Sensory Integration Education

This edition's big interview is with the world renowned Dr. Beth Pfeiffer. Dr. Pfeiffer is an associate professor in the Department of Health and Rehabilitation Sciences teaching courses in the doctorate of occupational therapy and mentoring research in the entry-level and post-professional occupational therapy programs. Dr. Pfeiffer's research focuses on treatment and measurement of person environmental interactions in individuals across the lifespan with autism spectrum and mental health disorders. Dr. Pfeiffer maintains her clinical practice in the area of paediatrics. During this interview we discussed a wide range of topics from the use of SI within the adult population, the future of SI research, the importance of the sensory environment and her ongoing research projects.

SensorNet (SN): Tell us about the research which you are involved in currently.

Beth Pfeiffer (BP): Much of our research funded studies explore the transition period for youth and young adults and transportation issues. Within that, some of our transportation studies are specific to individuals with autism and we consider the sensory environment relevant to each individual.. We look at how we can make that a better fit for people based on a variety of needs, with sensory being one of them. Because of the current state of the world, some of our work has also focused extensively on adding components to our interventions and curriculums where we are working with individuals to travel safely and be in essential environments. This has included how they social distance, when to use PPE and how to use that correctly. In some of our projects we have hired peer support individuals. These are individuals with autism that support the work we are doing. One of peer support workers has been working on the issues of wearing PPE and the sensory issues surrounding that. We have also been working on how to navigate environments for people with differences and exploring how sensory stimuli is perceived.

SN: How do you use an SI approach with an adult population?

BP: Intervention does and should look very different depending on the individual needs of the person.

That is always an important consideration. We typically use a consultation model when we are working with adults. Placing a focus on empowerment and self-efficacy is important. We also look at the lifestyle of the person and what environments they are involved in and how they can make changes or adaptations based on their unique sensory needs. As therapists, we can only be with our clients for a certain period of time in intervention. We are therefore working towards empowering adults to help them understand what specific types of sensory inputs help. Education and advocacy are essential. Helping adults to advocate for themselves when entering work or a social situation, so that they are able to participate. Their sensory systems may perceive different aspects of that environment very differently than another person.

SN: What are your feelings on how the field of SI is becoming more recognised within the adult population and what further work is needed in this area? 

BP: I am receiving a greater number of referrals from psychologists now more than ever. The reality is there are not that many of us who work specifically with adults with sensory processing differences. All of the children we work with grow up and sometimes their sensory issues are resolved and sometimes they are not, so there is a real need for use to address this. We need to have more people who are trained in how to work with this population.

I feel SI is starting to become acknowledged broadly within this population. Psychologists now know more about sensory processing difficulties and understand its relationship with anxiety, depression and mental health conditions. As occupational therapists we need to further address the sensory needs of adults, otherwise we are going to see other disciplines moving into this realm instead.

SN: You completed a pilot study on the “Effectiveness of Sensory Integration Interventions in Children With Autism Spectrum Disorders” which provided preliminary support for using SI interventions in children with ASD. How do you feel the field has progressed since this research was completed?

BP: When we were doing this study there was a real need for us to establish our theoretical basis, explore how that translated into intervention and find out whether it was effective. I feel we need to continue to do this. Roseann Schaff, a colleague and friend of mine, is doing a much larger randomised control trial comparing ASI to behavioural interventions and once that is completed, we will have a much larger study for our evidence base. Funding is always an issue and so as a result, we have lots of small scale studies. 

In terms of evidence I feel that we really need to connect our intervention to functional participation outcomes. We need to look at individuals' quality of life and what allows them to be actively engaged. Meaningful outcomes such as social participation, work, and reduction in anxiety are all significant and we need to do more work on that.

We need to start thinking about some of the environments that we are most embedded in. In the US, we are heavily embedded in the school system. In that case, how do we implement these types of interventions effectively for school based outcomes? Those outcomes can have a substantial impact on educational, social, motor and learning abilities. We have to start looking at what that intervention looks like within that context. We need to move away from taking a child out of a classroom for one hour a week to make a change within that environment. I would like to see a real focus on our theoretical principles and the basis for our interventions and pairing that with a child’s environment.

Therefore, delving further into the person environment fit. We need to consider how we can adapt the environment and how to implement the principles of ASI within the school system or work environment in order to support an individual in that area of function, participation and occupation. This is where we need to go with our research because this is what is meaningful to people and their families. Ultimately, we need to be able to demonstrate the meaningful impact of our interventions.

SN: You have a unique interest in the sensory environment and you developed an assessment tool around this - The Participation and Sensory Environment Questionnaire (P-SEQ) – Tell us about why this is important for us to consider.

BP: This is linked to how we can implement the intervention within the environment. We need to think about what environmental features can be adapted or used. In the school system, I constantly think about how all of the children can benefit from sensory integration intervention – so let’s consider universal design within this environment. Implementing cognitive sensory based strategies into the whole classroom would be another method. In order to get to that point, we need to educate and provide resources to those who work and support individuals within those environments. 

This is a step we need to take as therapists. We need to be advocates and educators for teaching staff, our colleagues in other disciplines and parents/caregivers. As therapists, we need to be thinking about the combination of consultancy regarding educational resources, the components of the environment and how to implement the intervention within the environment.

SN: Tell us about the Participation and Sensory Environment Questionnaire (P-SEQ) assessment tool itself. 

BP: I really wanted a tool that looked at functional areas that you could connect your intervention to. There are areas within the tool that cover everyday life as well as environmental components. In addition to this we need to connect the sensory to these everyday life activities so that you can show the impact. The foundation of the tool is built on the person environment occupation fit. When we were doing our randomised control trial instead of RCT, it was found that we needed better measures to be able to guide treatment. We often don’t use a tool that is specific or sensitive enough to detect our outcomes.

This may result in not seeing a change. There are so many areas that sensory can impact a person’s life and it is about tapping into that. You could have a profound impact on one area with your intervention that is substantial for that person’s life but depending on the tool you are using, this might not be detected. It might not be sensitive enough to pick up that very substantive change in that person’s life. We know the goal attainment scale works really well because it is specific and targeted and thus is able to determine outcomes. I can’t say whether the sensory environment participation scale is an outcome measure yet as it hasn’t been used enough to be established.

SN: Your research on caregivers perspectives on the sensory environment and participation in daily activities in children with ASD provided a useful insight. Do you feel we have enough parental perspective within the SI field – Do you feel we need to hear more from parents?

BP: That study was done so that we would have a foundation from parents about what activities are meaningful so that we could include them in the Participation and Sensory Environment Questionnaire. The caregiver perspective is important and there are a lot of different ways to look at that. Because I work with adults also, I always think it might be interesting to explore sensory processing and temperament with the child and with the adult to see how that impacts outcomes and participation. However, that is a very complex question and I am unsure how you would get at it. I see some parents and children who have a really good sensory match and some where both have sensory processing issues and it is a real challenge. This is an area I have always found interesting, but it is difficult to measure.

I think participation is an area that is hard to conceptualise at times and is difficult to measure. From the caregivers perspective it is important to think about what stops participation, what influences it, their perspective on a child with sensory processing difficulties and how that impacts their life.

The idea of parent effort in relation to participation is an interesting concept to consider. We all know that when you have young children, there is a lot of work and effort required from the parent. The intensity of this changes over time as the child grows, develops and becomes more independent. When you have a child with substantial sensory differences this amount of parent effort is increased. We devised the Parent Effort Scale which covers the same areas of participation as the Participation and Sensory Environment Questionnaire but it focuses on how much work and effort caregivers have to put into helping their child participate in these activities. The idea of how hard a parent is willing to work and the relationship between how meaningful the occupation for that family is, is an area that would be interesting to learn more about.

SN: In clinical practice we often hear about the relationship between sensory modulation difficulties and anxiety – as your research stated is “it the chicken or the egg”? What is our understanding about this now?

BP: I don’t think we fully know yet. However, I do think there is a really close relationship there. We are still exploring whether this is because anxiety heightens your senses or whether people are experiencing substantial higher levels of anxiety because they are so hypersensitive. In addition to this, individuals with ASD have a higher prevalence rate of anxiety disorders associated with the condition. The way in which Lucy Jane Miller and Sarah Schoen within the Star Institute conceptualised ADHD could be a way that we could approach this issue. They really looked at what ADHD is, what sensory processing is and then what are both. They found there was a group of children that fit into all three of these areas. I think this will happen with anxiety, sensory hypersensitivity and ASD for example.

Ultimately, I think there is probably the existence of three different groups, and I don’t know what the prevalence of each group is. I suspect that there is a small percentage that stems from sensory hypersensitivity as an anxiety. There is probably a larger percentage that have anxiety disorders and because of the anxiety neurochemistry in the brain, it results in sensory hypersensitivity. ASD is a whole other area. The next question is how would we measure or determine this? I am not sure that we know that yet. There are some other researchers further along in this. Research has been continuing in this area in Israel in particular so I would recommend keeping abreast of this updated research.

SN: Where do you feel ASI is headed in this new age since COVID19 and how can we adapt our practice?

BP: A lot of intervention is happening through telehealth right now and we are prioritising the face to face treatment for areas of practice which have to occur in that manner. I have been mentored by a few of the individuals who worked directly with Dr. Jean Ayres and they always told me that she anticipated that this would be an intervention and theory base that would evolve. The situation with COVID-19 now provides us with an opportunity to evolve. We need to figure out how we can implement this intervention into different environments and I think this is an ample opportunity for us to take the time to figure that out. We have individuals who have significant sensory processing disorders and so we need to respond to this.

I use a range of interventions all of which are multifaceted and so I believe that we need to think about how we can enhance the sensory input an individual needs within their natural environments. We then need to educate the people supporting those individuals. One of the positive changes that has come out of all of this is that we have started to think outside the box and be creative. Contextually based interventions are really important. When we take the child out of their environment and put them into the clinic only, I don’t think we are going to have as much of an impact as when we are considering their everyday environments. There has been so much hardship that has come out of COVID-19 for people, and so I can only hope that this very difficult situation propels us forward in some way.

SN: You received the Jean Ayres Award in 2017. It is her 100th birthday this year and her legacy continues to live on. What are your hopes for the practice and research of SI?

BP: Everything I have heard about Dr. Jean Ayres is that she gave us a really strong foundation. She wanted us to grow and develop this area of practice. I hope we continue evolving together, meaning that we all are contributing, acknowledging and understanding the process. There is so much value in bringing people and information together and moving the profession forward. It is pivotal for us to do this so that we are unified in our commitment to building evidence and building upon the work Dr. Ayres has done.

We don’t want to be stagnant and in her legacy she would want to see it evolve from the foundations she set up. I would like to see that happen and honour her in that way. She was very committed to science, evidence and research which was unusual for her time. That was extremely unique as evidence based practice was not discussed at this time. We didn’t have a strong research foundation back then and she had the foresight that a lot of people didn’t.

This leads us on to think about how we gather our evidence for the future. Not all evidence has to come from those of us in academia. People in practice can start building in structures to demonstrate evidence for their practice. This includes using tools such as goal attainment scaling. I use this with all my clients because I can show meaningful outcomes and that people are making outcomes. I think an important commitment that therapists need to make, is to determine how they are measuring outcomes and making them meaningful. It is important for therapists to make a commitment to understand enough about measurement and also to acknowledge when something doesn’t work. We need to know what is working and what is not because we don’t want to hold onto the things that are not working.

SN: What are your next research pursuits?

BP: We are working on the scoring procedures for the Participation and Sensory Environment Questionnaire (PSEQ) and Parent Effort Scale (PES) assessment tools. I have been doing a lot of work on important occupations for transition aged youth. I also spend a lot of time focusing on the person environment fit within important life activities. 

We wish to extend our gratitude to Dr. Beth Pfeiffer for taking the time to speak with us and share her expertise.