|Year : 2020 | Volume
| Issue : 1 | Page : 44-49
A randomised control trial to evaluate the effectiveness of sensory integration therapy on motor activity amongst children with intellectual disability
TM Assuma Beevi1, M Nimya2, Elizabath K Xavier3
1 Professor, MIMS College of Nursing, Malappuram, Kerala, India
2 M.Sc Nursing Student, MIMS College of Nursing, Malappuram, Kerala, India
3 Associate Professor, MIMS College of Nursing, Malappuram, Kerala, India
|Date of Submission||12-Mar-2020|
|Date of Decision||20-Jun-2020|
|Date of Acceptance||22-Jun-2020|
|Date of Web Publication||14-Sep-2020|
Dr. T M Assuma Beevi
MIMS College of Nursing, Puthukode Post, Malappuram - 673 633, Kerala
Source of Support: None, Conflict of Interest: None
Children with intellectual disability across the world are facing several issues. In most situations, they have problems in motor activities such as sitting, lying, walking, jumping and crawling. Many therapies have been researched for improving the quality of life of these children. Sensory integration therapy (SIT) is one of the many therapeutic modalities used for promoting motor activity in these children. The aim of this study was to evaluate the effectiveness of SIT on motor activity amongst children with intellectual disability. A randomised control trial design was adopted for the study. Sixty children who fulfilled the inclusion criteria were selected and randomly allocated to the experimental and control groups. A structured observational checklist for motor activity assessment was used to collect the data and analysed using SPSS software version 17. The results of the study revealed a significant improvement (P < 0.01) in the level of motor activity amongst children in the experimental group after SIT. SIT is found to be effective in improving the motor activity of children with intellectual disability. However, the study can be replicated with large samples to enable generalisation of findings.
Keywords: Intellectual disability, motor activity, sensory integration therapy
|How to cite this article:|
Assuma Beevi T M, Nimya M, Xavier EK. A randomised control trial to evaluate the effectiveness of sensory integration therapy on motor activity amongst children with intellectual disability. Indian J Cont Nsg Edn 2020;21:44-9
|How to cite this URL:|
Assuma Beevi T M, Nimya M, Xavier EK. A randomised control trial to evaluate the effectiveness of sensory integration therapy on motor activity amongst children with intellectual disability. Indian J Cont Nsg Edn [serial online] 2020 [cited 2020 Oct 23];21:44-9. Available from: https://www.ijcne.org/text.asp?2020/21/1/44/295042
| Introduction|| |
Parents develop wishes, expectations and dreams for their children, even before the child is born. The birth of a baby with intellectual disability threatens and shatters their hopes and dreams. Intellectual disability is a condition, which affects an individual because of some changes or damage within the developing brain and neurologic system. According to the American Association of Intellectual and Developmental Disabilities, 'intellectual disability is a disability characterized by significant limitations in both intellectual functioning and in adaptive behavior, which covers many everyday social and practical skills. This disability originates before the age of 18'.
The WHO  estimates that 10% of the global population has some form of disability. The World Health Assembly  has recognised intellectual disability as a worldwide problem since 1975. The National Survey on Drug Use and Health  reports that India has a child population of 6 million, and out of these, approximately 2 million children are intellectually disabled. According to the census report of 2011, in Kerala, there were about 761,843 individuals with disability, in which 51.81% were male and 48.19% were female.
Children with intellectual disability across the world face several issues. One of the main problems is that these children lack the ability to perform self-care activities. Parents of children with any disability want to overcome all these issues and would like to enable their children to lead a normal life. There are many training programs available to train children with intellectual disability to meet their needs related to activities of daily living. Different stimulation techniques and therapies such as play therapy, vestibular stimulation, and neuro-developmental therapy have been used to promote better functioning in children with intellectual as well as developmental problems. Sensory integration therapy (SIT) is of the many therapeutic modalities used for promoting motor activity in children with intellectual disability.
Sensory integration is a normal process where the brain receives stimulus information from different parts of the body as well as the environment and processes it to produce appropriate response. Sensory information should be processed and integrated adequately to enable appropriate adaptive behaviour. Lack of sensory integration may pose difficulties in behaviours that are fundamental to everyday life.
SIT as a framework was first described by Jean Ayres an occupational therapist in the 1970s. According to Ayres, the sensory system develops over time, like other aspects of development (language, motor, etc.), and that deficits can develop in the process of maturing a well-organised sensory system. It is believed that this deficit occurs when the sensory neurons are not functioning efficiently that may lead to learning difficulty or problems with emotional regulation.
It is a form of therapy in which the therapist encourages a child to respond appropriately to sensory input by making organised and successful responses. SIT involves oral stimuli, visual stimuli, tactile stimuli, positioning and movement exercises within a controlled environment. Jumping, walking heel raised, zigzag hopping, playing, musical games, catching and bouncing balls with both hands are some examples of activities that are included as tactile, vestibular, proprioceptive input and feedback activities involved in SIT., Although SIT is widely suggested as a therapeutic intervention for children with disability, it is rarely used in India and specifically in Kerala.
Objectives of the study
The objectives of the study were to assess the current level of motor activity in children with intellectual disability both in the experimental group and in the control group, to determine the effectiveness of SIT on motor activity children with intellectual disability and to find an association between the level of motor activity amongst children with intellectual disability and selected demographic and clinical variables.
| Methods|| |
Research design and sampling
A randomised control trial was conducted with the total of 60 children with mild and moderate intellectual disability selected from a school for the differently abled in Kerala, South India. Sample size was calculated with 80% power and 5% error. Inclusion criteria for study participation were (i) children aged between 6 and 15 years, (ii) children of both genders and (iii) children who were with mild-to-moderate intellectual disability decided on the basis of the institutional assessment criteria, which was already existing in selected setting. Children with visual and auditory impairment were excluded from the study.
A total of 60 children who met the inclusion criteria were purposively selected and a list of their names in alphabetical order was prepared. Each child was assigned with a number ranging from 1 to 60 based on random allocation sequence, which was prepared using computer software program. Allocation concealment was implemented using sequentially numbered opaque sealed envelopes and enabling allocation by a second person who was not directly involved with the study.
The proposal of the study was approved by the institutional ethics committee. The purpose of the study was explained and permission was obtained from the administrators of the school. Informed consent was taken from parents. Confidentiality of data and anonymity of the subjects were ensured.
The study used three different tools to collect data. The first tool was sociodemographic pro forma with 13 items such as age of the child, gender, religion, father's educational status, mother's educational status, father's occupation, mother's occupation, type of family, monthly family income, consanguinity, birth order of the child, age of father at birth of the child and age of mother at birth of the child. The second tool was clinical profile of the child with two sections: Section A included factors related to the child and Section B was on factors related to the mother. The third tool was a structured observation checklist to assess the motor activity, and this tool was prepared by the researcher. It consisted of 15 items which observed the ability of the child to perform activities such as touching nose with index finger-eyes closed, using thumb and index finger to pick up the object, copying a circle with preferred hand, cutting out a circle with preferred hand, drawing lines through path curved, connecting dots, threading beads, transferring coin, standing on one leg on a line, walking forward on a line, walking heels raised, jumping in place, zigzag hopping, catching a tossed ball with both hands and throwing a ball at a target. The maximum score for the assessment was 60. Children were graded into 4 categories based on their motor activity, i.e., 1–15: severe motor impairment (not yet meeting expectations), 16–30: moderate motor impairment (approaching expectations), 31–45: mild motor impairment (meeting expectations) and 46–60: no impairment (exceeding expectations). The instrument was validated for content by subject experts. The content validity index of the tool was 1. The reliability of structured observation checklist was assessed by inter-observer reliability method and was found to be 0.87.
Content and description of sensory integration therapy
SIT was administered to the children who were included in the experimental group. Sensory integrative therapy is an intervention designed to help children with poor sensory integration. The control group received routine training provided at the school. Warm-up exercises were planned to practice before starting the therapy such as placing the palm and feet together and clapping hands twice. Therapy consisted of 6 activities including hand-to-eye coordination activities (1–5 days), oral motor activities (6–9 days), balance and coordination activities (10–13 days), proprioceptive active activities (14–16 days), tactile activities (17–19 days) and crossing midline activities (20th day), and these activities were performed for the designated number of days.
Data collection procedure
After getting approval from the ethics committee and school authority, the researcher selected 60 children (30 experimental and 30 control) based on eligibility criteria. Demographic data and clinical profile of the children were collected from their parents by interview technique. The baseline motor ability of both groups was assessed first with the help of structured observation checklist. The experimental group received the SIT for 20 days, while the control group received routine training that is given at the school. The intervention was instituted by the researcher herself with the assistance of occupational therapist of the institute. Post-test of both groups was done by the researcher after the completion of therapy. The control group received the same therapy at the completion of actual study [Figure 1]. Fortunately, there was no attrition. Parents expressed their willingness to continue the therapy even after the conclusion of the study.
Analysis of demographic variables and clinical variables of children with intellectual disability was done using frequency and percentage distribution. The effect of SIT amongst the experimental group and the routine therapy in the control group were analysed using paired t-test, and the effect of the SIT on motor activity between experimental and control groups was assessed using independent t-test. Chi-square test was used to find out the association between sociodemographic and clinical variables with motor activity. The results were summarised using tables and narrative descriptions. There was no missing data in the statistical analysis.
| Results|| |
Most of the samples (66.7%) in the experimental group and 53.3% in the control group belonged to the age group of 6–10 years, and majority were female in both the groups. Majority of them in both the groups were Hindus (experimental group, 76.7% and control group, 63.3%). In the experimental group, 3.3% of parents had consanguineous marriage and no parents in the control group had consanguineous marriage. In both groups, majority (53.3%) were second child in the family as per the birth order. Majority of fathers were between 31 and 40 years (experimental group, 53.3% and control group, 70%). Most of the mothers in both groups were aged between 31 and 40 years (60% in the experimental group and 70% in the control group) [Table 1].
|Table 1: Distribution of children according to sociodemographic variables of child and parent|
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None of the study participants had a history of genetic disorder. In both groups, 26.7% of children did not cry immediately after birth. Cranial anomalies were present in 3.3% in the experimental group and 20% in the control group. Seizure disorder and metabolic disorders were present in 3.3% of participants of both groups. None of the mothers had a history of maternal infections, exposure to cigarette smoking and exposure to X-ray/teratogens during pregnancy. All mothers in both groups had taken iron/folic acid supplements and had an anomaly scan during their pregnancy.
Existing levels of motor activity of study children
The level of the existing motor activity was checked using the observation checklist after recruitment and randomisation. Most of the children with intellectual disability in both experimental (47%) and control (66.7%) groups had mild motor impairment on overall score for motor activity [Figure 2].
|Figure 2: Overall percentage distribution of children based on motor impairment in the experimental and control groups.|
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Most of the children in both groups were approaching expectations in all fine motor activities [Figure 3] and [Figure 4]. As for the gross motor activities, most of the children in the experimental group were approaching expectation such as standing on one leg on a line (56.7%), walking forward on a line (63.7%), walking heel raised (63.7%), jumping in place (56.3%) and zigzag hopping (56.3%), whereas 50% were meeting the expectations for activities such as catch tossed ball and throwing ball at a target [Figure 5]. In the control group, most of the children were approaching expectation in all gross motor activities [Figure 6].
|Figure 3: Distribution of children in the experimental group based on level of fine motor activities.|
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|Figure 4: Distribution of children in control group based on level of fine motor activities.|
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|Figure 5: Distribution of children in the experimental group based on level of gross motor activities.|
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|Figure 6: Distribution of children in control group based on the level of gross motor activities.|
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Effectiveness of sensory integration therapy
There was a significant difference between the mean pre-test and post-test scores of fine motor and gross motor activities in the experimental group (P < 0.01), whereas in the control group, no significant difference between the mean pre-test and post-test scores of fine motor and the gross motor activities was seen. In the experimental group, there was a significant difference between the mean pre-test post-test scores for overall motor activity (P < 0.01), whereas in the control group, there was no significant difference [Table 2]. There was a significant difference in the mean post-test scores of motor activities between experimental (37.5 ± 8.1) and control (29.4 ± 6.5) groups (MD, 8.06, t = 4.24, P < 0.01) [Table 3].
|Table 2: Difference in the mean post-test total scores of motor activity scores in the experimental and control groups|
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Association of motor activity with selected demographic and clinical variables
There was no significant association of pre-test scores of motor activity of children with intellectual disability with selected demographic and clinical variables.
| Discussion|| |
The intent of the study was to determine the effectiveness of SIT on motor activity amongst children with intellectual disability. The result of the study revealed that there is a positive change in the experimental group after the intervention compared to the control group. Majority of the children in this study were between 6 and 10 years and came from Hindu religion. The distribution of subjects by demographic data is similar to the findings of another study conducted by Bhagya and Ramakrishna  in 2013 to determine the prevalence of intellectual disability amongst children in Mangalore in which most of the subjects belonged to Hindu religion and were between 6 and 10 years.
The present study showed that majority of the subjects were female in the experimental and control groups. The higher proportion of females in this study represents the general findings of higher prevalence of intellectual disability amongst females. There is also a study which gives a contradictory finding that intellectual disability is reported more in boys than girls.
The present study findings showed the importance of using SIT as a management measure to increase the capability of children with mild-to-moderate intellectual disability. These findings are in par with a quasi-experimental study done by Monica  in 2015 in Tamil Nadu in which a large proportion of children with intellectual disability had moderate motor impairment at baseline assessment. After intervention, although some children with moderate impairment shifted to mild impairment, the number of children with severe impairment remained the same after intervention in Monica's study. The present study also had not shown any improvement in children with severe impairment, which may be related to the short duration (20 days) of intervention.
A study conducted by Devi et al. in 2016 to determine the effectiveness of SIT on gross motor function in spastic diplegic cerebral palsy children in Punjab found that there was an improvement in gross motor activities such as rolling (P = 0.03), sitting (P < 0.01) and crawling (P = 0.21) after SIT. The present study supports these findings as there was an improvement in the gross motor activities of children such as standing on one leg on a line, walking forward on a line, walking heel raised, jumping in place, zigzag hopping, catching a tossed ball with both hands and throwing a ball at target after SIT. Similar findings were also reported in another study conducted by Karim and Mohammed  in 2014, which showed improvement in motor skills of children with autism after the SIT. In both studies, SIT was found to be effective in improving both fine motor and gross motor skills.
The generalisability of the study findings is limited as it was restricted only to a single setting and was limited to children aged 6–15 years. The absence of significant association with demographic or clinical variables may be due to smaller sample size with which it is hard to draw definite conclusions.
Implication of the study
The findings of the study have several implications in nursing practice, nursing education, nursing research and nursing administration. Nurses working in the health-care services can train the children with intellectual disability using SIT and can teach the caregivers of these children about the SIT. SIT need to be introduced to nursing students, so the awareness of this therapy will improve in the early nursing career itself and they will be sensitive to the needs of intellectually disabled children. The study may be a valuable reference material for further research.
| Conclusion|| |
The level of motor activity amongst children with intellectual disability may differ. However, this study has shown that SIT can be a useful intervention in improving motor function in these children showing a ray of hope for parents. Nurses if trained can be a support in providing the therapy, especially in settings where designated professionals are unavailable.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Smith B. Mental Retardation: An Introduction to Intellectual Disability. Englewood Cliffs NJ: Prentice Hall; 2005.
World Health Assembly. The Work of WHO, 1975: Annual Report of the Director-General to the World Health Assembly and to the United Nations; 1975. Available from: https://apps.who.int/iris/handle/10665/86025
. [Last accessed on 2020 Jun 03].
Census 2011. Population Census 2011. Kerala Disability Census; 2011. Available from: http://www.census2011.co.in
. [Last accessed on 2020 Jun 03].
Stamatelos T, Mott DW. Learned helplessness in persons with mental retardation: Art as a client-centered treatment modality. Arts Psychotherapy 1983;10:241-9.
Uyanik M, Kayihan H. Down syndrome: Sensory integration, vestibular stimulation and neurodevelopmental therapy approaches for children. Stone JH, Blouin M. Int Encyclopedia Rehabil 2010;9:68-73.
Ayres AJ. Sensory Integration and the Child. Los Angeles, CA: Western Psychological Services; 1979.
Bhagya B, Ramakrishna A. Prevalence of mental retardation among children in Mangalore. J Health Allied Sci NU 2013;3:63-6.
Devi M, Arora L, Arora R. Effectiveness of sensory integration therapy on gross motor function in spastic diplegic cerebral palsy children. Int J Sci Res Methodol 2016;3:23-34.
Karim AE, Mohammed AH. Effectiveness of sensory integration program in motor skills in children with autism. Egypt J Med Hum Genet 2015;16:375-80.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]