This single case study investigated one family's experiences of using sensory integration strategies at home. Four key themes were identified following analysis of data from semi-structured interviews. Results illustrate that occupational therapists have an important role to play assisting children and, educating and reassuring family. The findings suggest that when providing family-centred services in the community, the goal is to empower parents to take control of their child's therapy. Occupational therapists can offer valuable education on sensory strategies that enable a child to carry out everyday occupations within the family context. Recommendations include the need for flexible services to accommodate varying family needs.
Qualitative research, case study, occupational therapy, sensory integration, family-centred practice
Occupational therapists have been involved in sensory integration since it was introduced by Dr. A. Jean Ayres in 1972. Ayres viewed sensory integration as a complete process from registering and organising sensory information in the brain, to engagement in meaningful and purposeful daily occupations (Ayres, 1972). In the early 1980s, researchers began questioning the positive outcomes of Ayres' research (Arendt, MacLean, & Baumeister, 1988; Hoehn & Baumeister, 1994: Polatajko, Kaplan, & Wilson, 1992; Schaffer, 1984). Despite the large number of studies, no definitive conclusions were made about the efficacy of a sensory integration approach. Spitzer, Smith Roley, Clark, and Parham (1996) acknowledged that although recent studies had been less supportive, they did not disagree that there was still a need for sensory integration intervention. Spitzer et al. (1996) noted that therapists and families reported positive outcomes of intervention that were not evident in the results of efficacy studies. Spitzer et al. suggested that by examining sensory integration using a rigid quantitative approach, the individual variation required to increase the motivation of each child was lost. Further research using descriptive single case studies and naturalistic inquiries was recommended (Stonefelt & Stein, 1998). Studies since have tended to focus on measuring the effectiveness of sensory integration in relation to functional outcomes and have focused on small sample sizes and case studies (Case-Smith & Bryan, 1999; Cohn, 2001a; Cohn 2001b; Cohn, Dunphy, Pascal, & Miller, 2001; Edelson, Goldberg Edelson, Kerr, & Grandin, 1999; Fertel-Daly, Bedell & Hinojosa, 2001; Frolek Clark & Ward, 1999; Linderman & Stewart, 1999; Vandenberg, 2001).
Over the last 20-30 years, the nature of occupational therapy intervention has changed in response to a global shift towards the provision of family-centred, community-based services. Traditionally, children with a long-term disability received child-focused intervention and health professionals set goals designed to bring about changes in the child separate from the family (Rosenbaum, King, Law, King, & Evans, 1998). This approach changed dramatically in the 1970s when it was recognised that parental involvement could improve the outcomes for the child. Legislation changes in many parts of the world were driven by parental advocacy to support integration and access for children with disabilities. As service providers began to listen to the needs of families, attitudes towards parent participation evolved. International research further investigated the purpose of family-centred services, identifying the strengths and subsequently recommending approaches such as best practice (Bazyk, 1989). Over time occupational therapy theories and models of practice have started to reflect the value of family-centred services. A family-centred service recognises that intervention is a dynamic process that is provided through a partnership between the parents and the professional (King, Law, King, & Rosenbaum, 1998).
In striving to follow best practice guidelines and in response to parental demand for involvement in service provision, paediatric services in New Zealand have also started to move towards a family-centred approach. Whilst there is no specific legislation in New Zealand to direct how services are provided, Government strategies and current Standards of Practice for Occupational Therapists reflect the value of family involvement. One of the key objectives of The New Zealand Disability Strategy (2001) is to "Value families, whanau and people providing ongoing support" (Ministry of Health, 2001, p. 7). In line with this principle the central questions being investigated in this study were:
* How does the family perceive the use of sensory strategies in the home environment, and how does the use of such strategies affect the family as a whole?
* What implications do the family's experiences have on the implementation of community paediatric occupational therapy services?
As a result of the changing demands in practice, the provision of sensory integration intervention has evolved over time (Spitzer et al., 1996). For example, therapists started considering sensory strategies for use in the home and school environments (Cohn, Miller & Tickle-Degnen, 2000). Recent literature on best practice recognises that therapists may be required to act more as educators to families, than as 'therapists' (Campbell, 1997). Dunn (2000) supported this view, commenting that community-based therapists play an important role in educating family members, teachers and others about the principles of sensory integration theory and the practical sensory strategies that may benefit their child. Chow (2002) proposed that consultative approaches which help parents understand their child's needs may be more beneficial in the long-term.
It is difficult to define what constitutes a sensory integration based approach, as classifications have been inconsistent in the literature and therapists worldwide apply a broad range of sensory based techniques. A common sensory integration approach used by occupational therapists in the community is based on the concept of a sensory diet, introduced by Julia and Patricia Wilbarger. A sensory diet is a planned activity programme designed to meet a child's individual sensory needs throughout the day, enabling them to regulate their attention and therefore consistently engage in daily activities (Nackley, 2001). The diet is commonly used with children who have difficulty with sensory modulation; such as the ability to organise and regulate incoming sensory information (Dunn, 2000). Sensory modulation difficulties generally present as a child who either lacks responsiveness (hyporesponsive) or is sensitive to sensory stimulation (hyperresponsive). Therapy input for children with tactile sensitivities usually focuses on providing calming, deep pressure input and recommending environmental modifications to allow the child to feel safe at home and school/ playcentre (Dunn).
Thompson (1998) recognised that the literature advocated for a family-centred approach to therapy, however few studies questioned families about …