Weighted Vests Vs. Standard Occupational Therapy on On-Task Behavior in Children with Autism Spectrum Disorders Brittney Schorr, MOTS Agenda • • • • • • • • Background Objective Intervention Methodological Quality of Studies Results Discussion Implications for OT Practitioners Implications for Future Research BACKGROUND photo: medicmagic.net On-Task Behavior photo: whatafy.com Sensory Integration • Regulates behavior through sensory systems: – Tactile – Proprioceptive – Vestibular • SI treatments: – weighted vests – pressured vests – weighted blankets Weighted Vests • Commonly cloth vests with pockets in the front and back • Weights in the pockets • Weights can be made of any material Occupational Therapy Treatment as Usual • Includes: – – – – Music Therapy Therapy Ball Chairs Picture Activity Schedules Hug Machine Picture Activity Schedule Hug Machine Objective • To examine the extent to which the research literature supports weighted vests as compared to treatment as usual as a more effective approach to improving on-task behavior in children with ASD Search Terms • Autism • Weighted vest • Therapy • On-task behavior • Attention • Developmental Disorder Types of Studies • Controlled Clinical Trials • Mixed Study Designs • Experimental Research • Single Subject • Children with: Participants – ASD – Attention deficit hyperactive disorders (ADHD) – Developmental delays • 2 to 13 years old • 45 boys, 11 girls (56 total) Diagnoses & Interventions Weighted Vest 4 Autism and PDD Fertel-Daly et al., 2001 Hodgetts et al., 2010 Kane et al., 2005 Leew et al., 2009 1 ADHD VandenBerg, 2001 1 Developmental Delays Reichow et al., 2009 Diagnoses & Interventions Therapy as Usual (all children with autism) 1 Music Therapy Kim et al., 2008 1 Hug Machine Edelson, et al., 1998 1 Picture Activity Schedules Bryan & Gast, 2000 1 Therapy Ball Chairs Bagatell et al., 2010 Inclusion Criteria • • • • • Confirmed physician diagnosis Between 2 and 13 years old Korean Childhood Autism Rating Scale Problematic behaviors interfering with ADLs 65 or above on Conners’ Teacher Rating Scale Exclusion Criteria • Diagnoses not confirmed by physicians • Over 13 and younger than 2 years old • Current therapy (OT, PT, SLP) in 9 studies • Co-morbid diagnoses Sample Sizes • Range: 1 child to 12 children • Average: 6 children per study Weighted Vest Intervention: ABA Withdrawal Design • Initial baseline phases (A) – Classroom fine-motor activity • Intervention phases (B) – – – – Classroom fine-motor activity 2 studies: Vests worn six 20-30 minute sessions 1 study: Vests worn 2 hrs. per day, 3x/wk for 12 wks 1 study: Vests worn 45 minutes during 14 sessions • Withdrawal phases (A) – Classroom fine-motor activity – Removal of vests Weighted Vest Intervention: ABC Withdrawal Design • Baseline phase (A): – Classroom fine-motor activity • Experimental phase (B): – Vests worn without weight 20-30 mins./day for 2 wks • Experimental phase (C): – Vests worn with weight 20-30 mins./day for 2 wks Treatment as Usual: Hug Machine • Two 20 min. sessions/wk. for 6 wks. • Experimental group: – Lie in Hug Machine – Lever provided deep pressure • Control group: – Lie in the Hug Machine – Lever disengaged Treatment as Usual: Therapy Ball Chairs • Baseline phase: – 15 minute classroom “Circle Time” – No therapy ball chairs • Intervention phase: – Utilized therapy ball chairs during “Circle Time” Treatment as Usual: Picture Activity Schedules • Baseline phase: – Classroom activity 45 mins./day for 5 days – No picture activity schedule • Intervention phase: – Picture activity books – 4 step activity Treatment as Usual: Music Therapy • Baseline phase: – Observed engagement during normal play – 30 mins./day for 12 weeks • Intervention phase: – Observed during normal play incorporating music – 30 mins./day for 12 weeks Outcome Measures • Data sheets (10 studies) • Data collection: – – – – – Videotaped recordings Researcher observations Conner’s Parent Rating Scale Parenting Morale Index Pre-tests and post-tests • Pervasive Developmental Disorder Behavior Inventory-C Data Analysis • MANOVA • Repeated measures ANOVA • 2-standard deviation • Celeration line approach – Predicted an increase or decrease in on-task behavior Methodological Quality of Studies • Natural environments – Classroom – Home • Randomization in 5 studies • Blinding in 5 studies Controlling for Threats to Validity • Same diagnoses • Did not include scores of 3 children who dropped out • Served as own control • Inter-rater reliability • Controlled for maturation by conducting the studies within weeks Limitations • Small number of participants • Only male participants in four studies • Only one facility when recruiting participants • Unequal groups in 4 studies: – Group numbers – 1 child had previous experiences with weighted vests – Experimental group rated higher on the Tension and Anxiety Scale than control group Limitations • Poorly defined procedures: – Did not state the frequency, duration, or intensity of OT • Undisclosed treatment environment • No means of controlling environmental distractions – Disruptive classmates – Loud noises • No randomization in group assignments in 5 studies Limitations • No experimenter blinding in 5 studies • No psychometric properties of tests were disclosed in 5 studies • Hawthorne effect – Children knew they were being observed Results: Treatment as Usual • Hug Machine: – Experimental group lower tension levels on the Tension Scale than control group • t(10)= 3.124, p<.05 – Lower on Anxiety Scale than the control group • t(10)=1.959, p<10 • Therapy Ball Chairs: – Positive effects during “Circle Time” – Decreased number of minutes spent out of chair – No p values given Results: Treatment as Usual • Picture Activity Schedule: – Children remained on-task and on-schedule when using the books – No p values given • Music therapy: – Increased eye contact (p<0.0001). – Medium effect on on-task behavior (d=.63) Results: Weighted Vests • ADHD: – Significant change (p<.05) from baseline to intervention – Increase in on-task behavior (18% - 25%) • Developmental Delays: – No improvement in on-task behavior – Greater incidences of problematic behavior – No p values Results: Weighted Vests • PDD: – 1st study • Decrease in number of distractions • Increase in focused attention • No p values – 2nd study (PDD & autism) • No increase in on-task behavior • No p values Results: Weighted Vests • Autism: – 1st study • No overall improvement in on-task behavior • Slight increase in on-task behavior in one child, but not maintained • No p values – 2nd study • No increase in on-task behavior • No p values Discussion • Evidence suggests that weighted vests are not a more effective intervention than OT as usual for increasing on-task behavior in children with Developmental Delays and ASD (autism, PDD) Discussion • Weighted vests appeared to temporarily improve on-task behavior in one child with PDD – Long term effects not evaluated – Child received OT throughout the study – Unable to determine whether the results were contributed to the vests or from OT Discussion • Weighted vests appeared to have significant effects on children with ADHD • Only included 4 children – Convenience sampling recruitment method – Long term effects not evaluated Discussion • OT as usual is noted to be a more effective method for promoting on-task behavior in children with ASD • Therapy ball chairs – Positive effects on in-seat and on-task behavior • Music therapy – Effective intervention Discussion • Hug Machine – Deep pressure can contribute to an increase in ontask behavior – Extensive measures to control for threats • Picture activity schedules – Children’s performance increased by 100% Conclusion • Efficacy of weighted vests depends on the child and his or her diagnosis • OT as usual appears to be a more reliable option for improving on-task behavior in children with ASD Implications for OT Practice • Weighted vests may provide short-term calming effects on children with ADHD, but long-term effects have not been evaluated • OTs should not generalize the results to adults and diagnoses outside of the study • OTs who use weighted vests must proceed with caution until further evidence can be established Implications for Future Research • Replicating in other contexts • Long term effects • Longer intervention period • Examining other protocols • Larger sample sizes • Boys and girls • Increasing amounts of weight in vests References • • • • • • • • • • • • • • Bagatell, N., Mirigliani, G., Patterson, C., Reyes, Y., & Test, L. 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Immediate effect of Ayres’s sensory integration–based occupational therapy intervention on children with autism spectrum disorders. American Journal of Occupational Therapy, 61, 574–583. Thank You!