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Use of Multisensory Environments (MSE) in Clinical Treatment Delivery: A review of the literature

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Use of Multisensory Environments (MSE) in Clinical Treatment Delivery: A review of the literature.

Rick Rader, MD
AADMD VP of Policy and Advocacy


Use of Multisensory Environments with People with Intellectual and Developmental Disabilities in Clinical Treatment Delivery: A review of the literature

David A. Ervin, BSc, MA,1 Betty Geer, DNP, RN, CPNP,2 Janice Ryan, OTD, OTR/L3

1The Resource Exchange, Developmental Disabilities Health Center
2The Resource Exchange
3University of Tennessee at Chattanooga, Dept. of Occupational Therapy

Corresponding Author: David A. Ervin, BSc, MA, The Resource Exchange, 24 South Weber Street, Suite 225, Colorado Springs, CO, 80903;
dervin@tre.org

Introduction

The Resource Exchange (TRE) and Peak Vista Community Health Centers (Peak Vista), co-founders and current partners in the Developmental Disabilities Health Center (DDHC), a healthcare collaborative designed to deliver culturally competent primary care to people with intellectual and developmental disabilities (IDD). Peak Vista was recently awarded a grant, which has been purposed to support the integration of a multisensory environment (MSE) in one of DDHC’s examination rooms. Before deciding an approach to this work, TRE and Peak Vista agreed that an appropriate initial step is a review of the scientific and/or practice literature relevant to the integrated use of MSE in a clinical service delivery environment.

Literature

There is a paucity of research and related literature that speaks to the intersection of MSE and acute clinical care. Most of the general research on the use of MSE is with people with dementia and other forms of neurological/cognitive decline; there is little in the literature on the use of MSE with people with IDD.

Multisensory environment, frequently referred to as Snoezelen™, a commercially trademarked name, is a designated space or room designed to stimulate the senses (visual, auditory, tactile and olfactory) via equipment that is designed to produce a state of mind (Staal, 2012). Snoezelen™ and MSE are often used interchangeably, although it is not entirely accurate to do so. For the purpose of this review, we will use MSE only.

Hogg, et al. (2001) offered a review of research in the use of MSE specifically with people with intellectual disabilities. At that time, there were relatively few studies (n=6) and there were substantial concerns as to research design. Nonetheless, there were a wide range of positive outcomes for people with intellectual disabilities (p. 367) shown in the reviewed research. For example, Fagny (1998) found that so-called ‘anguished’ behavior was markedly reduced in an MSE setting as compared to a non-MSE setting among adults with Autism, along with a reduction in stereotypical behavior and aggression. Further, Fagny observed anguished, stereotypical and aggressive behavior to be at its lowest during/within an MSE setting. Hogg, et al., note that Fagny’s study “vividly illustrates this with an overall beneficial effect demonstrated.” (p. 368)

Lotan and Gold (2009) performed a meta-analysis of the effectiveness of MSE for people with IDD. They reviewed 10 studies, and concluded, not unlike Hogg and colleagues, that rigorous research methodologies restrict our ability to confidently point to established evidence of effectiveness. Lotan and Gold conclude that MSE has a positive influence when used as an intervention tool. (p. 213) There is support for assuming MSE’s value as a therapeutic approach, however, and more research is needed.)

Little research examines the specific relationship of MSE to clinical care delivery. Cermack, et al. (2015) compared Sensory Adapted Dental Environments (SADE) to non-adapted dental treatment environments. In the former, MSE and sensory integration theory informed environmental modification designed to minimize sensory-related discomforts and maximize relaxation. (p. 5) Patients were all children with Autism, ranging in age from 4 to 14 years. The SADE intervention resulted in decreased physiological stress and anxiety compared to the non-adapted environments. Similarly, behavioral distress and child-reported measures of pain were both lower in the SADE intervention.

Shapiro and colleagues (2009) also examined the impact of MSE used during dental interventions for children, ages 6-11, with developmental disability. Children whose treatment was delivered in a sensory adapted environment performed better than those who were treated in a typical environment. She and her colleagues concluded that a sensory adapted environment “creates a significant calming effect for children with developmental disability undergoing a high anxiety procedure.” (p. 549)

Cermack, et al. (2015) and Shapiro, et al. (2009) reflect the preponderance of research on the use of MSE in dental treatment settings focusing on children, especially children with Autism. There is far less attention paid in the literature to adults with IDD and the application of MSE in adult clinical settings. Schoefield and Davis (2000) examined the use of MSE as a strategy in managing chronic pain, finding that patients who used MSE did slightly better that those who engaged in more traditional relaxation techniques (Bernstein & Borcoverc, 1973). It is unclear to what extent the traditional relaxation techniques were adapted to the needs of people with IDD, which raises important questions as to their effective use with this population.

Applications & Implications

Virtually every study of the use of MSE with people with IDD show positive and promising outcomes. Fava and Strauss (2010), in their study of the impact of MSE on the behavior of adults with intellectual disability, summarize that MSE is effective on disruptive behaviors of people with intellectual disability and Austim.

Lancioni, Cuvo and O’Reilly (2002) conducted analyses of research into the use of MSE with people with IDD and dementia. To that purpose, they reviewed 14 studies in the literature that specifically researched MSE and people with IDD. They concluded that results from the relatively few studies at that time resulted in a level of evidence they characterized as preliminary and circumscribed. (p. 180) They go on to suggest caution (p. 182) in drawing any conclusions on the positive impacts of MSE. Alternatively, they also suggest that MSE may indeed be effective, so long as people with IDD are allowed to choose MSE inputs and effects to the fullest extent of their capabilities. This orientation, called Stimulus Preference Screening, should be a part of any application of MSE in a clinical setting and is consistent with person-centered care.

Messbauer and Ryan (2014) describe MSE as a “treatment tool that supports therapeutic change by setting the conditions for transformative emotional, perceptual and behavioral patterns by healers as they promote this same state within their client.” (p. 83) This offers an excellent framework in contemplating the use of MSE in a clinical setting, as it implies the need for shared engagement by both the healer—in this case, a physician, for example—and the patient. It gives rise to contextually appropriate person-centeredness and offers a critical opportunity for the patient to participate in creating his or her own treatment environment. Messbauer and Ryan (2014) refer to Personal Preference Environments, which are “therapeutic for adult [patients].” (p. 94) It is reasonable to infer that use of MSE that is defined in substantial part by the patient is conceptually more likely to be successful than if exclusively determined by only a healthcare professional. Such an approach is also consistent with principles of person-centered care, borne in this context of the Person-Environment-Occupation model of performance that emphasizes the interdependence between the environment and the unique perspective of the person (Law, et al., 1996).

There is no research found in the literature that suggests that MSE should not be used in or is ineffective in application within a clinical setting. A number of studies support the use of MSE to decrease aggressive and/or self-stimulatory behaviors (Kaplan, et al., 2006; Cuvo, May and Post, 2001; Houghton, et al., 1998; Singh, et al., 2004), and there is consensus across the literature of promising clinically significant effects of the use of MSE with people with IDD.

Conclusion

There is relatively little research on the use of MSE in clinical settings for people with IDD, and still less for adults with IDD (Moore, Harris and Stephens, 1994). Studies of MSE in use with children with Autism and other intellectual and developmental disabilities show promise, particularly in dental treatment settings. It is difficult to generalize much of the research due to small sample size, the absence of randomly controlled trials in the studies, and the reliance on qualitative characterizations of impact versus methodologically-sound data collection.

Any use of MSE with a person with IDD in a clinical setting must engage the patient as directly as possible, thus allowing the patient to design, in some part, the MSE environment in which s/he will receive clinical treatment. MSE should be offered to people with IDD according to personal choice (Lotan & Gold, 2009, p. 207).

There are likely to be applications of MSE in a clinical setting that are inappropriate to the needs and desires of people with IDD. That is, the use of MSE is not standard practice and may even be clinically contraindicated.

Some of the research shows little to no impact of MSE on people with IDD (e.g., Meijs-Roos, 1990), with some evidence of behavioral deterioration associated with MSE (see Ashby, et al., 1995; McKee, et al., 2007). While the majority of studies contradict this, it offers an important caution as to expectations. Furthermore, it reinforces the heterogeneity of the community of people with IDD and the importance of proper training of healthcare professionals using this method to promote the relaxation response in clients.

Nonetheless, there is clinically significant evidence of the positive impact of MSE on people with IDD (see also, Ashby, et al., 1995; Shapiro, et al., 1997; Hogg, et al., 2001), as well as on adults with IDD in non-clinical environments (Lotan and Gold, 2009, p. 213). The literature, while consistently suggestive of the positive impacts of MSE on people with IDD, is uniform in urging additional and methodologically sound research on the effectiveness of MSE and its application to clinical settings.

Finally, people with IDD, whose needs and aspirations are fundamental to any treatment decisions, including the application of MSE, are entitled to provide or withhold fully informed consent. Further to this right, which may not be abridged, is the person’s right to information and appropriate accommodations to assure informed consent that allows the individual, or under appropriate legal conditions, a guardian, a health care power of attorney, or a surrogate decision-maker of the individual’s choice, to accept or refuse health-related services (The Arc of the U.S., 2012).

References

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Bernstein D. & Borcoverc T. (1973). Progressive relaxation training. A manual for the helping professions. Illinois: Champaign Research Press.

Cermack, S., Stein Duker, L., Williams, M., Dawson, M., Lane, C. & Polido, J. (2015). Sensory adapted dental environments to enhance oral care for children with Autism Spectrum Disorders: A randomized controlled pilot study. Journal of Autism and Developmental Disorders, 45(9), 2876-2888.

Cuvo, A., May, M. & Post, T. (2001). Effects of living room, Snoezelen room and outdoor activities on stereotypical behavior and engagement by adults with profound mental retardation. Research in Developmental Disabilities, 22(3), 183-204.

Fagny, M. (1998). Etude de l’influence de la technique du “snoezelen” sur les comportements d’adultes autiste profond en institution. Brussels: Universite Libre de Bruxelles.

Fava, L. & Strauss, K. (2010). Multi-sensory rooms: Comparing effects of the Snoezelen and the Stimulus Preference environment on the behavior of adults with profound mental retardation. Research in Developmental Disabilities, 31, 160-171.

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