Term Paper: Fidelity in Sensory Integration Intervention

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Fidelity in sensory integration intervention and research is an important concept because it measures the "faithfulness of intervention to the underlying therapeutic principles" (Parham et al., 2007). In other words, fidelity attempts to measure not whether the intervention is accomplishing therapeutic goals, but whether the intervention is using the therapeutic protocols outlined in a particular treatment regime. Fidelity procedures can help ensure treatment integrity, enable treatment differentiation, provide communication mechanisms about the core characteristics of interventions, and maintain consistency of treatment over time. Fidelity does not describe the efficacy or utility of any specific interventions, but the need for fidelity would be based upon research demonstrating that a particular intervention is useful.

Parham et al. wanted to examine the validity of sensory integration outcomes research as it was linked to fidelity. They began by identifying core sensory integration intervention elements by reviewing the existing research, selecting 34 studies for review. They grouped the research into two different groups: structural and therapeutic process. What they discovered was that most of the studies described fewer than half of the process elements and only 1 was presented in every study. They determined that weak fidelity threatens the validity of sensory integration outcome studies. They concluded that until fidelity is adequately addressed in outcomes research, it is impossible to draw inferences regarding sensory integration effectiveness (Parham et al., 2007).

They measured fidelity by using systematic ongoing documentation of intervention delivery, examining both structural and process elements. They defined structural elements as those elements that were relatively easy to quantify and to observe, including: number of participants, time-length, the therapist's professional qualifications, and the presence of environmental features (Parham et al., 2007). They defined process elements as less tangible things like the quality of the therapeutic relationship or alliance, and the treatment dosage (Parham et al., 2007). Then they focused their review on whether the descriptions of the interventions in the studies were consistent with the key intervention elements that they had identified. They used 10 core elements in their evaluation: provide sensory opportunities; provide just-right challenges; collaborate on activity choice; guide self-organization; support optimal arousal; create play context; maximize child's success; ensure physical safety; arrange room to engage child; and foster therapeutic alliance (Parham et al., 2007).

Although their article purported to describe fidelity, it was interesting to note that fidelity was not fully operationalized in the article. Instead, the definition of fidelity in the article seemed to beg the question, since there did not appear to be external validity in their definition of fidelity. Moreover, while there was internal reliability, without validity it seems unclear whether there would be external validity as well. In fact, their study seemed to suffer from the same weaknesses that the researchers had identified in prior research, which was a failure to address all aspects of fidelity. However, some of the prior research did mention using quantifiable score sheets as a measure of fidelity (Parham et al., 2007). They also identified their reliance on expert opinion as a weakness in creating their fidelity measurement (Parham et al., 2007).

Despite the flaws in the measures they used to determine fidelity, given that their research approach was a meta-analysis, they may have developed the best available instrument. Using a literature review as a means of study provides limitations in the operationalization of variables. Therefore, if confined to the study as designed, there may not be a better measure of fidelity for this design. However, rather than focusing specifically on the type of treatment offered, a better design may have compared the quantifiable aspects of the therapeutic interventions and compared those results to treatment success.

In 2007, Miller et al. conducted a pilot study to help prepare for a randomized control study of the effectiveness of occupational therapy for children with sensory processing disorders. The occupational therapy used a sensory integration approach. The researchers conducted a one-group pretest/posttest design with 30 children with sensory modulation disorder to determine whether the proposed intervention was sufficiently effective to merit additional study. What they determined was that a single pilot study was insufficient to develop their proposed research design. They examined: how to identify a homogenous sample; how to develop an intervention manual (manualized intervention), and how parental priorities impact outcomes. Prior research had focused on single projects in the sensory integration approach and had not been based on long-term research. As a result, they found that the background information was insufficient to complete high-quality effectiveness research (Miller et al., 2007).

Because this was a pilot study, one of the things that they were examining was how to measure fidelity in later studies. As a result, their measures of fidelity were somewhat fluid. They defined fidelity as adherence to a treatment protocol. Furthermore, they believed that the fidelity measure described by Parham et al. 2007 was sufficient to use as a basis in their research. They established both a preliminary intervention manual and a fidelity rating scale, but cautioned that both would need refinement before moving beyond the pilot program (Miller et al., 2007).

The vagueness of the overall research design and its failure to include a pilot manual make it difficult, if not impossible, to suggest a better measure of fidelity than the one employed by the authors. However, their discussions of fidelity do suggest some aspects of fidelity measurement that have not previously been discussed. For example, they devised a specific manualized intervention program. In order to determine fidelity, one would need to know what the intervention program entails and how it differs from or is similar to other intervention program. Based on those distinguishing factors, it would then be possible to develop a scale that specifically assesses adherence to the program, based on an examination of fidelity that focuses the most attention on the elements of the intervention that are not common to other intervention elements. If the interveners use those elements or combination of elements that are unique to a described intervention, it seems likely that their fidelity to the intervention, overall, is likely to be greater.

Schaaf et al. used the fidelity measure defined by Parham et al. 2007 in order to examine fidelity in a pilot research design that was used to specifically examine the feasibility, safety, and acceptability of a protocol of occupational therapy that was specifically designed and manualized for the study. The therapy used sensory integration principles with ten children ranging from 4 to 8, who had been diagnosed with autism. The study involved the application of intensive therapy to the children, which adhered to the protocol that had been developed in anticipation of the study. As part of the study, the researchers gathered measures of the feasibility, acceptability and safety of the protocols utilized from parents and the intervening professionals. They also examined fidelity using the fidelity instrument developed by Parham et al. They determined that their proposed manualized intervention was safe, feasible, acceptable, and that it could be implement with fidelity. This provided sufficient support to move on to an additional study, which will be described below (Schaaf et al., 2012).

To measure fidelity, they used the Ayres Sensory Integration Fidelity Measure designed by Parham et al. This measure uses a Likert scale to measure and weight ten items on a scale of one to five, with five indicating strong agreement. The scale is simply used to measure whether or not a therapist did use a particular intervention or component of an approach. Scores can range from 0 to 100, with 100 indicating perfect adherence to the intervention protocol and scores over 80 being considered acceptable (Shaaf et al., 2012). In addition, to help eliminate the potential for bias in the results and ensure inter-rater reliability, the researchers videotaped all sessions and selected 20% of them for random review by independent evaluators using the same Ayres Sensory Integration Fidelity Measure (Schaaf et al., 2012).

After developing their pilot program and determining that further research was possible and would have academic validity, Schaaf et al. looked specifically at interventions targeting children with autism, whose diagnosis had been confirmed in the research (2013). The children were divided into a treatment group and a non-treatment group. The treatment group was exposed to 30 sessions of an occupational therapy intervention. The non-treatment group was exposed to usual care. The treatment group had statistically significant better results in goal attainment, caregiver assistance in self-care, and socialization. They concluded that the results supported the use of the manualized intervention protocol with children with autism (Schaaf et al., 2013)

The research actually stated that it used the measure of treatment validity that was described by Parham et. al (Schaaf et al., 2013). The researchers felt that measure enabled them to evaluate the occupational therapy or sensory intervention within the context of a clinical trial. However, viewing the two research articles in context, it actually appears that Schaaf et al. used a standard scientific method research design to help operationalize and define fidelity within the context of their research. First, they… [END OF PREVIEW]

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