Developing A Snoezelen Assessment Scale for Therapists and Intervenors (English)

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This presentation is based on a literature review done for the purpose of developing a Snoezelen Assessment Scale for therapists and intervenors. It is a work in progress and something that I hope to share in full with other Snoezelen experts at a later date. The literature review does not focus on the efficacy of Snoezelen as a therapy since there are a number of research articles which have already identified some benefits to clients. Nor is it an attempt to analyze the merits of each and every research methodology used in the studies, since this has already been determined by various researchers such as Lancioni (2002) and Hogg (2001). Rather, it looks at the various measures used to identify which might be the most useful in developing the content of a Snoezelen assessment scale. For that reason, I have listed the sources although not all have been quoted. For a more detailed outline, please contact me at This email address is being protected from spambots. You need JavaScript enabled to view it.

I. Why develop a SNOEZELEN ASSESSMENT Scale?

From my perspective of being involved in the world of Snoezelen over the last three years, I am constantly reminded of Albert Einstein who said:

"Not everything that can be counted counts and not everything that counts can be counted. "

We are all familiar with the work by Jan Hulsegge and Ad Verheul (1987) who state that: "We do not wish to give development and therapy a central focus within Snoezelen. It is fully open. We do not declare aims beforehand." From this perspective, the Snoezelen approach focuses on communicating with clients without pre-judgements, specific programming or sequenced tasks. There are no pressures to perform or achieve, and medical diagnosis and known limitations become secondary. This absence of pressure allows clients to react and respond to this sensory world in their own individual way.

At Bloorview MacMillan Children's Centre, the Snoezelen program currently provides an all important leisure component, which is separate from the various client therapeutic sessions. The Snoezelen room is also viewed as an ideal place for a child to recover emotionally from a potentially traumatic procedure such as a doctor's visit or hospitalization. Thus while Snoezelen is not promoted as a therapy, there is the tacit recognition that the therapeutic effects of Snoezelen are not to be denied.

An ongoing challenge, however, is the absence of a measurement tool that will allow our therapists to reasonably assess the impact of Snoezelen on their respective clients. For example, the Glasgow Coma Scale is used to indicate the depth of the coma and recovery potential. Then, once the patient comes round, they are switched to the Ranchos Los Amigos scale of Acquired Brain Injury (ABI) recovery where each stage is quite predictable and has many sensory needs. Thus, if we had a client in the ABI recovery stage and Snoezelen was inserted at some point in the recovery program, the therapist would have a complementary scale to work with.

A Snoezelen Scale will provide the therapist or caregiver with the opportunity for subtle intervention and assessment of the client's processing, sequencing, and communication skills. The non -stressful environment will provide opportunities for new handling and positioning techniques, and new ways to relate to clients regardless of their age and level of disability. For the client, therapeutic assessment and intervention become less stressful because Snoezelen environment is perceived as being interesting, exciting, relaxing, friendly and safe.

{mospagebreak}II. Research concerns

"Scientific reliability"

One of the primary concerns surrounding Snoezelen for the last decade is the perceived lack of "scientific reliability." Until recently, there has been little research into Snoezelen and its effectiveness with clients (Lindsay, Pitcaithly, Geelen, Buntin, Broxholme & Ashby, 1997). Even then, there are problems within existing studies because many assessment tools while useful clinically, have either not been tested for reliability or validity (Shapiro and Bacher, 2002).

To further reinforce the confusion surrounding Snoezelen, even in 2004, I quote from an article in The New York Times, by reporter Gwen Kinkead, December 23rd 2003 :

-The [Snoezelen] rooms do not provide a cure. They may not even be therapy. Scientists have not examined their effects on sensory-deprived brains. Rather, the rooms are set up to promote well-being without medication. For that reason, experts who expect a wave of Alzheimer\'s cases are looking at them anew

- "It\'s like lots of things that don\'t have a lot of evidence base behind them," Dr. Peter Whitehouse, a neurologist at Case Western Reserve University in Cleveland , said. "You will find some skeptics and some enthusiasts."

- The health care industry in the United States has been less enthusiastic about multisensory stimulation, in part because studies that show that it reduces anxiety and improves sociability have been criticized for their methodology and small sample size

"Do disabled children benefit? asked Joe Kewin, the chief executive of a health care organiztion in Northumberland who introduced Snoezelen to Britain . "This is down to personal feelings. If benefit means smiling, engaging and relaxing, then I believe it is beneficial." www.globalaging.org/health/us/color.htm

"Multiple categorizations and Baseline Concepts"

A major barrier to doing Snoezelen research is the difficulty of establishing a baseline concept. Concepts are essential to the research process (Wimmer, 1997) because they combine particular characteristics, objects or people into more general categories. Concepts also facilitate communication among those who have an understanding of them, such as researchers seeking to establish the validity of Snoezelen as a therapeutic intervention for different populations. However, because of the multiple categorizations of Snoezelen, it makes a literature review more complicated. As therapeutic intervention involving sensory environments evolve , more terms have emerged to describe the "Snoezelen" such as "sensory integration therapy", "multisensory stimulation", and "sensory stimulation" (Chitsey et al, 2002).

{mospagebreak}III. LITERATURE REVIEW: SUGGESTIONS FOR SCALE DEVELOPMENT

This researcher decided to sort the articles by the subject matter as identified in the article's titular heading and abstracts. Seven possible categories were identified: Children (3 articles); Chronic Pain (1 article); Dementia (5 articles); Intellectual disabilities (3 articles); Learning disabilities (4 articles); Multiple Disabilities (6 articles) and; Other- which included general information on Snoezelen, its history, etc., (8 articles). This made a total of 30 articles reviewed. Please note that this categorization is not meant to be definitive since in many cases, the articles could easily fit under more than one category. The articles were then grouped depending on a particular methodology used in the assessment of Snoezelen intervention and their subjects. What then, should one consider in developing a future Snoezelen Assessment Scale?

i) Utilizing existing Scales

Houghton, Douglas, Brigg, Langsford, Powell, West, Chapman & Kellner (1998) used a previously existing scale to measured Snoezelen outcomes on a sampling of 17 students with disabilities. They based their findings on what is called the Foundation Outcome Statement Skills (FOS) mapping instrument, which is used in the Australian education system. This mapping instrument is used to obtain information about childrens- and adolescents- skills in five learning areas. Houghton et al sought to see if exposure to a multi-sensory environment assisted children with severe disability in achieving Foundation Outcome Statement Skills and to assess whether achievements generalize to outside environments. FOS data was collected prior to the multi-sensory room intervention to establish a baseline.

ii) Measuring Emotion

Long and Haig (1992) conducted an exploratory study with four clients with a learning disability to determine whether exposure to a Snoezelen environment would instigate a change in behaviour. Long et al did a study of affect i.e. emotional expression and mood, they did four case studies and in each, a quantitative measure of pleasure is reported a positive, with displeasure never being reported in a Snoezelen setting.

iii) Measuring Interaction

Haggar (1994) recognizes that reciprocal interaction is fundamental to Snoezelen, and adopts the Social reinforcement Scale (S.R.R.S., Gelfland et all 1967) for comparative analysis. The S.R.R.S focuses on the consequences of a given interaction e.g. reward, punishment. It considers whether these consequences are appropriate or inappropriate, and who gave the consequences i.e. staff or client. This measure is particularly useful because one assumes that if there was a high frequency of client rejection of the carers attempts to interact with them, it would suggest that the clients were unrewarding or aversive, which in turn might convey data on measuring client response.

iv) Recognizing Communication Needs

Another consideration comes from Lindsay, Black & Broxholme, (2001) who recognize the fact that 50% of individuals with intellectual disabilities are either pre-verbal or non-verbal, and thus use non-verbal means of communication. In their investigation into four comparative treatments on the concentration and responsiveness of people with profound learning disabilities, they utilize a five point communication scale as a measure of effectiveness. Communication was measured using 10 dependent variables using a five point Likert scale that included positive variables such as friendly vocalization and negative variables such as aggression to others.

{mospagebreak}v) Choice Making

Thompson and Martin (1994) highlight the importance of establishing choice making by people with intellectual disabilities - namely how preferences for different combinations of multisensory equipment may be established in such a group. Egan, (1998) employs a case methodology which involves a multiple case study design consisting of document analysis, focused interviews and participant observation to assess the leisure value of Snoezelen.

vi) Physiology

Shapiro (1997) did a cross-over design between two environmental conditions, which compared Snoezelen and playroom sessions with 20 children who had moderate to severe mental disabilities and exhibited stereotypic behaviour. One half the group started with Snoezelen sessions, which were followed after a seven day hiatus by the playroom sessions. The other half started with playroom sessions, and then attended snoezelen sessions after the stipulated seven day break. Shapiro's study is notable in that it utilized a physiological variable, ambulatory heart rate to determine if stress was lowered by Snoezelen as reflected in a reduced heart rate.

vii) Video

Rozen (2003) took a similar approach to Shapirio in utilizing a cross over design, albeit with one child with severe autistic tendencies. Since this was a five week pilot study, results can not be generalized, although findings were positive for the subject's response to the Snoezelen room. However, what makes Rozen's study quite unique in that it makes extensive use of video record to establish findings - randomly sampled tapes were made in a Snoezelen room and playroom control setting which were rated using a time sample technique. Other studies have utilized recordings but not to the extent where the tapes are analyzed for data.

viii) Including staff responses to Snoezelen

One of the first formal research studies done on Snoezelen was at Whittington Hall, England (Hutchinson and Haggar, 1991) utilized 14 individuals and incorporated an evaluation of staff attitudes towards their clients. Methods of collecting observation data involved kinetic analysis, interviews with staff, and collection of quantitative data. Comparative studies also abound, where compared client behaviour inside and outside Snoezelen allow for the determination of how mood and functioning is influenced by environmental variables. Hope (1997) identified geographical and staffing constraints as factors that would preclude staff willingness to use an already established multi-sensory room within the facility.

ix) Pre-Assessment Tools

Shapiro & Bacher (2002) identify the importance of pre-assessment tools which include baseline observation of performance forms to chart the client's progress; activity sheets which are filled immediately after treatment sessions to gain insight into a particular behaviour; and reactions to set stimuli e.g. massage, to the caregivers facilitating the session.

{mospagebreak}IV. CONCLUSION: DEVELOPING AN ASSESSMENT SCALE

In weighing the research data and methodologies to be utilized toward developing a Snoezelen assessment scale, one must consider that conceptually, Snoezelen has a close relationship to occupational therapy theory (Egan , 1998). In Occupational Therapy theory, there are three main components:

i) Person : Cognitive, Physical, Emotional, Feelings

ii) Environment : Cultural, Social, Institutional, Physical (what's in the environment that will enable them to do the task)

iii) Occupation : Leisure, Self-Care, Productivity

It could be said that Snoezelen's impact is primarily upon the individual's physical well being and leisure. Its therapeutic factors include choice and control over environment; communication; the opportunity for companionship and human contact and; progress from the passive to active involvement in an activity.

Based on the evidence presented in the research articles reviewed, it is suggested that the following be considered in the development of a Snoezelen Assessment Scale:

1. Preliminary Portrait sheets to outline the behavioral indicators of mood as

noted by the primary caregiver and the therapist. This will allow the Assessor to accurately interpret and be aware of client responses and actions. For example, due to physical limitations, a gesture of excitement may be mis-interpreted as being "agitated" and thus a negative response is noted.

2. assess clients using three basic categories which already have established scales of measurement to refer to: Intellectual; Motor; and Language communication domains. The Scale measures should be designed with Snoezelen's original population in mind i.e. moderate/severe physical disabilities with cognitive delays.

3. IMPACT VERSUS BENEFITS that the Scale should focus on measuring the impact of Snoezelen on clients, as opposed to seeking the "benefits" which is more emotive and can potentially prejudice an Assessor's data collection. On should also avoid including "pleasure" as a primary response/outcome because it has been shown that repetitive exposure to Snoezelen is needed for a client to become comfortable to optimally experience and exhibit pleasure (Egan, 1998; pg. 43).

4. Population Is it possible to have a "universal scale"? Perhaps a common preliminary information sheet can be developed that will be appropriate for all individuals but then individual scales be developed for the different populations such as Autism and developmental disabilities.

It is of the utmost important for the development of Snoezelen that a consistent scale of measurement be developed. A recognized Snoezelen Assessment Scale would satisfy the therapeutic profession's need to record outcome based measurements, yet complement the Snoezelen environment. In other words, it will prove that Snoezelen can satisfy science without sacrificing the heart (Dr. Krista Mertens, 1999).

{mospagebreak}APPENDIX 1

Please note that this is in the beginning stages only.
It is not to be considered a final version of the proposed assessment scale

SNOEZELEN ASSESSMENT SCALE

Physiological responses

PRE - Snoez

Snoez

SESSION

POST- Snoez

Breathing :

     

Slow/calm

     

Rapid

     

Agitated

     

Drooling:

     

Mild

     

Moderate

     

Excessive

     

Degree of Locomotion

     

Reflexive

     

Non-reflexive

     

Communication level (I):

Vocalization/gesture/ in response to stimuli

     

No change

     

Slightly improved

     

Marked response

     

Communication level (II)

Interaction with facilitator/caregiver

     

No change

     

Slightly improved

     

Marked response

     

Overall response to room:

Positive (P) Negative (N)

     
 

PRE- Snoz

Snoz SESSION

POST-Snoz

Response to auditory input

Positive (P) Negative (N)

     

Response to aromatherapy

Positive (P) Negative (N)

     

Response to Caregiver (# of times) measure the level of interaction?

     

Visual response to stimuli

     

Brief

     

Sustained

     

Ongoing

     

Duration of response to stimuli (interest):

under 1 min

1 - 3 minutes

Over 5 min

Bubble Wall Panel

     

Projector

     

Fibre Optics

     

Vibrating mat

     

Bubble Tube

     

Projector

     

Vibrating mat

     

Catherine Wheel

     

Evening Breeze

     

Star Panel

     

Magic Glow Board

     

{mospagebreak}Children

Shapiro, M., Parush, S., Green, M., & Roth, D., (1997). The efficacy of the "Snoezelen" in the management of children with mental retardation who exhibit maladaptive behaviours. The British Journal of Developmental Disabilities, 43 (85), _____.

Houghton, S., Douglas, G., Brigg, J., Langsford, S., Powell, L., West, J., Chapman, A., Kellner, R., (1998). An empirical evaluation of an interactive multi-sensory environment for children with disability. Journal of Intellectual and Development Disability, 23(4), 267-278.

Rozen, A., (2003). The effects of a Snoezelen environment on a seven year old male with Severe Autism: a pilot study. Unpublished Degree of Psychology, York University , Toronto .

Chronic Pain

Schofield, P., & Davis, B., (2000). Sensory Stimulation (snoezelen) versus relaxation: a potential strategy for the management of chronic pain. Disability and Rehabilitation, 22 (15), 675-682.

Dementia

Baker, R., Dowling, Z., Wareing, L., Dawson , J., & Assey, J., (1997). Multisensory Environments: The Long -Term and Short Term effects on Older People with Dementia. British Journal of Occupational Therapy , 60, 213-218.

Pinkney, L., (1997). A Comparision of the Snoezelen Environment and a Music relaxation Group on the Mood and Behaviour of Patients with Senile Dementia. British Journal of Occupational Therapy, 60 (5). 209-212.

Spaull, D. & Leach, C., (1998). An evaluation of the effects of Sensory Stimulation with people who have dementia. British Association for Behavioural and Cognitive Psychotherapies , 26, 77-86.

Hope, K. W. , (1998). The effects of multisensory environments on older people with dementia. Journal of Psychiatric and Mental Health Nursing, 5, 377-385.

Lancioni, G., Cuvo, A., & O'Reilly, M., (2002). Snoezelen: an overview of research with people with developmental disabilities and dementia. Disability and Rehabilitation, 24 (4), 175-184.

Intellectual Disabilities

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

Hogg, J., Cavet, J., Lambe, L., & Smeddle, M., (2001). The Use of Snoezelen as multisensory stimulation with people with intellectual disabilities: a review of the research. Research in Developmental Disabilities (22), 353-372.

Lindsay, W., Black, E., & Broxholme, S., (2001). Effects of Four Therapy Procedures on Communication in People with Profound Intellectual Disabilities. Journal of Applied Research in Intellectual Disabilities, 14, 110-119.

{mospagebreak}Learning disabilities

Cunningham, C. C., Hutchinson, R., Kewin, J. Recreation for people with profound and severe learning difficulties: the Whittington Hall Snoezelen project (1991). In Hutchinson, R. (ED). The Whittington Hall Snoezelen Project: a report from inception to the end of the first twelve months. Chesterfield : North Derbyshire Health Authority.

Thompson, S., & Martin, S., (1994). Making Sense of Multisensory Rooms for People with Learning Disabilities. British Journal of Occupational Therapy, 57 (9), 341- 344.

Lindsay, W.R., Pitcaithly, D., Geelen, N., Buntin, L., Broxholme, S., & Ashby M. (1997). A comparison of the effects of four therapy procedures on concentration and responsiveness in people with profound learning disabilities. Journal of Intellectual Disability Research, June 41, 201-207.

Martin, N.T., Gaffan, E. A., & Williams, T. (1998). Behavioural effects of long-term multi-sensory stimulation. British Journal of Clinical Psychology, 37, 69-82.

Multiple Disabilities

Haggar, L., & Hutchinson, R., (1991). Snoezelen: an approach to the provision of a leisure resource for people with profound and multiple handicaps. BIMU Publications, 51- 55.

Long, A., & Haig, L. , (1992). How do Clients Benefits from Snoezelen? An Exploratory Study. British Journal of Occupational Therapy, 55 (3) 103- 106.

Hutchinson, R., & Haggar, L., (1994). The Development and Evaluation of a Snoezelen Leisure Resource for People with Severe Multiple Disability. Sensations and Disability, Exeter , Great Britain : Polestar Wheatons Ltd 18-48.

Ashby, M., Lindsay, W. R., Pitcaithly, Broxholme, S., & Geelen N., (1995). Snoezelen: its Effects on Concentration and Responsiveness in People with Profound Multiple Handicaps. British Journal of Occupational Therapy, July, 58 (7)303-307.

Kenyon, J., & Hong, Chia S. (1998). An explorative study of the function of a multisensory environment. British Journal of Therapy and Rehabilitation, December, 5 (12), 619- 623.

Egan, L.K., (1998). An exploration of a Snoezelen Multisensory Leisure Program for individuals with multiple disabilities: a pilot study. Unpublished Degree of Bachelor of Science, Dalhousie, Halifax.

Other: History/Background/Reviews

Chitsey, A., Haight, B., & Jones, M., (2002). Snoezelen - A Multisensory Environmental Intervention. Journal of Gerontological Nursing, 28(30), 41-49.

Haggar, L., (1994). A Short Training Package for Care Staff using Snoezelen Environments with Profoundly and Multiply Disabled Clients: Design, Implementation and Evaluation. Sensations and Disability, Exeter , Great Britain : Polestar Wheatons Ltd., 49-87.

Hulsegge, J., & Verheul, A., (1987). Snoezelen - Another World. A Practical book of Sensory Experience Environments for the Mentally Handicapped. Exter , Great Britain : BPCC Wheatons Ltd.

Hutchinson, R., (1994). Sensory Environment and Experience - Some Ideas for their Application. Sensations and Disability, Exeter , Great Britain : Polestar Wheatons Ltd., 196 - 212.

Kewin, J. (1994). Snoezelen - The Reason and the Method. Sensations and Disability, 6-17. Exeter , Great Britain : Polestar Wheatons Ltd..

Mertens, K. (1999). "Additional Qualification of Snoezelen: Ideas for a further Traininig and Education Progamme" Snoezelen 3rd World Congress - The Gentle Revolution.

Moore, A., Harris, G., & Stephens, J., (1994). People with a Disability - Therapists and Sensory Activity. Sensations and Disability, Exeter , Great Britain : Polestar Wheatons Ltd., 88- 108.

Shapiro, M., & Bacher, S., (2002). Snoezeling: Controlled Multi-Sensory Stimulation. A Handbook for Practictioners. Israel : Beit Issie Shapiro.

Stephenson, J. (2002). Characterization of Multisensory Environments: Why Do Teachers Use Them? Journal of Applied Research in Intellectual Disabilities, 15 (1).

Wimmer, R. D. & Dominick, J. (1997). Mass Media Research - An Introduction. Belmont California , USA : Wadsworth Publishing Company, 16 - 58.

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