Monday, December 03, 2007

This message can be for all anthropologists who are thinking about occupational therapy


I have often stated that the inter-activity generated as a result of this blog is endlessly entertaining to me. I just received this wonderful note about my statement on the blog that reads "This product is sold by weight, and not by volume" :

Hi Chris

Is that a little witticism referring to Gregory Bateson and his little metalogue on knowledge “How much do you know”? I’m soon to graduate with a BA in Anthropology. I’m thinking of pursuing a MS in OT I have a very holisitic view of communication and life; they are one and the same in my book. Do you have any advice or recommendations? I’m very interested in communication theory from bio-semiotic-cybernetic perspective. Hope to hear from you soon.

+++++++++++++++++++++++++++++++++++++++++

And my response... (slightly edited)

Thank you for your note – although I chuckled at your question and then started thinking about the act of deconstructing my own writing, and then got all tripped up on subject-object perception about what goes on my blog, and then I got a headache.

I am certain that some of these studies (anthropology, semiotics, cybernetics) belong in occupational therapy but I am not sure if occupational therapy belongs in them. OT is such a pragmatic science – a day to day methodology for understanding and taking action on complexities of individualism-disability-society. I am afraid that we may be so pragmatic that many street level practitioners would not be interested if they were asked to read a study on the carceral archipelago. That reality might cause a sociologist or a linguist or a systems person or an anthropologist to become bored. Sometimes.

We had this debate in our field, hidden in the literature as a conversation about occupational science and occupational therapy. Funny how this came back for a visit in the form of an email.

Still, the occupational therapy field needs you, as do many people. If that calls to you, please go sign up.

And keep me posted on your trajectory.

Warm regards,

Chris

Wednesday, November 28, 2007

Intervention for adults who have sensory processing disorders

I received this email today, and I thought it was a great question:

I am an adult who has Sensory Integration problems that were diagnosed three years ago. I also have central auditory processing disorder and was recently diagnosed with Asperger's. I have had some OT in the past for the SI difficulties, and was wondering if you knew of services for adults with these problems.

++++++++++++++++++++++++++++++++++++++++++

Sensory integration refers to an 'unseen' process that has not yet been clinically defined - people have suggested that it may be a neurochemical problem, or perhaps a neuromigrational problem, or perhaps something else entirely. However, occupational therapists are claiming that it is SOMETHING that has to do with neurological processing - a lot of current research is looking at sympathetic and parasympathetic sensory processing of information.

There are also some occupational therapists who claim that the prevalence of SPD can be as high as 5% (in the 'normal' population), and I have seen this number posted around the Internet, but have not been successful in finding any source documentation for this claim. The prevalence may be higher in populations of people who have other developmental disabilities.

So you see the problem here is that we have a relatively undefined problem that is occuring with a relatively undefined prevalence - and there does not seem to be face validity to the concept that 5% of all adults are walking around with some kind of sensory processing problem. The problem seems to be notable in children but why does it seem to mediate with age/maturity? Is it likely that if there was some structural neurological problem that it would all just 'disappear' with age?

Now I don't doubt that some people process sensory information differently than other people. I also don't doubt that people have different learning styles and different neuropsychological profiles that cause them to have strengths and needs in relation to their abilities. I am not sure that these all represent some distinct clinical disorder.

I spent quite a bit of time researching sensory processing abilities of adults, and I even spent some effort in trying to link sensory processing patterns with known neurophysiologic patterns of hypersensitivity (complex regional pain syndrome). I found that adults who had complex regional pain problems all had differences in the way that they processed sensory information but that those differences were not in the directions that one might expect (toward hypersensitivity, for example).

Yes, I am guilty of not attempting to publish my own doctoral work (perhaps I will someday, with a larger sample). Very little else has been published about adult sensory processing disorder. For as little as we know about sensory processing problems in children, we know even less about whether or not this is an issue that carries through to adulthood.

Now I know that I will undoubtedly get emails from some people who are 'treating' adult SPD and they will provide evidence that they learned about it from a video or from some newsletter that is not peer-reviewed. I will state in advance that I can't consider these as adequate resources of information.

So for people who receive this 'diagnosis' I encourage them to sit with their occupational therapist and discuss what the functional problems are that are interfering with daily life functioning. I would encourage people to use tried and true (and evidence based) interventions relating to anxiety control, situational coping, and stress management. Simple behavioral techniques can provide structure and sameness that can help ameliorate problems with sensory modulation. Education about activity participation and organization/planning around potential 'triggers' or 'stressors' also seems to be pragmatic and functional.

Please note that none of these interventions denies the presence of anyone's sensory processing disorder. Rather, I am just encouraging the use of rational intervention that is time limited, functionally based, and directly oriented to the individual's problems.

I would also strongly discourage anyone from trying unproven 'sensory' interventions that involve 'brushing' or 'deep pressure protocols,' 'therapeutic listening,' 'Brain Gym,' or whatever else happens to be popular at the moment.

I am interested in anyone else's ideas on this topic, and will graciously publish all comments in full.

Friday, November 16, 2007

the genesis of class warfare

When we see people who need occupational therapy they have to be understood in more than organic terms. That may seem obvious to some but I know it is not obvious to all. I know that it is not obvious to all because so much of clinical practice looks like it is oriented toward the organic or biological level.

People are more than the sum of their parts, of course - and that is why I find it so important to let my anthropologist out for a walk.


I was reviewing these 'field notes' from some time I spent teaching at a college - and I wondered how different the intervention plans would be if they both came to an occupational therapy clinic with similar injuries or needs:


Penny and Natalie are moving in two different directions. I watched their trajectories intersect for a couple months and it provided a lot material to think about.


Let me start by saying that they don't even know each other. But they are the same age - having both just turned 21. Natalie will graduate in a year from a professional college program and Penny will still be working as a housekeeper at the college.


Natalie celebrated in the typical college way. Her friends made her wear a t-shirt all day that announced her birthday and they got her rip-roaring drunk to celebrate the occasion. Standard 21 year old college fare.


Penny didn't celebrate her birthday other than to have her mother watch the baby. Penny is a single mom, and so is not able to go out much with friends. Most of them have moved on anyway - they just don't have much in common with her now that she is a mom. Besides all this, her friends don't go out much anymore anyway - don't want to get into any fights with those students. Students are always talking down to townies.


Natalie dropped an essay on my desk today, hoping that it would meet approval for her acceptance into an Honor Society. This would be good on her resume, she posits.


Penny came and emptied my garbage can, standing in the same place that Natalie stood in, and told me how her baby's father couldn't be trusted, that he abuses drugs, that he just lost his job, and that she hates having to comply with handing over her daughter to him for court ordered (supervised) visitation.


Penny barely graduated from high school and was in special education classes. She tells me now that she needs help to do the math for her checkbook and that long division is beyond her comprehension. She thought about becoming a nursing aide but could not read well enough to understand those complicated medical terms.


Natalie studies for her classes. Based on her grades, she is having difficulty with those complicated medical terms too.


When Natalie comes back to the dorms after celebrating on a Friday night, Penny cleans up behind her.


Penny does not know Natalie, and so holds no direct animosity toward her. But those college students sometimes throw paper towels into the toilets and this backs them up. Penny made a sign and hung it up on the bathroom doors. It says:

Please


Do not


Throw


Paper Towels


in the


Toilet
.
.
The Janitorial Staff


Thanks You.


I sit and stare at that sign every day, and I can't get over how very much it represents.

on botany and telling the truth

I got email from a parent today asking me how to answer some difficult questions from her son. I told her that it was ok for parents to 'make up a story' for the short term if the real issue at question was too developmentally complex for the child to comprehend. Parents have a lifetime to be honest with their children, and sometimes it is ok to hold the truth for just a little while. The truth is hard for children to understand, sometimes.

I admit that I have a long history of 'telling stories' to children. I do this for fun, and to sometimes promote a fantastic world to them. The world is so much more fun when it is also fantastic. So although I 'stretch' the truth I also know that you reap what you sow (in so many ways). I know this intuitively.

This is something that I always keep in mind, hopefully in the forefront, as I go about the daily tasks associated with raising and also in working with young children. But inevitably, kids ask difficult questions and it is sometimes easier to answer obtusely rather than provide a real answer. Parents will know when they have to 'come clean' and make an adjustment in approach.

Case in point: My youngest, Casey, always wanted to know where things came from. For a very long time the brief answer "God made it" was quite satisfying to her - but that changed.

After a while the questions became a little more probing, as in "How did God make that?" Hm, this can start to get a little tricky.

Popular culture provides many easy outs that are reinforced by others without my having to make sure that everyone has the same story. So telling her that the moon was made of green cheese is something that I can count on others reinforcing (likely with a wistful smile).

One day she asked me where rabbits come from and I provided my pat answer "From God" and this was clearly not enough. "No Daddy, I mean HOW does He make them?" So I took her to her "secret garden" in our back yard and showed her the pussy willow tree and said, "God grows them on that tree."

Well she thought I was out of my mind, but the next spring I took her to that tree again and showed her all of the 'baby bunnies' that were growing on the tree. She was sold, and I immediately had a new way of explaining where things come from.

So for a long time when she asked me where something comes from (and if I was too pressed for time to give a proper answer), I told her that it grows on trees.

When she turned 6 I decided that I had to start being a little careful about telling her this as it may cause her some social embarrassment or ridicule from her peers. She truly believed that God grew many things on trees.

Why was this such a problem? One day, after coming home from McDonalds, I watched her quietly step into the secret garden with her Happy Meal bag and a shovel from the garage.
She was planting the seeds from the hamburger bun into the ground.

Why should I complain? She just wanted to reap what she was sowing.

Just like her Dad was.

So it is important to tell the truth to kids, eventually.

Thursday, November 01, 2007

ABC Therapeutics pictures


As promised, here are a few pictures of our new space... this is the desk I am currently sitting at and making this entry. It belongs to the receptionist but I have temporarily taken over until I get my own office out of boxes.












This is one of the gross motor areas. Phase II of our building project will add an additional gross motor gym, as well as an outdoor play area and bike path. With over an acre to develop we are having a lot of fun developing ideas!






















We especially love the interior design that makes it feel so open and fun for swings!


























Here is Danielle Green, a Level II student from Quinnipiac College, working with one of our friends in the fine motor treatment area!
















...and of course we always have time for fun at ABC Therapeutics! Here is a nice picture of our two Halloween ladybugs!

Wednesday, October 31, 2007

Sensory issues are not really that confusing, if we would only stop confusing them ourselves

People are easily confused whenever someone talks about sensory integration or sensory processing, mostly because of confusing messages that are sent by occupational therapists regarding these issues.

Confusion is evident in the public but it is also interesting evident among occupational therapists and researchers as well. There have been some recent efforts to address this confusion by initiating conversation about 'fidelity' in sensory integration research. This means that when someone claims that a study is about sensory integration that it REALLY is about sensory integration. I encourage people to look at the Sensory Integration Global Network website; it has a lot of good information that helps to clearly define the concept of sensory integration.

However, it is also important to understand that sensory integration research is not equivalent to occupational therapy research. Evidence supporting or refuting a sensory integration approach is NOT the same as evidence supporting or refuting occupational therapy intervention. Children improve function through a variety of therapeutic methods: direct trial practice and training, training in motor control, training in visual perceptual and visual motor skills, and by providing adaptations to the task or the environment. Sensory integration is only one small intervention method. Perhaps this concept is sometimes forgotten.

Occupational therapists need to stay 'on message' when it comes to representing sensory integration methods or other methods of intervention. An example of recent confusion is in the Advance for Occupational Therapy Practitioners magazine in the article Math and Science. Compare this article and the accompanying tables to the SIGN websites fidelity check-off. If we as professionals can't listen to ourselves regarding the fidelity issue, how can we ever hope to elucidate the nature of these difficulties for others?

Wednesday, October 10, 2007

Is Brain Gym Effective?

I frequently get email from people asking me about Brain Gym, so I thought I would post one of the emails here. Identifying details have been changed but the letter is essentially intact as written:


Dear Chris,

My son is 11 years old and in the 6th grade. He has Neurofibromatosis Type 1 which is a neurological disorder that affects his entire nervous system. He has Apraxia of Speech, ADHD, auditory processing issues and learning disabilities. We took him for a speech eval and they suggested sensory integration therapy. This summer, based on recommendations from our speech therapist who is GREAT and one of the few people who have actually been trained to treat Apraxia, we began OT with couple of therapists who do sensory integration therapy and are very much into Brain Gym.

I’m really starting to question whether Brain Gym is effective for us. We’ve only gone a couple of months, but I really don’t see any improvements. My child is social, independent and making progress…he is in a mainstream classroom at school and the special education teachers come into the class to work with him. His handwriting is horrible, he still doesn’t hold a spoon correctly, he can’t button on his own - he has a difficult time with coordination. I’m just trying to get some guidance on the type of therapy he really needs.

We do different exercises every week, but it seems like we should be “practicing” skills more. When I google “Brain Gym” all of the articles rave about it. However, it appears that most of them are written by therapists who use it in their therapies or by people doing training. Any advice? Thanks!

++++++++++++++++++++++++++++++++++++++++++++++++

Dear Parent,

Thanks for writing.

I have mentioned Brain Gym in my blog in the past and my basic opinion is that Brain Gym is pseudoscientific, unresearched, and experimental.

I am concerned about the claims made on their website. They state that their programs will help you "Learn ANYTHING faster and more easily" and other grandiose claims. According to the website, Brain Gym supposedly helps with outrigger canoe paddling, knitting, public speaking, transcribing tapes in criminal investigations, and overcoming learning challenges. (see http://www.braingym.org/users)

They have what they call a 'research packet' but the vast majority of the articles there are "published" in the 'Brain Gym Journal' which hardly qualifies as a respected, unbiased, peer-reviewed journal. There are a few other articles in there that are published in foreign languages so it is not possible to really evaluate their quality.

I would recommend that you focus your therapy efforts on functional skills training. If your child has difficulty holding a spoon correctly or writing neatly there are some very specific methods that can be used to help. Direct trial practice, correction, and positive reinforcement can go a long way to developing functional living skills. Adaptive methods may also be used if needed.

In addition to the functional skills training the occupational therapist can work on the underlying problems with motor coordination, but I would suggest methods that have what we call "FACE VALIDITY." This means that the intervention "looks like" it is going to address what it is supposed to address. For example, activities to address motor coordination should "look like" ball and target games, fine motor exercises, obstacle courses, etc. This is a good way for parents to assess therapy and I would encourage parents to ASK the therapist the purpose and intent of interventions that don't LOOK LIKE they address the problem.

Parents then need to appraise what the therapist tells them - do some internet research, talk to others, and see if there is evidence to support the intervention. Most importantly, if you are not getting results, talk to the therapist about changing their methods.

Best of luck,

Chris

EDIT 6/29/09 - fixed broken link! http://www.braingym.org/users

Saturday, September 29, 2007

Time and occupational therapy

Autumn is a point of change. A transition from green to gold. Certain things happen in Autumn; they are the same each year. Thoreau said that 'Time is but the stream I go a-fishing in.' I think that as occupational therapists we need to remember to consider how important time is, and how it is the grounded substance that we all function within.

Things look different when you see the time that they are occuring within.

Today, as I was driving through the winding backroads of the rural countryside on my way to home visits, the world was rotating through time.

Of course it rotates every day, but today the rotation was palpable. I noticed a school bus in back of me and two young children holding purple flowers on the side of the road, peeking around the hedges to see if the bus was coming. It was something that had happened a thousand times before - not just by these children today but by their parents before them. And their children will do the same. They will be running out of front doors, scurrying through the yard and picking flowers while their siblings search for the bus. As I watched I felt the rotations and repetition, but whizzing by in my car, it only lasted a moment.

Then I drove by some construction workers and two men were having a discussion. As one man finished what he had to say he turned and walked away, leaving the other man standing there. It was clear that he did not get what he wanted or needed from the conversation. It seemed apparent that this has happened to him all of his life; you could see it in the amount of time he stood there after the conversation. My car sped past him like another lost opportunity.

I had to slow down through a school zone and I watched some young children playing on the playground before the bell called them into class. Bells have been calling students into classes since there were schoolhouses. Children have always been playing outside wishing that the moments remaining would stretch into a warm afternoon. Adults tell them that their childhood will pass quickly but it is never necessary to tell them because they already know, even if they can't verbalize it. I saw silver cords tethering the children to the earth, and someday those cords will pull them back home.

These are things I noticed while I was driving this morning.

Tuesday, September 25, 2007

Diana Henry visits ABC Therapeutics

ABC Therapeutics staff took a break from beginning of the year activities of scheduling, working with children, and even unpacking boxes in the new office to visit with Diana Henry. Diana is in town to present her "Sensory Tools for Pre-Teens & Teens workshop" at the NYSOTA conference. She will also be presenting on the Sensory Processing Measure.

We had a wonderful visit with Diana and her husband Rick. We were all excited to hear their stories and she gave us some wonderful ideas about organizing our new clinic space!

From left to right in this photo: Marjorie Deschner, MS, OTR; Grace Kelley, MS, OTR; Diana Henry, MS, OTR; Lucy Pencille, MS, OTR; and Caroline Alterio, COTA, ROH. Somewhat hidden is Jean Luc Pencille, but I wouldn't want to neglect mentioning him!

Monday, September 10, 2007

Exciting changes on the horizon for ABC Therapeutics

I have neglected this poor blog lately, despite my intentions to write more. I apologize to all my fine readers who have sent me emails asking if my computer has died... ;)

My current activity configuration involves project management on a 'Flip this House' magnitude. We purchased a new building that required some substantial renovations, but now we are ready to move at the end of this month.

Soon I hope to have some pictures to post of our new 'home.' Stay tuned - I am hip deep in boxes and packing material, paint and drywall, building inspectors and certificates of occupancy.

Change is on the horizon!

Saturday, July 21, 2007

thoughts about teaching clinical reasoning

Teaching someone a skill is not necessarily a difficult thing. Skills are concrete, task-like, discrete, and relatively well defined.

I have always tried to avoid teaching my students skills because it is my opinion that they need so much more than skill (although sadly they clamor for skills more than they clamor for background knowledge and understanding).

Instead, I try to help my students develop some degree of critical reasoning, problem solving ability, analytical capability, and appreciation. I believe that these attributes will carry them farther than will the mere acquisition of skills.

This is a stretch for many of my students - these demands take them places where they have not really been challenged before. As a result I notice that their confidence is dramatically decreased when they are taken beyond the stages of rote memorization. Because certitude is important I do not accept questions when I have asked them for answers. "Are you asking me or are you telling me?" are the most common words heard from me in the classroom.

I will never forget when my most quiet and passive student eeked out a hesitant and tentative response to a question asked of her... marked with the typical fading voice at the end of the statement, lack of eye contact, and raised intonation typically associated with a "is ______ the right answer...?" response.

Immediately, the class saw it coming as I rose and loudly questioned back, "I don't know; are you asking me or are you telling me?"

Then I heard something that I have not heard from her before. Right back at me she replied, "I think I am mentioning it. I'm not telling you, but I do think that I am mentioning it."

Stunned into silence, I nodded and accepted her response. This, I thought, is progress.

Monday, July 16, 2007

Plato's response to the state of 'certificates' and 'certification' for sensory integration

I received my "certification" to administer and interpret the Sensory Integration and Praxis Tests in 1992. I believe that the test battery was published in 1989 so it was still fairly new at the time I was certified. At that time there was a certification examination that you had to pass. I don't know how psychometrically sound the SII program was - but they claimed that it was a certification program. SII never wanted me to 'recertify' though - which is a little scary.

In the past twenty years the Sensory Integration and Praxis Tests have not been updated and there are no new norms. I have never heard of an occupational therapist talking about the Flynn Effect or heterosis so I don't know if anyone believed that there is a useful lifespan of an assessment tool. Some OTs still use the old Bruininks-Oseretsky test that has 25 year old norms - they just got around to updating those norms recently but I still see a lot of reports with the old test given. Personally, I (mostly) stopped using the Bruininks in 1995, and I stopped using the SIPT heavily around 2002. I don't get nearly as many requests for the SIPT anymore, but I still administer it episodically.

OTs are a little funny with using old and outdated things, I guess. That is not a good characteristic. Maybe we would be less willing to use such outdated material if more information was readily available about the problems with this kind of material.

I got to thinking about this today because of an article that appeared in the Advance for OT magazine about Sensory Integration International. According to the report, SII is barred by the Superior Court of California from conducting business. If you do a Google search you can find a lot of people complaining about being charged for goods or services that were never delivered. That is an embarrassing thing to find if you are Googling 'sensory integration' on the web!

So I got my certification from SII a long time ago - and I imagined that by now it was a worthless certification anyway. The news reported in Advance for OT makes SIPT certification that much more worthless. If the reports in the Advance for OT article are true, this case is essentially as bad (and comical) as a modern day Doc Terminus.

There is a new/competing SIPT certificate now that you can get from Western Psychological Services. I am not certain how useful certificates are that don't require competency testing or that don't require any kind of recertification process. At least they acknowledge some conflicts of interest: "Note: WPS receives financial consideration for publications recommended for use during the Comprehensive Program in Sensory Integration through USC/WPS. Individual course instructors may be authors of such publications and as such may receive royalties or other compensation."

I have hope that therapists and consumers will learn to be savvy about these things. I would bet that WPS and USC know that they don't actually have a "certification program" and that is why they are careful about their wording about receiving a 'certificate' and not a 'certification.' Still, they claim that their certificate "acknowledges basic competency." That is just about as close to the line that their lawyers let them walk, probably.

For a profession that wants to be taken seriously and to have the concept of sensory integration taken seriously these are not good signs.

Most consumers don't spend time on the NOCA website (http://www.noca.org/) and don't know about standards of certification programs. Because consumers don't spend a lot of time on these sites that means that ethical professionals have to educate them about certificates and certification programs.

I encourage OTs to gather more knowledge about certification and certification programs. The example of Sensory Integration International makes an interesting case study in how a good idea being promulgated by well-meaning professionals can go very badly - very quickly.

What is the truth about sensory integration and certificates and certification? Like the people in Plato's cave - we have to have a willingness to 'see' both the unhidden and the hidden information. I'm glad that Advance for OT published that story - but still a little sorry that it took so long to really 'bring the issue into the light.'

I also have hope that the USC/WPS program will distinguish itself in ways that the SII program never accomplished. They have a real opportunity and could start by clearing up the whole certificate/certification issue. Then they could get to work on updating the norms for the SIPT. ABC Therapeutics will volunteer as a normative testing agency if anyone ever takes on this project.

Tuesday, June 12, 2007

Sensory Integration in NY Science Times

I was surprised to see an article in the NY Times (Science Times) on sensory integration on 6/5/2007. I grew up being addicted to the Science Times section of that paper so I have some long term positive bias for anything that appears in that section of the paper - even though I don't particularly like the NY Times in general any longer.

So I have some bias, because I am like Virginia O'Hanlon reading something that Frank Church wrote just for me... but the article on sensory integration was relatively even handed so I was pleased. I am a critic of the current state of research for sensory integration so I was happy to see the anecdotal reports of parents and the interesting research that people like Patti Davies are doing on neurophysiological underpinnings of sensory processing all in the same article.

The research funding problem is also described well. This is an article that will be good for the general public and for other researchers and professionals to read and consider.

Wednesday, June 06, 2007

Spring is supposed to be green, not blue...

My apologies for the prolonged absence - and thank you for all the emails wondering if I was still alive!

I began my private practice 7 years ago with the mission/intent to put myself out of business. At that time I was getting phone calls and requests from families to assist them with their IEP process. It seemed that a lot of the difficulties were in communication between educational teams and families - something that could be easily remedied. Since there is a prescribed 'rulebook' on how the process needs to be conducted I believed that helping families learn the rules would enable them to become better team players who could advocate for their children appropriately.

Fast forward 7 years and now I am helping both families and school districts with the rulebook - but the solutions remain elusive. More families who are dissatisfied with their IEP process find me each year. Sometimes the families need to adjust their approach. Sometimes the districts need to adjust their approach. My original intent/mission seems to be slipping farther and farther out of my grasp.

Many families are rightfully satisfied with their child's IEP. Still, schools struggle to really make the IEP 'individualized.' When they are faced with a child who has complex and seemingly intractable difficulties the school's solutions just don't always fit. Pragmatics come into play and it becomes very difficult for schools to adjust to the special case circumstances that are thrown at them on a daily basis. Parents are not interested in pragmatics - nor should they be.

How much accommodation is reasonable? The parents and the schools may never agree on this issue - and that is why I get busier each spring.

Here in the US the No Child Left Behind act places tremendous pressures on districts for accountability. This is not a bad concept but we are not yet sophisticated enough to solve the complex problems that cause poor academic performance. This is not a statement of surrender; it is simply a statement of fact. Our school systems need to continually improve.

Unfortunately the school systems will never change quickly enough, because Johnny is in 4th grade NOW, and he has to have an appropriate education NOW.

I am eyebrow-deep in meetings and will remain so for the next month. That's my excuse for not writing lately. But boy do I have some new stories to tell...

Monday, April 09, 2007

Update of therapeutic listening

As promised, I wanted to review some of the articles in the current (March/April 2007) issue of the American Journal of Occupational Therapy. Since I have gotten some emails and blog comments asking me about the Hall & Case-Smith study (see reference below) I thought that this would be a good article to begin discussing.

I was excited to see a study on this intervention technique because I have been hesitant in the past to fully embrace 'therapeutic listening.' In my opinion there is not adequate evidence to support promoting this technique so I was interested to see if this new study would change my mind.

I believe that the authors should be commended for initiating this inquiry, but I also believe that their conclusions are far overstated. There are several fundamental flaws in their design that are concerning.

To begin with, they used a convenience sample. This might have been appropriate if the study was truly exploratory, but there have been several other studies already completed on this topic. Convenience sampling limits our ability to state that the subject pool is truly representative of the entire population.

Sampling size is also an issue - it was based on expected effects for the Sensory Profile but the authors don't discuss the sample size that would be needed for the other tests used. This information is needed in order to determine if the sample size is adequate to draw conclusions about visual motor or handwriting skills.

Finally, their study population was very heterogenous - so even if there were effects within this group it is difficult to know what was causing any of the effects based on the sampling methods used. In sum there are many problems with the sampling procedures reported that severely limit the study.

Another problem is that the measurement methodology relies strongly on parental report. This is also a confounding factor because you are asking the parents if there are changes in behavior, but the parents have invested heavily in the intervention program - and in fact they may be expecting changes based on whatever communication occured in the process of educating them about the 'sensory diet.' It would have been much more useful to have the teachers fill out the Sensory Profile (school version) because they are completely separate from the intervention and could give an opinion that has much less opportunity for bias.

Another problem with measurement is that some of the evaluation tools were administered three times within the three month study period - opening the question of practice effect of these particular tests.

It is also unclear how many of these children were participating in other therapy programs and what the nature of those programs was. The presence or absence of other parallel intervention programs is a significant confounding factor.

All of these factors could be partially acceptable if the study was truly exploratory and if the conclusions were stated more modestly. Instead, this is just another in a long line of studies with significant limitations. What makes it particularly difficult to accept is that the authors conclude that "The present study produced encouraging findings to support the use of therapeutic listening as part of an overall sensory-integrative approach to occupational therapy in elementary school-age children" (p. 215). I don't think that the study accomplished this at all. Rather, I believe that the study is very limited, they relied primarily on the potentially biased self-report of parents that participated in the program, the conclusions overstate the results, and there is very little real conversation about the severity of the problems in sampling and measurement methods.

So for me the jury remains 'out' on therapeutic listening. I don't see any reason to encourage parents to invest heavily in these programs at this time. If anyone wants to rebut my conclusions I will happily post their comments, in full, on this blog.


References:

Hall, J. & Case-Smith, J. (2007) The effect of sound-based intervention on children with sensory processing disorders and visual motor delays. American Journal of Occupational Therapy, 61, 209-215.

Thursday, April 05, 2007

Tying some loose ends

About a year ago I posted about the use of passive tactile sensory stimulation and the lack of evidence that we have about the technique. You can find more discussion on this topic by typing in "Wilbarger" as a search term in this blog or by going to this link.

In any event, I wanted to update a statement that I made last year that reads: While surfing around tonight I think I found a potential source of very useful information - and I think we might be able to thank Ruth Segal..." Dr. Segal did publish her article "Integration and application of a home treatment program: A study of parents and occupational therapists" (Segal & Beyer, 2006). This is an excellent article for all pediatric therapists to read. It reviews in detail the perspective of parents regarding home programs and the disconnect that sometimes occurs between the therapist's thinking and reality of normal family lifestyle. This article isn't directly assessing the effectiveness of a 'brushing program' but it does look at the issues of 'prescribing' a program that is potentially intrusive to a family's normal occupational routines.

Dr. Segal makes some critical observations including "Although therapists should continue to educate parents about this intervention, it is important that they keep in mind that parents' lives may not revolve around occupational therapy and the child who needs this particular intervention." The question then is: How ethical is it to prescribe some type of intervention program that is fundamentally disconnected and in fact is disruptive to the normal flow of activity within a home? One could argue that chemotherapy and radiation interventions for cancer are maximally disruptive to normal living - but then again the MDs who prescribe these interventions don't claim to care about lifestyle and occupational performance issues directly. As lifestyle and occupational performance are the bailiwick of the occupational therapy profession do we need to be more responsive to these concerns?

On a related note, the March/April 2007 issue of AJOT is chock full of good material that also needs to be discussed as it relates to evidence and sensory integration/processing - so please find your recent AJOT and read it - a few upcoming entries will be directly related to that content.


References:

Segal, R., & Beyer, C. (2006). Integration and application of a home treatment program: a study of parents and occupational therapists. American Journal of Occupational Therapy, 60, 500-510.

Saturday, March 31, 2007

another apparent failure

I wrote this four years ago, and since I am recording stories with different endings I thought this would be another scenario that deserves to be dusted off and posted here.

_____

Camille called me tonight, somewhat frantic, with an obvious need to tell me some news about her daughter.

Camille is an overprotective mom and grandmother who has been disapproving of her daughter's choices. However, as she is ultimately interested in her daughter's well being (and the associated well-being of her grandchild) she mostly keeps her mouth shut for fear of alienating her daughter.

About two months ago Camille had to be hospitalized for gall bladder surgery, and that left all the caregiving responsibilities of the new grandchild to Karen, her daughter, as it should be. Because it had been my job to go to their home and help educate the family on caregiving for this disabled child, I was trying to split my time between Camille and Karen. As I said though, since the surgery I have been spending all of my visiting efforts directed toward Karen.

From my perspective, Karen was giving all her best efforts toward being a mom. Unfortunately she is not married, although she does live with the child's father. Karen is young and a little immature perhaps and clearly in over her head, but I always got the idea that Karen has had this role in her family forever, so it is not an unfamiliar position for her to be in. She is not a black sheep, because her family does their best to support her, but she tends to make bad choices and as a result she never really seems to meet their expectations.

Over the last two months I decided that I was glad that Camille had the gall bladder surgery because it forced Karen into the role of primary caregiver, and that was necessary. Also, I got to spend more time with Karen and impart a little wisdom and a little perspective on dealing with the myriad of issues related to parenting a child who has a disability. I thought Karen appreciated me, and we talked turkey about a couple important issues. I thought we were on target.

Sometimes, I have a tendency to interpret eye contact as connection. I experienced eye contact with Karen several times over the last month, generally as I was relating some supportive statement and positively reinforcing her efforts.

Back to the story here... so Camille called, in obvious frantic mode, announcing loudly that she was a grandmother, yet again and that Karen had another baby.

My mind spun around the possibilities, and I was immediately thinking, "How strange.. how could she have had twins, and why did she only keep one, and where has the other one been???" It is the only way I could get my mind to process the information.

But as Camille spoke, it became more clear. Karen had been pregnant, 9 months in fact, and went into labor on Friday and subsequently delivered a very healthy and very large 8 pound baby girl. Of course the entire family was shocked. Is shocked. No one had any idea.

As Camille spoke, I thought of Karen, who is not a heavy woman. In fact, it never struck me that she was even overweight at all. I understand how a woman can theoretically hide such a thing, but I always wondered how everyone around could have been so clueless. I suppose she frequently wore sweatshirts. I never knew.

According to Camille, as Karen was rushed to the hospital and began delivering, she simply kept repeating, "I can't be pregnant, and I can't have this baby, it is already too hard just taking care of one!" Karen was distraught and crying, and her beautiful baby girl came into this world under her repeated protestations and outright denial of the reality that was playing out in front of her eyes.

Camille is still shocked, and she went on to give me the statistical details that accompany every birth. Apparently the baby is healthy, and Karen is doing "well."

The difficulty I am having is in the definition of "well." Despite my contact with Karen, and despite the time that I spend in serious conversation with her, and despite any connection I may have imagined, and despite the eye contact that validated the transmission of communication between us, I obviously totally missed the boat.

I can only imagine Karen's pain that would cause her to remain in denial for so many months. I can only imagine her fear that would make her cry as her new baby was being born. She had all this content under the surface, and it was totally impacting on her ability to care for her son, and I never even realized it.

I understand that her own family did not know, but that is not the point. Her family is not trained, and does not interpret eye contact as connection. Her family is not charged with the responsibility of educating Karen on how to care for a child who has a disability. To do this effectively, I needed to be inside Karen's head and I needed to understand her heart. I accomplished neither. And it doesn't matter that the other care providers didn't know either.

None of that matters because they are not me, and I expect more of myself.

I just expect a little more out of myself. And I have apparently failed.

When I see Karen next, I will pull her aside and apologize to her. She will not understand why, probably. Then I will tell her that her new daughter is beautiful, and I will pray for a little clearer vision from now on.

Thursday, March 29, 2007

Not every story has a successful ending

On most days people appreciate the things I do, which is a positive reinforcement for me to continue with those tasks that keep my private practice running. However, the reality is that sometimes people don't appreciate or understand what you are doing, even if you take the time to explain. Today seems to be the right day to talk about an experience I had when someone was not able to appreciate my efforts.

Collin’s mom is single or divorced – I am not sure which. She has two children by two different fellows, neither of whom believes that their presence is important in the lives of the children. The mom does not work outside of the home; her primary role is as a parent.

Their apartment is in a blue-collar town outside of a large metropolitan area. The town is famous for its chemical dumps and environmental toxins. I do not know if it means anything, but I cannot listen to AM radio in their neighborhood – there is just too much RF interference from the high-tension electricity lines. Some people think that these electric lines are dangerous. All the studies I read are inconclusive, but I sure do see many kids who have developmental disabilities in this area. Maybe it is the environment, or maybe it is the culture. Probably it is both.

Collin is a high-energy kid who likes to run and bounce. That is hard to do in their very modest apartment. I do not imagine that the mom can afford a larger apartment on her welfare check. I do not know if she gets child support. I doubt it, somehow.

Bad things seem to happen to Collin’s mom. She has too many medical issues for a person who is only twenty-three years old. She had some suspicious skin lesions removed, but maybe they were only skin tags. Today she told me that she may have lymphoma, or it may just be a swollen lymph node or two. She tends to hear the worst-case scenario, and then she hangs onto it.

Collin’s mother is always enmeshed in the tragedies of her family. Her sister was recently in a car accident, and that caused chaos for Collin's mom. The grandmother needed a place to stay for some reason, so she ended up in the already too-small apartment for a week or so.

Collin supposedly had a cardiac problem a couple months back and the mother did not return my calls for a month. Nothing seems to have come of that problem, but at the time, it was a big deal. Most therapists would have asked for re-assignment because of the family's high cancellation rate, but I do not generally do that. I figured that they were doing their best with the resources that they had available to them.

Over the course of the last half of a year, I worked with Collin. Now he is able to sit and attend to an age-appropriate activity for a reasonable amount of time. He is able to listen to and follow directions. He is able to tolerate different sensory characteristics of toys that he previously could not tolerate (like the way that they felt to him). His fine motor skills have improved dramatically. I taught the mom strategies for providing him with the deep tactile and proprioceptive sensation that his little body craves, so now he gets hugs instead of crashing into people and furniture. I also taught the mom how to use cognitive and behavioral strategies to help him learn self-regulation of his attention and behavior.

Collin is a child who enjoys routine, structure, and predictability, probably a factor of his limited experience outside of the small apartment that he lives in. Conversely, his tendency to ‘melt down’ in new situations causes the mom to avoid new places, so the problem is self-perpetuating. A few months back I tried to have Collin come to my clinic, which is a bright, open, and busy environment that would have challenged his ability to maintain behavioral control and self-regulation. It would have been a good environment for him to practice these skills in, but the mom’s car would break down, or someone else would be having a catastrophe that needed her attention, so they constantly cancelled his appointments. Then the mom simply requested home visits again, which were more convenient for her.

I taught the mom safe ways to challenge Collin’s limits. We reviewed how to provide positive reinforcement of his behavioral self-control. I also taught her how to use predictability and routine therapeutically when he really needed it. In preparation for his transition out of the early intervention program and into the preschool system, I provided her with self-advocacy materials.

Collin’s needs are ongoing; they will not remediate quickly. Despite Collin’s progress, there is still work to do.

Today, at the end of our session, Collin’s mom asked me if we could review his intervention plan. She told me that she is unsure what the goals are and if we have been doing anything for Collin.
I stared at her blankly, agreeing to review anything she wanted.

Her words stung, even though I should not let them.

Tuesday, March 13, 2007

Best treatment options for autism

In a recent comment a reader asked my opinion about the best treatment options for autism. This is inherently a loaded topic because there are so many people who have aligned themselves with particular treatment approaches. Also, there are some people who have experienced significant improvement with a single approach.

I form my opinion on this question based on twenty years of clinical experience working with children and families. I don't believe that there is a single approach that works for everyone. Also, just because something works for someone at some point in time has not been an indicator that it will work for everyone else at countless other moments in time.

From an evidence-based perspective it seems that behavioral approaches have the best research to support their efficacy. However, behavioral approaches are not unitary and the concept of 'efficacy' needs to be clearly defined. Certainly, there is no overwhelming evidence that any behavioral approaches will cure autism.

Lack of evidence in other approaches is often a reflection of the approaches themselves. Behavioral interventions, with their reductionistic focus, lend themselves to measurement. It is more complex to measure 'relationships' or 'communication.' This causes some people to mistakenly believe that only behavioral approaches can be helpful - and that most certainly is not true at all.

All this being said, I believe that there are certain components that are critical in any 'best' intervention program:

1. A child who has an autistic spectrum disorder needs a family that can provide love, nurturance, and support.

2. Structure and consistency are important for all children, but this seems to be a particular need of children who have autism.

3. Given their preferences for structure and consistency, children who have autism often learn skills best with simple behavioral approaches.

4. Sensory differences need to be respected and accomodated for. Sometimes this means modifying the environment to reduce noises, or decreasing visual distractions, or allowing normative opportunities for movement or other sensory experiences that the child is driven toward.

5. Children who have autism need to have access to typical peers and need social modeling from the children and adults that they interact with.

6. Children who have autism have the right to experience typical childhood, including normal play and socialization experiences. Not everything should be part of a program.

7. Parents and caregivers need education, coaching, and support. They also need access to respite services.

For different people and for different families these basic program components may vary over time. Sometimes the most important intervention is family education on the IEP process, and sometimes the most important intervention is environmental modification, and sometimes the most important intervention includes a behavioral plan.

A lot of families ask me about gluten or casein free diets, hyperbaric oxygen, megavitamins, chelation, and swimming with dolphins - among other interventions. I have a stock answer that I provide when people ask me about these things: If my child had autism I would be swimming with dolphins too. However, I think it is important for families to measure their resources (and resources are broad, meaning time, energy, money, family needs, etc.). If there are adequate resources to support a parent flying to some distant city to sit in a hyperbaric chamber with their child, and if there are no known negative side effects - then why not?

Any practitioner who understands and can promote the seven major components listed above into a program can provide the 'best intervention.' Above all else, autism has an impact on the entire family - and the family has to be a focal point during interventions. So, an effective practitioner can council with the family to make choices about interventions over time. An effective practitioner has to evaluate the child and understand the child's skills and needs - and just as importantly, has to interact with the family in a way that provides guidance and support.

I offer no references, because this is just my opinion.

Saturday, March 10, 2007

The perils of mediocrity and the pursuit of a Centennial Vision

By definition, mediocrity implies ordinary or unremarkable quality. For occupational therapy to achieve the centennial vision that is proposed by AOTA I believe that the profession needs to move far beyond mediocrity.

This week I experienced mediocrity in occupational therapy and in educational systems - it was concerning, so I wanted to share it here.

A parent asked me to attend a meeting at school in preparation for a CSE meeting. The parent was informed that occupational therapy services would be discontinued for her daughter. I won't even argue the child's needs here - but rather will point out the process by which this determination was made.

The child has an IEP but there are no statements on the IEP that indicate her present levels of performance as they relate to her occupational therapy needs or her academic functioning. There are also no goals on the IEP that relate to any needs that might be typically associated with occupational therapy as a related service. Still, the child was being seen for OT twice weekly because the service was listed on the IEP - I really don't know what they were doing all year because there are no progress notes. The therapist verbally states (there is no written discharge note or recommendation) that the child should be discharged. The OT recommended that the child should participate in home economics where she can get practice in functional measurement and fine motor skills instead of skilled occupational therapy.

I raised the point that in order to determine if someone was ready for discharge that there needed to be some statement of their level of functioning, and hopefully some record of progress related to goals that were established to improve functioning. The occupational therapist and the school team could provide neither. There is no written record of anything.

Instead I was told that this particular child had fewer needs than other children who are in special education and even those other children weren't receiving occupational therapy. Does this mean that we should lower our standards to the lowest level of care that is provided? Does it mean that if a district decides to only provide services to children who are profoundly delayed that the parents of children with severe delays should be told to stop 'forcing' districts to provide services?

Later in the week, in an unrelated case in the same district, a parent is trying to get their child out of regular education and into a self-contained classroom. The child has severe physical disabilities and does not fit into the regular education class. As the years go by it is more and more evident that the child can not meet the demands of the curriculum. In my opinion the child needs a 12:1:1 class - still academically oriented but moving at a slower pace. Also, I was hopeful that a self-contained class would be taught by a special educator and there would be a greater chance that the teacher would understand the nature of the child's disabilities - this way the needed physical accomodations would be more likely to occur. For example - after four years in the school there is still no written evacuation plan for this child. Although he can walk (slowly) he is not able to physically navigate stairs or busy hallways in an emergency. This is one small example of how the child needs educators who understand his physical disabilities.

The district wants to maintain the child in the regular education classroom, but reluctantly agreed to tour the parent through a 12:1:1 class. The parent asked me to accompany her on the tour: the class has six kindergarten and first grade students, one in a wheelchair, one with Down Syndrome, a couple with autism, and most non-verbal. The one outlying child in the class is in fifth grade - somehow the district got a 'variance' for this class so they can include this much older students with the non-verbal K and 1st graders. The district is 'willing' to place the student in the class, if that is what the parent wants.

The problem here is that there is such an amazing disconnect between what this child needs and the current program - and perhaps an even larger disconnect if the district thinks that the K-1 12:1:1 class full of profoundly disabled children would work for this third grader. What amazed me was that the teacher conducting the tour indicated that the district believed that the child should stay in regular education. When asked if they had a more appropriate 12:1:1 class they just shrug their shoulders - this will mean sending the child out of the district and it will require 'administrative approval.' Should we hold our breath?

Most parents are not keen on self contained or restrictive environments, but sometimes it is necessary. Other times parents want regular education but just want appropriate supports (including appropriate related services, properly written IEPs, and goals). What does it say about a district when it fails to meet the needs of children on so many different levels and in so many different ways??

Worse, I don't know how professionals work in these places. Is anyone who works there willing to stand up and question the way that the district operates? Why aren't there goals? Where is the district OT to advocate for the needs of this child - and why does the parent have to bring in an outside person?

This OT doesn't represent the entire profession and this district does not represent all of education, but these stories are in no way uncommon. I witness this kind of mediocrity - and sometimes even ineptitude - on a frequent basis. I understand that my private practice draws those families who are not satisfied with the regular process - but is the system really aware of how many families are overtly dissatisfied with special education in general and school-based occupational therapy in particular???

Can OT achieve its centennial vision when it fails to meet the basic needs of people in this way?

Tuesday, March 06, 2007

Occupational therapy and cones

If a cone fell on the floor, what is the chance that it would land ‘standing up' on its base??

I wonder this because a family member had a total hip replacement and is receiving occupational therapy in a short term rehabilitation facility. In OT they are teaching her how to pick up objects that have fallen on the floor. That seems like a reasonable point of intervention to me: it is important that people avoid placing undue stress on a new hip joint and I am sure that the OT does not want her to bend excessively.

Why, though, does my family member have to pick up cones?

I know a little about cones, more from my experience with geometry than from my experience as an occupational therapist. A cone is a three dimensional geometric shape. It is the locus of all line segments between a base and a point outside the plane. I know that the base of a cone can be any shape as long as it connects to an apex at any point outside the plane of the base. As far as I know there is nothing in her home that is cone-shaped. I don’t know if they have ice cream cones right now – I guess that would be an exception. However, the dog would probably eat it long before someone got to it with a long handled reacher. Anyway, I think it is fair to say that nothing that is cone-shaped regularly finds its way onto the floor.

When I think about the things that people do have to bend to pick up, I think that clothes get dropped on the floor all the time. A magazine or the television remote control probably gets dropped. Tupperware and Tupperware lids always seem to fall out of my cupboards onto the floor, but I don’t think that any of those are cones.

So why do occupational therapists have such a fascination with cones? I suppose I should be thankful for small favors that my family member is not stacking cones. We are still waiting for the OT to start teaching her how to get dressed and use the bathroom. How long should I wait before I ask?

Thursday, March 01, 2007

Cultural awareness and occupational therapy

Here is an excellent email question I got from a gentleman in India who is considering a career change and would like to practice OT in an English-speaking country.

My question is: Even if I got good command over English, would indigenous people prefer a foreign therapist and would I be able enough to know their problems?

I had this exact same question when I was completing my fieldwork in a mental health setting in an inner-city environment. I grew up in a suburban mostly middle-class world and when I came into my new worksite I looked around and could not recognize the culture around me.

I understood that poverty existed in the world, but I had not seen people trying to get admitted into the psychiatric unit until the monthly governmental check came.

I understood that some people were on drugs, and I had even seen some of my friends try drugs, but I never saw anyone needing to be strapped down to a gurney after a bad PCP trip because they thought that they could see the devil if they looked closely into people’s eyes.

I heard about people trying to commit suicide, but I never met so many of them who actually tried.

I recall seeing the movie One Flew Over the Cuckoo’s Nest, and imagined that mental health was advancing so much because I saw that electroshock therapy was being conducted on anesthetized patients in an operating room. But it still didn’t fit in with my cultural reality.

My point here is that I had absolutely no basis to understand the sociological morass around me. When I reached for a life preserver I looked for Mary Reilly who had never before failed me – but I found that she spoke about occupational roles and at that time I couldn’t understand how to bridge the divide between the reality of street level mental illness and the need to help people return to normal role behavior where ‘normal’ was nothing that they had ever even approached previously. The model just didn’t seem to fit, and perhaps I was not sophisticated enough at that time to understand.

Since then we have conceptually refined our terminology and we are better able to articulate concepts of occupation and context so that we have models that can help us. I think that Reilly and role theory are still extremely relevant – but perhaps from a broader economic and social perspective that is perhaps beyond the point of this emailer’s question.

Anyway, I think that there are ways to ‘bridge’ these divides – and of course the first step is to be aware of the gap. Once you are aware of the gap you can take active steps to help people in relevant ways. But that is true for all of OT – not just when the gap is represented by language barrier and cultural barrier.

OTs need to have a meta-awareness regarding the interaction between the therapist’s cultural perspective and the cultural perspective of the person receiving services. Without this meta-awareness you will not be able to be maximally effective. It sounds like the emailer is already well on his way to being a good OT.

In the alternative, you can forget about all this cultural meta-awareness diatribe and you can just stack cones, but your patients will leave the encounter unfulfilled and unhelped.

Tuesday, February 06, 2007

Sensory integration: warning to parents and insurance companies

In a recent entry I talked about the issues of pseudoscience and the problems with sensory integration theory from an academic and theory-based perspective. Today I got an email from a parent that illustrates the problem from the street:

QUESTION:

My child has just been diagnosed with sensory integration difficulties. I must admit the evaluation results are scary and seem overwhelming. I can only imagine what my child is feeling.

I am very anxious to get my child help. We had my child tested at A PROMINENT AND WELL KNOWN SENSORY INTEGRATION CLINIC (name redacted). They are excellent - but the treatment is very expensive and not covered by insurance.

Do you have any experience with how to get the insurance company to make an exception?

It has been recommended that we get 1 hour of weekly therapy for about 18 months and if possible a 3 week summer camp. The hourly sessions cost $165.00

Your response would be appreciated.

Thank you
NAME REDACTED

++++++++++++++++++++++++++

Insurance companies see the term 'SENSORY INTEGRATION' and they almost immediately deny the claim - and I DO NOT BLAME THEM! This is why:

First of all, we are occupational therapists, not sensory integration therapists. Most therapists use an eclectic grouping of intervention strategies in order to improve the functional performance of a child. If the accepted purpose of occupational therapy is to improve the functional performance of a child, and if there are CPT codes that correspond to this type of activity, why would OTs feel any need to try to bill using esoteric sensory integration codes that are marginally accepted - even at best??

Second, on what basis can any therapist tell a parent UP FRONT that a child will require 18 months of therapy??? Every child is unique and progress should be measured at regular intervals - I recommend every three months for children with developmental disabilities. If a child is not making adequate progress toward goals then either the goals should be modified or the methods should be changed.

I don't have evidence to support that 3 months is the 'correct' amount of time - it is simply based on common sense and a hope to measure progress at a more reasonable interval.

Some children benefit from long term supportive or maintenance-types of interventions. Insurances are not keen on paying for maintenance - and that is ok. These kinds of costs should be reasonably shared with families or school districts. Generally, for those children who require long term intervention, a good deal of the intervention should be directed toward the family in educating them about extracurricular activity configuration and educational planning.

To firmly state that a child will require 18 months of intervention plus a summer camp is not consistent with what I consider to be appropriate or ethical practice.

In summary, here is my warning to parents and insurance companies:

1. If someone tries to tell you that a child's problem with motor planning, attention, or learning will require a prescribed amount of therapy they are probably making it up. There is no evidence that states that a prescribed amount of therapy is required for fixing any particular problem.

2. It is reasonable to expect that you and your OT will set goals that you agree to. It is reasonable to expect that progress will be measured toward those goals at a prescribed interval that is reasonable.

3. It is reasonable to seek third party reimbursement for OT when problems are likely to remediate quickly. Some children's problems will remediate quickly, or therapy will 'set them on the path' toward changing their activity choices so that problems are not so disabling.

4. Some other children require long term intervention, beyond what can be achieved in short time frames. When therapy is long term, it is because problems are intractable and because there are constantly new issues that require skilled intervention to assist the family or school in developing strategies to work around. It is reasonable for third party insurers to restrict benefits so that therapy doesn't continue without any end in sight. Schools and families should help absorb costs for long term or maintenance types of interventions.

Insurance companies should run for the hills whenever an OT tells them up front that a child requires 18 months of therapy for a specified condition. I believe that is disingenuous. I also have some pretty significant concerns about charging a family $165 an hour. I suppose that there are demographic variations in rates for services but there would have to be some very specific and measurable progress and outcomes to suggest to a family that $165 an hour was worth the investment.

If we used Medicare as a national model of reasonably reimbursed occupational therapy - $165 an hour is FAR BEYOND any Medicare reimbursement for therapy services. WHY would an OT charge a family such a ridiculous rate when the insurance companies don't reimburse anywhere near that rate? Isn't that taking advantage of people who are willing (desperate enough) to private pay?

So here at the bottom of this entry I will post my secondary warning to OTs: if you ever expect to be taken seriously and if you want to insulate yourselves from this kind of criticism and if you want insurance to reimburse for services - please think very carefully about what I have written.

Saturday, February 03, 2007

Is a doctoral degree necessary for entry level Occupational Therapy practice?

I entered my profession in 1987 and at that time a bachelor’s degree was required to practice as an occupational therapist. At the American Occupational Therapy Association's Annual Conference in 1999, the Representative Assembly passed Resolution J, mandating post-baccalaureate education for entry into the profession.

I still have not seen any study that indicates that baccalaureate-trained professionals are in any way less effective than people who enter the profession at the master’s level. The marketplace also never acknowledged the alleged benefit of the master’s degree, as people with advanced credentials did not make any more money than people with bachelor’s degrees.

I summarize from this set of facts that the move to post-baccalaureate education served the needs of educational institutions who were able to get more tuition from students who were trying to enter the profession. Students stay in school longer and educational institutions benefit by collecting more tuition. I do not see any other benefit to any other stakeholder (consumers, therapists, or others). I imagine that the possible intent of OT post-baccalaureate education was to ‘keep up with the Jones’ – that is the PTs and pharmacists who moved in that direction. Still, important decisions should be based on what is good and necessary for the occupational therapy profession, not based on what someone decided was a good idea for some other profession.

Following Resolution J, ACOTE (the educational credentialing agency for OT) began looking at doctoral level education and formed a committee to look into the issues. The ESRC (Educational Standards Review Committee) identified some significant concerns about any move toward accrediting doctoral level programs. It seems that someone didn’t care what ESRC had to say because a different committee was formed (the ACOTE OTD Standards Committee) to develop standards for doctoral degrees despite what ESRC reported. This represented a major switch for ACOTE, who traditionally was always in the business of credentialing PROGRAMS, but now would be granting different credentialing for different DEGREES.

Additionally, the AOTA Representative Assembly was supposed to be the body responsible for making recommendations about the doctoral level of education. They were supposed to finish this work in 2006 but had to extend their process until 2007. Now whatever the RA has to say is a moot point because ACOTE has already made unilateral decisions about doctoral level education.

At this point I imagine that the eyes of many street-level occupational therapists begin to glaze over… but this is an important issue to study. The question I have is this: why does it appear that ACOTE, with the tacit approval of AOTA, is trying to ramrod an entry level doctoral level of training on the profession?? Is there some unpublished study that has been done that identifies how this change will benefit consumers?

Just because other professions have moved to a doctoral level of training doesn’t mean that OT also has to. Just because some people have the IDEA that advanced training is needed for practice doesn’t mean that IN FACT advanced training is needed for practice.

As collective shepherds of our occupational therapy profession we can’t allow major decisions like this to occur without the input of the membership or without careful and thoughtful study of the impact.

What should street-level OTs be concerned about:

1. If it is true that practice is becoming so complex that doctoral training is required, what does this mean for people who are functioning as occupational therapy assistants and only have an associate’s degree?

2. Are there some glaring inadequacies in the skill sets and competencies of associate and baccalaureate and master degree level practitioners that need to be acutely addressed in order to ensure the safety of consumers?

3. If there will be two levels of entry into the profession (from the masters level and from the doctoral level) does this mean that people with degrees below the doctoral level will be restricted from certain areas of practice?

4. If it is true that doctorally trained professionals are practicing at a stratospheric level of competence do they even need to be credentialed for entry level practice? How would they be credentialed and what will state regulatory boards think of multiple levels of certification?

5. Since there was an RA process in place to look at the issue of doctoral level education, does this mean that the RA is irrelevant since ACOTE already acted on this issue?

6. If the RA is irrelevant and if constituent feedback to the ESRC was irrelevant, and since the ESRC report was summarily dismissed, do we even really have a representative membership organization?

So if you managed to read through all of this, contact your RA representative and ask them what they think.


References/background:

AOTA (11/12/06). Frequently asked questions about the Doctor of Occupational Therapy Degree (OTD). Downloaded 2/3/07 from http://www.aota.org/nonmembers/area13/links/link56.asp

AOTA (July 2006). Background on the development of ACOTE standards for OTD programs. Downloaded 2/3/07 from http://www.aota.org/nonmembers/area13/docs/otd-process-7-06.pdf

Wednesday, January 31, 2007

pseudoscience and sensory integration theory

Pseudoscience is defined by characteristics including the use of vague, exaggerated or untestable claims, over-reliance on confirmation rather than refutation, lack of openness to testing by other experts, lack of progress, and personalization of issues (see Wikipedia article which is a nice summary). As the article notes, however, it is important to distinguish protoscience with pseudoscience.

At this point in time, 35 years after Jean Ayres wrote Sensory Integration and Learning Disorders, I am willing to consider that this concept of sensory integration theory is no longer 'nascent' and that we have not made appropriate progress toward researching and validating the theory as it is now constituted. For perspective, in 1972 when that book was published, the first hand-held calculator was marketed. Has science not moved forward since that time?

This is not to say that children don't have learning problems, or that they don't have problems in processing sensory information that leads to functional and behavioral problems. What it means is that we need to toss out the proverbial bath water without throwing out the baby when it comes to sensory integration theory.

Why do we need to revisit this? Sensory integration theory does not EXPLAIN why children behave the way they do. Sensory integration theory does not help us PLAN intervention. Sensory integration theory does not PREDICT how behavior will change as a result of intervention.

The most recent textbooks still state that "sensory integration cannot be observed. (Bundy & Murray, 2002, p.3). When I went to school as an undergraduate in the early 1980s I was told that there may be a neurochemical basis to sensory integration difficulties. It was an exciting concept that I was interested to see develop. Twenty five years later after completing my doctorate there is still no definitive cause for the disorder that can be identified.

This matters because there is a credibility gap when an occupational therapist states that a child has SI problems. Therapists have mistakenly believed that if we change the names to SID, or DSI, or SPD that this will somehow change people's minds about the theory. In reality we can call it chicken soup or anything we want - if the theory can't be validated then the name is irrelevant.

Occupational therapists are continuing to dialogue about classification and naming in sensory integration theory. Now we are making distinctions between sensory-seeking vs. sensory avoiding typologies. Or distinctions between active vs. passive coping styles. Ad nauseum. Less attention is paid to neurophysiological underpinnings and basic science research that would actually DO something to elucidate the nature of the disorders.

There is NO LACK of basic science that applies. Why aren't we studying neuronal migration (see Chang, et.al. 2005) or undetected brain damage (see Looney, et.al., 2007)?? Instead we focus on endless classification and naming of some 'unseen process' that we can't define. Then we state that by engaging the child in a series of experiences that they will somehow improve - but here we begin to disagree, with some people advocating passive and prescriptive sensory input and others advocating child-directed approaches. So as a consumer (parent, insurance company, etc) imagine their confusion and hesitancy when they go to some OTs who tell them that their child has some alphabet soup disorder (DSI, SID, SPD, whatever) that can be treated by either active or passive strategies - depending on who you talk to - and that we can't define what is REALLY wrong but we just know that these active or passive strategies will help the brain to function normally.

I wouldn't buy it either.

What I would buy is going to a therapist who tells me that learning disorders often have a physiologic or genetic component and that these causative factors can vary between children. Some of our research points to brain damage, some to neuromigration deficits, and some we just don't understand yet. Either way, the distinct problems that the child has as a result of the organic neurologic problem can be quantified by performance on standardized testing that looks at motor, perceptual, and other cognitive factors that impact occupation. When children have known deficits that we can quantify or measure, we can gather baseline data so that we can measure the effect of our intervention and training attempts. Intervention can involve participation in sensory-based and other activities, but we still need to quantify our progress with a behavioral measure.

After we proceed this way we are left holding data that quantifies the nature of the problem. We have basic science that could be analyzed to determine if there is a 'fit' between the identified organic problem and the clinical signs that are seen. We also have intervention strategies that can be evaluated in terms of progress on standardized measures.

Contrast this to our current state of affairs where all we have is a loosely defined set of behavioral observations, no real science to back it up or validate our intervention strategies, and a pile of people (OTs and non-OTs alike) with products rushing to market music CDs, weighted vests, brushes, and yet another sensory integration book that parents will buy because they are desperate to find answers for the problems that their children are having.

We can do much better.

This is why I now purposefully label sensory integration theory as pseudoscience.



References:

Ayres, A.J. (1972) Sensory integration and learning disorders, Los Angeles: Western Psychological Services.

Bundy, A.C., & Murray, E.A. (2002). Sensory integration: A. Jean Ayres' Theory Revisited in A.C. Bundy, S.J. Lane, & E.A. Murray (2002) Sensory integration: Theory and practice, 2nd ed., Philadelphia: F.A.Davis.

Chang, B.S., Ly, J., Appignani, B., Bodell, A., Apse, K.A., Ravenscroft, R.S., Sheen, V.L., Doherty, M.J., Hackney, D.B., O'Connor, M. et al. (2005) Reading impairment in the neuronal migration disorder of periventricular nodular heterotopia. Neurology, 64, 799–803.

Looney, C.B. et al. (2007). Intracranial hemorrhage in asymptomatic neonates: Prevalence on MR images and relationship to obstetric and neonatal risk factors. Radiology, 242, 535-41.

Friday, January 19, 2007

another look at child passenger safety

Earlier this week Consumer Reports reported on the performance of certain child restraints in side impact crashes. That generated a few calls and emails to me from concerned parents.

Now I see that they are retracting the article because of new data they are considering. It seems that the crash velocities used in the Consumer Reports testing far exceeded the 35-38 mph standard that is typically used. Go check out their retraction statement HERE.

I like to highlight this information because any pediatric OTs out there who have young children on their caseloads should be sharing this information with parents. When parents hear about these reports they begin to lose confidence in their car seats - it is critical that parents continue to place their children in their car seats.

This is particularly true for parents of children who have disabilities. Many of these parents already lack confidence in child restraints. Traditional child restraint devices do not address the unique positioning needs of children with disabilities (AAP, 1999). Premature babies and children who are smaller or larger than average are not well protected in typical child restraints. Children who have tracheotomies require special consideration for protection of their airways. Children who have muscle tone abnormalities require specialized external support to accommodate for their positioning needs. Because of these and other complexities, parents and school personnel make inadvertent installation and securement errors when the children are riding in their families' cars and on their school’s buses.

Providing education to parents and professionals regarding options for safe transportation of children with disabilities helps to improve children's health and well-being and prevents injuries and deaths.

The parents of children with disabilities have unique occupational needs associated with the safe transportation of their children. Parents must accommodate their children’s physical disabilities as well as their own adaptive habits and routines of caregiving. Many experienced child passenger safety professionals do not know how to evaluate and intervene in these complex scenarios. Conversely, many occupational therapists who understand the multi-factorial issues associated with childhood disability do not have any experience with crash dynamics, securement systems, and legal mandates of safe transportation.

So this is a good opportunity for OTs to have conversations with parents about child safety restraints. Stay tuned for new information once Consumer Reports re-evaluates its crash testing on infant seats.

References:

American Academy of Pediatrics, Committee on Injury and Poison Prevention (1999). Transporting Children With Special Health Care Needs. Pediatrics, 104, 988-992.

Monday, January 08, 2007

answers to questions

(I intended to post this over a week ago; life got in the way).

Here are some recent questions that I will answer here:


Hi Chris, I'm an occupational therapist working in a child development clinic in Israel. I am looking into the validity of the Wilbarger brushing technique. I've come across very little that validates the intervention. I thought I read on your blog some sort of critique of the lack of evidence. It might have been on a different blog, but would appreciate your feedback nonetheless especially after reading your thoughts on evidence based practice. Thanks and have a happy new year!-dena


Hi Dena!

Happy New Year to you too! I have blogged about the Wilbarger protocol here (http://abctherapeutics.blogspot.com/2006/04/wilbarger-approach-how-patient-should.html). Nothing has really changed since I wrote that last April. There has been nothing new published that I have seen.

People use the search terms ‘Wilbarger protocol’ frequently, based on hits to this blog. I believe that people like the idea of an intervention that is so concrete in its application for such a troubling problem.

All that being said, just because something isn’t fully researched doesn’t make it worthless. A lack of evidence just means that we need to be judicious in the way that we present information to consumers (families, insurance companies, other professionals, etc.). A lot of statements have been made about this intervention as if there was evidence to support a deep pressure protocol being done a certain way, or with a certain brush, or with a certain schedule. I don’t believe it is fair to say that we really know that much about this intervention at all.

In my opinion the problem with lack of evidence for a Deep Pressure Protocol is troubling primarily because of the conviction with which it has been presented to consumers.


Here is another one:

My Grandchild does not seem to react well to transitions ie. He keeps repeating phrases over and over, almost stuck of them and he gets fixated on certain toys. The only thing he likes when he gets upset is I give him BIG hugs and sort of rough house with him, for some crazy reason he is much calmer AFTER I play hard with him. WHY? I don't even know if you can help me with him but we are open for suggestions.


I get a lot of questions like this, asked on the website or in a comment on the blog. The problem is that there is NO CONTACT INFORMATION! So, I would love to help, but so much more information is needed. The best I can say is to see an occupational therapist for an evaluation. Also, please leave contact information so we can contact you if you have this kind of question!

Happy New Year to everyone!