Ayessa Escandar

Lauren Hawkins
OCCT 526

Research Question: Is therapeutic listening an effective intervention strategy in children with

Sensory Processing Disorder?
Article: Hall, L., & Case-Smith, J. (2007). The effect of sound-based intervention on children
with sensory processing disorders and visualmotor delays. American Journal of Occupational
Therapy, 61, 209215.
How does this study relate to your research question?
Through our time spent in a small pediatrics sensory gym for our fieldwork, we were
exposed to children who seeking occupational therapy due to Sensory Processing Disorder
(SPD). Because of this, we created a research question that would explore whether or not
therapeutic listening would be an effective intervention in improving behaviors related to sensory
processing. The study, The Effect of Sound-Based Intervention on Children with Sensory
Processing Disorders and Visual Motor Delays, investigated the effects of therapeutic listening
and sensory diet as an intervention program (Hall & Case-Smith, 2007). Based on the
information found in the study, we can determine if this would be a beneficial intervention to use
in our future practice.
What is the purpose of the study?
What are the research questions/hypotheses?
The purpose of the study was to explore the effects of therapeutic listening while
incorporating a sensory diet as a home program for children who have (SPD and visual motor
delays. The study hypothesized that after an 8-week therapeutic listening and sensory diet
program, the children would display fewer symptoms of SPD and improve visual motor
integration compared to just having a sensory diet plan (Hall & Case-Smith, 2007). In addition,
the researchers hypothesized that the children would also exhibit less behaviors related to SPD
after the 8-week session.

Ayessa Escandar
Lauren Hawkins
OCCT 526

Does the literature review justify the need for this study?
Research has shown that music provides therapeutic factors that can affect your body and
psyche. In the healthcare field, there is a growing use of music and sounds as an intervention
technique. The study justified the need to explore therapeutic listening as a preparation for
therapeutic activities due to finding of past studies. Music can calm and organize the child (Hall
& Case-Smith, 2007). Those studies found that music provides benefits in helping patients with
differing conditions such as attention deficit disorders and autism. To further past research, the
researchers wanted to examine therapeutic listening as a supplement to intervention instead of
just a preparatory activity as there is limited data regarding it.
What is the study design/type of study? What is the level of evidence?
The study design used is a causal design, which investigates a topic and looks at the
effect of one thing on another. In addition, it measures what impact a specific change will have
on an existing norm, and it will seek relationship by testing a hypothesis (Betensky, 2003).
Specifically, the study looks at the topic of SPD and observed the effects of therapeutic listening
and sensory diet. The results from the study will help determine if therapeutic listening could be
a valid tool to use as a sensory integrative approach in occupational therapy. This study was a
level IV study.
How many participants? All together and in each group if applicable.
If applicable how were participants assigned to groups?
In the beginning of the study, 12 children were recruited, however two dropped out
within the first phase making it 10 participants by the end of the 12-week study. The 10
participants were all considered one group where each of them received the same home

Ayessa Escandar
Lauren Hawkins
OCCT 526

intervention program for 12 weeks, which consisted of 4 weeks in phase one and 8 weeks in
phase two.
How were the participants recruited and selected?
How are the participants described- demographis (ex: diagnosis, age, gender, race)?
The participants were recruited using convenience sampling, specifically children who
were referred to occupational therapy in an outpatient clinic associated to a childrens hospital.
All the participants were between 5 and 11 years old. There were nine male participants and only
one female. The researchers set strict inclusion criteria for the participants.
Children who were recruited took the Berry Developmental Test of Visual Motor
Integration (VMI) and had to obtain a score of at least one standard deviation below the mean
(Hall & Case-Smith, 2007). In addition, children had to display behaviors of SPD and indicate a
score of definite difference on at least three subsets of the Sensory Profile. Some exclusion
criteria for participants in the study consisted of those who had moderate to severe mental
retardation, cerebral palsy, Down syndrome, severe autism, and visual and hearing impairment
(Hall & Case-Smith, 2007). However, participants who have attention deficit hyperactivity
disorder, sensory integration disorder, mild autism, Asperger syndrome, developmental
coordination disorder, and developmental or motor delays could be included in the study (Hall &
Case-Smith, 2007).
What are the variables? Independent and dependent if applicable.
The hypothesis of the study predicted that children with SPD will improve visual motor
integration after completing an eight-week therapeutic listening and sensory diet plan compared
to just having a sensory diet plan for four weeks (Hall & Case-Smith, 2007). Therefore, the
independent variable used in the study are the participants in the sensory diet and therapeutic

Ayessa Escandar
Lauren Hawkins
OCCT 526

listening group. While, the dependent variable is improved visual motor integration and reduced
behaviors associated with SPD.
What measures were used?
The study consisted of four standardized instruments, such as the Sensory Profile, VMI,
Draw-A-Person test (DAP), and the Evaluation Tool of Childrens Handwriting (ETCH). The
Sensory Profile was performed twice during the study, one in the beginning and one in the end.
The Sensory Profile consisted of a standardized questionnaire that completed by a parent, which
evaluated the sensory processing of their child. On the other hand, the VMI, DAP, and ETCH
were administered three times before and after each treatment phase. The VMI and DAP
evaluated visual motor integration, while the ETCH evaluated manuscript and cursive
handwriting skills. These instruments were used to evaluate whether the child demonstrates
improvement in behavior and visual motor skills after the second phase.
If applicable, what is the intervention?
The intervention of the study required two phases to be completed. The first phase
consisted of a four-week sensory diet plan, while the second phase required an additional eight
weeks that consisted of therapeutic listening and a sensory diet program. During the first phase
of the intervention, the researchers provided a sensory diet program to the families of the
participants to help them modulate sensory responses and arousals that they may have
throughout the day (Hall & Case-Smith, 2007). The specific strategies that were included in the
sensory diet plan varied upon the needs of the child and the results of their individual Sensory
Profile. Some of the activities within the sensory diet plan include slow rhythmic rocking, deep
pressure massage, heavy work, and tactile stimulation (Hall & Case-Smith, 2007).

Ayessa Escandar
Lauren Hawkins
OCCT 526

During the therapeutic listening and sensory diet phase, families were provided a
therapeutic protocol, which consisted of equipment and two to three individually selected CDs
for each child. During the eight-week intervention plan, participants were required to listen to the
CDs twice a day for 20 to 30 minutes, with at least 3 hours between each session (Hall & CaseSmith, 2007). In order to prevent habituation with the music, all CDs were replaced with a new
CD after 3 weeks. Throughout the second phase, the parents were asked to fill out a record of the
process.
What statistical analyses were used?
What are the findings?
The statistical analyses used to analyze the scores from the instruments is a computerized
program called the SPSS. The pretest and posttest scores from the VMI, DAP, and ETCH were
tested using a repeated measure analysis of variance ANOVA. The ANOVA results from the
VMI visual and motor subscale and the ETCH total legibility subscale demonstrated that vast
improvements were made when comparing the posttest scores to the mean of the pretest scores
(p<.05) (Hall & Case-Smith, 2007). However, scores of the DAP did not show significance.
The Sensory Profile pretest and posttest scores were compared using a paired t-test. The
results from the t-test demonstrated that 9 out of the 14 subscales in the Sensory Profile
improved significantly (Hall & Case-Smith, 2007). For example, auditory, touch, multisensory,
and oral sensory processing subscales all showed a significance level of p<.05. The participants
increased an average of 71 points on the Sensory Profile, reflecting improvement.
Lastly, the researchers observed some of the parents responses from their journals. As a
result, many of the parents described that their child's behavior has improved. Specifically, 4 out
of 5 parents reported that those with children with hypersensitivity were more tolerant of noise.

Ayessa Escandar
Lauren Hawkins
OCCT 526

In addition, many parents reported that tantrums have either stopped or decreased immensely and
performance in school has improved. One parents even reported their childs prescription for
attention deficit hyperactivity disorder was discontinued because he/she no longer needed it.
Do these findings support the hypothesis?
The results of the study demonstrated that the hypothesis was supported through
improvement of behavior and sensory processing. Specifically, the hypothesis indicated that
children with SPD would improve in visual motor integration and decrease in SPD behaviors
after an 8-week program of therapeutic listening and sensory diet compared to a 4-week sensory
diet program (Hall & Case-Smith, 2007). Some of the improved SPD behaviors after the study
were greater interaction with peers, improved attention and transition, and better communication
(Hall & Case-Smith, 2007). In addition, visual subscales, such as visual perception also
demonstrated significance. However, the VMI motor subscale did not change between the pretest
and posttest (Hall & Case-Smith, 2007). Therefore, further study needs to be produced to
demonstrate the effects of visual-motor integration with therapeutic listening and sensory profile.
How do the findings relate to previous research as described in the literature review?
In previous research done by Auditory Integration Training (AIT), similar results have been
presented, such as a decrease in children's sensory processing problems by the use of sound
treatment. Particularly, the study used electronically enhanced popular or classical music that
distorts sound frequencies at random intervals to correct hypersensitive or distorted hearing (Hall
& Case-Smith, 2007). Although this study demonstrated a reduction in sensory problems, mixed
results were produced in determining whether behavior changes could be observed. In another
related study, the technique of therapeutic listening was utilized to determine potential effects on
sensory processing and behavior. The study demonstrated that listening programs displayed

Ayessa Escandar
Lauren Hawkins
OCCT 526

influences in childrens behavior and resulted in improvement in visual motor skills,

handwriting, and coordination (Hall & Case-Smith, 2007).
Does the author state any clinical implications for the findings?
Overall, the authors stated that therapeutic listening, as a sensory integration intervention
should be researched more. However, it was found to be a valid intervention strategy for
elementary-aged students with Sensory Processing Disorder. When used in addition to sensory
diet strategies, it may be particularly beneficial. In addition, the improvements found for the
childrens handwriting may hold some important implication for school-based occupational
therapists.
What are the limitations that the author identifies?
The main limitation of the study was that parents administered the therapeutic listening
program at home instead of a professional. Because of this, the authors were unable to ensure the
consistency of the program. In addition, the study only looked at the therapeutic listening
program for an 8-week time period instead of the normal three to six month duration. Therefore,
the full benefits of the program may not have been realized in that short time period. Last, the
researchers used a convenient sample, therefore providing the researchers with a wide range of
conditions relating to SPD.
Does the author discuss implications for future research?
Further research is necessary to continue to support the benefits of therapeutic listening
on SPD in general. In addition, research is needed to specifically look at the impact the listening
program has in conjunction with traditional occupational therapy. Last, because of the short
duration of this study, the long-term effects of the therapeutic listening program need to be
researched.

Ayessa Escandar
Lauren Hawkins
OCCT 526

What would you say about the sample size? Do you think it is adequate?
The study began with twelve participants and finished with ten. As one of the first
research studies of its kind, the sample size was appropriate. It would have been harder to
educate the parents on the program while continuing to make individualized sensory diet plans.
However, if another study were to be completed again, the number would need to increase. Hall
and Case-Smith (2007) determined that a sample size of ten would be large enough to find
effects.
If the researcher did not find a significant difference between the groups, is it possible that
this is due to type II error? If so, why do you think so?
The researchers did find a significant difference before and after beginning the
therapeutic listening program. Significant improvements were found in nine out of the fourteen
subtests after the 8-week program. Due to this finding, type II error is invalid.
Is there a control or comparison group? If so, the control or comparison group comparable
to the experimental group on key features?
There was no control or comparison group in this study.
Are those administering the outcome measures blind to group assignment?
Because there was no control group, there was no group assignment. In addition, each of
the therapeutic listening programs and sensory diet strategies were individualized to each
participant making it important that both researchers knew the child well. The only part of the
study that was blind was the scoring of the four assessments. The first researcher administered
the assessments, but other occupational therapists blind to the children and the study scored the
tests.

Ayessa Escandar
Lauren Hawkins
OCCT 526

9
Are the participants blind to group assignment?

Again, because there were no group assignments, the participants did not have to be blind
to their intervention. In fact, the participants and parents were educated and trained on the
therapeutic listening program.
Does the researcher account for dropouts in the study? Could dropouts have influenced the
outcomes?
Yes, the researchers acknowledged that two of the participants dropped out from the
study. However, both participants dropped out within the first stage of the study; therefore, the
potential to negatively influence the results is minimal.
Does the researcher report reliability and validity of the outcome measure? Are there
questions about the outcome measures chosen?
Yes, the researchers provided the reliability and validity of the four outcome measures
(sensory profile, Draw-A-Person test, ETCH, and VMI). Though we have not heard of the DrawA-Person test (DAP), the researchers provided an explanation of the test and the reasoning of
using it for this study. There were no questions.
What confounding factors could contribute to or influence the study outcomes?
The researchers mentioned one potential confounding factor in this study. Because there
was a wide range of conditions in addition to SPD, the improvements solely for SPD were
difficult to gage. In addition, many of the children were on medications for their various
conditions that could have influenced the results. Last, some of the children were also receiving
other services during the time of the study. Because of this, it may be difficult to attribute the
childs gains solely to therapeutic listening.

Ayessa Escandar
Lauren Hawkins
OCCT 526

10

What are the major strengths of this study? (list 3)

1. The individualized therapeutic listening program and sensory diet strategies for each
child.
2. The multiple assessments utilized to measure all possible improvements made by the
children.
3. The researchers had strict inclusion criteria for the participants. All of the requirements
were listed in depth within the article.
What are the major weaknesses of the study? (list 3)
1. The children in the study had comorbid disorders making the effects of the therapeutic
listening program solely on Sensory Processing Disorder and visual motor delays
difficult.
2. The parents administered the therapeutic listening program instead of a trained
professional. If the program is utilized in an intervention outside of a study the program is
normally administered a professional.
3. The researchers had to rely on the parent log to judge the consistency of the
administration of the program at home.
How would you use this article as a therapist?
After reading more studies relating to therapeutic listening and understanding the
qualifications to administer it, I would implement it in my practice. Based on this article and
other articles read in the literature review process, I have much respect for this as a supplement
to traditional occupational therapy interventions. Especially if other interventions have plateaued
or have had minimal effects, I would consider using this on a client.

Ayessa Escandar
Lauren Hawkins
OCCT 526

11

How does this article support/not support participation in occupation and field of
occupational therapy?
This article supported the field and benefits of occupational therapy. By utilizing
different techniques unique to the profession, the researchers showed the benefits of the sensory
diet and therapeutic listening. Both of those are integral to the pediatrics branch of occupational
therapy. However, the article did not provide direct support for the field of occupational therapy
or participation in occupations. Though reducing the effects of SPD would increase participation
in occupations, this was not discussed in the paper.

Ayessa Escandar
Lauren Hawkins
OCCT 526

12
References

Betensky, R. (2003). Advance Mixed Message Research Design [PDF document]. Retrieved
from Lecture Notes Online Web Site:
http://libguides.usc.edu/content.php?pid=83009&sid=818072
Hall, L., & Case-Smith, J. (2007). The effect of sound-based intervention on children with
sensory processing disorders and visualmotor delays. American Journal of Occupational
Therapy, 61, 209215.