OTFC response to Forbes article - OTFC
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OTFC response to Forbes article

OTFC response to Forbes article

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As a 20-year experienced Occupational Therapist, private practice director at Occupational Therapy for Children (OTFC), provider of Sensory integration therapy – certified in Sensory Integration Assessment (SIPT) and treatment through the University of Southern California, advocate for families with disabilities (especially children with Autism Spectrum disorder) and mentor/clinical director to 10 amazing occupational therapists I feel compelled to respond to the article “Sensory Therapies For Autism: How much sense do they make?” written by Emily Willingham.

Upon receiving an email from a parent at my practice providing me with the link to the Forbes article, OTFC management and clinical staff have had measured and thoughtful discussions about the article and how to respond. For the record, this is the email I received:

____________________________

Hi Dino

I hope you are well.

This article is being shared far and wide, interestingly by providers of ABA.  I feel like my kids are the poster children for sensory integration therapy so this annoys me so much.

Thinking it might be time for you to write a response for your blog.  ;).

https://www.forbes.com/sites/emilywillingham/2017/05/27/sensory-therapies-for-autism-how-much-sense-do-they-make/#6f9502e04d79

kind regards

Rebecca

____________________________

My response followed:

____________________________

Hi Rebecca

Thank you for the email. Yes, we have seen it already, and we are thinking about how to respond in a positive way and not a reactive way through social media. The fact is that some people are impressionable when it comes to information like this but I have always known that honest work, a sound theoretical base and years of proven hard work and real progress for children will always prevail. Those outside (and even some within the profession of OT) have gone to great lengths to question and even condemn SI therapy over the years and this current Psychologist will not be the last. The fact is, there is good evidence based research but there isn’t the same amount as there is in ABA for instance. The research that has been done often states SI therapy but if they actually knew what it was they would see that their research doesn’t actually look at SI therapy in the way it is conducted at OTFC (Ayres SI Therapy). Many OT’s claim to do SI therapy but they do not reach the fidelity measures (gold standard in SI therapy) and therefore it serves to make SI therapy vulnerable to criticism which is understandable. We can talk about this forever but I know what we do at OTFC works and helps many children and their families. Parents like you are our greatest advocates, allies and protectors – we judge what we are doing by scientific data as much as the feedback we get from children and families. It once made me angry and concerned but now I laugh and OTFC keeps pushing forward doing what we have always done. Thank you for your concern and for being a ‘protector.’ The best thing you can do is talk to people about your experiences and hope they take that at face value rather than look at false stats and opinions.

Have a great weekend. Regards,

Dino Mennillo (BAppSC – OT)

Clinical Director

____________________________

We discussed the options available and determined that analysing the referenced articles to see exactly what was used to base the author’s and researcher’s opinions was the most logical approach to take. An amazing final Masters OT student, Erika, took it upon herself to work through a systematic review of the articles and compared them to whether or not they met the fidelity measures for Ayres Sensory Integration. This is also provided for your reference in the table at the end of this response (appendix).

Erika took greater initiative and provided the following correspondence to myself and OTFC staff:

____________________________

Dear OTFC staff and community members,

On May 27th, 2017, Forbes business magazine released an article titled “Sensory Therapies for Autism: How Much Sense Do They Make?”. This article purported to criticize sensory integration as a treatment modality for autism. A systematic review of 24 journal articles published in Pediatrics by Wietflauf et al was used to make this argument, concluding that the evidence for Jean Ayres Sensory Integration for autism is non-existent (1). On behalf of Occupational Therapy for Children, we seek to clarify and address any concerns elicited by the Forbes article.

Looking at the evidence

Firstly, through thorough analysis of these articles, it becomes apparent that the material cited does not reflect Jean Ayres Sensory Integration, but refers to broader sensory based therapies. These include environmental enrichment, qigong massage and auditory enrichment, to name a few. Moreover, upon further analysis, we have found that only two of the cited articles adhered to Jean Ayres fidelity measures criteria (2). These consist of structural and process elements which are used to measure the degree to which the sensory integration intervention in a study reflects the therapeutic principles of Jean Ayres Sensory Integration (2). For example, a current requirement of Jean Ayres Sensory Integration fidelity measures is that a minimum of two types of sensory opportunities need to be present in a sensory integration based intervention. These include, proprioceptive, tactile or vestibular input (2).

As we examined the evidence further, we found further research supporting the Jean Ayres Sensory Integration therapy approach not cited in the Forbes article. These articles include positive outcomes such as parent reported increases in children’s occupational performance, decreases in sensory reactivity and increases in self-regulation (3).

The research currently published on Jean Ayres Sensory Integration treatment is promising, as it produces significant changes in social skills and self-care, due to improvements in praxis skills, behavioural regulation, and sensory modulation (4). Other beneficial outcomes of Jean Ayres Sensory Integration include increases in fine motor skills, gross motor skills, as well as auditory, tactile, vestibular and movement perception (4). These findings further align with parent perceived improvements, such as needing less caregiver assistance during social activities and during self-care.

As the wealth of information pertaining to Jean Ayres Sensory Integration is gathered and synthesized, more rigorous research is needed. No one therapy will work for every child or every family. At OTFC, we emphasize a client-centered, coordinated approach incorporating multiple disciplines, such as occupational therapy, speech therapy, psychology, neurology, and education. However, the most important voice is and will always be that of the child and their family.

References

  1. Weitlauf AS, Sathe N, McPheeters ML, Warren, ZE. Interventions Targeting Sensory Challenges in Autism Spectrum Disorder: A Systematic Review. Pediatrics. (2017) May;139(6): 1-22
  2. Parham LD, Smith Roley S, May-Benson TA, Koomar J, Brett-Green B, Burke JP, Cohn ES, Mailloux Z, Miller LJ, Schaaf RC. Development of a Fidelity Measure for Research on the Effectiveness of the Ayres Sensory Integration Intervention. The American Journal of Occupational Therapy. (2011) March; 65(2):133-14
  3. Schaaf RC, Cohn ES, Burke J, Dumont R, Miller A, Mailloux Z. Linking Sensory Factors to Participation: Establishing Intervention Goals with Parents for Children with Autism Spectrum Disorder. The American Journal of Occupational Therapy. (2015) September; 69(5)
  4. Schaaf RC, Benevides T, Mailloux Z, Faller P, Hunt J, Van Hooydonk E, Freeman R, Leiby B, Sendecki J, Kelly D. An intervention for Sensory Difficulties in Children with Autism: A Randomized Trial. Journal of Autism and Developmental Disorders. (2014) July; 44(7):1493-1506

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I feel that the systematic review and responses provide the objective perspective that is needed, rather than to give opinions. I understand that the author, Emily Willingham, is employed to provide ‘her opinion’ and that Forbes clearly states that “opinions expressed by Forbes contributors are their own’, however this does not excuse incorrect citation or one person’s opinion that can have a direct impact on many families and their children with autism worldwide. Interestingly, Emily references her own son having therapy and the gains that he made. She also discusses the gains possibly being attributed to the ‘Awesomeness of the people and place’ and relates this to the ‘placebo effect.’ A very important part of Sensory Integration therapy is the child-therapist relationship and see it as integral to ‘therapy’ we provide. Many honest parents have questioned the effectiveness of ‘Sensory Integration’ in contributing to the gains their children have made at my practice over the last 15 years and whilst I sincerely thank them for their honesty, my response in question is always the same: “Given the progress your child has made, the money you have spent and what your family life is like today, if you had the time again, would you choose to include Sensory Integration at this practice as part of the coordinated approach to supporting your child’s development?” The answer is always the same.

 

APPENDIX

 

Review of articles 13-32 cited in journal article:

 

Weitlauf, Amy., Nila Sathe, Melissa., McPheeters, Melissa., Warren, Zachary. (2017). Interventions Targeting Sensory Challenges in Autism Spectrum Disorder: A Systematic Review. Pediatrics, 139(6). DOI: 10.1542/peds.2017-0347, 1-22

                                                                                    ASI Fidelity Measures
                                                                                     Structural Elements      Process Elements
 

 

 

Fazlioglu, Yesim & Baran, Gulen. (2008). A Sensory Integration Therapy Program on Sensory Problems for Children with Autism. Perceptual and Motor Skills, 106,415-422. O – Does not mention qualification of the leading therapist

 

-No mention of mentorship or supervision

 

 

-No specification of number of hooks for suspended equipment or sensory integration related equipment

 

Gattinoa, Schulz, Gustavo., Dos Santos Riesgo, Rudimar., Longob, Danae., Loguercio Leitec, Julio, Cesar., Schuler Faccini, Lavina. (2011).  Effects of relational music therapy on communication of children with autism: a randomized controlled study. Nordic Journal of Music Therapy, 20(2), 142–154

 

 

 

-Led by graduate music therapists -Equipment relevant to relational music therapy interventions and clinical routine activities; such as psychiatric and neurological consultations, as well as medical examinations. The former used musical instruments such as an acoustic guitar, drums, metal rattles, a tambourine, a cow bell, a cabasas, wood claves, a 4-octave keyboard, drum sticks, a rain stick, and an audio system.

 

 

 

 

 

 

-Does not meet 2 of 3 sensory opportunities (tactile, vestibular, proprioceptive)
·         Corbett, A, Blythe., Schickman, Kathryn., Ferrer, Emilio. (2008). Brief Report: The Effects of Tomatis Sound Therapy on Language in Children with Autism. Journal of Autism and Developmental Disorders. 3(38), 562-566

 

-The Tomatis Method was administered by two trained assistants at The Listening Clinic in Sacramento, CA

 

-No mention of mentorship or supervision

-No motor coordination skills, gross motor skills or praxis skills mentioned: tests auditory perception, receptive and expressive language

 

 

-Acoustic signal modulation equipment

 

– “Electronic Ear” (EE) headphone, with attached oscillator

 

 

 

-Does not develop 2 of 3 types of sensory opportunities: tactile, proprioceptive and vestibular input

 

 

 

Schaaf, C, Roseann., Benevides, Teal., Mailloux, Zoe., Faller, Patricia., Hunt, Joanne., Van Hooydonk, Elke., Freeman, Regina., Leiby, Benjamin., Sendecki, Jocelyn., Kelly., Donna. (2014). An intervention for Sensory Difficulties in Children with Autism: A Randomized Trial. Journal of Autism and Developmental Disorders. 44(7), pp 1493-1506

 

*Adhered to fidelity measure, with section on fidelity measures, no other gaps*
Pfeiffer, A, Beth., Koenig, Kristie., Kinnealey, Moya., Sheppard, Megan. (2011). Effectiveness of Sensory Integration Interventions in Children with Autism Spectrum Disorders: A Pilot Study. The American Journal of Occupational Therapy, 65(1)

 

-Led by experienced occupational therapist and occupational therapy graduate student

 

-No mention of mentorship or supervision

-No interpretation of effects of sensory integration and praxis on referring problem -Equipment designed for sensory integration, but not specified
Gringas, Paul., Green, Dido., Wright, Barry., Rush, Carla., Sparrowhawk, Masako., Pratt, Karen., Allgar, Victoria., Hooke, Naomi., Moore, Danielle., Zaiwalla, Zenobia., Wiggs, Luci. (2014). Weighted Blankets and Sleep in Autistic Children-A Randomized Controlled Trial. Pediatrics, 134(2), 298-306. DOI: 10.1542/peds.2013-4285

 

-No mention of therapist credentials or mentorship/supervision: carried out by researchers -Postural ocular control, visual perceptual, fine motor skills not mentioned

 

-No mention of performance patterns, or sensory preferences

 

-No mention of visual-perceptual and fine motor skills

 

-No mention of motor coordination, praxis, and gross motor skills

 

-No summary interpretation: effects on auditory integration

-No data collected testing reduction of sensory problems

-Equipment limited to weighted blankets, actigraphs and sleep diaries

 

-Equipment not relevant to sensory integration therapy: no hooks, no rotational devices, no bungee cords, no mats, no cushions, no pillows

 

-No discussion of potential influence of praxis on the child’s performance

 

-No discussion of the child’s praxis abilities and their influence on the child’s and family’s participation in the home, school, and community

-No collaboration on activity of choice

 

-Activity not gauged to just-right challenge

 

-Intrinsic motivation to play not included: not play based

 

Mudford, OC., Cross, BA., Breen, S. (2000). Auditory integration training for children with autism: no behavioral benefits detected. American Journal on Mental Retardation, 105(2), 118-129 -All children seen by consultant psychologist with occasional assistance from undergraduate psychology students

 

-Auditory integration training provided by trainees of Director of the Society of Auditory Intervention Techniques. Trainees and assistants had a minimum of 4 years working with children with problem behaviors and autism

-No summary interpretation: effects on auditory integration

 

-No data collected testing reduction of sensory problems

-Audio tone enhancer/trainer evaluated by electronics technician

 

-CD players for control group

Porges, W, Stephen., Bazhenova, V, Olga., Bal, Elgiz., Carlson, Nancy., Sorokin, Yevgeniya., Heilman, J, Keri., Cook, H, Edwin., Lewis, F, Gregory. (2014). Reducing auditory hypersensitivities in autistic spectrum disorder: preliminary findings evaluating the listening project protocol. Frontiers in pediatrics, 2(80), 1-10. DOI:  10.3389/fped.2014.00080 – The listening project protocol (LPP): questionnaires scored by researchers, frequencies of sharing behaviors coded by professional coders

 

-Led by clinicians and

experimenters

-Postural-ocular control, visual-motor and fine motor skills not mentioned

 

-Motor coordination, gross motor skills and praxis not mentioned

 

-No summary interpretation: interpretation of the effects of sensory integration and praxis on referring problem

 

 

-Circumaural headphones and play materials (books, house accessories, doll house, stuffed animals, coloring books and crayons, pretend kitchen accessories, pretend parking and garage and cars)

 

-No hooks for suspension, mats, cushions, pillows, bungee cords or rotational equipment: auditory based therapy

 

-Variety of equipment not present

 

-No discussion of potential influence of sensory integration and praxis on the child’s performance

 

-No discussion of the child’s sensory integration and praxis abilities and their influence on the child’s and family’s participation in the home, school and community

-Does not challenge ocular, oral, postural, or bilateral motor control

 

-Does not challenge praxis and organization of behavior

 

-No mention of therapeutic alliance

Thompson, GA., McFerran, KS., Gold, C. (2014). Family-Centred music therapy to promote social engagement in young children with severe autism spectrum disorder: a randomized controlled study. Child Care Health Development, 40(6), 840-852 -Led by accredited university-trained music therapist (15 years experience)

 

-Children in Family Centred-Music Therapy (FCMT) group received additional therapies: occupational therapy, applied behavioural analysis therapy, speech and language therapy

 

-No mention of mentorship/supervision

-Musical instruments: percussions, guitar

 

-No mention of other equipment

-No summary interpretation: effects of sensory integration and praxis
Latham, O, Susan., Stockman, J, Latham. (2014). Effect of Augmented Sensorimotor Input on Learning Verbal and Nonverbal Tasks Among Children with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders, 44(6), 1288-1302. DOI: 10.1007/s10803-013-1990-9

 

-Author did the teaching of juice making, and audio-visual recording of the data

 

-Performances scored by other people blind to the study

-Absence of physical activities, and related equipment -No mention of a just right challenge

 

-Does not tailor to activity of choice

Kim, Jinah., Wigram, Tony., Gold, Christian. (2008). The Effects of Improvisational Music Therapy on Joint Attention Behaviors in Autistic Children: A Randomized Controlled Study. Journal of Autism and Developmental Disorders, 38, 1758-1766. DOI: 10.1007/s10803-008-0566-6

 

-Two music therapists, one play therapist and three music therapy graduate students formed the research team -Does not specify which materials are used
Woo, C, Cynthia., Leon, Michael. (2013). Environmental Enrichment as an Effective Treatment for Autism: A Randomized Controlled Trial.

Behavioral Neuroscience, 127, 4, 487– 497. DOI:
10.1037/a0033010

-No sensory integration therapy was permitted at any time during the study
Srinivasana, M, Sudha., Eigstic, Inge-Marie., Neellyd, Linda., Bhat, N, Anjana. (2016). The effects of embodied rhythm and robotic interventions on the spontaneous and responsive social attention patterns of children with autism spectrum disorder (ASD): A pilot randomized controlled trial. Research in Autism Spectrum Disorders, 27, 54–72. DOI: 10.1016/j.rasd.2016.01.004

 

 

 

 

 

 

 

 

-No mention of mentorship or supervision

 

-Two expert and two parent’s sessions, no specification of qualifications

-No mention of the sensory process: modulation and discrimination, postural-ocular control, or visual-perceptual and fine motor skills

 

-No summary interpretations mentioned: interpretation of the effects of sensory integration and praxis on referring problems

-Equipment relevant to rhythm, robotic, and comparison groups: xylophones, tambourines, as well as scissors, Lego, and playdoh

 

-Equipment not relevant to sensory integration therapy: no hooks, no rotational devices, no bungee cords, no mats, no cushions, no pillows

 

-No mention of equipment safety

-No discussion of influence of sensory integration or praxis on the child’s and family’s participation in the home, school,  or community -No mention of physical safety

 

-No mention of sensory opportunities

 

-No mention of challenges of praxis and organization of behaviour

 

-No mention of a just right challenge

Srinivasan, M, Sudha., Eigsti, Inge-Marie., Gifford, Timothy., Bhat, Ajana, N. (2016). The effects of embodied rhythm and robotic interventions on the spontaneous and responsive verbal communication skills of children autism spectrum disorder (ASD): a further outcome of a pilot randomized controlled trial. Research in Autism Spectrum Disorders, 27, 73-87. DOI:
10.1016/j.rasd.2016.04.001
-Details of expert training reported in first manuscript; physiotherapist led

 

-No mention of supervision/mentorship

 

-Focus on language and social skills, no mention of postural ocular control -Equipment: play based intervention with robot and rhythm initiated conversations
Additional articles reviewed-meeting ASI fidelity measures 1. Schaaf, C, Roseann., Benevides, Teal., Mailloux, Zoe., Faller, Patricia., Hunt, Joanne., Van Hooydonk, Elke., Freeman, Regina., Leiby, Benjamin., Sendecki, Jocelyn., Kelly, Donne. (2014). An Intervention for Sensory Difficulties in Children with Autism: A Randomized Trial. Journal of Autism and Developmental Disorders, 44(7). DOI:  10.1007/s10803-013-1983-8.

 

2. Schaaf, C, Roseann., Cohn, S, Ellen., Burke, Janice., Dumont, Rachel., Miller, Amy., Mailloux. (2015). Linking Sensory Factors to Participation: Establishing Intervention Goals with Parents for Children with Autism Spectrum Disorder. (2015). The American Journal of Occupational Therapy., 69(5).  DOI:  10.5014/ajot.2015.018036

 

3. Pfeiffer, A, Beth., Koenig, Kristie., Kinnealy, Moya., Sheppard, Megan., Henderson, Lorrie. (2011). Effectiveness of Sensory Integration Interventions in Children with Autism Spectrum Disorders: A Pilot Study. The American Journal of Occupational Therapy, 65(1), 76-85

 

 

 

 

4. Smith Roley, Susanne., Mailloux, Zoe., Parham, Diane., Schaaf, C, Roseann., Joy Lane, Christianne., Cermak, Sharon. (2015). Sensory Integration and Praxis Patterns in Children with Autism. The American Journal of Occupational Therapy, 69.

 

 

 

 

 

5. Schaaf, C, Roseann., Hunt, Joanne., Benevides, Teal. (2012). Occupational Therapy Using Sensory Integration to Improve Participation of a Child with Autism: A Case Report. The American Journal of Occupational Therapy, 66, 547-555. DOI:  10.5014/ajot.2012.004473

-Evaluation of manualized interventions for sensory difficulties; effects of intervention on parent report, individual goal attainment and sensory behaviors

-Contextualized in play therapy

-Adheres to Ayres Sensory Integration fidelity measures

-Outcome:

 

o   Support for SI-OT approach: subjects with ASD randomized to treatment scored higher on the outcome measures, needing less caregiver assistance during self-care and social activities (improved praxis and body awareness)

 

o   Methodological limitations: preclude conclusions due to lack of manualized protocol and measurement of treatment adherence, need for well characterized sample

 

 

 

-Analysis of 160 parent-identified ASD related goals and their sensory factors

-Customized interventions that were tailored to parent concern, addressing sensory integrative factors

-Theoretical perspective used was Ayres Sensory Integration (adhered to ASI fidelity measures)

-Outcome:

 

o   Parents identified participation in ADL’s, play and social participation as top three goal areas. Problems in sensory reactivity were the most frequent sensory integrative factor identified

o   Methodological limitations: Based on analysis of existing data with reliance on the evaluators’ skills and interpretation of the sensory integrative factors influencing occupational performance

 

 

-RCT to identify effectiveness of SI intervention in children with ASD

-The training and interventions were based on ASI fidelity measures

-Outcome:

 

o   Results were mixed, yet demonstrated significant changes in social responsiveness and toward individualized goals in the areas of sensory processing and regulation, FM skills and social-emotional functions. Provides preliminary evidence of effectiveness for SI interventions and provides information to guide the development of future high-level research studies

 

o   Methodological limitations: The interventions may not reflect common clinical practice, as recommendations for generalization into other environments were not provided. Sensitivity of measurement tool may have influenced ability to detect change (SPM and QNST-II). Supports use of more individualized measures (ex: GAS)

 

-Retrospective study defining characteristics of SI and praxis patterns of children with ASD

-Analysis of existing data using ASI fidelity measures (heavily based on the SIPT)

-Outcome:

 

o   Children with ASD displayed difficulties with imitation praxis, somatosensory perception, vestibular bilateral functions, imitation praxis and sensory reactivity. Areas of strength were visual construction and visual perception. Social participation is more strongly associated with somatopraxis than with sensory reactivity.

 

o   Methodological limitations:

 

– Based on the analysis of existing data in clinical records

– Larger sample size needed (people with ASD assessed with SPM and SIPT)

– Seek subjective experiences of people with ASD and their caregivers

 

-10-wk intensive OT-SI approach of one child, study examining efficacy of OT-SI (SIPT based)

– Adheres to ASI fidelity measures

-Outcome:

 

o   Confirmed deficits in sensory processing and praxis affecting ability to participate in play, social, home and community activities

o   Significant gains in self-care routines, with social relationships and in auditory, vestibular, tactile and oral sensory input and movement. Parent perceived improvement also increased.

o   Explication of a systematic method of clinical reasoning present which can be used as a model for best practice

o   Builds on existing evidence showing that GAS is a useful method for quantifying individual outcomes

o   Methodological limitations:

 

–           The evidence linking changes in these mechanisms to the observed changes in behaviors is limited

 

–          Lack of generalizability and ability to distinguish treatment effects from maturation effects

 

 

 

 

Articles not meeting the fidelity measures:

 

1. Silva, LM., Schalock, M., Ayres, R. (2009) Qigong massage treatment for sensory and self-regulation problems in young children with autism: a randomized controlled trial. American Journal of Occupational Therapy, 63(4), 423-432

 

2. Piravej, K., Tangtrongchitr, P., Chandarasiri, P. (2009). Thai traditional massage on autistic children’s behavior. Journal of Alternative Complementary Medicine, 15(12), 1355-1361

 

3. Silva, LM., Cignolini, A., Warren, R. (2007) Improvement in sensory impairment and social interaction in young children with autism following treatment with an original Qigong massage methodology. American Journal of Chinese Medicine, 35(3), 393-406

 

4. Silva, LM., Schalock, M., Gabrielsen, K.  (2011). Early intervention for autism with a parent-delivered Qigong massage program: a randomized controlled trial. American Journal of Occupational Therapy, 65(5), 550-559

 

5. Silva, LM., Schalock, M., Gabrielsen, KR. (2015). Early intervention with a parent-delivered massage protocol directed at tactile abnormalities decreases severity of autism and improves child-to -parent interactions: a replication study. Autism Research Treatment.

 

6. Woo, C, Cynthia., Donnelly, H, Joseph., Steinberg-Epstein, Robing., Leon, Michael. (2015). Environmental Enrichment as a Therapy for Autism: A Clinical Trial Replication and Extension. Behavioral Neuroscience, 129(4), 412-422

 

 

 

 

3 Comments
  • Esme Le Roux
    Posted at 19:06h, 28 August Reply

    Good work Dino! Even though it’s a long one, it has such important info: advocating the difference between sensory based treatment modalities (many of the articles made use of those) versus Ayres Sensory Integration. I’m saving this one as a handout 🙂

    • Michelle Mennillo
      Posted at 11:05h, 30 August Reply

      Thank you!

  • Online Toy Stores Australia
    Posted at 16:50h, 30 August Reply

    Excellent!

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