Evidence-Based Occupational Therapy Interventions for
Children with Autism: Current Practices and Continuing
Education in Minnesota
Bryden Giving, OTS
Fall 2018
Background Learning
Increasing
Prevalence of
Children with
Autism
Spectrum
Disorder
EvidenceBased Practice
Process
Complementary
and Alternative
Medicine
(CAM)
2
Increasing Prevalence of Autism Spectrum
Disorder (ASD) and Linked Cost
▰ Autism Spectrum Disorder (ASD) is a neurologic disorder with
rapid increases in prevalence in the last twenty years (American Psychiatric
Association, 2013; Ashburner et al., 2014; Center for Disease Control, 2016; Lang et al., 2012; Miller-Kuhaneck, 2015)
▰ Increased research is being conducted related to interventions to
support children with ASD due to high costs associated with the
diagnosis (Wong et al., 2014)
Range of cost in 2011 in medical costs for treating
children with ASD in the US
(Centers for Disease Control and Prevention, 2016):
$12 Billion - $60 Billion
3
Evidence-Based Practice Process
•
Evidence-based practice is the implementation of:
o clinical and professional expertise
o the patient’s unique circumstances and values
o best research evidence into practice (Law & MacDermind, 2014; Straus, Richardson, Glasziou, & Haynes,
2005; Wong et al., 2014)
•
Fostering and utilizing evidence-based practices is a precedent within
occupational therapy practice (American Occupational Therapy Association, 2017; Gillen et al., 2017)
•
Implementing evidence-based practice has been a challenge for
occupational therapists working with children with ASD (Ashburner et al., 2014)
4
Complementary and Alternative Medicine
(CAM)
▰ CAM refers to a group of health-care interventions
that are not a part of conventional medicine (Hofer, Hoffman, &
Bachman, 2017; Kurtz, 2008)
▰ The twelve focused interventions are all considered a
form of CAM
The cost consumers spent in out-of-pocket
expenses on CAM therapies:
$33.9 Billion
5
The Twelve Focused Interventions: My
Cohort’s Work
Listening
Therapies
Auditory
Integration
Training
The Listening
Program
Therapeutic
Listening
Movement
Therapies
Brain Gym
Interactive
Metronome
Makoto Therapy
Reflex
Integration
Therapies
Masgutova
Method
Reflex Integration
Training
Rhythmic
Movement
Training
Sensory /
Manipulative
Therapies
Wilbarger Protocol
Therasuit
Craniosacral
Therapy
6
Practice Dilemma
•
There are significant concerns related to the evidence and safety of the interventions
identified, which are used across Minnesota (MAOT Students at St. Catherine University & Bass, 2016)
The use of these interventions pose ethical and practical implications:
1. Any interventions provided occupational therapists should be addressing a child’s
occupations and supported by evidence
2. Reduction in coverage of therapy services insurances or other payer sources
3. Expert review groups have cited many of these interventions as unsupported by
evidence (MAOT Students at St. Catherine University & Bass, 2016)
7
Three Phases of Data Collection
Website
Content
Analysis
Survey
Focus
Groups
8
Website Content Analysis
▰ A website content analysis was completed to see how
many settings in Minnesota endorsed the 12 specified
interventions
▰ Any setting that provided pediatric occupational
therapy services in Minnesota was included
▰ A total of 49 settings were included within the
analysis
9
Website Content Analysis - Results
▰ Of the 49 settings, 12 were “systems” and 37
were “sites”
▰ The specified interventions were more
endorsed on the websites of “sites”
▰ The most endorsed intervention was
Therapeutic Listening
10
Website Content Analysis - Results
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Listening
Movement
Site
System
Twin Cities
Reflex
Sensory/Manipulative
Outside Twin Cities
Figure 1. Percentage of Settings Endorsing at Least One Intervention
11
Survey
▰ The survey consisted of demographic questions
as well as questions pertaining to the
interventions
▻ Ex. How many years in practice?
▻ Ex. Have you used Therapeutic Listening to
treat a child with ASD?
▰ 197 invitations were sent out and 105
participants answered at least one item for an
estimated response rate of 53%
12
Survey – Demographic Results
▰ All respondents but two were occupational
therapists
▰ Over one-half (51%) of survey respondents’
primary setting were in schools
▻ Other frequent responses for primary
practice setting include: 17% in inpatient and
22% in outpatient care
13
Survey – Percentage of Intervention Time
▰ Clinicians were asked to provide information on the
percentage of time they used each of the twelve
interventions when treating a child with ASD
▰ “Less than 25% of the time” was the most frequent
response
▰ As the percentage of time of an intervention session
went up, the percentage of respondents went down
except for MNRI and Reflex Integration Training
14
Survey – Reasons for Pursuing Training
Auditory Integration Training
Therapeutic Listening
The Listening Program
Brain Gym
Interactive Metronome
Makoto Therapy
Masgutova Method
Reflex Integration
Rhythmic Movement Training
Wilbarger
Therasuit
Craniosacral Therapy
0
5
10
15
20
25
30
35
A caregiver of a client mentioned it
A colleague was trained in it
My site requires / endorses the intervention
I read about it in a journal or other scholarly work
I heard about it through mailing to my workplace or home
I saw it on the AOTA approved provider list
Social media groups
Other
40
45
15
Survey – Analysis of the Specified
Interventions
▰ For all 12 interventions, more clinicians reported seeing
the intervention with children with ASD than those
reported being trained in them
▰ For six of the twelve interventions, more clinicians
reported using the intervention with children with ASD
than those who reported being trained in that intervention
▰ Significant chi-square analyses
16
Focus Group
▰ Ten participants
▰ Each participant was a registered occupational
therapist
▰ Two focus group sessions with five participants
▰ The sessions were audio-recorded and
transcribed and coded into themes
17
Focus Group – Main Themes
Knowledge and Use of
Evidence-Based
Practice
Current Practices with
the Specified
Interventions in
Minnesota
Continuing Education
Needs and Future
Direction of Pediatric
Occupational Therapy
18
Knowledge and Use of Evidence-Based
Practice
▰
Though participants mentioned utilizing research within
their definition of evidence-based practice, they reported a
reliance on clinical experience over research evidence
▰
Participants reported multiple barriers to being evidencebased
▻
▻
▻
Lack of access to research
Time
Affordability
19
Knowledge and Use of Evidence-Based Practice Selected Quotes
“It depends on what you call ‘evidence-based practice.’…
peer-review journals is what of course the insurance
companies are looking for and what doctors are looking
for… and we just don't have access to that…so some of
the...things that we do are a little bit anecdotal… it goes
away from the scientific model.”
“I always chose the cheapest
easiest things, which weren't
always related to what I needed to
know as an OT working in the
schools.”
“What does surprise me a little
bit is that… a lot of these
interventions like websites or
like research…will tell you...
differently”
“…in terms of Brain Gym…our
district paid for all the OTs in our
district to be trained in it”
20
Current Practices with the Specified
Interventions in Minnesota
▰
Practitioners are using the interventions more as
preparatory methods and education and training for
families than as occupations and activities
▰
Many participants acknowledged that a variety of
interventions are not being used with fidelity in practice
▰
Participants also noted the difference in quality of
occupational therapy throughout Minnesota
▰
Participants stated that many of these interventions are not
used in schools
21
Current Practices with the Specified Interventions
in Minnesota - Selected Quotes
“I think advocacy is a big thing as I start to build my practice
into more alternative types of things like Craniosacral,
Reflex Integration, and things like that … so I've been ...
needing to do … advocacy to my boss on how … this would
be beneficial and to my coworkers and parents…”
“I would say it's probably not being used (Brain Gym) to
fidelity or the way that it should or was designed to be
used…people are picking and choosing...what would work for
them...in the school setting.”
“…there’s also situations that I’ve seen of
students that have private therapies that…you
know…everybody that goes to this particular
place gets brushing (Wilbarger Protocol), or
everybody is gonna do the Listening
Program.”
“These aren’t programs
that my school district
would send me to
trainings on or…not
allow.”
22
Continuing Education Needs and Future Direction
of Pediatric Occupational Therapy
“
…I would like to see…whether it be MOTA or… St.
Kate's … at least provide some...leadership to...in
the field...in areas that we should
be…knowledgeable about and I don't know what
those areas are because I don't...that's not really my
area of expertise. I just work with kids in a school,
and I'm…I have a lot of other things going on in my
life…I'm not sure that…I don't want it to be my job
to stay on the forefront.”
23
Continuing Education Needs and Future
Direction of Pediatric Occupational Therapy
▰
Due to barriers and access to trainings, participants
stated a reliance on private companies
▰
Having newer practitioners is helpful to being more
evidence-based
▰
Participants mentioned there needs to be more
training concerning being evidence-based
▰
Participants mentioned that there are opportunities
within their work settings to help them be evidencebased
24
Continuing Education Needs and Future Direction of
Pediatric Occupational Therapy - Selected Quotes
“…the people who were formally trained in
specific interventions...no matter what you brought
up that was their truth because they went to that
class. They provided them the evidence they
needed to…get their buy-in. Working with...
more…newer graduates…they have no problem
saying ‘well why would you do that?’ which I
like”
“There isn't the research to say,
‘you should really get trained in
something’ or in this specific
thing and ‘it will pay off’…it's
just not there”
“…I think….probably getting
some good research on our
methods so that we can get
some funding for studying
these things”
25
Analysis – Main Themes
General
Prevalence and
Use of the
Specified
Interventions
Practitioner’s
Awareness of
Evidence-Based
Practice
Utilizing the
Specified
Interventions with
Fidelity
Why Practitioners
Pursued Training
in a Specified
Intervention
What Practitioners
Would Find
Helpful as
Continuing
Education and
Resources
26
General Prevalence and Use of Specified
Interventions
▰ This study supports the notion that the twelve specified interventions are
being used extensively within pediatric occupational therapy practice in
Minnesota
▰ Therapeutic Listening and Wilbarger were two of the most prevalent in
the web-content analyses, survey, and focus group data
▰ Differences were noted between school-based and clinic-based therapists
27
General Prevalence and Use of Specified
Interventions
▰ More experienced clinicians were more likely to use these
interventions when treating a child with ASD
▰ Many clinicians are utilizing these interventions with children
with ASD without training
▰ Some interventions are being used for large percentages of
the intervention session.
▰ Many of these are being used a preparatory methods and
for education and training, not many are being used as
occupations and activities
28
Practitioners’ Awareness of Evidence-Based
Practice
▰ Practitioners reported more reliance on clinical experience and
colleague advice than research, which is congruent with past
research (Ashburner et al., 2014; Dubouloz, Egan, Vallerand, & von Zweck, 1999)
▰ Participants mentioned they read about these interventions in journals
but often these interventions are not found in peer-reviewed journals
(MAOT Students at St. Catherine University & Bass, 2016)
▰ There were more opportunities to have professional learning
communities to help be evidence-based in some settings more so than
others
▰ Having recent graduates helps to be more evidence-based and challenge
ideas
29
Why Practitioners Pursued Training in a
Specified Intervention
▰ The most frequent reasons for pursuing
training in a specified intervention were due
to knowing a colleague was trained it and
their setting requiring training or endorsing
training in the intervention method
▰ Occupational therapy graduate programs have
“It’s been requested by
parents (Wilbarger
Protocol) from…based on
private clinic
recommendations”
promoted training in these interventions
▰ Parents have requested these interventions
30
Utilizing the Specified Interventions with Fidelity
▰ The interventions are not being used in a consistent
manner or the way they were created to be used
(without fidelity)
▰ Practitioners are attempting to utilize them to address a
functional goal for an extended amount of time while
other practitioners are utilizing them for a shorter
duration of time
31
What Practitioners Would Find Helpful as
Continuing Education and Resources
▰ Practitioners stated they have a lack of
access to research and journals, much of it
due to affordability and time
▰ Some participants stated that there no
interventions for children with ASD that are
evidence-based, which is not true
▰ Continuing education concerning CAMs is also
needed
▰ All participants agreed more research is vital
“…I would love to see more
of a push toward…the
acceptance of and knowledge
about alternative types of
interventions”
32
Implications for Practice and
Recommendations for Practitioners
▰ Ethics
▰ Creating a culture where practitioners
prioritize evidence-based practice
▰ Could PEOP and the occupation
outcomes of an intervention be a
strategy for therapists to use to evaluate
the benefits of an intervention?
33
Implications for Practice and Recommendations
for Professional Associations
▰ MOTA and Minnesota OT Licensure Board
▻ Should ethics be a required area of
professional development?
▰ AOTA
▻ How does AOTA promote interventions that
are occupation based as approved providers
and continuing education?
34
Limitations
▰ We did not ask focus group participants how many years in
occupational therapy practice and pediatric specific experience
they have.
▰ Most of our focus group participants primarily worked in schoolbased settings, and over half of our survey respondents were
school-based therapists.
▰ The survey did not reach many occupational therapy assistants
(OTA) and no OTAs participated in the focus group.
35
Final Words
▰ Occupational therapy practitioners should reflect on their willingness to perform as
change agents in making evidence-based methods a priority within occupational
therapy practice, and how well their treatment methods are addressing the
occupational participation of children with ASD
▰ Occupational therapists need to make our distinct value with kids with ASD to
consumers, other professionals, policy makers and payers
“…we need to continue to make
sure that people know that OT
has a lot to contribute to kids
with ASD”
"Being willing to like try new things or hear new
things or question what you're already doing ... you
might still do it but just really questioning it each
time and not just kinda following blindly what's
always been done and being willing to change I
think is important. It's hard sometimes but
important"
36
Quick Conversation On:
Evidence Based
Practice
Practice –
Based
Evidence
37
A Few Comments on Evidence-Based
Practice and Practice-Based Evidence
▰ Reviewing formal definitions is helpful in
understanding what
EBP and PBE is/isn’t and dispelling
myths.
▰ EBP and PBE are complementary, not
mutually exclusive.
▰ EBP and PBE have distinct and
overlapping roles in demonstrating
targeted outcomes from interventions
used in occupational therapy practice.
http://www.onlinejacc.org/content/66/11/1234
38
Evidence-Based Practice
Best
Research
Evidence
Professional
And Clinical
Expertise
▰ Integration of best research
evidence with clinical
expertise and patient values
(Sackett, et al., 2000)
Patient / Client
Unique
Values and
Circumstances
39
What are Evidence-Based Interventions?
▰
Practices or programs that have peer-reviewed, documented
empirical evidence of effectiveness and the greatest potential to
achieve targeted outcomes (SAMHSA, 2018)
▰
Are summarized in:
▻
▻
national registries of evidence-based practice interventions OR
▻
sufficient detail that it is clear it meets all the criteria of being 1)
theory driven,
2) similar to interventions in registries or peer-reviewed journals, 3)
documented for a consistent pattern of effectiveness related to
targeted outcomes using scientific standards, 4) approved by a
panel of experts (SAMHSA, 2018)
peer-reviewed journals and demonstrate effectiveness in targeted
outcomes OR
40
What is Practice-Based Evidence?
▰
▰
Definition and processes of PBE are still in
development (IOM, 2007)
Entails
▻
▻
▻
Selecting and applying evidence-based
interventions for practice
Systematically collecting data of
effectiveness related to targeted
outcomes in practice setting and with
practice population
▰
Knowledge generation that is embedded into the core
of practice … leads to continual improvement in
care… focuses on narrowing the research-practice
divide and increasing generalizability…
Systematic collection of data that supports
effectiveness studies…
data are collected along with implementation of
evidence-based interventions (IOM, 2007)
Making data-driven decisions regarding
evidence-based interventions most
effective (IOM, 2007)
41
Other Characteristics of Practice – Based
Evidence
▰ Is complementary with EBP and focuses on demonstrating
effectiveness related to targeted outcomes in practice (IOM, 2007;
Kovacs, 2015)
▰ Supports a ‘learning organization’ culture that emphasizes
knowledge development and implementation (Kovacs, 2015)
▰ Helps to evaluate the effectiveness of evidence-based
interventions in practice, especially when working with
populations that were not studied in primary research (Ammerman, Smith,
& Calancie, 2014; IOM, 2007; Kovacs, 2015; National Professional Development Center on Autism Spectrum Disorders, 2011; SAMHSA, 2018)
▰ Uses systematic collection of organization’s data to examine
effectiveness of selected evidence-based interventions (Ammerman,
Smith, & Calancie, 2014; IOM, 2007; Kovacs, 2015; National Professional Development Center on Autism Spectrum Disorders, 2011; SAMHSA, 2018)
42
Thank
you!
Any questions?Please contact
Bryden Giving at
bgiving@stkate.edu for more
information!
43
References
American Occupational Therapy Association (AOTA). (2005). Complementary and Alternative Medicine (CAM) position paper. American Journal of Occupational
Therapy,59(6), 653-655. doi:10.5014/ajot.59.6.653
American Occupational Therapy Association (AOTA). (2017). Evidence-based practice & research. Retrieved from https://www.aota.org/Practice/Researchers.aspx
American Occupational Therapy Association (AOTA). (2018). About AOTA. Retrieved April 08, 2018, from https://www.aota.org/AboutAOTA.aspx
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Ammerman, A., Smith, T. W., & Calancie, L. (2014). Practice-based evidence in public health: improving reach, relevance, and results. Annual review of public health, 35,
47-63.
Ashburner, J., Rodger, S., Ziviani, J., & Jones, J. (2014). Occupational therapy services for people with autism spectrum disorders: Current state of play, use of evidence
and future learning priorities. Australian Occupational Therapy Journal, 61(2), 110–120. https://doi.org/10.1111/1440-1630.12083
Black L.I., Clarke T.C., Barnes P.M., Stussman, B.J., & Nahin, R.L. (2015) Use of complementary health approaches among children aged 4–17 years in the United States:
national Health Interview Survey, 2007–2012. National Health Statistics Reports 78: 1–19. Retrieved from https://www.cdc.gov/nchs/data/nhsr/nhsr078.pdf.
Centers for Disease Control and Prevention. (2016). Autism spectrum disorder. Retrieved from http://www.cdc.gov/ncbddd/autism/data.html#references
Clarke T.C., Black L.I., Stussman B.J., Barnes, P.M., & Nahin, R.L. (2015) Trends in the use of complementary health approaches among adults: United States, 2002–2012.
National Health Statistics Reports 79: 1–16. Retrieved from https://www.cdc.gov/nchs/data/nhsr/nhsr079.pdf.
Dubouloz, C.-J., Egan, M., Vallerand, J., & von Zweck, C. (1999). Occupational therapists’ perceptions of evidence- based practice. American Journal of Occupational
Therapy, 53, 445–453. https://doi.org/10.5014/ajot.53.5.445
Ericsson, K. A. (2004). Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains. Academic
Medicine,79(Supplement). doi:10.1097/00001888-200410001-00022
Gillen, G., Lieberman, D., Stutzbach, M., & Arbesman, M. (2017). Five interventions/assessments our clients should question. OT Practice, 22(15), 19-20. Retrieved from
https://www.aota.org/~/media/Corporate/Files/Secure/Publications/OTP/2017/OTP-Volume-22-Issue-15-bridge-obstacles.pdf
Hofer, J., Hoffman, F., & Bachmann, C. (2017). Use of complementary and alternative medicine in children and adolescents with autism spectrum disorder: A systematic
review. Autism,21(4), 387-402. Retrieved from https://doi-org.pearl.stkate.edu/10.1177/1362361316646559
Institute of Medicine (IOM). 2007. The Learning Healthcare System:Workshop Summary. Washington, DC: The National Academies Press.
44
References
Kovacs, R. J. (2015). Using practice-based evidence to reduce disparities in care: a virtuous cycle turns. Journal of the American College of Cardiology, 66 (11), DOI:
10.1016/j.jacc.2015.07.046. Retrieved from http://www.onlinejacc.org/content/66/11/1234
Kurtz, L. A. (2008). Understanding controversial therapies for children with autism, attention deficit disorder, and other learning disabilities: a guide to complementary and alternative
medicine. London: Jessica Kingsley.
Lang, R., O’ Reilly, M., Healy, O., Rispoli, M., Lydon, H., Streusand, W., …Giesbers, S. (2012). Sensory integration therapy for autism spectrum disorders: A systematic review.
Research in Autism Spectrum Disorders, 6, 1004-1018. https://dx.doi.org/10.1016/j.rasd.2012.01.006
Law, M., & MacDermind, J. (2014). Introduction to evidence-based practice. In M., Law & J. C., MacDermind (Eds.), Evidence-Based Rehabilitation: A Guide to Practice (3rd ed., pp.
1-14). Thorofare, NJ: SLACK.
MAOT Students at St. Catherine University & Bass, J. (2016). MOTA Peds SIG: EBP Pediatric Interventions. Unpublished Manuscript, Department of Occupational Therapy, St.
Catherine University, Saint Paul, Minnesota.
McCluskey, A. (2003). Occupational therapists report a low level of knowledge, skill and involvement in evidence-based practice. Australian Occupational Therapy Journal,50(1), 3-12.
doi:10.1046/j.1440-1630.2003.00303.x
Miller-Kuhaneck, H. (2015). Autism Spectrum Disorder. In J. Case-Smith & J.C. O’Brien (Eds.), Occupational Therapy for Children and Adolescents (pg. 766-792). St. Louis,
Missouri: Elsevier.
Nahin R.L., Barnes P.M., Stussman B.J., & Bloom, B. (2017). The use of complementary and alternative medicine in the united states: cost data. Retrieved January 28, 2018, from
https://nccih.nih.gov/news/camstats/costs/costdatafs.htm
National Professional Development Center on Autism Spectrum Disorders (2011). Evidence-Based Practices in Autism Spectrum Disorders. University of California Television.
http://autismpdc.fpg.unc.edu/ Retrieved from https://www.youtube.com/watch?v=rNlL12Ef8to
Nickel, R. E. (1996). Controversial Therapies for Young Children with Developmental Disabilities. Infants & Young Children, 8(4), 29-40. doi:10.1097/00001163-199604000-00005
SAMHSA. (2018). Defining “Evidence-based”. Retrieved from https://www.samhsa.gov/capt/applying-strategic-prevention-framework/step3-plan/defining-evidence-based
Straus, S. E., Richardson, W. S., Glasziou, P., & Haynes, R. B. (2005). How to practice and teach EBM. Evidence-Based Medicine. Third edition. Elservier, 13-29.
doi:10.1177/1049731506296167
Thomas, A., & Law, M. (2013). Research utilization and evidence-based practice in occupational therapy: a scoping study. American Journal of Occupational Therapy,67(4).
doi:10.5014/ajot.2013.006395
Vital Links. (2016). Therapeutic Listening. Retrieved from https://vitallinks.com/therapeutic- listening.
Watling, R., & Hauer, S. (2015). Effectiveness of Ayres Sensory Integration® and sensory-based interventions for people with autism spectrum disorder: a systematic review. American
Journal of Occupational Therapy,69(5). doi:10.5014/ajot.2015.018051
Wong, C., Odom, S. L., Hume, K. Cox, A. W., Fettig, A., Kucharczyk, S., ... Schultz, T. R. (2014). Evidence-based practices for children, youth, and young adults with Autism Spectrum
Disorder. Retrieved from http://autismpdc.fpg.unc.edu/sites/autismpdc.fpg.unc.edu/files/2014-EBP-Report.pdf.
45