An Increasing Emphasis of Evidence-Based Practice in Children with Developmental Disabilities

Theme A: Sensory Interventions Designed to Improve Occupation and Overall Development

A total of 19 articles were focused on sensory interventions that were designed to increase occupational performance and enhance the overall development of children. Of these 19 articles, the majority of the articles (53%) were related to children with Autism Spectrum Disorders (ASD).

A total of seven articles were specifically focused on the utility of occupational therapy interventions. The first of the articles [16], explored the usefulness of a brief implementation of the Ayres Sensory Integration-Based intervention in children diagnosed with ASD. This intervention had a positive effect on transitions, socialization, compliance, and general behavior in these children during the treatment sessions, and subsequently in their home environment. The next article Hall L, et al. [17] aimed to investigate the effects of incorporating a therapeutic-listening program with a sensory diet on children with sensory processing disorders and visual–motor delays. The participants demonstrated a significant improvement in their behavior associated with sensory processing, and especially auditory processing, along with a modest improvement in motor functions. A subsequent study by Silva, et al. [18] aimed to describe the efficacy of Qiqong massage therapy, an approach that is based on the Chinese medicine concept of energy channels.

The objective of this study was to explore if occupational therapists educated in Western medicine could be trained to effectively deliver this intervention in children with ASD. The study concluded that all occupational therapists that had successfully completed the Qiqong training program were capable of effectively delivering this intervention. A quasi- experimental study Wuang YP, et al. [19], compared the effect of sensory integrative therapy, neurodevelopmental treatment, and perceptual–motor approach in children with mild mental retardation. The results indicated that these therapeutic interventions, when conducted on a regular basis, were beneficial in improving sensorimotor functions in school-age children. An isolated article Bellefeuille, et al. [20] presented a case report of a child with fecal incontinence and tactile over-responsivity. The results suggested that occupational therapy-based interventions could assist in the acquisition of age-appropriate toileting habits. In recognition of the need to enhance oral care in children diagnosed with ASD, a study Cermak, et al. [21] examined the implementation of a sensory adapted dental environment. The findings suggested that this intervention could be integrated into regular practice considering that though oral health is important for children’s psychological and physiological health, it is often neglected in many children with ASD. The most recent article in this category Blanche, et al. [22] was a retrospective study that aimed to evaluate the effectiveness of the Interdisciplinary Sensory Enriched Early Intervention (ISEEI) group program for children with developmental delays. The results indicated that children with sensory processing difficulties demonstrated significant improvement in all areas of development except fine motor skills. In children without sensory processing difficulties the ISEEI intervention showed significant improvement in language and cognition.

Three studies in this category aimed to investigate the utility of sensory integration (SI) in children. The first study May-Benson, et al. [23] demonstrated that a SI approach may result in positive outcomes in behavioral regulation and achievement of individualized goals that are sustained for a significant amount of time. This study was followed by a pilot study Pfeiffer, et al. [24] that aimed to obtain preliminary information on the effectiveness of SI interventions in children with ASD. The results of the study, though moderate, demonstrated significant improvements in autistic mannerisms, and progress toward individualized goals in areas of sensory processing, self-regulation, emotional function, and fine motor skills. The third article Koester, et al. [25] was a retrospective study that investigated the role of SI in children who had received cochlear implants. The study concluded that occupational therapists working with children with cochlear implants should examine sensory integration function in greater detail during assessments and while planning interventions.

Two studies examined the relationship between sensory over-responsivity and anxiety in children with ASD and ADHD. A qualitative study Freuler, et al. [26] aimed to conduct a retrospective analysis of infant home videos to identify some behavioral characteristics of ASD. This study was able to identify some early precursors of ASD that included hyporesponsiveness, hyper responsiveness, sensory repetitions and atypical motor postures. These findings are significant, considering that despite noticeable heterogeneity in sensory patterns in these children, the evidence suggested that hyper responsiveness may be a precursor for extreme sensory disruptions at later ages in ASD. Another study Lane, et al. [27] aimed to analyze the relationship between sensory over-responsivity and anxiety in children with ASD and ADHD. The authors concluded that the magnitude of physiological responses to sensations is influenced by the child’s baseline state of attention and arousal, which impacts the outcomes of anxiety and physiological responses. The authors also suggested that investigation on behavioral tools are necessary to measure sensory over-responsivity since current available tools rely are based on the perceptions of a child’s responses (Table 1).

Total articles: 943 Table 1: Categories of article published in AJOT (2007-2016).

A series of three articles were focused on the role of caregivers and parents in the management of children with mental disabilities. The first study Cohn, et al. [28] aimed to identify the expectations and concerns of parents of children, who were receiving occupational therapy based sensory interventions. The major expectations included self-regulation, participation in skilled motor activities, and enhanced self-confidence. In addition, parents and caregivers hoped that occupational therapy interventions would help their children to self-regulate their behavior in socially acceptable ways and transition into productive adults. A pilot study Kirby, et al. [29] described the development of the Caregiver Strategies Inventory (CSI), with a specific focus on cognitive-behavioral, sensory-perceptual, and avoidance strategies in children with ASD. The findings of the study supported the design and utility of the CSI as a measure of caregiver strategies that addressed sensory features during everyday activities, and measured the frequency of their usage. Lastly, a study by Bulkeley, et al. [30] explored a sensory-based, family-centered coaching approach for modifying sensory-related problem behaviors of young children with ASD. The results from the study suggested that this intervention was acceptable to all parents and caregivers since it addressed family priorities that were guided by the cultural standpoint of the participants.

Two studies aimed to delineate outcome measures in sensory programs designed to increase occupation were identified. The first study in this category Mailloux, et al. [31] explored the utility of the Goal Attainment Scaling (GAS) for evaluation of patient participation in goal-setting. The study concluded that this client-centered tool provided a valid and reliable means to identify functional and meaningful intervention outcomes that are specifically relevant to occupational therapy. The more recent study in this category Faller, et al. [32] recognized the need for a systematic process to guide occupational therapy practice with a focus on outcome measurement in children. The article described the application of the Data-Driven Decision-Making process to aid in the systematic selection of precise interventions and outcome measurements to support decision making.

The last two articles in this category were more isolated in their approach towards improving occupation and overall development. The only pilot study in this category Miller, et al. [33] outlined the steps involved in designing a randomized controlled study with a specific focus on occupational therapy research. It utilized a SI model of approach in children. While reporting positive results, this study also emphasized the need for pilot studies to guide the designing of randomized control trials, with a special emphasis on quantifiable outcomes that are sensitive to change. A systematic review Case-Smith, et al. [34] on children with ASD brought to the forefront the intervention themes that are relevant to occupational therapists in both direct service and supportive team roles. The authors concluded that research in occupational therapy was well aligned with the philosophical and conceptual basis of the management of ASD. However, several of the current approaches of greatest relevance to occupational therapists were at a low level of evidence, suggesting a need to enhance the level of scientific rigor of research [35].

Theme B: School-Based Interventions Aimed to Improve/Increase Social Participation

A total of nine articles, in three of which the target population was ASD, explored the role of school-based interventions that aimed to improve or increase social participation in children with developmental disabilities [36, 37].

Four articles with the specific aim of utilizing school- based interventions to improve and increase social participation were identified. The first article in this category Bundy, et al. [38] demonstrated that a random arrangement of materials, with no defined purpose, when placed on a school playground was beneficial for the mental development of children. Over a period of time, this approach increased the socialization, creativeness, and resilience in children and thus had potential to be used in children with developmental delays. Another study Bazyk, et al. [36], reported the utility of integrating occupational therapy services into the classroom curriculum in children with and without disabilities. The results showed statistically significant improvements in fine motor and emergent literacy outcomes in these children. The next study Golos, et al. [37] examined the effects of a school-based multidisciplinary and multimodal intervention program among preschool boys. The intervention was effective in improving skills and performance and participation in the preschool daily activities of both the children at risk and those with normal development. Lastly, the focus of a study by Kinnealey, et al. [38] was on the utility of classroom modifications in children with ASD. It was demonstrated that modifications such as soundproof walls and halogen lighting improved classroom performance and mood in these children. In addition, journaling themes recorded by students suggested that changes in the classroom environment generated a positive emotional response and improvement in handwriting, hearing, and thinking (Table 2).

Total articles: 943 Table 1: Authors of article published in AJOT (2007-2016).

In relation to the above theme, another study Hilton, et al. [39] aimed to identify the out of school activity of high-functioning children diagnosed with ASD. Using the Children’s Assessment of Participation and Enjoyment, the most significant finding was that these children participated in a more limited range of activities, with a smaller group of other participants, and within a narrower geographic area.

There were three articles that focused on the lack of preparation of occupational therapists in the implementation of school-based interventions that aimed to improve or increase social participation in children. A study by Myers, et al. [40], recognized that the majority of occupational therapists felt that their participation in assisting the transition of young children with special needs into preschool was not satisfactory. The identified barriers reported by occupational therapists included a lack of time and support, or not being included in the process of planning. On a similar note, another study Leigers, et al. [41] concluded that occupational therapists were lacking in their role in addressing social participation in schools for students with specific disability categories, such as handwriting, sensory processing, self-care, and general fine motor activities. The consensus was that occupational therapists had a limited understanding of their role in the process. The last study Glennon, et al. [42], examined the perceptions, preparedness, and practices of occupational therapists involved in designing supports for transitioning into college in students with ASD. Again, the majority of the therapists indicated the need for more institutional guidance and training in designing such support services.

The final article in this category Daunhauer, et al. [43], aimed to outline the distinct patterns of strengths and weaknesses of students with Down syndrome. The study concluded that children with Down syndrome demonstrated a distinct and pronounced pattern of assistance- and adaptation-related needs across various domains of school function that would benefit from a school-based education plan. Theme C: Interventions Designed to Improve Handwriting While a total of eight articles were broadly related to improving handwriting skills in children, the majority of those were directly related to specific interventions to improve handwriting.

The first study Ratzon, et al. [44] in this category aimed to test the efficacy of a short-term intervention in the improvement of visual–motor skills in first graders. Interventions such as threading beads, inserting pegs and guided play with coins demonstrated a significant improvement in the handwriting skills of these children. The next article Roberts, et al. [45] examined the role of kinesthetic writing interventions in young students. The study concluded that these interventions were effective in improving legibility, speed and personal satisfaction in students with handwriting challenges. Another study by Howe, et al. [46] reported that students exposed to traditional handwriting instruction that included intensive practice and repetition performed significantly better in legibility than the students exposed to other visual–perceptual–motor activities. Following previous reports, Pfeiffer, et al. [47] aimed to assess the utility of the Buktenica Developmental Test for Visual-Motor Intervention (VMI) as an outcome measure for handwriting interventions. The study reiterated the conclusions of previous studies regarding the validity of the VMI for the assessment of changes after a handwriting intervention. Another study Zylstra, et al. [48] examined the effectiveness of the Size Matters Handwriting Program, an occupational therapy-led handwriting intervention for special education and at-risk kindergarteners. The kindergarteners who participated in the intervention demonstrated considerably greater improvement in handwriting legibility, and thus providing initial support for its utilization in the training of kindergarten children. The most recent intervention approach in Palsbo, et al. [49], was a preliminary evaluation of the safety and efficacy of robotic- assisted, three-dimensional repetitive motion in children diagnosed with ASD and ADHD who faced challenges in their motor abilities. Through the haptic computer–user interface was designed to deliver a precise program of multisensory therapy; mixed success was observed in the improvement of handwriting skills (Table 3).

In keeping with the theme of handwriting, another study Engel Yeger, et al. [50] examined the perceived self- efficacy relationships and self-reports of children of their handwriting skills, and their actual handwriting process. This study concluded that the students included in the study were aware of their handwriting deficits and were able to report them accurately.

An isolated study Schwellnus, et al. [51] aimed to investigate the anatomical basis of handwriting in children, in relation to kinetics, speed and legibility. The results suggested that while there were no kinetic differences in the number of fingers on the writing instrument, the position of the thumb had a significant impact on handwriting skills. However, the study also emphasized that the focus of occupational therapy intervention should be on the improvements in the speed and formation of letters to enhance legibility rather than on alterations in the grasp patterns.

Theme D: Physical Activity or Gross Motor Interventions to Increase Participation and Behavior

A total of seven articles were focused on improving behavior and participation in occupations through physical activity or gross motor interventions. The first study in this category Gutman, et al. [52] aimed to improve social skills and participation through roleplay in children diagnosed with High Functioning Autism. The participants were trained in the appropriate use and interpretation of motor behaviors, facial expressions and body language. The results showed that these children were able to significantly improve their verbal and nonverbal behaviors. The second article in this category Bellows, et al. [53] focused on overall improvement of gross motor skills in all children through a short-term implementation of “The Food Friends: Get Moving’ With Mighty Moves program”. This program, developed in conjunction with experts in nutrition and exercise science, aimed to enhance motor skill performance and provide opportunities to increase physical activity in a preschool setting. The program demonstrated significant improvements in gross motor skills, without any significant improvements in levels of physical activity or weight status. A succeeding article Hilton, et al. [54] required participants to rapidly strike lighted targets with a ball in a Makato arena training arena. The authors reported a significant improvement in reaction speed, executive functioning, and motor performance in the participants. This study suggested that a longer implementation of this approach might be of significant benefit in children with and without ASD. In an attempt to increase physical activity, a study by Koenig, et al. [55] aimed to train students in the principles of the Get Ready to Learn classroom yoga program. Its aim was to train students in yoga techniques through visual instructions. Students who received these instructional materials showed a reduction in maladaptive behaviors and signs of irritability, lethargy, social withdrawal, and hyperactivity. The next study Silva & Schalock, et al. [56] was a follow up to a previous study Silva, et al. [18] that aimed to improve behavior in children with motor delays using the Qigong massage intervention. This study reported that Qigong massage delivered through a trained therapist and a parent, resulted in lasting improvement in motor skills in children diagnosed with Cerebral Palsy and Down syndrome, though no sensory improvement was observed. A systematic review of yoga interventions by Weaver, et al. [57] assessed the usefulness of yoga in reducing anxiety in children and adolescents of all ages. The review concluded that yoga- based interventions could have positive effects in reducing anxiety across a variety of populations. However, due to the heterogeneity of the studies, large-scale, randomized trials were still necessary to establish its utility.

This most recent article in this category was a scoping review Jirikowic, et al. [58] that aimed to address the lack of literature regarding health-promoting physical activity (HPPA) for children who use assistive mobility devices (AMDs). This review, accurately identified child, family, and environmental facilitators and barriers relevant to HPPA participation among children who use AMDs. The most significant of these barriers were the severity of disabilities and the financial constraints of parents.

Theme E: Cognitive-Based Functional Interventions to Increase Behavior and Overall Daily Functioning

A total of seven articles, of which four studies focused on children with ADHD, were related to increasing behavior and overall daily functioning through cognitive-based functional interventions.

The role of Cognitive-Functional (Cog-Fun) interventions that are based on the theoretical foundations of the Dynamic Interactional Approach was examined in children with ADHD, in the following four articles. The first study Hahn Markowitz, et al. [59] reported significant gains in the acquisition of executive skills, and improved performance on meaningful occupations, that were maintained at follow- up. The succeeding article Maeir, et al. [60], reiterated that Cog-Fun interventions improved occupational performance and executive functions in daily life in young children with ADHD. The role of Cog-Fun intervention for preschoolers diagnosed with ADHD was again investigated by Rosenberg, et al. [61]. It reported that this intervention improved daily functioning, executive function and social functioning in children diagnosed with ADHD. Within this category, a systematic review Clark, et al. [62] also concluded that Cog- Fun interventions resulted in early and sustained gains in early cognitive development in infants and preschool children with inconclusive gains in older children. The study summarized that educating parents of these children to be more sensitive and responsive in their interactions would increase cognitive outcomes in their children.

The aim of the two studies was to specifically examine assessments that could be used to measure strengths and weaknesses in cognitive function in children. The first study Katz, et al. [63] aimed to validate the Dynamic Occupational Therapy Cognitive Assessment (DOTCA-Ch) in children diagnosed with ASD. In addition, the study sought to identify potential areas of cognitive strength that may benefit from occupational therapy mediated learning in these children. This study concluded that the dynamic testing properties of the DOTCA–Ch tool were robust in enabling pediatric occupational therapists to plan intervention strategies for their clients. In recognition of the need for a reliable tool for occupational therapists, the aim of this study Weiner, et al. [64] was to establish a Weekly Calendar Planning activity (WCPA) as a performance-based measure of executive functioning. The study demonstrated that the WPCA could aid occupational therapy practitioners in training students, in cognitive strategies such as time use and self-awareness of performance particularly those at risk of failing high school.

An isolated study in this category Wells, et al. [65], examined the role of a group therapy intervention on children who had been exposed to alcohol in the prenatal period. This approach enabled affected children to recognize individual deficit areas and develop strategies to compensate for areas of weakness, and build on their existing skills and strengths.

Methodological Considerations

This study analyzed scientific publication in peer- reviewed journal over a ten-year research period, since it is considered the most impactful period across all healthcare disciplines [66]. This is primarily because the most effective translation of research findings to clinical practice has been reported to occur during this length of time [67]. The ten- year period is also the period when the clinical utility of these research studies and their role in the modulation of healthcare policies is rigorously tested [68]. Hence, the time period that was chosen for this study allows the optimum opportunity for an accurate scrutiny of the clinical significance of the direction of research trends in occupational therapy.

Peer-reviewed journal articles are important repositories of specialized knowledge since they provide the most meaningful information that defines a profession [1]. Considering the exponential growth in the quantity of unstructured research data in occupational therapy research Richards, et al. [14] it was necessary to make this data accessible, useful and relevant. However, language text in scientific articles can be confusing Pedrami, et al. [69] and ambiguous due to inconsistent syntax Wright, et al. [4] and semantics Haynes, et al. [70]. Hence, it is very challenging to minimize human bias during the analysis of such data Marc, et al. [1]. The method of text mining, also referred to as text analytics, involves the analysis of data contained in natural language text in a systematic manner to identify trends in text-based content Green, et al. [71]. This is a very rational approach as it is based on the transposition of words and phrases in unstructured data into numerical values Atakpo, et al. [72]. In this study, 50 curated articles containing the five common words were analyzed using a stringent and iterative approach to identify relevant terms within their context. In addition, the NLP tool was used to eliminate negative or unimportant terms. Thus, the approach that was used in this study has provided content-specific information regarding the future direction of research in occupational therapy [67].

Significance of Identified Research Themes

There is a paucity of literature that has examined the research trends in occupational therapy. The first of the studies Ottenbacher, et al. [73] on the analysis of research trends based on publication in American Journal Occupational Therapy revealed a significant change in the type of articles that appeared in the journal during 1970 to 1980. The study concluded that there was an increase in data-based articles in which an independent and dependent variable were explicitly identified and a statistical test of a hypothesis was conducted. In addition, there was an increase in quasi-experimental articles and a decrease in articles of purely descriptive types, particularly during the last two years of the study.

A succeeding article by Ottenbacher, et al. [74], examined articles published in the American Journal of Occupational Therapy between 1973 and 1983. The specific aim was to analyze the approaches that were utilized research articles published during the period. The study reported a striking increase in studies that reported valid statistical information along with an improvement in the quality and scientific rigor of the investigations. The study also noted a trend toward multiple authorship of articles over the ten-year period of the study.

The present study reiterated some of the findings of the previous studies. Most significantly, it was observed that the vast majority (69.88%) of articles were experimental in nature with only a smaller number being quasi-experimental (2.55%) or descriptive (6.26%) in nature. In addition, a significant number of systematic reviews (13.68%) were also published during this period. These studies were well designed and generated valid and reliable empirical data. The number of articles with multiple authors had also increased, suggesting collaboration of occupational therapists across multiple institutions. Finally, majority of the studies (92%) were carried out in the United States suggesting that the findings from this study are fairly representative of the research carried out in this country. Hence, in summary there has been an expansion in the quantity of a research literature in occupational therapy profession that has been paralleled by an emerging sophistication in the use of research designs and statistical analyses.

In terms of the inherent research theme of the articles published during the time period of the study, the major focus was on children with developmental disabilities. The largest number of studies was on ASD (34%) and ADHD (12%), which is encouraging since developmental disabilities are the most common (13%–20%) clinical condition among children in the United States Murray, et al. [75]. The spectrum of ASD represents a heterogeneous group of disorders that are characterized by impairments in social communication and the presence of restricted, repetitive patterns of behavior or interests Viner, et al. [76]. The condition of ADHD typically presents as age-inappropriate levels of attention, hyperactivity, and impulsivity that impair the normal development and functioning of an individual Heller, et al. [13]. Though outcomes are variable, children with both these conditions continue to experience problems with independent living, inequalities in employment, and mental health even in adult life [43]. In addition, this condition is further aggravated by the associated societal stigma Thapa, et al. [77], and limitations in the availability of healthcare resources to improve this condition Murray, et al. [75]. While there is evidence that pharmacological treatment may have a beneficial effect, nonpharmacological interventions such as psychoeducation programs, cognitive behavioral therapy and especially occupational therapy directed behavioral interventions and have been reported to exert a major beneficial effect in the management of core symptoms [75]. Thus, it is encouraging that occupational research is being directed towards the promotion of self- care, enhancing academic skills Glennon, et al. [42]; Leigers, et al. [41] and aiding students in their transition to college [40]. In addition, published studies indicate that efforts are being made to explore approaches for the early detection of ASD Freuler, et al. [26]; Lane, et al. [27]. This is encouraging as it presents an opportunity to identify unique windows of opportunity and vulnerability in these children. This is of great clinical since children are very amenable to behavioral interventions Lane, et al. [27] while being most susceptible to the acquisition of negative behavioral traits Daunhauer, et al. [43] during these periods. Hence, occupational therapy is adopting a multipronged approach that takes careful cognizance of environmental influences aimed at addressing behavioral issues related to ASD and ADHD.

Another encouraging finding in this study was that the role of the development of handwriting skills in children was being recognized by the occupational therapy profession. This is important considering that handwriting difficulties are observed in 10%–30% of school-age children with and without and other identifiable developmental disabilities [78]. Studies have reported that children experiencing handwriting impairments tend to have a lower academic performance Novak, et al. [79] and has been linked to reduced working memory capacity [80], leading to cascading negative effects on learning [81].

In addition, efforts are being made to understand the biomechanics involved in handwriting difficulties, along with the incorporation of technological advances Palsbo, et al. [49] to address some of these deficiencies. Thus, a contextualized approach is being initiated by the occupational therapy profession that is directed at enhancing developmental maturation in these children.

Based on the results of this study, another relevant observation was that occupational therapists are beginning to recognize the modulating effects of parents and caregivers in the management of a child with developmental disabilities. This is significant since developmental challenges in children have been reported to result in problems such as the loss of confidence and in extreme cases of even rejection of the child by the parent or caregiver. Thus, studies are being specifically designed to recognize the expectations [28, 29] and concerns of parents and caregivers Bulkeley, et al. [30]. Thus, there is an ongoing shift in occupational therapy practice from a client-centered service delivery model to a more family- centered model [31, 32] that recognizes that a development disability in a child has a significant impact on the entire family Bulkeley, et al. [30]. Thus, this contemporary approach will allow parents to integrate the needs of the child into family life and play crucial role in the management and social recognition of children with developmental disabilities.

Hence it can be surmised that the discipline of occupational therapy is actively promoting research directed at interventions and assessments to address developmental disabilities in children. This is supported by an increase in research on the training of parents and caregivers in efficient management strategies.

Thus, the results of this study demonstrate that the current research on behavior-based interventions in occupational therapy aligns with the American Occupational Therapy Association’s Framework-III (2014) that supports interventions on children that focus on health promotion, self-management, educational services, and environmental modification through the use of occupational therapy -based interventions.