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Manualization of Occupational Therapy Using Ayres Sensory Integration® for

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DOI: 10.1177/1539449217697044

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OTJXXX10.1177/1539449217697044OTJR: Occupation, Participation and HealthHunt et al.

Article

OTJR: Occupation, Participation and

Manualization of Occupational
Health
2017, Vol. 37(3) 141­–148
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Integration® for Autism DOI: 10.1177/1539449217697044

https://doi.org/10.1177/1539449217697044
journals.sagepub.com/home/otj

Joanne Hunt1, Elke van Hooydonk2, Patricia Faller2,

Zoe Mailloux3, and Roseann Schaaf3

Abstract
This article reports on the development of a Stage 3 manual (following pilot effectiveness study) for implementing occupational
therapy using Ayres Sensory Integration® (OT/ASI) for children with autism spectrum disorders to enhance participation in
daily occupations. Three stakeholder groups were surveyed to aid in translation of manual from research to practice (i.e.,
Stage 3 manual) and an expert consensus meeting was held to finalize recommendations. Data indicated that the manuals
usability could be improved by including a section on frequently encountered problems and solutions, and by including video
case examples. Also recommended were greater chapter uniformity, improved clarity of forms and charts, and inclusion of a
glossary. Changes were made and subject to expert review and consensus using modified Delphi process. The Stage 3 manual
has been rigorously vetted and is ready for practice and research replication.

Keywords
sensory integration, knowledge translation, autism

Introduction Occupational therapy using the principles of Ayres Sensory

Integration® (OT/ASI) is a frequently utilized and requested
Translation of research evidence to clinical practice is intervention for children with autism spectrum disorders
urgently needed to promote evidence-based practice (Clark, (ASDs) to facilitate the child’s participation in activities and
Park, & Burke, 2013; Forsyth, Summerfield-Mann, & improve the quality of life (QoL) for the family. More than
Kielhofner, 2005; Murphy & Gutman, 2012; Schaaf, 2015), 95% of occupational therapists (OTs) working in pediatrics
and one important way to bridge this gap is the translation of report using this approach as part of their practice (Mailloux
research intervention manuals and protocols to clinical prac- & Smith Roley, 2010), and it is one of the most utilized ser-
tice (Blanche, Fogelberg, Diaz, Carlson, & Clark, 2011; vices by parents of children with ASD (Goin-Kochel,
Lopata, Thomeer, Volker, Nida, & Lee, 2008; Schnyer & Mackintosh, & Myers, 2009; Green et al., 2006; Mandell,
Allen, 2002). Manuals that provide guidelines for practice Novak, & Levy, 2005). OT/ASI is a complex intervention that
and research also assure that interventions can be replicated utilizes individually tailored sensory motor activities to facili-
and utilized with high fidelity (Carroll & Nuro, 2002). To tate participation and QoL. The intervention activities are
translate an evidence-based, manualized intervention from based on the child’s unique needs, which are identified in the
research to clinical practice, Carroll and Nuro (2002) pro- assessment data. The intervention involves active participa-
posed a three-stage progression in which a Stage 1 manual tion of the child, with the therapist guiding the process by
tests the feasibility of implementation of the intervention, a facilitating therapeutic activities in the context of play. The
Stage 2 manual evaluates efficacy of the intervention, and a
Stage 3 manual translates the intervention for clinical use
1
with the potential to evaluate its efficacy with diverse popu- Children’s Specialized Hospital, Mountainside, NJ, USA
2
Children’s Specialized Hospital, Toms River, NJ, USA
lations. As the level of complexity evolves through each 3
Thomas Jefferson University, Philadelphia, PA, USA
stage of testing an intervention, a more explicit framework to
guide clinical practice is achieved (Des Jarlais, Lyles, Crepaz, Corresponding Author:
Roseann Schaaf, Department of Occupational Therapy, Jefferson School
& TREND Group, 2004). Westen (2002) advised that seek-
of Health Professions, and Faculty, Farber Institute of Neuroscience,
ing input from clinicians during the development of a Stage Thomas Jefferson University, 901 Walnut Street, Suite 605, Philadelphia,
3 manual is important to ensure clinical utility and applica- PA 19107, USA.
bility of the intervention for practice. Email: [email protected]
142 OTJR: Occupation, Participation and Health 37(3)

therapeutic activities involve sensory motor experiences

aimed at a level of challenge that is considered “just-right” for
the child, and that produce an “adaptive response” as a basis
for enhancing the child’s participation in play, activities of
daily living, learning and social activities in the home, school,
and community (Ayres, 2005; Parham & Mailloux, 2015).
Outcomes of this approach are measured at the proximal (sen-
sory) and distal (participation/occupation-based) levels. The
core principles of the intervention are described elsewhere
(Parham et al., 2011; Schaaf & Mailloux, 2015). Figure 1. Steps in the study process.
Note. This figure illustrates the survey methodology and consensus group
Although OT/ASI is frequently utilized as an intervention processes used in this study. OTP = occupational therapy practitioners;
for children with conditions such as ASD and is highly OTI = occupational therapy interventionists; OTE = occupational therapy
requested by parents, a manual that systematically describes experts in Ayres’ sensory integration.
the procedures of this approach has not been published prior
to the effort explained in this article. The lack of a manual
has resulted in the identification of research studies that outcome measure (Haley, Coster, Ludlow, Haltiwanger, &
claim to be using an ASI approach but are, in fact, not consis- Andrellos, 1992), we found that caregivers rated children in
tent with the principles of this approach (Clark, 2012; Schaaf the treatment group as needing less assistance for participa-
& Case-Smith, 2014). The publication of a manual on this tion in the occupations of daily living skills (p = .008, ES =
approach will help eliminate this confusion. 0.9) and socialization (p = .04, ES = 0.7). With the Stage 1
The American Occupational Therapy Association manual tested for feasibility and the Stage 2 manual tested in
(AOTA) published practice guidelines for OT using sensory an RCT, the next stage for development of this manualized
integration (Watling, Koenig, Davies, & Schaaf, 2011), and intervention is to gather data from key stakeholders to facili-
although this document presents the evidence available at the tate translation of the manual from research to clinical prac-
time, as well as general guidelines for practice, it was not tice (Stage 3). Therefore, the purpose of the study reported
intended to provide specific step-by-step procedures to here was to gather and analyze data that informed the
assure the intervention is replicable, systematic, and focuses advancement of the Stage 2 manual to a Stage 3 manual.
on occupation-based outcomes. Thus, more specific guide-
lines were needed for implementing OT/ASI in clinical prac- Method
tice and research in a consistent, replicable manner with high
fidelity (May-Benson & Koomar, 2010; Miller, Coll, & Overview: The study was approved by the University institu-
Schoen, 2007; Parham et al., 2007; Pfeiffer, Koenig, tional review board of the fourth and fifth authors. Participants:
Kinnealey, Sheppard, & Henderson, 2011). Three groups of key stakeholders were included in the study:
To meet this need, a Stage 1 manual that operationalized occupational therapy practitioners (OTP) who used OT/ASI
the principles of OT/ASI into clinical guidelines was devel- in their clinical practice (n = 25), occupational therapy inter-
oped (The Sensory Integration Research Collaborative, ventionists (OTI) who used the Stage 2 manual during the
2011) and tested in a feasibility study. Findings showed that Schaaf et al.’s (2014) RCT (n = 4), and a group of occupa-
the OT/ASI was safe and feasible to deliver and that parents tional therapy experts (OTE) on OT/ASI (n = 10). We sur-
and therapists rated the intervention as acceptable (Schaaf, veyed each group of participants to obtain the data using a
Benevides, Kelly, & Mailloux-Maggio, 2012). Revisions to step-by-step process, and then, as a final step, a modified
the Stage 1 manual were made to help clarify and guide the Delphi process was used with the OTEs to reach consensus.
interventionist’s clinical reasoning. The participants, methods, and findings for each step are
These substantial revisions included the use of a prelimi- shown in Figure 1 and described below.
nary version of the data-driven decision-making process
(Schaaf, 2015) as the organizing framework to guide the OT
Step 1: Survey of OTPs and OTIs
process during ASI to ensure that the manual was contextual-
ized within occupation and participation, and that outcome Participants
measurement was an integral part of the approach. This Stage OTPs. The OTPs consisted of a convenience sample of
2 manual was tested in a randomized control trial (RCT) for 25 OTs from central and northern New Jersey. They were
children with ASD (Schaaf et al., 2014). This study found surveyed to obtain recommendations for the type of infor-
that children who received OT/ASI using the manualized mation they perceived would be useful for an OT/ASI
intervention scored significantly better on individual goals, intervention manual. Experience ranged from 1 to 25 years
t(23) = −3.23, p = .003, ES = 1.2. In addition, using the with nine (56%) practicing for 1 to 5 years, one (6%) for
Pediatric Evaluation of Disability Inventory as a second 7 years, four (25%) for 16 to 20 years, and two (13%) for
Hunt et al. 143

more than 25 years. Twelve were educated at the master’s Findings from the OTI survey: One hundred percent of
degree level and four at the bachelor’s degree level. Six the OTIs returned their surveys. The data showed that (a)
completed Certification in Sensory Integration via a 60-hr 75% recommended greater organization and uniformity in
program offered by the University of Southern California chapters; (b) 50% recommended greater clarity in the Goal
and Western Psychological Services® (2015). All the OTPs Attainment Scale (GAS) forms, tables, and charts; and (c)
reported using sensory integration theory frequently and 100% recommended consistent terminology throughout the
four reported using it always, within their practices. manual using a glossary of terms.

OTIs. A second group of participants in step 1 were the Step 2: Revisions Based on Survey Findings From
therapists who participated in the Schaaf et al. (2014) RCT
of OT/ASI (n = 4). These therapists were surveyed to gather
OTP and OTI
their recommendations for the Stage 3 manual. The OTIs The five main suggestions from the survey data, namely, (a)
had an average of 22 years of experience, and all completed video case examples, (b) frequently encountered problems
Certification in Sensory Integration via the University of and suggested solutions, (c) greater uniformity in chapters,
Southern California and Western Psychological Services® (d) greater clarity in GAS forms and tables, and (e) a glos-
(2015) program. Two were educated at the master’s level sary of terms were considered for revision in the Stage 3
and two were educated at the bachelor’s level. manual as described below.
To address the recommendation for frequently encoun-
Instruments. Separate online surveys for the OTP and the tered problems and suggested solutions, reflective questions
OTI groups consisted of targeted, forced-choice questions, and tips were developed for each of the main treatment areas
using a Likert-type scale, and open-ended questions. of the manual. Adult learning theory supports the use of strat-
Response options for the OTP survey were always, fre- egies such as self-reflection questions and tips to enhance
quently, occasionally, seldom, and never for the forced- clinical reasoning and to facilitate transformational learning
choice questions. An example question from the OTP survey in which critical reflection is central to the learning process
was, “I would benefit from a treatment manual that would (Merriam, 2001), and thus adult learning guided the develop-
guide clinical reasoning of OT/ASI.” Open-ended questions ment of these.
then queried the participants about the content that would be To address the recommendation for consistent terminology,
helpful in such a manual. a glossary of terms was developed by identifying terms in the
The response options for the OTI survey were strongly Stage 2 manual that were specific to ASI and not part of the
agree, agree, disagree, and strongly disagree for the forced- usual English lexicon. For example, terms such as sensory per-
choice questions. An example question from the OTI survey ception, sensory reactivity, and praxis were identified, and
was, “Using the manual provided structure in the evaluation then, classic literature on sensory integration and neuroscience
process,” and open-ended questions provided an opportunity was used to define these (e.g., Bundy, Lane, & Murray, 2002;
for respondents to indicate specific content they felt would Kandel, Schwartz, & Jessell, 2000; Parham & Faxio, 1997).
be useful in a manualized protocol. An expert in survey To address the recommendation for greater clarity of
development reviewed the surveys and made recommenda- forms and charts, revisions were made to the organizational
tions to improve clarity and to ensure that the items were structure of the GAS quick tips check sheet, the GAS techni-
clear and relevant to the research area. cal checklist, and the parent interview template for GAS.
Research by Beaumont and Russell (2012); Casati and Bjugn
Data analysis. Summary statistics were compiled and (2012); Kerber, Hofer, Meurer, Fendrick, and Morgenstern
responses were calculated and reported as a percentage. (2011); Mason (2012); and Haynes and colleagues (2009)
Qualitative data from the open-ended questions were ana- reported that templates and checklists have good utility in
lyzed using an inductive reasoning process. standardizing patient care processes and optimizing clinical
assessment by cueing important elements. They also show
Results of Step 1 that templates and checklists are useful strategies for stan-
Findings from OTP survey. Sixteen of the 25 OTPs (64%) dardizing patient care and promoting completeness of
returned the survey. One hundred percent of survey respon- documentation. Thus, recommendations regarding clarity
dents indicated that a manual for ASI would always or fre- and organizational structure from this literature guided revi-
quently aid with consistency in practice, including guiding sions of these forms.
clinical reasoning for assessment and intervention. They rec- The suggestions to include video case examples and
ommended that the Stage 3 manual include case examples greater organization and uniformity of chapters deferred as
to exemplify the treatment process, and description of fre- it was decided that these enhancement would be better
quently encountered problems with suggested solutions to addressed in concert with a publisher and copy editor in the
guide clinical reasoning. development and production of a published manual.
144 OTJR: Occupation, Participation and Health 37(3)

Step 3: Review of Revised Documents by the Step 4: Modified Delphi Meeting With OTE
OTE Participants. A Delphi meeting with the OTEs was held to
Participants. The OTE group was comprised of twelve gain consensus on the manual revisions. Seven of the origi-
experts in OT/ASI who were recruited to review the addi- nal 12 OTEs accepted the invitation to participate in the Del-
tions and revisions to the manual. These individuals were phi meeting. One of the seven members was not able to join
chosen because of their expertise in ASI and OT. Experience the meeting in person, but participated remotely.
ranged from 11 years to more than 25 years in practice, with
70% currently practicing in the area of pediatrics for more Procedures. Delphi methodology was used to consider the
than 25 years in a variety of settings, including private prac- revised items (Hartnett, n.d.). The modified Delphi method-
tice, academia, hospital-based setting and schools. All the ology was utilized because this final step necessitated a
OTEs were educated at the doctoral level and had completed methodology that allowed for determination of the extent to
Certification in Sensory Integration in a recognized program. which the OTEs agreed with the revisions. Following this
Within the group of experts, 60% were involved in teaching methodology, the Delphi meeting had an established time
continuing education courses in sensory integration, and frame; a facilitator, note taker, and time keeper; rules regard-
85% had authored or coauthored in publications on the topic ing time for each item and the entire meeting; rules for facili-
of sensory integration. tating consensus; and strategies for resolution of items that
did not achieve consensus as described below. In keeping
Instruments. An online survey was developed and was sub- with Delphi methodology, the OTEs were asked to maintain
ject to expert validation as described previously. The OTE mutual respect, be open to suggestions, and build on ideas.
survey consisted of targeted forced-choice questions using a The procedures are outlined below:
4-point Likert-type scale with responses of strongly agree,
agree, disagree, and strongly disagree, as well as open-ended •• Total time for the meeting was set at 90 min.
questions. Responses of strongly disagree or disagree trig- •• Time for each topic was 2 min.
gered an open-ended question for responders to provide sug- •• A time keeper tracked the discussion time and called
gestions for improvement. Following are examples of OTE for a vote at the 2 min mark.
survey questions: “The Goal Attainment Scale technical •• When 100% consensus was not reached, another
checklist template provides sufficient structure to guide the round of discussion (2 min) occurred followed by a
technical assessment of the goal attainment scales” and “The second vote.
reflective questions and tips section address useful areas to •• Items that reach consensus were considered resolved,
guide clinical reasoning of the therapist in providing Ayres while unresolved items were deferred.
Sensory Integration.” The criterion for acceptance of manual •• Unresolved items were given to a designated expert
revision was set as a rating of agree or strongly agree by 90% from the group who made the final recommendation.
of expert participants.
Results. Of the thirteen revised glossary terms presented for
Data analysis. Frequency distribution of all responses were review, discussion, and vote, consensus was reached on
analyzed and described with the percentage of total response eight. Five glossary terms were deferred (sensory discrimi-
to each of the Likert-type scale answers. nation, bilateral integration, arousal, self-regulation, and sen-
sory reactivity), and one of the OTEs was chosen by the
Results. Eleven of the 12 (92%) OTEs reached consensus on group to make the final revision based on the panel’s conver-
the revised reflective questions and tips; thus, this section sation and their own expert opinion. A sample of glossary
reached acceptable criterion. An example of the final reflec- terms and definitions is shown in Table 2. The entire glossary
tive questions and tips is shown in Table 1. can be found in the Stage 3 manual publication (Schaaf &
The OTE group also reached consensus on 24 of the 37 Mailloux, 2015).
glossary of terms. For those that did not reach consensus, the
OTEs suggested greater clarity in definitions using literature
Discussion
in neuroscience and ASI. The terms were revised accord-
ingly and then subject to re-review at the Delphi meeting as Manualization of an intervention is an important part of evi-
described below: dence-based practice. Manualization provides a systematic
Two forms did not meet the 90% consensus criterion by description of an intervention so that it can be replicated in
the OTEs, namely, the GAS quick tips form and GAS techni- future studies and utilized in clinical practice. A crucial step
cal quality checklist. Specific suggestions for greater clarity in the manualization process is obtaining input from key
and organization of these forms to provide systematic guid- stakeholders (Westen, 2002). In this study, key stakeholders
ance in developing and rating the GAS goals were made. The were represented by the OTPs, OTIs, and OTEs who
forms were revised accordingly. reviewed and contributed input for manual revisions.
Hunt et al. 145

Table 1. Examples of Reflective Questions and Tips.

Reflective questions for sensory perception Tips

Did I provide sensory opportunities (tactile, vestibular, and Choose activities that are rich in total body sensory experiences
proprioception) that address the child’s participation-based that are consistent with the child’s interests and needs.
challenges? Reflect on the child’s assessment data and assure the activities
In what ways did I provide opportunities tailored to the child’s are targeted toward the identified areas.
needs? Identify the adaptive responses and assure they are consistent
Did the child respond to the therapeutic activities with with the stated goals for intervention.
appropriate adaptive responses? Review the assessment data with an eye toward the sensory and
What can I do differently next session to assure that the motor factors that are affecting the child’s participation and
sensory activities are matched to the child’s needs? choose activities that are a good match with these.

Praxis
Were the activities utilized rich in somatosensory experiences Assure that the environment contains a variety of materials and
and require that the child plan and execute purposeful props to allow for total body somatosensory experience and
movements as a basis for participation? that facilitates praxis through play.
In what ways did I support and present challenges to the Tap into the child’s interest and then gradually expand their
child’s ability to conceptualize and plan novel motor praxis and play repertoire.
activities, and to organize his or her own behavior in time Provide a model play for the child if needed.
and space? Beware of being too directive; instead, offer opportunities and
What amount and type of structure did I need to provide for wait for child to respond.
the child to execute and/or create new action ideas for play Be mindful of collaborating with the child on activity choices.
and other activities? Consider phrasing verbal cues in form of questions, for
What changes did the child exhibit related to organized example, “What could we use this for?”
behavior for participation? Allow children time to process and figure things out by
themselves.

Table 2. Sample Terms From Glossary.

Adaptive response
“An appropriate action to an environmental demand. Adaptive responses require good sensory integration, and they also further the
sensory integrative process” (Ayres, 1979, p. 181).
Body awareness (body perception)
A person’s perception of his own body, consisting of sensory pictures or “maps” of the body stored in the brain, may also be called
body scheme, body image, or neuronal model of the body (Ayres, 1979).
GAS
Setting up a measurable scale for goals (Kiresuk & Sherman, 1968); a means of individualized, criterion-referenced, quantifiable
measurement of change across time that involves defining a unique set of goals for each child based on their functional needs
(Mailloux et al., 2007); a method of goal setting and objective measurement of individualized functional responses to therapeutic
interventions (Kiresuk, Smith, & Cardillo, 1994).
Gravitational insecurity
A type of sensory hyperreactivity that involves signs of distress in response to movement or change of head position or center of
gravity that is greater than would be expected; anxiety and distress when head position is changed or movement occurs (Ayres, 1979).

Note. GAS = Goal Attainment Scale.

Carroll and Nuro (2002) suggested that a manual’s util- that such strategies would enhance the clinician’s clinical
ity can be increased by anticipating and acknowledging reasoning process and assure adherence to the interven-
challenging clients and problem areas. They also recom- tion. Adult learning theory also supports the use of strate-
mended strategies such as trouble shooting guidelines, gies such as self-reflection questions and tips to enhance
templates for organizing complex treatments, brief session clinical reasoning and to facilitate transformational learn-
summaries, and outlines to direct clinicians to the key ing in which critical reflection is central to the learning
points of the intervention. Consistent with this literature, process (Merriam, 2001) and guided the development of
our survey data showed that the OTPs and the OTIs recom- these. Thus, the use of reflective questions and tips for
mended the use of self-reflective questions and tips to elu- each intervention area in the Stage 3 manual may be useful
cidate specific intervention principles and solutions. In strategies to shape clinical reasoning and decision making.
keeping with Carroll and Nuro (2002), they also indicated In particular, these reflective questions help tailor the
146 OTJR: Occupation, Participation and Health 37(3)

intervention to the child’s unique participation-based or Conclusion

occupation-oriented outcomes.
Regarding the finding that the inclusion of a glossary Manualization of OT interventions, using the rigorous
with consistent and well-defined terminology would methodologies such as those described in this study, is
improve usability, Schnyer and Allen (2002) promoted the essential to intervention development to provide standard
use of standard terminology in manual development as a procedures for research and clinical practice. Not only do
basis for ensuring replicability, adherence, and internal manualized intervention protocols establish fidelity to
validity of an intervention. They recommend that terminol- intervention principles, but they also assist in developing
ogy be housed in the conceptual framework of the interven- the therapists’ clinical reasoning and facilitating the trans-
tion and promote understanding of the intervention by both lation of research findings to the clinical setting. The meth-
clinicians and researchers. Schnyer and Allen (2002) rec- odologies outlined by Carroll and Nuro (2002), which
ommended the following terminology guidelines when supported the translation of a Stage 2 to a Stage 3 manual
developing manuals: (a) defining terms used, (b) providing for clinical practice, can serve as a model for developing
a substantive term list, (c) stating the sources used, and (d) Stage 3 manuals for other areas of OT practice and research.
establishing agreement among clinicians about the use and Clinician input for the Stage 3 manual helped bridge the
meaning of the terms (Schnyer & Allen, 2002). We fol- divide between research and practice.
lowed these guidelines when identifying and defining ASI The process used in the development of the Stage 3 man-
terms. Although the glossary of terminology was challeng- ual complied with literature that recommends clinician
ing due to varying definitions of some of the terms, the use involvement in the early stages of manual development as
of consensus group methodology was particularly useful as essential for the translation of research to practice (Carroll &
it provided the mechanics to facilitate decision making Nuro, 2002). Thus, the Stage 3 manual for OT/ASI offers a
among experts. This was especially important because we detailed, tested protocol to guide research and practice for
found inconsistent terminology in the literature, use of pro- children with ASDs, thus facilitating evidence-based prac-
fessional jargon rather than lay terminology, and that the tice. Although the manual was specifically tested for children
same term was attributed to different concepts. This lack of with ASDs, it is also easily translatable to other clinical pop-
consistent terminology is one factor contributing to unclear ulations that may have participation challenges related to dif-
practice standards for ASI (Smith Roley, Mailloux, Miller- ficulty processing and integration sensation. Furthermore,
Kuhaneck, & Glennon, 2007), may affect clear articulation the manual describes the use of occupation-based outcomes
of the scope and domain of ASI, and contributes to ASI as part of the OT/ASI approach, and clinicians and research-
being misunderstood and mislabeled (Case-Smith, Weaver, ers may want to consider inclusion of such measures in their
& Fristad, 2015). Thus, the development of a glossary of work. Of note, it is recommended that those utilizing the
terms and the use of OTE via the modified Delphi process manual supplement their knowledge and skills by obtaining
is an important contribution. Given that the glossary of certification in the ASI approach by attending a recognized
terms was subject to rigorous review and consensus, it has certification program
the potential to serve as a guiding document to assure that
terms used are universally understood and communicated Authors’ Note
within and among professionals and parents. This research was approved by the Thomas Jefferson University
Schnyer and Allen (2002) reported that case examples Ethics Committee/Institutional Review Board (phone: 215-503-
help to shape and tailor clinical reasoning as well as provide 8966). This work was completed by the first three authors in partial
fulfillment of an occupational therapy doctoral degree at Thomas
strategies for handling unique clinical situations. Because the
Jefferson University, Department of Occupational Therapy, College
literature on manualized interventions also provides support
of Health Professions.
for our finding regarding use of systematic case examples to
illustrate the assessment and intervention process, this rec-
Declaration of Conflicting Interests
ommendation was considered as highly important. The sug-
gestion for video case examples was deferred so that it could The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
be addressed more comprehensively in concert with a pub-
article.
lisher and copy editor. Dimeff et al. (2009) showed that ther-
apists learning a dialectical behavior therapy preferred
Funding
multimedia on-line training to a written treatment manual.
Thus, online video segments illustrating treatment concepts The author(s) received no financial support for the research, author-
are a useful consideration for presentation of case material in ship, and/or publication of this article.
conjunction with the Stage 3 manual. Similarly, the continu-
ity of chapters in terms of organization, as suggested by the References
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