Arbetsterapeuters perspektiv på
implementeringen av sensoriska
integrationsinsatser vid internationella
skolor.
HUVUDOMRÅDE: Arbetsterapi, examensarbete I FÖRFATTARE: Hanna Toll
HANDLEDARE:Frida Lygnegård
EXAMINATOR:Anita Björklund Carlstedt
Arbetsterapeuters perspektiv på implementeringen av sensoriska
integrationsinsatser vid internationella skolor.
Syfte: Syftet med studien var att utforskas och beskrivs arbetsterapeuters sensoriska integrationsinsatser i internationella skolor. Den ger en inblick i förutsättningarna för genomförandet av dessa insatser och redogör för några av de utmaningar och fördelar som arbetsterapeuterna som arbetar i internationella skolor identifierar.
Metod: En deskriptiv kvalitativ design användes för att samla in data med hjälp av en digital enkät som bestod av både öppna frågor och flervalsfrågor. Enkäten ifylldes av sju arbetsterapeuter som arbetar på internationella skolor i olika länder. En
innehållsanalys användes för dataanalysen.
Resultat: Resultaten visar att förutsättningarna för att genomföra sensoriska integrationsinsatser i de olika skolorna varierar. Målen med sensoriska
integrationsinsatser är dock likartade och syftar till att möjliggöra elevernas deltagande och engagemang i skolan. Utmaningarna grupperades under fyra underkategorier: skolmiljö, samarbete, kulturell bakgrund, samt rättsliga ramar och riktlinjer.
Genomförandet av sensoriska integration ansågs vara till nytta för skolorna, lärarna och eleverna. Arbetsterapeuterna ansåg att skolorna generellt stödde implementeringen av sensoriska integrationsinsatser.
Slutsats: Genom att arbeta med sensoriska integration tar arbetsterapeuter hänsyn till både person och miljö (social och kulturell), för att möjliggöra elevens engagemang i det dagliga arbetet. Detta leder i sin tur till de fördelar som arbetsterapeuterna identifierat för eleven, lärarna och skolan. Skolornas fysiska, sociala, kulturella och institutionella miljö varierar och kan begränsa de sensoriska integrationsinsatserna, vilket då leder till utmaningarna som identifierats av arbetsterapeuterna.
Nyckelord: aktivitetsengagemang; arbetsterapi; integrering; internationella skolor; miljö; sensoriska integration; skolbaserad
Occupational Therapist Perspectives on the Implementation of Sensory
Integration Interventions in International Schools.
Hanna Toll
School of Health and Welfare, Jönköping University, Jönköping, Sweden
Hanna Toll, P.O. Box 30739, Addis Ababa, Ethiopia. hanna.toll@icsaddis.org
Occupational Therapist Perspectives on the Implementation of Sensory
Integration Interventions in International Schools.
Aim: The purpose of this study was to explore and describe the implementation of sensory integration interventions by occupational therapists in international schools. It gives insight into the conditions for the implementation of sensory integration, outlining some of the challenges and benefits faced by the occupational therapists working in international schools.
Method: A descriptive qualitative design was used to collect data using a digital survey composed of both open ended and multiple-choice questions. Seven occupational therapists working in international schools in different countries completed the survey. The data was analyzed using a content analysis.
Results: Results reveal that the conditions for implementing sensory integration in the different schools vary. The aim are, however, similar; to enable participation and engagement of the student in the school. The challenges were grouped under four subcategories: school context, collaboration, cultural backgrounds and legal framework and policies. Implementing sensory integration was regarded as being beneficial for the schools, teachers, and students. The international schools were also generally regarded as being supportive to the implementation of sensory integration.
Conclusion: By implementing sensory integration interventions, the occupational therapists address the person and environment (social and cultural) to enable the student’s occupational engagement. This in turn leads to benefits, identified by the occupational therapists, for the student, teachers, and school. The physical, social, cultural, and institutional environment of the schools vary and can limit the types of sensory integration interventions provided, leading to challenges identified by the occupational therapists.
Keywords: environment; inclusion; international schools; occupational engagement; occupational therapy; sensory integration; school-based
Introduction
Five to sixteen percent of elementary children are estimated to have Sensory Integration difficulties, with an even higher estimate among children with disabilities (Ahn et al., 2004; Ben-Sasson et al., 2009). A sensory-based approach is an evidence-based practice (May-Benson, 2012; Roley et al., 2015), that lays the foundation for high functioning skills like academic learning and social behavior (Ayres, 2005; Fazlioglu & Baran, 2008). Therefore, studying how sensory integration interventions is being implemented in international schools becomes important.
In today’s global world the mobility of people is increasing and, with that, the number and significance of international schools. Hayden and Thompson (1995) write that
“international schools in their many guises are rapidly becoming an influential force on a global scale”. Between 1983-2009 six million persons are estimated to have had some part of their education in international schools and many of them are today key players as artists, scholars, performers, and policy makers (Willis, 2010). There is not one definition that can be applied to all international schools, but in general terms these institutions are often fee-paying private schools with an internationally mobile student and staff population from a variety of cultures and a curriculum different from the country in which they are situated, thus preparing students for study or work globally (Hayden, 2006). International schools whose main
purpose has been to prepare students for higher education are becoming more inclusive, offering services to support students that learn differently, and thereby requiring support from health services like occupational therapy, and speech and language therapy (ISC research, 2020).
Being an influential force, international schools become an example for inclusivity and support offered within the school system. The World Federation of Occupational Therapy (WFOT, 2016) made a position statement promoting the right of children to an inclusive education where occupational therapists (OTs) are “skilled to work collaboratively to enable participation of all students in the occupation and school environment”. This statement shows the importance and need for OTs working with children within the school environment. Children attending an international school are no exception and should have these same rights to an inclusive education. OTs believe that health and wellbeing are promoted by enabling meaningful engagement in occupation (Townsend & Polatajko, 2013), occupation being everything that a person does throughout their life (Wilcock & Hocking, 2015). For the child who spends much of their days in school, engaging in the school activities and play are their major occupations. Enabling the child’s participation and engagement to their full potential in the school environment is therefore one of the OTs’ main priorities. Despite this fact, we find only a few countries with school-based OTs. In most countries OTs work within the clinical setting.
Today we find a few international schools employing or contracting OTs whereas many international schools don’t. Since occupational therapy is not well established in the school settings of many countries, the knowledge that there are schools and international schools that employ OTs is not well known. This study would help fill this gap and, in so doing, promote one aspect of what OTs can contribute to within the international school setting.
School-based OTs use sensory integration (SI) to address difficulties for children to engage and participate in school. Wilcock and Hocking (2015) write the following: “The integrative functions of the central nervous system, which processes external and internal information which is activated by engagement in occupation, are focal to survival, the
maintenance of homeostasis, and facilitating health and well-being” (p.89). This function of processing external and internal information by the central nervous system to be able to generate an appropriate response is what defines SI (Ayres, 2005). Research shows that using a sensory-based intervention has a positive impact on schools and improves student
participation when the intervention matches the student’s sensory needs (Benson et al., 2019; Ouellet et al., 202; Roley et al., 2015). However, there are still differences in how much SI training OTs receive in different countries (Holmlund & Orban, 2020).
There are a few studies on SI in school-based occupational therapy. A recent survey in Pennsylvania investigating school-based OTs perspective on sensory-based interventions in schools found that the school context, the sensory resources available, and the collaboration of teams, teachers and parents are some aspects OTs found challenging when implementing SI (Benson et al., 2019).
Relevance for occupational therapy
To the author’s knowledge, there are to date no studies done on SI in an international school setting, leaving this largely unexplored in the academic community. Since the student population in international schools is mobile, moving after some years either to another international school in a new country, or back to their home country, knowing how other international schools implement SI would help the OTs in preparing students and parents for a smoother transition. This would help minimize the short-term occupational loss of the child, and in so doing the child’s problems at the personal and emotional levels (Townsend and Polatajko, 2013).
Since occupational engagement is the central objective for the OTs, understanding what limits or enables it becomes important. The Canadian Model of Occupational
Performance and Engagement (CMOP-E) defines occupation as occurring by the interaction of person, occupation, and environment. It further describes occupational engagement as
being either limited or enabled by the environment (Townsend and Polatajko, 2013).
Therefore, identifying some of the conditions of the schools, which in line with the CMOP-E can have physical, social, cultural, and institutional components, lay the prerequisites for the understanding of how SI is being implemented. Thereby, describing the implementations of SI in the international setting would help answer how engagement is being enabled or limited for the student. This, in turn, would help OTs learn from each other and strengthen the
practice by acquiring a better understanding of the implementation of SI in different contexts.
Purpose
The purpose of this study is therefore to explore and describe the implementation of sensory integration interventions by school-based OTs in international schools.
The following questions will be addressed in this paper:
• What are the conditions for the implementation of SI in international schools? • How is SI being implemented in international schools?
• What challenges and benefits are there when implementing SI in international schools?
Materials and methods
This thesis has a descriptive intent. Therefore, a qualitative descriptive design was chosen since, according to Doyle et al. (2020), this provides a straightforward description of experiences and perceptions.
Reflexivity
To add credibility to the study the researcher needs to be reflexive about their role, context, position, and framework (Doyle et al., 2020). As a school-based occupational therapist
working in an international school, and certified in sensory integration, I have a basic
understanding of sensory integration. On the one hand, this gives me a better understanding of the difficulties facing OTs in this setting as well as a level of objectivity resulting from not reading in what is familiar to my context. On the other hand, not fully knowing and
understanding the different contexts and cultures can lead to misinterpretations.
Participant selection
A purposive sampling which implies selecting participants with specific knowledge and experience in the studied area (Doyle et al., 2020) was conducted. The only inclusion criteria was that the participants needed to be OTs working at international schools. The size of the sampling was limited to the number of OT’s that could be found meeting these criteria. In January 2020, some OTs working in international schools started a network to provide for the opportunity to support each other and share resources among professionals in similar settings. This network has since then grown and now has twelve members currently working in: Belgium, Germany, the Netherlands, Ethiopia, Uganda, Ecuador, Japan, and China. An invitation to participate was sent out to the members of this network. The members were asked if they know of any other OTs working at international schools, but no other contacts were received. An email was also sent to the overseas school contact person for the United States government asking if they had any knowledge of OTs working at international schools, but no response was received.
Out of eleven surveys that were sent out, seven responses were received. From the four remaining, two sent an email explaining that since they were not actually working at a school, they found they did not meet the given criteria. They were invited to fill in the survey even though they are not directly employed by a school given that they serve students
attending international schools, but they never did. [Table 1. Description of the participants, Here]
Data collection
Doyle et al. (2020) describe surveys with open-ended questions as a useful method to collect data. For this study, a digital survey with open-ended and multiple-choice questions was distributed. The multiple-choice questions would give a quick overview of the conditions and implementation whereas the open-ended questions would help gain the OTs perspective (see appendix 1). Having studied Benson et al. 's (2019) survey questions, relevant questions in relation to the purpose of this study were considered and discussed with the supervisor. Each question's relevance to the purpose was then reassessed. These questions were entered into a digital survey (Google form) and emailed to the participants. Reminders were sent out by email after the first and second week to participants who had not responded.
The google form included an informatory first page explaining the purpose of the study and ethical considerations (see appendix 2). Before continuing to the second page the participants gave their consent to participate in the study and stated their willingness to be contacted should there be a need for clarifications (see appendix 3).
Data Analysis
An inductive qualitative content analysis was conducted to identify categories from the responses. A conventional data analysis method was used as this study aims to be of a
descriptive nature (Hsieh and Shannon, 2005). Under each question, the responses from all of the participants were grouped. This quick reference to the question was a precaution not to take the responses out of context and in so doing change the intended meaning by the respondent. From each response, all the meaning units were systematically listed and coded and then grouped into subcategories and categories from which a tree diagram was developed (Hsieh and Shannon, 2005). To make sure the meaning of the response was not altered it was then double checked by going back to the original responses. The responses from the multiple choice questions were compiled and integrated in the results showing the range of the
responses.
[Table 2. An example of the analysis process. Here]
Ethical considerations
The World Medical Association’s (WMA, 2018) policy document states that a research protocol should be submitted to the concerned ethical committee. In line with this, the research protocol of Jönköping University School of Health and Welfare, a self-assessment form was filled out and discussed with the supervisor, to review any ethical issues that may be related to this project. This form was then submitted with the project proposal for
consideration and approval to the University.
The WMA (2018) stresses that every precaution must be taken to ensure the privacy and confidentiality of the participants. The privacy and confidentiality of the participants in this study were observed by handling the forms and data on a password protected personal computer and hard drive that other people do not have access to. No personal information of any of the participants was shared. Furthermore, the results were presented making sure that the information could not be traced back to any individual person or country. The collected data will only be used for this study.
The WMA (2018) further stresses the need for receiving informed consent. The participants were given written information about the purpose and ethical considerations of the study. They gave their consent on the google form and engaged willingly knowing they can at any point withdraw from the study, no questions asked. They were also asked for consent to use anonymous quotes and will receive a copy of the thesis upon request after it has been finalized.
The WMA (2018) also states that the risks and burdens should not outweigh the potential benefits of the study. As this study aims at OTs explaining their professional
understanding and implementation of sensory integration and with the ethical considerations taken, no risk or burden was identified for the participants.
Results
The data was analyzed and grouped in four categories: conditions, implementations,
challenges, and benefits. Under each category different subcategories emerged, presented in the tree diagram in figure 1.
[Figure 1. Here]
Conditions for Implementing Sensory Integration
This category is grouped into the following three subcategories: general conditions for the OT, the physical environment, and the referral process at the school. The general conditions are presented in Table 3. [Table 3. Here]
Within the physical environment some OTs have a designated room while others use shared spaces, in the same way some have access to suspended equipment while others don’t. The following equipment was listed as being used in the different schools: swings, indoor trampolines, scooters, exercise balls, balance boards, belly scooters, beanbags, wobbly stools, sensory toys, sensory brushes, fidgets, therabands, weighted vests/blankets, wiggle disk seats, playdough, modelling foam, beads, pegs, markers, pencils, scissors, and fine motor
manipulatives.
“Shared spaces. Playgrounds, gym if available/ booked. A room for desk work which may be used by others at the same time. We have no swings or treatment space for it.” survey 4.
The referral process starts with either teachers, parents or psychologists raising concerns. In some schools the learning support team does an initial assessment and sends a referral to the OT, after which parents are asked for their consent, and an evaluation is
initiated. One of the schools requires parents to consent to additional fees for OT services. In other schools the OT is part of the response to intervention (RTI) process or works as a consultant. The OT does observations and gives general recommendations to the teacher. In this process the parent’s consent is not required. In yet other schools, teachers communicate their concerns to the parents and the parents contact the OT for an evaluation or services.
“following an RTI framework, students first receive universal intervention, then target-group intervention, then intensive intervention - students requiring additional assistance are flagged in the universal intervention phase OR identified by their teachers” survey 7.
Implementations of sensory integration
This category is grouped into the following three subcategories: SI services, assessment tools, and student needs and difficulties.
The SI services provided were in turn grouped into three further subcategories: accommodation and coping strategies, SI therapy, and training in SI. Accommodations and coping strategies are given by providing sensory tools like weighted products, noise
cancelling headphones, seating placement, artist gloves, visual support, and wobbly disc seats, or strategies like movement breaks, sensory diets, home programs and self-regulation
techniques (like the Zones of Regulation or the Alert program) which can be arousing,
organizing, or calming. Some of the accommodations and coping strategies are addressed on a consultancy basis, with teachers or staff implementing some of the interventions. SI therapy are direct therapies provided by the OTs either individually or in groups. Training in SI to staff and/or families is provided by OTs for a better understanding of sensory integration and help with the implementation of the recommendations provided.
To assess SI, OTs use standardized assessments, observations and information gathered through reports and interviews. Most commonly used are the Sensory Profile, Sensory Profile 2, and Sensory Processing Measure (SPM) questionnaires, combined with
clinical or other observations, reports or interviews from teachers and parents, and informal checklists. A couple of OT’s use the Bruininks-Oseretsky Test of Motor Proficiency 2nd
edition and the Visual-Motor Integration assessment. One OT uses parts of the Sensory Integration & Praxis Test (SIPT) and Ayres clinical observation of postural and ocular reactions, and the Motor-Free Visual Perception Test-4 (MVPT-4).
The OTs interventions focus on the student’s individual needs. SI difficulties impact the students’ ability to participate and engage in individual or group activities, either during whole class instructions, group work, transitions, recess, lunch, self-care or life skills. These difficulties affect the degree of academic success of the student as well as the student’s social emotional wellbeing.
“Difficulty focusing, participating in individual or group tasks, sensory regulation and awareness, challenging and aggressive behaviors, academic success, lack of self-esteem and confidence, perimeter playing (or being alone) during recess.” survey 6.
The OTs goals are therefore geared towards enabling participation by addressing difficulties with sensory processing, self-awareness, self-regulation, emotional wellbeing, and social interaction. The OTs help students understand and internalize their sensory needs, have ownership and self-advocate. However, students' diagnoses, their decreased cognitive
capacity, age, and language barriers are factors that can limit the students' understanding of the provided SI services.
[Table 4. List of sensory integration difficulties addressed by the occupational therapist. Here]
Benefits of implementing sensory integration in international schools.
Benefits are grouped into the following four subcategories: benefits for the school, teachers, students, and occupational therapist.The school benefits by being able to reach out and accept children with more diverse needs, increasing inclusion in the classrooms. SI implementation also increases the
effectiveness of teaching and learning because of the support that is provided in the
classroom. The schools are also able to educate teachers and administrators about students' sensory needs.
“It is important to recognize that all students benefit from sensory integration, these are strategies that create an inclusive learning environment for all.” survey 2.
The teachers benefit by gaining a better awareness and understanding of the impact of SI on learning, they can also more easily differentiate between their learners and know when to refer the students for more support. SI interventions make teaching easier for the teachers.
The students benefit by gaining a better understanding of their sensory needs. They learn self-regulation, self-advocacy, gain better self-esteem, and become more confident. It helps students’ emotional wellbeing because they feel better/calmer and become more organized, making learning easier for them. They become more engaged, increase their participation, and attain a higher degree of academic success. They also increase their social interactions and get help to self-regulate. Students get the opportunity to receive evaluations and therapy that they may not have access to when they move to their next locations. The effectiveness of SI in increasing student participation and wellbeing were considered to be effective by most OTs.
Working in a school that is generally very supportive because they want to be inclusive, makes it easier for the OTs to implement SI services. The schools encourage parents and teachers to learn more about SI. Many teachers in international schools are aware and acknowledge the benefits of SI making them more responsive, enthusiastic, and willing to implement interventions. They have a good understanding of the students’ needs and seek support appropriately. There is a good collaboration with the learning support teams and
home room teachers. Many parents are also aware of SI and are more willing to give their time and learn.
Challenges of implementing sensory integration in international schools
Challenges are grouped in the following four subcategories: limitations in the school context; challenges when collaborating with teams, teachers, and parents; cultural limitations, and limitations in the legal framework and school policies.Within the school context, physical limitations in space and equipment available as well as limited allocation of time and funding are named challenges. Because of these limitations some services will not be provided for all students that would benefit from SI interventions and the time allocated for direct services may also be restricted. One OT refers students to OTs working outside the school setting because of limitations of equipment available. The opportunities of working preventively, with student groups, and teacher training are also limited. Administrative structures and routines can hinder access to already available equipment as well as professional development opportunities for occupational therapists.
“I would like to provide more group work and access to equipment within our special education classrooms. This is currently limited by space and the separate cost structure set up for OT within the school.” survey 3.
When collaborating with teams, teachers, and parents, one of the challenges is the varying level of teachers' understanding of OT or SI. Some teachers have difficulties to differentiate between behavior versus sensory differences. There is also an inconsistency in teacher and parent follow through with some programs and additional recommendations given by the therapist. Too few consultancy hours and a limited number of formal meetings with teachers, are also raised challenges. Scheduling conflicts when pulling students for
Cultural perspectives can negatively impact the implementation of sensory integration, being more or less limiting depending on the culture. Language barriers as well as cultural differences require more time from the occupational therapist to explain and, in some cases, convince the parents as to the need for additional services, especially for those cultures where needing additional support is looked upon negatively. The high mobility of the population means that the student may move to another school before the goals have been achieved.
Legal framework and school policies can also be challenging. International schools are not required to offer special education programs and can be more business oriented. This leads to occupational therapy services typically not being prioritized. Some schools choose to outsource the services leaving gaps within the learning environment, whereas others may not provide support unless they feel pressured to do so, sense an expectation to provide them, or believe the increased costs can be covered financially. When the added cost for OT services is directly attributed to the parents, they may need to be convinced of the need for this service.
Discussion
Results discussion
The results in this study show that from the OTs perspective implementing SI in international schools has clear benefits for the student, teacher, and school. SI is the way in which the student processes external and internal information to be able to generate an appropriate response (Ayres, 2005). Looking at this through the lens of CMOP-E (Townsend and Polatajko, 2013), parallels could be drawn between the internal information and the person, the external information and the environment, and the responses and the occupation.
Helping the students understand, internalize their sensory needs to be able to self-regulate and self-advocate as well as providing therapy sessions would fall under developing the skills within the person on both a cognitive and affective level. Although assessment tools were not lifted as a challenge in this study, only one of the OT’s used parts of the SIPT which
measures the sensory processing status of the vestibular, proprioceptive, kinesthetic, tactile, and visual systems (Ayres,1989). Since the SIPT is costly, has a limited age range and the normative data is only available for the United States, a new tool “Evaluation in Ayres Sensory Integration” (EASI) has been initiated giving promising preliminary analyses and discriminative validity data (Maillous et al., 2018) and could become an accessible
standardized assessment tool.
The results from this study could be structured under the two essential environmental factors of CMOP-E: physical (natural and constructed world) and social (general, cultural like values, institutional like policies and regulations) (Townsend and Polatajko, 2013). A SI approach gives a structured way of understanding the impact of the physical environment on the student by identifying sensory stimuli and differences that need to be addressed. The use of standardized sensory questionnaires provides a structured way of identifying the effects of sensory processing on functional participation in the home, school, and community like the Sensory Profile (Dunn, 2014), or the Sensory Processing Measure (Schaaf et al., 2014). This helps the OTs provide accommodations and strategies and sensory resources within the physical environment that would help enable the student’s participation.
From a social point of view, enabling the student’s understanding and ownership over their sensory needs enables social participation and wellbeing. By training teachers, parents and children about SI, a better understanding of the students’ sensory differences and needs are met, improving the students’ social environment, and minimizing misunderstandings.
Using a SI approach, OTs identify difficulties for the student that need to be addressed within the cultural environment. Providing training to teachers, staff, and parents about SI, as well as offering strategies, provides the student with increased engagement as well as
By analyzing the student’s immediate physical and social environments, SI identifies areas enabling or limiting the student´s participation. The CMOP-E model allows addressing other aspects impacting the implementation of sensory integration. Townsend and Polatajko (2013) put forward that institutions enable or limit occupation. Although not all international schools are inclusive, the demands for inclusion have increased, pushing international schools to adopt an inclusion policy which leads to challenges on how to provide services to these students (ISC research 2020). One of the challenges identified in our survey is related to the legal and policy framework which would fall under the institutional environment, the policies guide priorities and distribution of resources. They dictate the types of employment, facilities, and equipment available, as well as the time and resources allocated to the services rendered. All OTs in this study work in schools that have adopted an inclusion policy, the majority of the schools are assisted by the US government. However, in spite of commonalities, even among American international schools, the general conditions for occupational therapy and SI services vary, limiting in some cases the types of interventions that can be offered.
The institutional environment also influences the school cultural and social
environment by setting norms around collaboration and inclusion. Some of the challenges identified in the international setting correspond to challenges met by other school-based OTs. One example is the findings in Benson, Breisinger and Roach (2019) study in which the main challenges were identified as belonging to the school context, the sensory resources available, and the collaboration of teams, teachers, and parents.
The implementation of SI in international schools helps address the diverse sensory needs of the student and, in so doing, promote participation and inclusion. This corresponds with the findings of other studies on school-based interventions (Benson et al., 2019; Ouellet et al., 202; Roley et al., 2015). Promoting these benefits in discussions with school
contributions that the occupational therapy profession can provide in the school setting as well as address some of the challenges that are derived from the school policies. These discussions should not be confined to the individual school administrations but should also be discussed on a higher political arena to make changes and promote inclusion as this is part of the Sustainable Development Goals: ensuring inclusion and equitable education for all (UN, 2017).
Methodological considerations
For data collection both a survey and online interviews were considered. Although interviews are common for a quantitative research and give the opportunity for follow up questions, a survey was chosen based on the assumption that the nature of the questions were descriptive and could be completed at a time chosen by the participant. This also allows for greater flexibility, minimizes costs and allows for the gathering of information from a large geographical reach (Doyle et al., 2020). The risk of unreliable internet connections and differences in time zones were additional contributing factors for the choice of a survey.
Dependability refers to the consistency and reliability of the research findings and can be demonstrated by the documentation of the research procedures and allowing for outsiders to follow and critique it (Moon et al., 2016). To assure dependability the method used is described in detail making it possible for the reader to understand what process has been followed throughout the research.
The credibility of the study is the extent to which the author has been able to portray the participants meaning (Moon et al., 2016). To ensure credibility during the result analysis, careful consideration was taken by consistently referring back to the question and making sure that the responses were not taken out of context or the meaning altered. The relevance of each question in relation to the purpose of this study was reviewed to make sure there was a clear
link. The analysis of the responses showed that the questions were useful as they reflected the studies purpose.
Confirmability can be described as the clear link between the results and the conclusion in a way that can be followed and replicated (Moon et al., 2016). This has been taken into consideration by providing a detailed description of the method used, as well as adding the questionnaire to the appendix and describing the model that was used to discuss the results.
Transferability refers to how applicable the findings are in a different context (Moon et al., 2016). Although this study shows that the contexts of the different international schools vary based on the environmental factors (physical and social), the purpose for the
implementation of sensory integration remains similar. These findings and the practical implementations would be transferable to other inclusive internationals schools.
Conclusion
This study shows that by implementing SI, the OTs address the person and environment (social and cultural) as described in CMOP-E to enable the student’s occupational engagement. Which in turn leads to the benefits identified by the OTs for the student, teachers, and school. The physical, social, cultural, and institutional environment of the schools vary and can limit the OTs sensory integration interventions, leading to the challenges identified by the OTs in the four subcategories: school context, collaboration, cultural
backgrounds and legal framework and policies.
Practical implementations for occupational therapy and suggestions of
further research
To enable the best practice to reach students by providing different interventions in the
their daily occupation to be successful and enhance wellbeing. From a SI perspective this implies removing some of the barriers within the school environment by having discussions with the administration over the resources necessary for implementing SI and the benefits that this model provides both to the student but also to the school as a whole.
However, more in depth, studies addressing the physical and social environment within this setting and what occupational therapists can do to address these challenges would help acquire a better understanding and promote best practice within the international setting for OTs. Describing SI from the students’, parents’, and teachers’ perspective would also provide additional insight and a more holistic picture of the effectiveness of this model.
Acknowledgements
My special thanks goes to all those who participated in the survey making this thesis possible, to my family who supported and encouraged me, to my supervisor Assistant Professor Mrs. Frida Lygnegård for all the support and valuable questions and feedback during the entire process of this thesis. I would also like to thank the Jönköping University as well as the program coordinator for the opportunity to do this thesis and the support of my workplace, the International Community School of Addis Ababa.
Declaration of interest statement
There are no known conflicts of interest associated with this thesis and no financial support has been acquired for this study.
References
Ahn, R. R., Miller perception of sensory processing disorders among kindergarten children. American Journal of Occupational Therapy, 58, 287–293.
American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625–688.
Ayres, A. J. (1989). Sensory Integration and Praxis Tests manual. Los Angeles: Western Psychological Services.
Ayres, J. (2005). Sensory Integration and the Child: Understanding Hidden Sensory Challenges. Western Psychological Services.
Ben-Sasson, A., Carter, A., & Briggs-Gowan, M. (2009). Sensory Over-Responsivity in Elementary School: Prevalence and Social-Emotional Correlates. Journal of Abnormal Child Psychology, 37(5), 705–716. https://doi.org/10.1007/s10802-008-9295-8
Benson, J., Breisinger, E., & Roach, M. (2019). Sensory-based intervention in the schools: a survey of occupational therapy practitioners. Journal of Occupational Therapy, Schools & Early Intervention, 12(1), 115–128.
https://doi.org/10.1080/19411243.2018.1496872
Dunn, W. (2014). Sensory Profile 2 user’s manual. Bloomington, IN: Pearson.
Doyle, L., McCabe, C., Keogh, B., Brady, A., & McCann, M. (2020). An overview of the qualitative descriptive design within nursing research. Journal of Research in Nursing, 25(5), 443–455. https://doi.org/10.1177/1744987119880234
Fazlioğlu, Y., & Baran, G. (2008). A Sensory Integration Therapy Program on Sensory Problems for Children with Autism. Perceptual and Motor Skills, 106(2), 415–422. https://doi.org/10.2466/pms.106.2.415-422
Glasper, E., & Rees, C. (2017). Nursing and healthcare research at a glance . Wiley Blackwell.
Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24(2), 105-112.
Hayden, M. (2006). Introduction to international education, international schools and their communities . Sage.
Hayden, M., & Thompson, J. (1995). International schools and international education: a relationship reviewed. Oxford Review of Education, 21(3), 327–345.
https://doi.org/10.1080/0305498950210306
Holmlund, M., & Orban, K. (2020). Translation and cross-cultural adaptation of the performance-based test - Evaluation in Ayres Sensory Integration. Scandinavian Journal of Occupational Therapy, (ahead-of-print), 1–12.
Hsieh, H., & Shannon, S. (2005). Three Approaches to Qualitative Content Analysis. Qualitative Health Research, 15(9), 1277–1288.
https://doi.org/10.1177/1049732305276687
ISC research (2020), Inclusion in International Schools. In collaboration with Next Frontier Inclusion. www.iscresearch.com/schools
Mailloux, Z., Parham, L., Roley, S., Ruzzano, L., & Schaaf, R. (2018). Introduction to the Evaluation in Ayres Sensory Integration ® (EASI). The American Journal of Occupational Therapy, 72(1), 7201195030p1–7201195030p7.
https://doi.org/10.5014/ajot.2018.028241
May-Benson, T, A., (2012). Locating Evidence for Practice of Occupational Therapy Using a Sensory Integration Frame of Reference. Sensory Integration Special Interest Section Quarterly / American Occupational Therapy Association, 35(3), 1–4.
Moon, K., Brewer, T. D., Januchowski-Hartley, S. R., Adams, V. M., & Blackman, D. A. (2016). A guideline to improve qualitative social science publishing in ecology and conservation journals. Ecology and Society, 21(3), 17–. https://doi.org/10.5751/ES-08663-210317
Ouellet, B., Carreau, E., Dion, V., Rouat, A., Tremblay, E., & Voisin, J. (2021). Efficacy of Sensory Interventions on School Participation of Children With Sensory Disorders: A Systematic Review. American Journal of Lifestyle Medicine, 15(1), 75–83.
https://doi.org/10.1177/1559827618784274
Roley, S., Bissell, J., Clark, G., & Amini, D. (2015). Occupational Therapy for Children and Youth Using Sensory Integration Theory and Methods in School-Based Practice. The American Journal of Occupational Therapy, 69 Suppl 3(Supplement_3),
6913410040p1–6913410040p20. https://doi.org/10.5014/ajot.2015.696S04
Schaaf, R. C., Burke, J. P., Cohn, E., May-Benson, T. A., Schoen, S. A., Roley, S. S., Lane, S. J., Parham, L. D., Mailloux, Z. (2014). The Issue Is—State of measurement in
occupational therapy using sensory integration. American Journal of Occupational Therapy, 68, e149–e153. http://dx.doi.org/10.5014/ajot.2014.012526
Siedlecki, S. (2020). Understanding Descriptive Research Designs and Methods. Clinical Nurse Specialist, 34(1), 8–12. https://doi.org/10.1097/NUR.0000000000000493 Taylor, M.C. (2007). Evidence-based practice for OTs. (2. ed.) Oxford: Blackwell. Townsend, E.A., & Polatajko, H.J. (2013). Enabling occupation II: Advancing an
occupational therapy vision for health, well-being & justice through occupation. Ottawa: Canadian Association of OTs.
United Nation (UN) (2017). Sustainable Development Goals: 17 Goals to Transform Our World. http://www.un.org/sustainabledevelopment/ (Retrieved, 16.05.2021) World Federation of OTs (2016), Position statement on occupational therapy services in
school-based practice for children and youth, WFOT, London, UK.
World Medical Association (2018) Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects https://www.wma.net/policies-post/wma- declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/
Wilcock A, A., & Hocking C. (2015). An occupational perspective of health. Thorofare: Slack.
Willis, D. (2010). Book Review: International Schools: Growth and Influence: by Mary Hayden and Jeff Thompson Paris: United Nations Educational, Scientific and Cultural Organization (UNESCO), 2008 90 pages, ISBN 978—92—803—1320—8 Also available for download:
http://www.iiep.unesco.org/fileadmin/user_upload/Info_Services_, L. J., Milberger, S., & McIntosh, D. N. (2004). Prevalence of parents’
Appendix 1: Survey
Background Information
1- In which country and what year did you graduate from OT? 2- Was Sensory Integration (SI) part of your OT education?
Yes No Other:
3- Have you taken any other training on SI? If so, please describe the type of training or courses you have taken.
4- What is the name of the international school(s) you are working at? 5- How long have you been working as an OT at international schools? 6- What is your employment status?
Employed by the school Contracted by the school
Contracted by more than one school Other:
7- How many students do you have on your caseload per year?
8- How many are in preschool (3,4,5 year old), elementary school (ES), middle school (MS), and high school (HS)?
10- How many of those receiving SI services are in preschool, ES , MS and HS? 11- Give some examples of how frequently (ex. hours/week) and for how long (ex.
number of weeks/months) you work with a student.
12- Please describe what kind of facilities, equipment and resources you have available to you at the school/schools.
13- Please describe the referral process at your school. (starting by who refers the students up until they end up on your caseload)
Assessments/ Interventions/ Goals
14- Please name and describe as many of the different kinds of SI services you provide. (Both direct and indirect services)
15- What assessment tools/ methods do you use for SI?
16- In what way does your student's SI differences impact their participation or wellbeing in school?
17- Name as many of the student's difficulties that you address through SI.
18- How often do your students goals address the students difficulties to participate during the following situations?
Seldom Occasionally Often Almost always Whole class instruction
Independent work Group work Transition Recess Lunch Other
If you checked other please specify:
19- Give examples of the most frequent types of goals you set for the student.
20- How many of your students would you say understand why they are receiving SI services and how it relates to their participation or wellbeing in school?
21- If you have students that don't understand why they are receiving SI services, what are the reasons for why they don't?
22- How often do you give interventions in the following locations?
General education classroom Special education classroom OT treatment area
Other school environment (cafeteria, playground) Other
23- If you use another location please specify.
General Questions
24- Would you ideally have liked to provide any other types of interventions than the ones you are providing? If yes, what kind of intervention and why can't you provide them? 25- How effective would you say SI intervention is to increase student participation or
wellbeing in your school? o Not effective o Somewhat effective o Effective
o Very Effective o Other:
26- List the benefits you see from providing direct and indirect SI services at your school. 27- Are there benefits when implementing SI specific to working at international schools?
If yes, what are they?
28- List the challenges you face when providing direct and indirect SI services at your school.
29- Are there challenges when implementing SI specific to working at international schools? If yes, what are they?
30- What does the collaboration of the team, teachers and parents look like when working with students needing SI interventions? What is working well and what are the
challenges?
31- How would you rate the level of support do you receive from the school to help implement SI?
o 1 No support o 2
o 3 o 4
o 5 Very good support
32- Is the school atmosphere supportive with regards to SI interventions? Please elaborate. (Admin, Teachers, Parents, Others)
33- What kind of additional support would you have liked to receive from the school with regards to SI interventions?
34- Do you have any additional reflections or comments about the implementation of SI in international schools?
Appendix 2: Information letter
Background and purpose of the project
This research is undertaken as a part of a one-year Master of Occupational Therapy thesis at the University of Jönköping in Sweden. Sensory Integration based approaches are one of the interventions that school-based OTs (OTs) use to help students participate in school and access the curriculum. In different countries, the level of training OT’s receive on sensory integration can look different. In the United States, 95% of the OTs have sensory integration training whereas in Sweden only a handful of OTs have that training.
There are different studies published on sensory integration and the impact of a sensory-based approach in schools but none done in an international school setting. We can assume that OTs working at international schools would have diverse backgrounds having been trained in different countries. They also serve students from different cultures and backgrounds. It is therefore of interest to explore similarities and differences as well as benefits and challenges when implementing a sensory integration approach at international schools. This research will help us understand how OTs implement sensory integration in international schools, the challenges and benefits they face in this setting.
Why have I been invited?
You are invited to take part in this study because you are a qualified occupational therapist working in an international school setting. You are receiving this invitation because you are a part of a network for school-based OTs working at international schools.
What will this study involve?
If you are willing to participate in this study, you will be asked to complete a survey. You will be asked some background information on your training and setting, as well as information on your practice, challenges and benefits of working with sensory integration in an international school. You will also be asked if you give your consent to a short online interview should there be a need for clarifications once the responses have been collected.
What are the possible benefits?
This study will help give an overview of how OTs working in international schools are implementing sensory integration. It will help OTs learn from each other and strengthen the practice by acquiring a better understanding of the implementation of sensory integration in different contexts. It could also help OTs when planning further interventions or trainings.
Will my information be kept confidential?
All information collected will remain strictly confidential making sure no answer can be traced back to an individual occupational therapist or a specific country. The results will be presented in a narrative form based on themes and categories that will be deduced from the answers given. All information will be stored on a private computer that other people don’t have access to. Once the thesis has been approved all information will be deleted from the form.
How do I get feedback from the results of the study?
The study will result in a thesis towards a one year master’s thesis in Occupational Therapy. Upon request, you will receive a copy of the thesis once it has been approved and finalized.
Do I have to take part?
Your participation in this study is entirely voluntary and you are free to withdraw at any time without giving a reason.
Contact details
If you have any questions please do not hesitate to contact the research student, Hanna Toll through email at hanna.toll@icsaddis.org. This study has been undertaken under the
supervision of Dr Frida Lygnegård and has been reviewed by the University of Jönköpings research Ethics committee. You may contact my supervisor Dr Friday Lygnegård through email at frida.lygnegard@ju.se
Informed consent
If you would like to take part in this study, please continue to fill in the survey below. If you do not want to take part you don’t need to do anything further.
Thank you for taking the time to read this information.
Appendix 3: Informed consent
By ticking the box below, I confirm that:
1. I have read and understood the information for the above study.
2. I understand that my participation is voluntary and that I am free to withdraw from the research anytime, without giving reason.
3. I am willing to take part in the above mentioned study.
4. I give permission for anonymous quotes to be used in the reporting of the findings. I give my consent
Do you give your consent to be contacted should there be a need for clarifications? Yes
No
Table 1. Description of the participants.
Background information of the seven
participants Responses
Graduation year from OT programs Between 1990 and 2017
OT degree 4 from the USA (includes SI)
3 from the UK (doesn’t have SI) Have you taken additional courses in SI after
graduation 7 yes, the range is from courses giving a general overview of SI in the school system to certifications in SI
Year working at international schools From 1 years 9 months to 12 years
Countries of employment Belgium, Ecuador, Germany, Netherlands, Uganda Type of schools 5 assisted by the American government
1 American school
Table 2. An example of the analysis process where the test was divided into meaning units and coded leading to subcategories and categories.
Question Partici pant
Response in its entirety
Meaning units Code Sub-categories Categorie
s List the benefits you see from providing direct and indirect SI services at your school.
1 Makes life easier for teachers. Makes learning easier for students who struggle, helps kids with sensory disruptions feel better/ calmer/ more organised. = better interactions socially sense of self=. Better academic outcomes = Better Makes life easier for teachers
Facilitation Impacts the teacher
Benefit
Makes
learning easier for students
Facilitation Impacts the student Benefit Makes students feel better/calmer organized Emotional wellbeing Impacts the student Benefit Is the school atmospher e supportive ….. Please elaborate .… 2 Yes, very supportive. Some teachers don't understand what OT is, let alone SI, so this education piece is very important but I would say the majority are supportive and onboard.
Majority are supportive and onboard
Attitude Impacts the OT Benefit
Teachers don’t understand what OT is let alone SI
Table 3. Examples of some of the general conditions of the occupational therapists.
General conditions Responses
Types of employment 4 employed
2 contracted 1 freelancing
Case load Employed between 20-40 students
Contracted or freelancing 8-15 students Spread across divisions of students on the
caseload.
16-25% in Nursery or preschool 50-100% in ES
0-25% in MS 0-20% in HS
Percentage of students receiving SI 23% -100%, majority in ES Intervention per week including handover and
collaboration and parents and teachers
30 -90 minutes, majority receiving 60 minutes.
Table 4. List of sensory integration difficulties addressed by the occupational therapist.
SI difficulties addressed Examples (of areas within category)
Sensory processing · sensory defensiveness
· sensory seeking behaviors
· auditory processing
· visual perception difficulties
· vestibular processing
· proprioceptive processing
· balance e.g. falling out of the chair
· body awareness e.g. getting too close to
peers
· hypo responsivity
· tactile processing
· tactile defensiveness with eating
· primitive reflexes
Self-regulation · impulse control
· attention and focus
· engagement
· endurance
· frustration
· following directions
· struggling with test taking or project work
Emotional wellbeing · self esteem
· self confidence
Social interaction · peer interaction
· aggressive behavior
Figure 1. Tree diagram representation of categories and subcategories. Implementation of SI in international schools
Conditions General conditions Physical environment Referral process Implementation SI -services Accommodations and coping strategies SI therapy Training on SI Assessment tools Standardised assessments Observations Information from parents teachers and staff Interventions Students challenges OT goals Benefits
For the school
For the teacher
For the student
For the OT
Challenges
School context
Collaboration
Culture
School policies and legal framework
