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The following information may be downloaded as a PDF document here.

17th October 2015:

SI Research - Response to COT Briefing April 2015


Statement in response to College of Occupational Therapists’ OT Practice Briefing Sensory Integration of April 2015

  • i.  As the leading membership body and training organisation of sensory integration in the UK and Ireland, the Sensory Integration Network is totally committed to people who require sensory integration interventions and the therapists that deliver them.  Our role is to professionally, sustainably and tenaciously campaign for their needs.
  • ii.  The Sensory Integration Network believes that the recently published ‘Practice Briefing: Sensory Integration’ by the College of Occupational Therapists  (COT) for its members is both ill informed and poorly governed.
  • iii.  We seek to work openly and constructively alongside the COT and are disappointed that this paper has been released without appropriate consultation.
  • iv.  Reflecting a diverse membership which includes over 1300 active occupational therapists around the UK and Ireland, the Sensory Integration Network has access to the best world-wide current knowledge base from neuroscience, child and adolescent development, adult mental health and learning difficulties, learning theories and (re)habilitation principles in order to inform what sensory integration interventions should be tailored to what client.
  • v.  Our concern is that the current content of this paper reflects very negatively on all the positive work being done by therapists who are supporting people with sensory integration intervention. We are in the process of expressing this and other concerns with our colleagues at the COT.
If you have any specific enquiries to the Network please contact support@sensoryintegration@org.uk    

Open Letter of Complaint concerning the UK College of Occupational Therapists' Briefing 'Sensory Integration'

We, the members of the Board of Sensory Integration Network (UK & Ireland), write this open letter to you to represent the views of our members and to ‘give voice’ to those families and vulnerable individuals whom they support. We wish to reject, in the strongest possible terms, both the tone and content of the Practice Briefing recently issued by the College of Occupational Therapists entitled ‘Sensory Integration’ (April 2015).   

We are extremely disappointed that you have taken the decision to release this illconsidered document into the public domain. You have chosen to do so without any apparent consultation with your own membership or with recognised experts. Furthermore, the document fails to take into consideration the views of the wider stakeholder group and pays scant attention to service users and carers.   We are alarmed at the tone adopted and believe this kind of rhetoric has highly damaging implications for many other areas of occupational therapy practice.      

We highlight seven key failures:  

1. a questionable, vague, undefined purpose of the briefing 

2. a lack of balance and an overtly negative bias 

3. contradictory standpoints: both within the document and with other similar College publications 

4. sweeping statements and generalisations 

5. factual inaccuracies, misrepresentations and omissions 

6. a lack of rigor and transparency 

7. subjective and reductionist views of the unnamed author/s  

1. The purpose of this ‘briefing’ document is vague and undefined.   

This paper is purported to be a ‘practice briefing’.  Your website states that ‘Briefings provide up to date guidance and reference material to enable occupational therapists to remain informed and aware of changes and developments relating to practice’ and ‘Briefings are short, practical advice and information documents enabling practitioners to remain informed and aware of changes and developments relating to their work’  ( ref website ).   

We contend that this particular paper fails to meet the identified purpose of ‘informing and providing practical advice.’ Its stated intention to ‘explore where sensory integration is situated in relation to current perspectives of occupational therapy and occupation-centred practice’ (p1) would, in our view, be better suited to an opinion piece in the College’s Journal publication.  The exploration of abstract theoretical perspectives does not enable occupational therapists to ‘remain informed’ or make them ‘aware of changes and developments relating to practice’.    

We are confident that all UK Occupational Therapists, without exception, have been taught about ecological models of Occupational Therapy during their pre-registration education. It is, therefore, somewhat condescending to be describing this underpinning philosophy to Occupational Therapists in such simplistic terms.       

We would contrast this ‘vagueness of purpose’ with the visibly stated purpose of another of your practice briefings, ‘Measuring mental well-being in older people’ (COT Feb 2011). This briefing clearly sets out how the Department of Health asked the National Institute for Health and Clinical Excellence to produce public health guidance on interventions that promote the mental well-being of older people.  It is entirely appropriate, therefore, to inform occupational therapists about the needs of this group and the implications for ‘occupational therapy researchers trying to improve the evidence base’ (p1).   

We challenge the intended purpose and motivation behind the release of this ‘Briefing on Sensory Integration’ into the public domain. This is clearly in breach of your own guidelines which state that ‘BAOT members will need to login to access briefings’. In doing so, you have exceeded the scope of your remit to provide these briefings to ‘occupational therapy practitioners’ alone. No reason has been presented for this action.  

2. The document has an overtly negative bias and fails to give a balanced overview of the subject.

It is our assertion that the particular ontological and epistemological position of the author/s has led to an unbalanced paper with a blatantly negative bias.    

  • There is excessive use of emotive terms such as ‘ongoing controversy’ (p2), ‘controversy exists’ (p3), ‘opinions remain divided’(p3),’ ‘attempt to evaluate’ (p4), ‘claim to improve functioning’ (p5), ‘hypothesis is that…(p5), ‘limited results on standardised outcome measures’ (p5) ‘what has been termed….’(p5), ‘… based on the hypothesis that…’(p6), ‘use extreme caution’(P6) and so on. The document cites ‘a lack of effectiveness’ at least five times on page 6 alone. It asks leading questions such as ‘should an occupational therapy assessment focus only on sensory issues?’ The ‘summary and implications’ section mentions the views of carers. In it you choose to highlight that ‘some families reported that....programmes can be overly burdensome’ or have concerns about ‘social stigma’ (p7).

The Sensory Integration Network (UK & Ireland) is deeply concerned at the lack of objectivity and balance in this paper. We take issue with the adversarial stance and overtly negative  tone taken.  One thousand, three hundred and forty eight of our members are occupational therapists and we do not find this document to be in keeping with our person-centred approach.  We wonder how many other areas of Occupational Therapy you would wish to see restricted as a result of their failure to adhere to ‘standardised outcome measures (p5)’?   

To further make our point, we contrast this stance with the more inclusive and respectful one taken in another of your other briefings: ‘Ensuring the children’s and parents’ voices are heard should be an integral part of the child/family journey’ (p4) and ‘It is important that, wherever possible, the child’s views should also be sought in line with person-centred practice’ (Diagnosis of Developmental Coordination Disorder November 2013 p3).     

3. The document presents contradictory and conflicting standpoints, both within the document itself and in relation to other similar College publications.  

a. We have identified a number of contradictory opinions and unsubstantiated viewpoints within this paper. Two  examples include:   

  • In section 5 (p3) a diagram, adapted from the work of eminent occupational therapy theorist Anne Fisher, has been chosen to illustrate the Occupational Therapy Intervention Process. You have added the term ‘including sensory’ under the heading entitled ‘assessment’. However, despite the fact that this section is entitled ‘where should ‘sensory’ fit into the occupational therapy assessment and intervention process?’, you have failed to include any reference whatsoever to ‘sensory’ under the ‘intervention’ heading. Are you suggesting that ‘sensory’ should only be assessed and no intervention/s should be provided?
  • The column entitled ‘intervention’ (p5) states : ‘Enhance performance through:  Develop skill, Compensate, Modify the environment, Remediate/enhance of bodily functions/structures’. We are entirely in agreement with Dr. Fisher that occupational performance may be enhanced or improved through any of these four approaches, either alone or in combination. You choose, however, to ignore this perspective by asserting that approaches to intervention are split between those that are ‘impairment-focused’ and those that are ‘performance orientated’.

This overly-simplistic dichotomous classification is not one with which we are familiar. We challenge its validity as we see no reference or evidence source to substantiate it. We certainly do not accept your later thesis that the latter form of intervention (which you have called sensory strategies) is an acceptable form of practice, whilst the former (which you have termed sensory-based interventions), is not.     

b. Our analysis of this paper also identifies messages it contains which not only contradict but are, in fact, in direct conflict with those found in other briefings produced by you. An example is provided below.   

In your briefing entitled ‘Legislation, policy and research related to housing for individuals with autism spectrum disorders and challenging behaviours,’ which was published less than a year ago (July 2014), you state :       

‘Occupational Therapy is a ‘research emergent profession’ (Illot et al 2006 p39). There are many interventions currently being used by therapists that have not been rigorously tested to prove that they enhance occupational performance. As the role of the Occupational Therapist working with individuals with ASD expands, more diverse interventions are being used which do not yet have an evidence base. Illot (2003) uses the NHS as an example of a system which supports clinical effectiveness…….despite a lack of current evidence there are alternative methods through which Occupational Therapy interventions for individuals with ASD who present with challenging behaviour can be measured in terms of their clinical effectiveness’.   

We would contrast this pragmatic acknowledgement of the current state of our evidence base in relation to Occupational Therapy interventions with the following, excessively punitive, synopsis:   

‘In the climate which values evidence based practice, those who are funding occupational therapy services are increasingly requesting information about effectiveness and efficiencies of interventions. Evidence for Ayres Sensory Integration Therapy® and sensory-based strategies remains inconclusive and hence may not be considered justifiable and cost effective.’  (p7)    

Returning to the purpose of a briefing - we fail to see how this summary will, in any way, ‘enable occupational therapists to remain informed and aware of changes and developments relating to practice’.  

Sensory Integration Network (UK & Ireland) is committed to expanding and improving the evidence base within this field. To help achieve this, we are developing and promoting a range of innovative initiatives, including making grant-funding available to our members, to support the professions’ research leaders in building the knowledge base in this vibrant and emerging growth area of practice. 

4. The document contains a number of sweeping statements and over-generalisations.   

It is unclear which area/s of practice about which this paper is intended to ‘inform’.  The paper is published under the ‘Children, young people and families’ category of member briefings, but does not make explicit that it is targeted at this age group.  In section 6 (p 3) it also makes passing reference to other client groups, including adults with learning disabilities, mental health difficulties and dementia. 

Of the 46 reference sources upon which this paper is based, at least half make direct and specific reference to children, and ten to autism spectrum conditions. There is extremely limited use of sources in relation to adults (mental health n=3; learning disabilities n=2) and almost no evidence in relation to other neuro-developmental conditions (Attention Deficit and Hyperactivity Disorder n=1; Developmental Co-ordination Disorder =0).  For dementia, just one source is cited (Jakob and Collier 2014) and this is not a research-based article.   

We posit that this paper is characterised by a serious paucity of evidence. You make sweeping generalisations such as ‘these interventions are designed for less engagement from the person but are intended to fit into the daily routines’ (p5); ‘sensory-based interventions do not directly address a person’s occupational performance in daily life occupations’(p6) and ‘for some people they may require enhanced sensory experiences and more intense or busier schedules’ (p7).  There are, at best, tenuous links to any ‘’evidence’ for these far-reaching statements.   

We consider this paper to be far too superficial and too broad in its scope to do any justice to the wealth and depth of knowledge which is available to occupational therapists. We are in a  position to hold an informed view as hosts of the 4th European Congress of Sensory Integration 2015, with oversight of the International Scientific Committee’s abstract submissions for the congress.  

5. The document contains factual inaccuracies, misrepresentation of the evidence and selective omissions.  

There are a number of factual inaccuracies, misrepresentations and selective omissions in this paper. We highlight just a few:    

  • Your unreferenced statement ‘a child’s sensory processing will mature as they get older’ (p1) is factually inaccurate. Klintwall’s (2010) study showed high and consistent levels of impairing sensory difficulties from childhood through to adulthood in almost all of individuals diagnosed with classic autism. Experts in the field can attest to the negative impact this can have on everyday occupations at college, work and in intimate relationships.
  • The concluding statements you draw from the Segal & Beyer (2010) article in section 7 (p7) are factually inaccurate: ‘Moreover, some families reported that intensive sensory programmes can be overly burdensome or have concerns about the social stigma associated with carrying them out in school settings’. In stark contrast, the actual article describes ’a qualitative exploratory study with six parents and eight occupational therapists who used the brushing and compression technique (Wilbarger Protocol). Participants were interviewed one or two times, exploring their experiences in adhering to the protocol. Data analysis focused on facilitators and hindrances to parental adherence and on occupational therapists’ strategies used to encourage it. Parents identified their children’s responses to brushing, its perceived efficacy, and interaction of the protocol with family daily schedules, as factors influencing their adherence. Occupational therapists identified only family daily schedules as influencing parental adherence’ (p500).

We challenge the judgement that a piece of qualitative research involving just six parents justifies its inclusion in the summary and implications section of this paper.   

  • The Law and Darrah (2014) article (p3) is cited as supporting your assertion that ‘Controversy exists as to the definition of what constitutes interventions to address sensory needs and their effectiveness’.

The actual article is concerned with research findings which ‘indicate that rehabilitation interventions embracing family-centered services and focusing on functional improvement can be more effective in promoting participation’. The population group under study was children and young people with cerebral palsy. In our view, this is a blatant misrepresentation of the focus of this article.   

  • In presenting the findings of Gringras et al. (2014) (p6), you state: ‘there is also no evidence that the use of weighted blankets improves sleep’. We agree that in this sample of 67 children, one of the study’s conclusions was that ‘the use of a weighted blanket did not help children with ASD sleep for a longer period of time, fall asleep significantly faster, or wake less often’. You have omitted the second, more positive, finding that ‘the weighted blanket was favoured (English spelling) by children and parents, and blankets were well tolerated over this period’.

We would contend that the choice of parents and children is a valid source of consideration for all health and social care professionals, including occupational therapists.  

  • You claim (p6) that a systematic review by Weeks, Boshoff and Stewart (2012) found ‘a lack of evidence for the use of this technique’. In fact, the authors’ actual finding was ‘A lack of high quality evidence currently exists to support or refute the use of the Wilbarger protocol’ (underscore added) and that this ‘warrants future robust research on this topic’.
  • You draw attention to the decision of North American reviewers, tasked with producing the latest Diagnostic and Statistical Manual, DSM-5 (American Psychiatric Association 2013). Based on a robust review of the current evidence base, they decided not to include sensory processing disorder as a distinct diagnostic category for physicians’ use. The relevance of this decision does not align well with the stated intentions of the paper (as set out in point 1) and its subsequent rejection of ‘impairment-oriented approaches’ within occupational therapy in the UK. It also fails to mention, as part of a balanced argument, that The Diagnostic Classification Manual of Mental Health and Developmental Disorder of Infancy and Early Childhood (2005) does refer to the ‘Regulation of Disorders of Sensory Processing’.

Arguably, more importantly, you fail to mention that it was decided to include sensory processing in the new DSM-5 criteria for autism, referring to ‘hyper- or hypo- reactivity to sensory input or unusual interest in sensory aspects of the environment’. The text goes on to acknowledge that these responses to sensation limit and impair everyday functioning.     

Surely this should have presented a golden opportunity for you to highlight and expound the skills and expertise of the 500+ professionals who have, over the three years, gained additional qualifications through the joint Sensory Integration Network and Ulster University postgraduate, post-registration, course in Sensory Integration?      

We would contend that a briefing paper, setting out the implications of the decision by the DSM-5 committee, and the opportunities it presents for occupational therapists, would have been a useful alternative briefing resource for you to have developed.   

6. There is a lack of rigor and transparency.   

As highlighted previously in this letter, there is no clear and transparent rationale for the systematic appraisal and selection process for the particular articles, books and other  sources you have chosen to utilise. In our view, these appear, at best, to have been selected randomly and, at worst, deliberately chosen to reflect the particular opinions of the author/s.  Her/their repeated assertions of a lack of scientific evidence are more than perplexing in a paper which purports to be a theoretical / philosophical exploration of ‘occupation-centred practice’.     

There is no evidence of any consultation with experts in the field or any real consideration given to the views and experiences of service users and carers.  We are concerned that the most vulnerable and disabled members of this client group would not be able to engage with, or benefit from, the largely cognitively-based approaches you have decided are worthy of your endorsement as ‘performance-oriented approaches’ (p7).     

The resulting assertions and conclusions lack the rigor and robustness we would expect from a publication produced by the College.  As the professional body of Occupational Therapists in the UK, your values would indicate that you have a duty to pay due diligence to ensuring your representation of practice is done in an informed, considered, professional and balanced manner.      

7. The opinions expressed are subjective and reductionist in nature.  

We are extremely concerned that only a small number of areas of occupational therapy practice at most, may, perhaps, reach the level of scientific evidence demanded by you in this specific paper.    Do the conclusions in another of your briefings, mean that occupational therapy in housing ‘may not be  considered justifiable and cost-effective’ (p7)?   

‘….to date there is a lack of research into the effect of housing adaptations specifically aimed at ensuring the safety of individuals presenting with challenging behaviour and most literature exploring the use of safety devices to ensure the safety of individuals with ASD within the home environment has been undertaken by other professionals’ (p8) (Legislation, policy and research related to housing for individuals with autism spectrum disorders and challenging behaviours July 2014),   

Do you intend to apply the same severe and exclusive criteria to psychological / mental health / biomechanical approaches?    

We believe this reductionist approach sets a dangerous precedent for the wider profession as a whole.  

Conclusion  

In this letter we have highlighted some of the numerous and serious flaws in both the tone and content of this paper.  On the basis of this critique, we insist that you withdraw this briefing paper forthwith and issue an immediate retraction of this sub-standard piece of work.  

As an organisation, Sensory Integration Network (UK & Ireland) is committed to ensuring the delivery of high quality postgraduate education, training and research for health professionals, including occupational therapists, in this emerging field.     

Core to our ethos, as it is to yours, is to meet the needs of the person with sensory processing difficulties and their family, using the current best knowledge available. We therefore would want to offer our support to you in producing an informed and balanced briefing, which is more reflective of current practice and the needs and aspirations of service users and carers.      

Yours sincerely


Rosalind Rogers

Chair, Board of Directors of Sensory Integration Network (UK & Ireland) 


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