculums, cognitive–behavioral strategies and programs, task-specific practice, compensatory strategies, and environmental modifications, among others, as appropriate for individual client needs. At the conclusion of the OT intervention, caregivers were provided with a sensory lifestyle document that provides a written summary of strategies used during OT intervention and home programming suggestions that can be practiced and implemented in the child’s everyday environments.
Quantitative Data Collection
We obtained quantitative data by collecting pre- and postintervention scores from the children’s electronic medical record and 6- to 12-mo follow-up scores from the parent–caregiver phone interviews. We extracted data from the medical record by running a query through which discrete flowsheet data were automatically retrieved and downloaded into an Excel spreadsheet. Data collected included scores for the COPM and GAS goals that were identified before OT intervention. The GAS and COPM are two assessments commonly used by occupational therapists to measure the effectiveness of sensory integration intervention. To obtain 6- to 12-mo follow-up COPM data, we asked the parents–caregivers to rate their child’s current performance in previously identified goals for OT as well as their satisfaction with the child’s performance in these goal areas. We asked parents–caregivers to describe their child’s performance in each GAS goal area to assign a new GAS score. Data from the quantitative portion of interviews were then compiled into one spreadsheet for data analysis.
COPM
The COPM is an assessment tool used to measure perceived occupational performance in the areas of self-care, productivity, and leisure (Law et al., 2019). The COPM is designed to help therapists identify important goals for therapy intervention and is used to determine changes over time in occupational performance and satisfaction (Law et al., 2019). The COPM requires clients or a proxy to identify goals for intervention, including a perceived performance and satisfaction score. Although the COPM is based on client perception, Eyssen et al. (2011) found that perceived changes over time agreed with changes detected by other outcome measures, and they therefore concluded that the COPM is valid in determining changes in occupational performance over time. Because of the impact that sensory processing and integration challenges have on potentially every aspect of daily life, the COPM is an appropriate tool to measure sustained changes over time following OT intervention. A change of 2 points or greater for self-perceived performance or satisfaction is considered clinically meaningful (Law et al., 2019).
GAS
GAS is a standardized means of identifying and scaling relevant goals to indicate the level of goal attainment from intervention (Schaaf, Burke, et al., 2014). Initially developed for program evaluation, GAS has demonstrated sensitivity as a measure to show outcomes of individualized interventions (Kiresuk et al., 2014). It has been reported as one of the most sensitive assessments in detecting change after OT sensory integration intervention (Mailloux et al., 2007; Miller et al., 2007; Pfeiffer et al., 2011; Schaaf, Burke, et al., 2014).
GAS goals were set based on COPM goals identified for OT intervention. For example, if COPM goals related to sensory overresponsiveness to grooming or participating in an activity at school in a noisy environment, GAS goals were developed and scaled to reflect whether the child made progress toward tolerating or participating in these ADLs or educational activities.
Qualitative Data Collection
We collected 6- to 12-mo follow-up data via one-time, follow-up semistructured phone interviews with parents–caregivers of children who had completed the OT program. During the interviews, we asked parents–caregivers open-ended questions about their perception of the OT program and what they found to be the most beneficial aspects of the program. We also asked them about any other positive changes that their child made or maintained since completing the program or any regression or challenges their child had experienced since completion of the program. They were also asked whether they had any suggestions for areas of improvement in the OT program for their children or whether there was any additional information or education they wished they had received through the program. Examples of questions asked during semistructured interviews included the following: ▪ What improvements has your child maintained since finishing the sensory intensive program? ▪ What area or areas have you noticed declines in since the completion of the sensory intensive program? ▪ What thing or things did you find to be most helpful in the sensory intensive intervention program? ▪ What things, if any, would you have liked to be done differently if your child were to participate in OT all over again? ▪ Is there anything you would have wanted more education or information on during this program? If so, what? ▪ Is there anything else that you would like to share about your child’s experience during or after the sensory intensive program?
Phone interviews lasted an average of 36 min (range = 28–44 min). Interviews were recorded and completed by three members of the research team (Victoria Ann McQuiddy, Marissa Ingram, Madison Vines). We then transcribed the interviews verbatim.
Data Analysis
We analyzed data using quantitative and qualitative methods. We conducted repeated measures analyses of variance (ANOVAs) with Bonferroni correction to determine whether statistically significant change occurred (p < .05) from baseline to postintervention, baseline to follow-up scores, and postintervention to follow-up using the GAS goal scores and COPM performance and satisfaction scores. COPM scores were also examined for clinical significance; a 2-point change on the COPM was considered clinically meaningful (Law et al., 2019). We analyzed qualitative data using a thematic analysis process. Specifically, all parent–caregiver interviews were coded individually by three members of the research team (McQuiddy, Ingram, and Vines); codes were used to assign meaning to the qualitative data gathered for the study (Miles et al., 2019). After individual coding, we met as a group to compare codes. After reaching agreements on codes, we further synthesized data by developing clusters in which similar codes were grouped together. Clusters and codes were further synthesized into themes as a method of second-order generalization to draw further conclusions from the data following the process outlined by Miles et al. (2019).
Results
Participants
Of the 16 children who completed the intensive OT program, 6 were girls and 10 were boys ranging in age from 2 to 10 yr (M = 5.73 yr). Phone interviews were completed by 16 parents– caregivers (1 maternal grandmother and 15 mothers) 6 to 12 mo (M = 9.5 mo) after the children completed OT intervention. Common goal areas identified for the intensive OT intervention included tolerance for or participation in daily self-care activities, transitioning between activities and environments, following directions, self-regulation and adaptive coping skills, social participation, and improved sensory modulation. All children who completed the OT intervention had sensory modulation challenges, which were identified using clinical observations, information from the occupational profile, and the Sensory Processing Measure (Parham et al., 2007). Some common sensory challenges experienced by the children included overresponsiveness to tactile and auditory input, mixed responsiveness to vestibular input, and proprioceptive underresponsiveness or sensory craving. Most of the children were also identified as having difficulty with planning and ideas on the Sensory Processing Measure. The most common comorbid diagnoses included ADHD, mixed expressive receptive language disorder, and anxiety. See Table 1 for additional information on the children’s demographics and comorbidities.
Demographic Information of Children (N = 16) With Sensory Challenges
Quantitative Data
GAS Scores
Mean GAS scores for children completing the intensive OT intervention were −2.00 before intervention, 0.44 immediately following intervention, and 0.65 at 6- to 12-mo follow-up. There was a statistically significant difference when comparing preintervention GAS scores with GAS scores immediately after intervention and 6- to 12-mo follow-up scores (p < .001). We found no significant difference (p = .305) when comparing scores immediately following intervention with 6- to 12-mo follow-up scores. See Table 2 for additional information.
GAS Scores for Children With Sensory Processing Challenges
Note. GAS = Goal Attainment Scaling
COPM Scores
We analyzed COPM performance and satisfaction scores using repeated-measures ANOVAs at the same three points as GAS scores. There was a statistically significant difference when comparing preintervention performance and satisfaction scores on the COPM with scores immediately after intervention and 6- to 12-mo follow-up scores. We found no significant differences when comparing performance scores (p = .450) and satisfaction scores (p = .564) immediately following intervention with 6- to 12-mo follow-up scores. See Tables 3 and 4) for additional information.
COPM Performance Scores for Children With Sensory Processing Challenges
Note. COPM = Canadian Occupational Performance Measure
COPM Satisfaction Scores for Children With Sensory Processing Challenges
Note. COPM = Canadian Occupational Performance Measure
Qualitative Data
A total of 61 unique codes were identified from the parent–caregiver interviews, which were further synthesized into 19 clusters and then into five themes. The five themes were (1) parent or caregiver perception of child’s progress and current performance in goal areas; (2) value of occupational therapist’s knowledge, skills, and ability to form therapeutic relationships; (3) value of parent–caregiver education during OT program; (4) accessibility of the OT program; and (5) benefits of intensive service delivery model and additional program feedback.
Parent–Caregiver Perception of Child’s Progress and Current Performance in Goal Areas
The five clusters within this theme included the child’s challenges before the OT program, the child’s area of improvement or sustained improvements, no regressions in goal areas following completion of the OT program, the child’s area of decline following the OT program, and areas still being addressed following the OT program. Every parent or caregiver interviewed was able to identify at least one area of sustained improvement since completion of the OT program.
All parents–caregivers described the challenges they felt their child experienced before the sensory intervention program. They reported that these challenges affected many different areas of their child’s lives, including ADLs or instrumental ADLs, social skills, transitions, self-regulation, sensory modulation, impulsivity, and inability to use or recall newly learned information. The parents–caregivers explained how these challenges affected their child’s life and their family. However, they reported that participating in the intensive OT program improved their child’s performance in many areas. For example, Parent–Caregiver 9 stated, “All of the goals have improvements . . . in every single category, from coping skills to social skills. There’s more awareness where in the past it would’ve just been full steam ahead.” In addition, many parents and caregivers noted that their child had been able to sustain improvements made during the intensive OT program. Parent–Caregiver 3 stated, “I don’t think there are any declines at all. I think she [the child] has good stretches and harder stretches. . . . I don’t think she really ever goes backwards.” Although all parents or caregivers reported that their child made improvements during OT intervention and that progress toward goals had been maintained, some reported that their child regressed with their participation in several goal areas.
Value of Occupational Therapist’s Knowledge, Skills, and Ability to Form Therapeutic Relationships
The four clusters within this theme were negative experiences with OT before the OT program, the parent’s–caregiver’s relationship with the child, the parent–caregiver valuing the occupational therapist’s expertise and knowledge, and the occupational therapist’s ability to structure sessions for success. There were consistently positive comments about the child’s specific occupational therapist during the program in each of the transcribed interviews.
Within this theme, parents–caregivers also discussed the value of the relationship with the occupational therapist and the importance of the occupational therapist’s experience and knowledge. These comments were consistent in all the transcribed interviews and ranged from a generally positive experience to specific therapist qualities that were valued. For example, Parent–Caregiver 4 stated, I think that is a big deal, that she [occupational therapist] can adapt to each child and understand that not every child is the same . . . she took it at his [the child’s] pace until she knew the trust was there and then she was able to challenge him . . . she was just what we needed and it made a huge difference for him.
Another parent (Parent–Caregiver 7) stated, “It was like the therapist would push her [the child] to this limit, but not in a way that would make her angry . . . she would really push to her limits, but she was just thinking she’s having fun.” Over half of the interviews discussed the occupational therapist’s selection of client-centered activities that supported the child’s successful participation in sessions and were motivating to the child for future sessions. Finally, parents–caregivers consistently reported the therapy interventions were helpful and related to the child’s goals and areas for improvement.
Value of Parent–Caregiver Education During OT Intervention
Most parents–caregivers expressed satisfaction with the education provided during the intensive OT program and felt that their educational needs were met. Many parents–caregivers expressed increased awareness and insight related to better understanding their child’s sensory challenges and how their child’s behaviors related to sensory processing and integration challenges. They continued to say that the increased insight gained through the education allowed them to better manage their child’s behaviors in response to sensory input. They also consistently discussed how the education provided during the program improved carryover of strategies at home. For example, Parent–Caregiver 1 stated, “The type of work she [occupational therapist] gave us to do at home was very helpful.” Although most information about the education provided during the intensive OT program was positive, 2 parents–caregivers expressed that they still lacked confidence regarding their knowledge about their child’s sensory issues and how to best manage behaviors related to these concerns following completion of the program.
Accessibility of the OT Program
The three clusters included in this theme were COVID-19, difficulties receiving intensive therapy services, and benefit of increased awareness and accessibility of the program. Parents–caregivers identified several factors that they perceived as barriers to accessing the OT program. The most commonly identified barrier was COVID-19. Parents–caregivers repeatedly mentioned that the pandemic negatively affected their child’s ability to participate in the program. One parent–caregiver reported that they believed that the pandemic interfered with their child’s ability to make progress toward his goals. Another parent–caregiver believed their child regressed some during the beginning of the pandemic because of the abrupt transition into quarantine. Another parent–caregiver discussed how continuing intensive services through telehealth was not as beneficial for their child’s progress toward goals compared with the in-person intensive sessions.
Another cluster identified under this theme included difficulties receiving intensive services. Some parents–caregivers shared that they had to join the waitlist to participate in the program because of high demand and they wished for increased availability to access the program. The third cluster under this theme included the benefit of increased awareness and accessibility of the program. Parent–Caregiver 3 reported that they were “just really thankful for it and lucky to have it right here and access to it.” Several parents–caregivers suggested increased marketing of the program so that other families can have access and benefit from it.
Benefit of Intensive Service Delivery Model and Additional Program Feedback
When providing additional feedback on the intensive OT program, each parent–caregiver interviewed identified at least one aspect of the program that they perceived to be beneficial. Most parents–caregivers stated that they were “impressed with the program.” Parent–Caregiver 6 even stated, “I just think that this is really a great program. I think that any child with a sensory issue, small or large, could benefit from this.” More than half the parents–caregivers interviewed stated that they would not change anything about the program. Other participants described the program as “excellent” and “really beneficial.” Overall, the additional feedback gathered about the program was positive.
Most parents–caregivers attributed their child’s initial changes that were able to be maintained over time to the program’s intensive service delivery model. Furthermore, all but 2 parents–caregivers discussed the value of the intensive nature of the program, with a frequency of three times per week, which they believed was very beneficial to their child’s progress. Several parents–caregivers reported that a frequency of OT services once a week before the program was not beneficial to their child’s progress. One of these participants (Parent–Caregiver 2) stated that their child retained it better going multiple times a week, like the 2 to 3 hr each week as opposed to 1 hr of therapy each week. . . . So intensive therapy is more beneficial for my child than the once a week and that’s why we’re switching back to intensive.
When asked for additional program feedback, several parents–caregivers discussed the termination of the intensive services as the most challenging thing. More than half of the participants reported the desire to increase the duration of the program. Specifically, these parents–caregivers believed that extending the program by an additional 1 to 2 wk would have facilitated further goal attainment. One parent suggested that the program should gradually, rather than abruptly, discontinue OT services. Last, several parents–caregivers expressed that they intend to return to the program or wish to return to the program in the future. Three parents–caregivers shared that their children enjoyed participating in the program and that they want to complete it again. Several parents–caregivers shared that they felt that the program had a major positive impact on their child’s life overall. Parent–Caregiver 8 stated, “This program just made a huge impact on his life going forward more than anyone would know.” Participants consistently discussed their satisfaction with the program’s intensive service delivery model.
Discussion
Challenges with sensory processing and integration can affect many aspects of a person’s daily life; therefore, it is important to better understand the effectiveness of OT interventions. Despite the expanding body of evidence of the benefits of OT intervention, there is limited research on whether changes are sustained following the intervention. The goal of this study was to determine whether changes were sustained 6 to 12 mo after OT ended. This study also provided insight into an OT program from a parent–caregiver perspective. Results suggest that participation in the intensive OT program was effective in allowing children to maintain changes for 6 to 12 mo after OT services had ended. Furthermore, this study identified five themes from transcribed interviews regarding parent–caregiver perspective of the OT program. In concurrence with preexisting literature, these findings support the use of OT interventions in treating children with sensory processing and integration challenges and further support that the progress made following OT intervention can be sustained over time. The quantitative results of this study identified both a statistically and a clinically significant difference in pre- to postintervention GAS scores and both performance and satisfaction COPM scores. These results align with existing literature that supports the effectiveness of OT intervention and that shows children with sensory challenges make changes immediately following OT intervention (Iwanaga et al., 2014; Pfeiffer et al., 2011; Schaaf, Benevides, et al., 2014; Schoen et al., 2018). This study also determined both a statistically and clinically significant difference in preintervention to 6- to 12-mo follow-up GAS scores and both performance and satisfaction COPM scores. Although there was no statistical significance between postintervention and current scores, this study demonstrated that OT intervention resulted in children making progress toward goals that were sustained 6 to 12 mo after OT intervention ended. In addition, results suggest that participation in skilled OT services contributed to significant improvements in goal areas; without skilled OT services, children did not continue making significant progress in goal areas or areas of concern. These finding highlight the importance of skilled OT services for children with challenges in sensory processing and integration.
The qualitative results of this study determined that parents–caregivers were generally pleased with the OT program. Across all transcribed interviews, parents–caregivers reported improvements or sustained improvements in at least one goal area following completion of the program, and over half of the parents–caregivers reported no regressions in any of the goal areas. Declines following completion of the program were found to be potentially linked to outside circumstances, specifically the COVID-19 pandemic, which affected the children’s ability to participate in goal areas. In addition, aspects of the OT program that parents–caregivers consistently identified as important included the three-times-per-week frequency of the program; the occupational therapist’s knowledge, skills, and ability to form therapeutic relationships; education, skills, or strategies provided to aid with carryover following completion of the program; and an increase in duration of the program to continue making improvements in goals.
Although there has been some research on parent–caregiver perspective of OT intervention, preexisting literature has focused more on the parents’ perspective of changes over time following intervention rather than their experience with the OT intervention. This study sought to further examine the parent–caregiver experience to better understand what they found most valuable in the program and possible areas of improvement to increase overall effectiveness of the program in the future. Cohn (2001) determined that parents–caregivers of children who participated in OT intervention “valued the support, information, and strategies learned” (p. 291) in the program to carry over into other settings. This is consistent with our findings suggesting that parents–caregivers valued the therapist delivering the OT intervention and the education provided during the OT program. Overall, qualitative results from this study suggest that parents–caregivers felt participation in the OT program was beneficial for their child and resulted in improvements in desired goal areas that were generally sustained over time. These sustained improvements were attributed to the development of a therapeutic relationship with the occupational therapist, education provided, and frequency of the program. Parents–caregivers also often reported they would like the OT intervention to last longer, which was likely reflected in performance and satisfaction scores that were improved but still generally about 6.5 out of 10 on the COPM. Finally, both quantitative and qualitative results of this study indicate that engaging in skilled OT services is essential for children with sensory challenges to make significant progress toward goal areas.
Limitations
There were some limitations to this study. One was the relatively small sample size, which can limit generalizability. To decrease this threat, we used a mixed-methods analysis to confirm findings across different data sources (such as the use of quantitative and qualitative data on goal attainment and progress and independent coding of data by members of the research team before thematic analysis). Data analyzed for qualitative analysis included self-report measures (COPM and GAS); the use of self-report measures are subjective, and while both measures are psychometrically sound and shown to measure change, this limitation should be considered when interpreting the results. Another limitation was the timing of this study in relation to the COVID-19 pandemic; the additional stress and limitations children and families experienced during the pandemic could have affected parents’–caregivers’ responses and the child’s ability to continue engaging in school or community activities that might have supported their continued progress in goal areas. The lack of a control group was another limitation. Although in some ways participants served as their own control because there was a period with OT intervention and then a period with no intervention, the lack of a control group made it difficult to know whether external factors or any other changes due to child maturation were potential limitations. Parents/caregivers interviewed often reported they would have preferred OT intervention to last longer than 6 to 7 wk; this may be considered a limitation because perhaps more improvements could have been made if the intervention period had been longer.
Implications for Occupational Therapy Practice
This study found that children with challenges in sensory processing and integration who participated in OT intervention made improvements toward individualized goal areas that were able to be sustained after intervention ended. Parents–caregivers consistently expressed positive experiences with their child’s participation in the intensive OT program. This study provides support for the value of skilled OT services to improve the participation of children with challenges in sensory processing and integration in everyday activities that are able to be sustained over time.
Conclusion
This study sought to determine whether change is sustained over time (6–12 mo) following the completion of an OT program for children with sensory processing and integration challenges, as well as to learn more about the parent–caregiver perspective of the OT program and explore potential methods for improving this program. Current literature is either outdated or focused on the effectiveness of sensory integration interventions immediately following the completion of such a program. Therefore, this study is important for understanding the long-term effects of an OT intervention to better determine the best ways to serve this population. Furthermore, it is important to understand parent–caregiver perspectives of the OT intervention and what aspects of the intervention are most valuable.