Monday, April 09, 2007

Update of therapeutic listening

As promised, I wanted to review some of the articles in the current (March/April 2007) issue of the American Journal of Occupational Therapy. Since I have gotten some emails and blog comments asking me about the Hall & Case-Smith study (see reference below) I thought that this would be a good article to begin discussing.

I was excited to see a study on this intervention technique because I have been hesitant in the past to fully embrace 'therapeutic listening.' In my opinion there is not adequate evidence to support promoting this technique so I was interested to see if this new study would change my mind.

I believe that the authors should be commended for initiating this inquiry, but I also believe that their conclusions are far overstated. There are several fundamental flaws in their design that are concerning.

To begin with, they used a convenience sample. This might have been appropriate if the study was truly exploratory, but there have been several other studies already completed on this topic. Convenience sampling limits our ability to state that the subject pool is truly representative of the entire population.

Sampling size is also an issue - it was based on expected effects for the Sensory Profile but the authors don't discuss the sample size that would be needed for the other tests used. This information is needed in order to determine if the sample size is adequate to draw conclusions about visual motor or handwriting skills.

Finally, their study population was very heterogenous - so even if there were effects within this group it is difficult to know what was causing any of the effects based on the sampling methods used. In sum there are many problems with the sampling procedures reported that severely limit the study.

Another problem is that the measurement methodology relies strongly on parental report. This is also a confounding factor because you are asking the parents if there are changes in behavior, but the parents have invested heavily in the intervention program - and in fact they may be expecting changes based on whatever communication occured in the process of educating them about the 'sensory diet.' It would have been much more useful to have the teachers fill out the Sensory Profile (school version) because they are completely separate from the intervention and could give an opinion that has much less opportunity for bias.

Another problem with measurement is that some of the evaluation tools were administered three times within the three month study period - opening the question of practice effect of these particular tests.

It is also unclear how many of these children were participating in other therapy programs and what the nature of those programs was. The presence or absence of other parallel intervention programs is a significant confounding factor.

All of these factors could be partially acceptable if the study was truly exploratory and if the conclusions were stated more modestly. Instead, this is just another in a long line of studies with significant limitations. What makes it particularly difficult to accept is that the authors conclude that "The present study produced encouraging findings to support the use of therapeutic listening as part of an overall sensory-integrative approach to occupational therapy in elementary school-age children" (p. 215). I don't think that the study accomplished this at all. Rather, I believe that the study is very limited, they relied primarily on the potentially biased self-report of parents that participated in the program, the conclusions overstate the results, and there is very little real conversation about the severity of the problems in sampling and measurement methods.

So for me the jury remains 'out' on therapeutic listening. I don't see any reason to encourage parents to invest heavily in these programs at this time. If anyone wants to rebut my conclusions I will happily post their comments, in full, on this blog.


Hall, J. & Case-Smith, J. (2007) The effect of sound-based intervention on children with sensory processing disorders and visual motor delays. American Journal of Occupational Therapy, 61, 209-215.

Thursday, April 05, 2007

Tying some loose ends

About a year ago I posted about the use of passive tactile sensory stimulation and the lack of evidence that we have about the technique. You can find more discussion on this topic by typing in "Wilbarger" as a search term in this blog or by going to this link.

In any event, I wanted to update a statement that I made last year that reads: While surfing around tonight I think I found a potential source of very useful information - and I think we might be able to thank Ruth Segal..." Dr. Segal did publish her article "Integration and application of a home treatment program: A study of parents and occupational therapists" (Segal & Beyer, 2006). This is an excellent article for all pediatric therapists to read. It reviews in detail the perspective of parents regarding home programs and the disconnect that sometimes occurs between the therapist's thinking and reality of normal family lifestyle. This article isn't directly assessing the effectiveness of a 'brushing program' but it does look at the issues of 'prescribing' a program that is potentially intrusive to a family's normal occupational routines.

Dr. Segal makes some critical observations including "Although therapists should continue to educate parents about this intervention, it is important that they keep in mind that parents' lives may not revolve around occupational therapy and the child who needs this particular intervention." The question then is: How ethical is it to prescribe some type of intervention program that is fundamentally disconnected and in fact is disruptive to the normal flow of activity within a home? One could argue that chemotherapy and radiation interventions for cancer are maximally disruptive to normal living - but then again the MDs who prescribe these interventions don't claim to care about lifestyle and occupational performance issues directly. As lifestyle and occupational performance are the bailiwick of the occupational therapy profession do we need to be more responsive to these concerns?

On a related note, the March/April 2007 issue of AJOT is chock full of good material that also needs to be discussed as it relates to evidence and sensory integration/processing - so please find your recent AJOT and read it - a few upcoming entries will be directly related to that content.


Segal, R., & Beyer, C. (2006). Integration and application of a home treatment program: a study of parents and occupational therapists. American Journal of Occupational Therapy, 60, 500-510.