CRITICALLY APPRAISED PAPER (CAP) Dunn, W., Cox, J., Foster, L., Mische-Lawson, L., & Tanquary, J. (2012). Impact of a contextual intervention on child participation and parent competence among children with autism spectrum disorders: A pretest posttest repeated-measures design. American Journal of Occupational Therapy, 66, 520 528. http://dx.doi.org/10.5014/ajot.2012.004119 CLINICAL BOTTOM LINE This study investigated the effectiveness of using coaching principles to foster competence in problem solving for parents of children with autism spectrum disorder. The aim of this study was to understand whether providing contextual interventions regarding the family s daily routine and the child s sensory-processing patterns could lead to improved parent competence and increased child participation. As part of the intervention, the parents identified activity settings where their child performed his or her routines and evaluated how the child s sensoryprocessing patterns influenced his or her ability to perform the routines in those settings. The therapist engaged in 10 sessions with the parents to discuss joint plans for each week, using the coaching methodology to create the plan. The results indicate that contextual intervention was effective in increasing the child s participation. In addition, this intervention improved parental competence by increasing the parents capacity to achieve their family s goals. Parents recognized that when they focused on their child s strengths and interests in activities, they were able to understand what was satisfying to the child to solve his or her problems related to sensory-processing patterns or context. The researchers found that the distress level of these parents decreased from the 85th percentile to the 50th percentile, which gave parents increased efficacy in their ability to identify and solve problems related to their child s ability to participate in his or her routine. This study informs future practice by highlighting the need for families to be efficacious in managing their daily life to decrease stress. Additionally, therapists can gain insight from this study to use the family resources a child has. Coaching techniques used in this way support prioritization of goals to achieve success in an effective manner. This study offers evidence that linking sensory processing to a child s routine and context provides structure for families to understand and apply sensory-processing concepts. Future studies should include a fidelity measure to allow for further understanding of the most important features of the protocol. RESEARCH OBJECTIVES List study objectives. 1
Evaluate an occupational therapy contextual intervention for improving participation in children with autism spectrum disorder and for developing parental competence 1. Do children increase their participation in family activities and routines? (p. 521). 2. Do parents increase their competence and decrease stress in their parenting role (i.e., parental competence)? ( p. 521). DESIGN TYPE AND LEVEL OF EVIDENCE Level III: One-group repeated-measures pretest posttest research design Limitations Was the study design type appropriate for the knowledge level about this topic? Circle yes or no, and if no, explain. YES/NO The design allowed for preliminary data to be obtained on the topic, given that coaching and contextual interventions with families together have not been studied in the past. SAMPLE SELECTION How were participants recruited and selected to participate? Please describe. Participants who met the inclusion criteria were selected on a first-come, first-served basis (convenience sample) from schools and support groups in the midwestern suburban area. Inclusion Criteria Families participating in this study had to demonstrate an unmet need in the family life, and their child had to meet the following criteria: have a diagnosis of autism spectrum disorder, be between the ages of 3 and 10 years, and exhibit at least one atypical sensory-processing pattern when compared with peers. Exclusion Criteria Families with children who exhibited typical sensory-processing patterns were excluded from this study. SAMPLE CHARACTERISTICS N = 20 % Dropouts 0% #/% Male 17/85% #/% Female 3/15% Ethnicity 1 Latino, 17 White, 2 who reported more than one ethnicity 2
Disease/disability diagnosis 12 autism spectrum disorder, 1 Asperger syndrome, 7 autism spectrum disorder and another diagnosis (developmental delay, attentiondeficit/hyperactivity disorder, depression, etc.) 11 participants were diagnosed by a physician, and 9 were diagnosed by a team of professionals. Check appropriate group: <20/study group 20 50/study group 51 100/study group 101 149/study group 150 200/study group INTERVENTION AND CONTROL GROUPS Group 1: Contextual occupational therapy intervention Brief description Setting Who delivered? The authors conducted a contextual occupational therapy intervention, using coaching principles, with parents of children with autism spectrum disorder. The intervention included three characteristics: (1) activity settings (the parent determined the types of activities in the family s routine that were an issue and the context of those activities), (2) daily life routines (the parent and therapist discussed the task itself within the routine), and (3) how the child s sensory-processing patterns influenced his or her ability to perform the task in the given context. In the first session, parents identified goals with the therapist and prioritized those goals for the week with the use of the Canadian Occupational Performance Measure and Goal Attainment Scale. During each visit, the parent discussed how the plan from the previous session worked or the issues that arose during implementation of plan and what new goals or priorities were to be worked on for the subsequent week. Each plan was designed to reflect the sensory information from the child and strategies to incorporate those patterns in his or her routine in a specified context. In accordance with the coaching principle, the therapist used the problem-solving mode to continually probe the parent rather than providing suggestions or asking yes-or-no questions, so that the parent could gain competence in solving everyday issues in the child s life for the future. This study was conducted in a midwestern suburban setting. Multiple settings were involved, including home (bedroom, bathroom, transitions) and communities (church, parking lots, and stores). Sessions were conducted by two occupational therapists who were trained in coaching. Training involved a 4-day workshop and 6 months of followalong, during which they implemented the services using coaching methodology and received feedback from the senior researcher, Winnie Dunn. This extensive training was done before the study was conducted. Frequency? Intervention sessions with the therapist involved ten 1-hr sessions over 12 15 weeks. Duration? Each session was approximately 1 hr, so the time with the family totaled 10 hours in the study. 3
Intervention Biases Circle yes or no and explain, if needed. Contamination: YES/NO This study used one group and one intervention. Cointervention: Timing: Site: YES/NO All children in the study received other services, and the authors stated that these services were not controlled for this study. In addition, the authors stated that half of the participants took supplements or medication along with their other services. YES/NO No control group was used in this study, and intervention (10 intervention sessions over 12 15 weeks) did not take place over a significant period of time for results to have been caused by natural maturation. YES/NO There was no site bias; however, the home environment, where much of the interaction in the child s routine took place, varied significantly for each child, because sensory-processing patterns were considered in the contextual intervention as well. Use of different therapists to provide intervention: YES/NO Researchers completing the intervention were also collecting the research data. Therefore, because they built a relationship with the family, the data could have been skewed to generate positive outcomes. However, therapists were blind to the parent s responses on the stress and competence measures. MEASURES AND OUTCOMES Measure 1 Name/type of measure used Sensory Profile What outcome is measured? This assessment measured the child s sensory-processing patterns to yield four processing scores (seeking, avoiding, sensitivity, registration) and six scores for each sensory stimulation (auditory, visual, proprioception, vestibular, tactile, oral). Is the measure reliable? Comment: Is the measure valid? Comment: Internal consistency, discriminant validity, and construct validity When is the measure used? Initial evaluation session, Week 1 4
Measure 2 Name/type of measure used What outcome is measured? Is the measure reliable? Is the measure valid? When is the measure used? Measure 3 Name/type of measure used What outcome is measured? Is the measure reliable? Is the measure valid? When is the measure used? Canadian Occupational Performance Measure (COPM) The COPM was used to identify self-care, productivity, and leisure issues from the parents to clarify their functional goals as well as an outcome measure. Parents were able to list their child s performance in those tasks and their satisfaction with that performance. Comment: Test retest reliability Comment: Internal consistency During the four testing periods in the study, this assessment was used in the Outcome Measures Battery as follows: Week 1 (initial evaluation meeting), Week 5 (after the authors waited 4 weeks with no intervention for baseline scores), Week 15 (after 10 intervention sessions), and Week 19 20 (4 weeks after the intervention sessions, as a sustainability measure). Goal Attainment Scaling (GAS) This assessment was used to measure the family s progress on their goals in their everyday routine after they had analyzed the steps needed for their child to achieve his or her goals using the measure. Comment: Interrater reliability and test retest reliability Comment: During the four testing periods in the study, this assessment was used in the Outcome Measures Battery as follows: Week 1 (initial evaluation meeting), Week 5 (after the authors waited 4 weeks with no intervention for baseline scores), Week 15 (after 10 intervention sessions), and Week 19 20 (4 weeks after the intervention sessions, as a sustainability measure). Measure 4 Name/type of measure used What outcome is measured? Is the measure reliable? Parenting Stress Index Short Form (PSI SF) This assessment measured the parent s response to life events. Comment:.84.93 5
Is the measure valid? When is the measure used? Measure 5 Name/type of measure used What outcome is measured? Comment: Internal consistency and discriminant validity During the four testing periods in the study, this assessment was used in the Outcome Measures Battery as follows: Week 1 (initial evaluation meeting), Week 5 (after the authors waited 4 weeks with no intervention for baseline scores), Week 15 (after 10 intervention sessions), and Week 19 20 (4 weeks after the intervention sessions, as a sustainability measure). Parenting Sense of Competence Scale (PSOC) This assessment was used to measure parents self-efficacy and satisfaction in their ability to conduct the intervention plan and manage their daily life struggles through problemsolving methods learned in the contextual occupational therapy intervention. Is the measure reliable? Is the measure valid? When is the measure used? Comment: Comment: During the four testing periods in the study, this assessment was used in the Outcome Measures Battery as follows: Week 1 (initial evaluation meeting), Week 5 (after the authors waited 4 weeks with no intervention for baseline scores), Week 15 (after 10 intervention sessions), and Week 19 20 (4 weeks after the intervention sessions, as a sustainability measure). Measurement Biases Were the evaluators blind to treatment status? Circle yes or no, and if no, explain. YES/NO The occupational therapists conducting the intervention were blinded for the results of the PSI SF and PSOC but were not blinded for the GAS and COPM, because these were used for intervention planning. Was there recall or memory bias? Circle yes or no, and if yes, explain. YES/NO All of the assessments used in this study relied on parental self-report. Therefore, there was the potential for significant impact of recall or memory bias. 6
RESULTS List results of outcomes relevant to answering the focused question. Include statistical significance where appropriate (p <.05). Include effect size if reported. Children s Participation The COPM showed statistically significant findings for performance (p <.001) and satisfaction (p <.001). These findings suggest that the parents were able to find successful methods for managing their everyday routines and displayed positive attitudes regarding their child s occupational performance. There was also a significant linear effect for performance scores (p <.001), whereby the correlation between Test 2 and Test 4 was significant (p <.001), in that ratings changed from 3.6 to 7.0 on a 10-point scale. There was a significant linear effect for satisfaction scores (p <.001) from Test 2 to Test 4, with ratings changing from 3.2 to 7.0 on a 10-point scale. The GAS showed a statistically significant linear effect (p <.001) from Test 2 to Test 4, with the average change for goals increasing 2 points on the 4-point scale. Parental Competence The PSI SF indicated a statistically significant time effect (p <.007) for the subtests of defensive responding (p <.001) and parental distress (p <.002). Comparison 4 was significant (p <.001) in defensive responding, with a change from the 96th percentile to the 70th percentile. Parental distress also decreased from the 85th percentile to the 50th percentile on the PSI SF. PSOC results indicated that there was a significant improvement in parents self-efficacy (p <.001). There was a significant linear effect (p <.000), and Comparison 4 was significant (p <.001), which indicates that parents increased their sense of efficacy from baseline to the conclusion of the study. Parental satisfaction did not increase as a result of the intervention, and the results were average compared with the rest of the population. Sensory Profile Half of the sample was 1 to 2 standard deviations greater than their peers in all four quadrants. Nine of the children in the sample fell into the more than others category when compared with their peers in 3 to 4 quadrants. One child had only registration in the more than others category. The following percentages indicate the results of the profile for the entire group in each quadrant: seeking (21%), avoiding (1%), sensitivity (10%), registration (13%), and two or more patterns (55%). The authors calculated each category for the whole group to represent the results, as follows: auditory (13%); visual (26%); touch (20%); movement (17%); body position (13%); and other, such as oral (11%). Intervention Characteristics Parents selected the following activity settings: home (74%), community (22%), routine self-care (49%), and leisure (37%). Tasks that they focused on for goals included bedroom, bathroom, transitions, church, parking lots, store behaviors, dressing, eating, sleeping, hygiene, playing, and watching TV. Interventions were to reflect family-centered care, occur in natural environments, and reflect interests of families (p. 521). Overall, self-care represented over half the goals created by parents, because school-based occupational therapists are not providing attention to this occupation at this time. 7
Was this study adequately powered (large enough to show a difference)? Circle yes or no, and if no, explain. YES/NO With only one group, power analysis is not applicable. Were appropriate analytic methods used? Circle yes or no, and if no, explain. YES/NO The authors chose specific outcome measures that they could use more than once to understand the change the intervention had for the child and the parents throughout the duration of the study. Were statistics appropriately reported (in written or table format)? Circle yes or no, and if no, explain. YES/NO Statistics were reported with statistical significance and were highlighted for the main findings throughout the text. CONCLUSIONS State the authors conclusions that are applicable to answering the evidence-based question. The authors concluded that the study contributes to evidence that families are a strong resource in managing their children s lives if therapists provide them with structure and guidance to use problem solving to achieve their goals for their child. Because the intervention focused on the parents ability to prioritize and achieve their goals, the study found significant improvement in the child s overall participation. The authors found that the coaching philosophy used with parents helped them feel an increased sense of competence to deal with their problems outside of therapy. Last, the authors conclude that by relating sensory-processing patterns to the child s routine in everyday life, the therapist is able to provide context-specific strategies and structure for problem solving through issues that arise on a daily basis. This work is based on the evidence-based literature review completed by Katrina Kotta, MOTS, and Sarah Nielsen, PhD, OTR/L, Faculty Advisor, University of North Dakota. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 8