Thursday, December 24, 2009

Luke 2:10

The day before Christmas eve is always busy, and yesterday was no exception. The office will be closed for several days and there were so many things that needed to be done. Payroll had to be audited and sent out, some schools had paperwork deadlines for the end of the second quarter, schedules needed to be coordinated for time off so we were sure to have coverage for those families that wanted services next week, some end of the year banking needed to be done... on and on.

It was busy, and the message was delivered this year on cue in the form of Tina. At the very end of the day we had three families jostling past each other between appointments and Tina burst through the front door on a mission. She made a bee-line straight toward me, absolutely disregarding all the social cues that might have otherwise indicated she needed to wait. It didn't matter that other parents were standing near me, that we were engaged in a conversation, or that her own mom was trying to corral her into the waiting room - her message HAD to be delivered.

As Tina jumped excitedly from toe to toe she reached as high as she could to show me a gift card to a local coffee shop and she could barely contain herself,"Here is a $5.00 gift card so that when you are done working today you can go to relax a little and get yourself a really nice cup of coffee or maybe a hot chocolate or WHATEVER YOU WANT!"

The 'WHATEVER YOU WANT" is what caught me on several levels, and I suspect it caught all the other people in the room too. The parents in the waiting room all understood the impulsivity, and the lack of attention to social convention, and the excited lack of emotional regulation in Tina's voice. They deal with those issues themselves every day.

But what demanded attention was the purity of the gift and the absolute joy of giving - which at the end of a day that was filled with attention to comparatively inane issues - was exactly the message that I needed to hear.

Monday, December 14, 2009

Conversation with a future OT student

From: A future OT student
Sent: Sunday, December 13, 2009 7:07 PM
Subject: from a future OT student: wanted to say thanks

Dear Dr. Alterio,
I just wanted to thank you for all of the great stories you posted on your blog... I am writing to you because I have been searching for stories by occupational therapists where they actually help people, where they make a real difference. After going through prerequisites, applications and finally being accepted into two of my top choice schools- I have found terrible posts on [a website] posted by ex occupational therapists and some physical therapists which all revolve around how occupational therapy is an ineffective, terrible profession to go into. They warn people to stay away from the profession. Many people have written in response to those posts saying that because of them, they have changed their mind. You helped me to not change my mind.

I started looking into occupational therapy after having worked with special needs children as an aide for several years. I particularly remember enjoying work with an occupational therapist as she treated a girl with cerebral palsy. I also enjoyed working with children with autism and Downs Syndrome. I have a back ground in the arts (thought I haven't been able to earn an income from it).

I'm just glad to hear your real stories that reveal that you really do help people, and that its not all about getting reimbursed (for something patients don't need) and [providing personal care].

I wanted to ask you what you thought of skilled nursing facilities (if you don't mind).

I also wanted to ask you if you think it would benefit my future to go to a better school like [University A] versus [University B] (which is good, but not as good in some areas). Do you think people who go to more reputable schools have a better shot at a job they want?

I hope you don't mind my questions. Initially, I just wanted this to be a note of appreciation for the work you do, and for documenting it.

Thanks a million,
A future OT student


Dear Future OT Student,

Thanks for your very kind note.

The Internet is a challenging place to get information because there is no guarantee that you are getting a balanced opinion and whatever you read may not always represent the true spectrum of opinion on any given topic. This even holds true for my own online writing. This does not invalidate anyone's opinions, but it is still important to remember!

As for skilled nursing facilities, I personally find them to be challenging places to work - but there is very important work to be done in those environments. I spent many hours in nursing homes early in my career, but this was before the so-called 'nursing home boom' of the 90s when the environment changed and became even more focused on reimbursement. My experience in nursing homes is that people in these facilities have incredible needs and that it is very challenging to meet those needs in that environment. The context is 'foreign' to most of the people placed there and in fact very few people choose to live in those facilities. In itself, this reality makes nursing home care tend toward tragic - at least when measured against the ruler of typical expectations of where people want to be in their lives.

There are exceptions, of course. Some skilled nursing facilities have re-engineered themselves into rehab facilities and people who reside there are only there on a short term basis for post-surgical or post-trauma recovery. Many skilled nursing facilities have sizable populations of people in this category. The problem happens when people who are elderly and experiencing declining health are determined to be 'eligible' for rehab beds or positions based upon someone else's formula. This causes unfortunate activity like rehab for someone who under other situations might not even choose it or might not even want it.

An exceptional skilled nursing facility situation I experienced was where the patients quite literally co-opted the occupational therapy room and created a 'culture' of work for themselves - they even went so far as to hang a sign on the door that said something to the effect of 'Let no one call another person's work inconsequential.' People who were long-term residents of that nursing facility came in and worked on things that they wanted to work on - some were functional activities and others were not! As a new graduate (at the time) I thought that it was my job to make sure all of their activity choices were respective of their occupational roles - any my naiveté almost prevented me from understanding that for many of these people the therapy was the environment and the culture - and not the activities! The people in this particular nursing home who created and participated in their occupational therapy routines were among the happiest residents of any skilled nursing facility I have ever seen in the twenty plus years since that time. These people, all with very broken physical bodies, represented a triumph of the human spirit that I have not again seen demonstrated - it was a rare and compelling experience.

My point is that even in desperate conditions there is hope, and hope is good when we can learn how to harness it for people who we are charged to care for.

Maybe the people who posted on those forums you refer to have lost some hope? I hope they can find it, somewhere - because spending your life doing something or being somewhere you don't want to be is not a way to spend a life.

Finally, regarding your question about schools - go to a place that feels like a match to you. Of course you should ask the school about their accreditation, graduation rate, and percentage passing the certification examination - but other than that your choice of a college has to match so many other factors in your life. Your future career as an occupational therapist will not be determined by the college that you go as much as what you choose to do with the college that you go to!

And I am very hopeful that you make all the best choices, for you!

Warm regards,


Monday, December 07, 2009

Questions about AOTA's response to the National Autism Center

The National Autism Center published a comprehensive National Standards report regarding evidence-based practice guidelines for children and young adults who have autism. The report is an excellent summary of research about intervention methods and effectiveness. It was particularly interesting to me that this report referenced and hoped to expand on the New York State Early Intervention Clinical Practice Guidelines for autism spectrum disorders which of course is a document that is familiar to many of the families in my geographic area. The NYS guidelines were published ten years ago so an update to include new research was needed.

The new report focuses on quantitative studies and in this sense some important occupational therapy literature may not have met the inclusion criteria. There have been some excellent qualitative studies completed that make important occupational therapy contributions to best-practice considerations so I am really looking forward to the next report that promises to include qualitative methodologies.

In reviewing the report I was intrigued by the treatment classification process. It is undoubtedly a daunting task to conglomerate such a large number of articles into discrete categories. It was particularly interesting to me that many articles that have 'sensory' issues in them were listed in 'behavioral' treatment packets - for example there was an excellent article on the use of a fading technique to improve tolerance for milk drinking. Now I suppose that you could describe this intervention as a behavioral fading but you could just as easily describe it in sensory terms because in this study they manipulated amount of chocolate syrup until the child was drinking plain milk. Either way, many OTs use similar techniques when addressing the feeding problems of people who have sensory intolerances associated with their autism.

There are many other important established and emerging interventions that are used by occupational therapists and supported in the NAC document including social stories, relation/interaction approaches, behavioral approaches, and functional skills training.

This brings us to the AOTA response to the report. The AOTA response stated "We believe it unfortunate that the National Standards Report of the National Autism Center did not include valuable research findings available regarding occupational therapy and sensory integration." I don't agree - I think that there was a lot of supportive evidence for occupational therapy interventions in general and also for sensory-based interventions in particular (depending, of course, on how you are choosing to 'label' and 'categorize' the studies)! Deep reading of the report validates this observation. The NAC report validated MANY important occupational therapy intervention approaches, including some sensory-based approaches that were just labeled in different categories.

Again, the underlying problem contributing to misconceptions about the report and about so-called "sensory integration" research is an absolute mish-mash of definitions and total lack of research and intervention fidelity. It is always disappointing to see summation reports or meta-analysis mislabel sensory interventions - but this time AOTA also contributes to the fuzzy definitions. The AOTA response letter references the Case-Smith & Arbeson (2008) study that lumps 'auditory integration' and 'massage' into the sensory-based category. I know a few respected OTs who might object to passive auditory and tactile sensory approaches being termed sensory integration.

So the bottom line here is this: what are sensory integration studies and can they be lumped together with sensory-based intervention studies? Are they classic sensory integration models in specially designed play environments? Are they deep pressure massage or weighted vests? Are they listening to music with headphones? Are they gustatory fading techniques to improve tolerance to milk????

My recommendation for practitioners is to read the report and be very happy that there is so much evidence for so many occupational therapy interventions. I encourage people to use those techniques that are established or those which are emerging. For those where there are less evidence - encourage families to use discretion and try those techniques AFTER other methods have not been effective. Resources are not unending and we need to first promote interventions that have the best likelihood of success.

My recommendation to AOTA is to re-think these response letters. I believe that there can be more harm than good accomplished with responses that don't celebrate the many OT interventions supported in the report - including those sensory-based and sensory-related studies that are listed in other categories! Finally, our profession really needs to get its definitions straight and we need to tackle this fidelity issue once and for all. Harm is being done by continually failing to appropriately define these interventions and have a robust professional debate on this topic.


(please read the links as well!)

Case-Smith, J., & Arbesman, M. (2008). Evidence-Based Review of Interventions for Autism Used in or of Relevance to Occupational Therapy. American Journal of Occupational Therapy, 62, 416-427.

Luiselli, J. K., Ricciardi, J. N., & Gilligan, K. (2005). Liquid fading to establish milk consumption by a child with autism. Behavioral Interventions, 20(2), 155-163.

Sustainable communities and disaster relief for people who have disabilities

In general, people are not inspired to continue monitoring post-disaster relief operations after most of the television cameras leave. So any commentary on this topic may seem to be johnny-come-lately except for those who sustain their interest and understand how big the problem really is.

This is an attempt to refocus a little bit of attention on an issue - and I am not as interested in getting preachy as I am in shining a flashlight on issues that are good fuel for action.

There is a great competition for students to examine the challenges that people who are elderly or disabled face during and after disasters in their own cultural and local contexts. I hope some students see this and become interested in the topic.

If you need some motivation for outrage, read this first.

Tuesday, November 17, 2009

Student survey: What education level is needed for COTAs?

Please consider helping an OT student by taking this non-scientific survey so she can gather opinions on what education level is needed for COTAs.

The survey is at


Distinctions between health care delivery problems and social policy problems regarding premature births

Today the March of Dimes released their 2009 premature birth report cards for each state. Premature births are an important issue to discuss for occupational therapists because so many of the children who require OT services have a history of prematurity. Even so-called 'late preterm births' where the children are 34 weeks gestation and older have a higher incidence of learning problems.

People will take advantage of the release of this report to politicize the findings as an indictment of the US health care system. This is only partially true because a multitude of social and cultural factors causes this problem, including:
  1. MDs practicing defensive medicine and increasingly using 'late preterm' cesarean delivery.
  2. Couples opting for fertility treatments that inevitably lead to increased incidence of twin/triple/quad pregnancies (and sometimes more).
  3. Poor prenatal care among illegal immigrants and undocumented aliens who do not have health insurance.
  4. Poor prenatal health care among groups who DO have access to Medicaid.
  5. Smoking, obesity, teenage pregnancy, and other lifestyle factors.
The best way to combat prematurity includes several approaches. There should be tort reform to limit the practice of defensive medicine and more education for physicians on best practice for late term pregnancy management. Couples who opt for fertility treatments (and the MDs who facilitate) should be held financially accountable for the costs of the prematurity that they create. Open border and sanctuary city policies need to be re-evaluated because rate of uninsured women is directly related to these factors.

The health care system CAN do more to improve access and quality of prenatal care delivery, particularly to vulnerable or at-risk populations who already have Medicaid coverage. Continued education and outreach to help control the impact of negative lifestyle factors is also critical. Still, the larger indictment is on our social policy and NOT on our health care system. Once preterm infants are born, the care they receive in the US is unparalleled in the world. The problem is in how the prematurity occurred - which is more about social policy than anything else. There seems to be a real confusion in separating out the CARE system from the SOCIAL POLICY. They are quite different from each other and each requires a very distinct approach for improvement.

Monday, November 16, 2009

Good question from a student

From: OT Student
Sent: Sunday, November 15, 2009 11:55 AM
Subject: OT student needs help


I just visited your website and found your blog section very interesting. I am a current MOTS student from XXX that is working on a project looking at whether COTAs should be required to have a bachelors degree rather then just an associates.
I am wondering if you are able to post this question on your blog as I need feedback from OTRs and COTAs on how they feel about this issue.

I would be most grateful.

Thank you in advance,

OT Student


Dear OT Student,

If you create an online survey (there are several free survey tools available) I will be happy to put the link on my blog.

I am not aware of any evidence that supported graduate degrees for OTRs - and this is an important question that should be raised. If more schooling is required and this feeds competence that is fine - but I don't know that anyone is able to say that someone trained at the masters level is more proficient or competent than someone trained at a baccalaureate level.

If you apply degree inflation to COTAs then you will undoubtedly price many people right out of the job market. People sometimes participate in associates level degree programs because they can't afford more schooling.

This is a big human resources issue for the profession.

There is a corollary issue to also consider: How is the education and skill set of a COTA suited to meet the needs of people who receive occupational therapy? What level of education is needed to provide occupational therapy services? This is a thorny problem for the profession that most people aren't willing to seriously discuss.

Individual states place limits on COTA practice but the limitations vary widely. There is very little specific guidance from the professional association, presumably because of the way that the issue would alienate some of their potential association participants. In the vacuum of this lack of specificity you will find some rather varied opinions about what COTAs should be able to do. You will find no such vacuum of guidance from our physical therapy colleagues and how they delineate the professional and technical levels of their profession.

Good question though. Please don't stop asking because we need a lot more questioners in order to advance our profession.



Thursday, November 12, 2009

Feedback on alternatives to the therapy cap

Occupational therapy payment restrictions, typically referred to as 'therapy caps' on Medicare Part B, are daily concerns for all occupational therapists working in private practice, outpatient clinics, and nursing facilities. AOTA is participating in a long-term project aimed at finding an alternative to the current cap system. RTI International, the entity that was awarded the government contract to conduct this research, states that "CMS envisions a new method of paying for outpatient therapy services that is based on classifying individual beneficiary’s needs and the effectiveness of therapy services, e.g., diagnostic category, functional status, health status. Currently, CMS cannot evaluate or implement this type of approach because CMS does not currently collect the appropriate data elements."

RTI is proposing assessment tools to describe the characteristics of Medicare Part B clients. The proposed tool for outpatient settings collects demographic data and consists primarily of a patient report of how well they think they are able to participate in tasks. There is a more extensive assessment based on therapist opinion for cognitive, speech, and swallowing functions - no such therapist data is collected for other functional performance areas. It seems that the outpatient tool is potentially very limited - it is rather odd that something as important as determining therapy reimbursement would essentially be dependent on patient opinion of their functional status. The facility-based tool relies more on therapist or professional assessment. For this reason I have fundamental disagreement with the assessment proposal and I don't understand why such different assessment methodologies are in place for the two tools.

I also have some concerns with their data collection and sampling. To begin with, the data collection forms are very long and burdensome - I cannot imagine that many private practitioners will be able to afford to participate because therapists and office staff will not want to wade through so many pages. The outpatient based form is 17 pages long - and when I think about who the Medicare Part B participants are who come into my outpatient clinic I just can't imagine that they are going to want to fill out this long, confusing, small-font form.

The researchers are planning to use a weighting formula during data analysis because of expected frequency and distribution differences between PT (which is a more heavily utilized service) and OT/ST (which are not as heavily utilized). This causes some potential problems with whether or not the OT data will capture the breadth and scope of actual practice. Simple weighting adjustment can really skew data - and weighting only works correctly if you are relatively certain that you have adequately captured a representative sample to begin with. Further confounding this issue is the extreme disparity between the nature of a nursing home Part B population and an outpatient Part B population. I have very little faith that there will be 'enough' correct data in the sample to adequately represent the population of people who come to small private outpatient clinics.

I don't have faith in this data collection tool or the methodology that is proposed for interpreting the data. The outpatient tool is limited to patient perspective on function and is likely to under represent and misrepresent the nature of outpatient Part B OT participation.

I would like AOTA to advocate for a better tool that is based on therapist assessment of patient function (there are already many that already exist) and to advocate for distinct separation between nursing home and outpatient Part B data analysis.

Background reading:

AOTA - Alternatives to the therapy cap update: Need your feedback. Downloaded from on November 12, 2009.

Monday, October 19, 2009

New York toughens child abuse laws, some.

Earlier this year I wrote about Nixzmary Brown and I was happy to learn that Governor Paterson signed the bills into law that toughened possible sentencing for child murderers.

Under the new law, an adult who intentionally causes the death of a person under the age of fourteen years old can be found guilty of Aggravated Murder if they tortured the victim prior to death. [Penal Law §§ 125.26] The bill also authorizes a sentence of life imprisonment without the possibility of parole. [Penal Law §70.00(5)].

Tougher sentencing options are good - and if you want to feel good about this outcome then don't look into the history of the case. If you want to feel good about this outcome then don't research any details about the trial.

If you happen to do any research into this you will still feel an empty aching in the pit of your stomach. I suppose there should be no rest for the wicked - and we really have not yet done enough.

Monday, September 28, 2009

Cloudy with a chance of ... pine cones?

Here is a picture of the wheelchair ramp on the front of the building. Thanks to a particularly unstable weather cell in our area we had violent winds this morning. While working with a small group of four year old children we heard THUNK THUNK THUNK THUNK outside the building and I immediately thought that I was hearing hail. When you are an adult it is sometimes reflexive to think about boring things like repair bills for damage - the noise was extremely LOUD and I was envisioning the dents all over the roof and hood of my car!

Thankfully I don't work in the world of adults and so the self pity over potential repair bills didn't last long. The children were curious so we all ran to the window and they were amazed at what we all saw. "OH MY GOODNESS IT IS RAINING PINE CONES!!"

The contextual world of children is currently rich with movie metaphors for odd rain events and so it all made very perfect sense to them. The kids were very excited to return to our pre-writing activity and modify the pictures they were working on by adding "pine cone rain." It was grand fun this morning!

Monday, September 21, 2009

How the health insurance industry is price gouging to its own demise

Here is an interesting anecdote of how the private health insurance market is killing itself:

Our health insurance costs (premiums + deductibles) for the plan we offer to employees have risen over 20% each year for the past five years. Some years our costs have risen as much as 45% when we were forced into the high-deductible product line.

There has been no accompanying increase in reimbursement rates for occupational therapy or physical therapy, by the way.

Aside from that, I was interested when I was informed three months ago that our current plan was being discontinued because the letter that we were sent said very specifically:

" In the short term, the impact of these changes will not be seen in premiums. Encouraging preventive care and providing new products and programs to empower members to take a greater role in their health care and will help address rising costs. Rest assured that XXX Health Insurance Company knows that the current pace at which health care costs are rising is unsustainable. We are working on a number of initiatives and programs to deliver better care to the community, as well as the country."

Well anyone reading that might expect that costs would not change! Of course they held off on telling us the new plan and the new rates, citing federal mandates for mental health parity - which actually don't apply to our company and a great many other employers because of the '50 employee rule' but that fact seems to be lost on the insurance companies. Undoubtedly, they model their price structure on total costs they incur and don't try to separately pool small from large employers. In this way the fact that there is an exemption for very small businesses really doesn't matter because the costs get applied in the global model anyway!

For the record (and as a provider) I believe that mental health parity should be a given - and I understand how that could increase costs. The problem is that insurance companies are using this as a smoke shield for ratcheting up premiums across the board, again - and that the whole model that burdens small businesses with these costs does not work. There has to be a better way!

OK well I received the new plan and rates today and they amount to ANOTHER 20% increase in premiums and deductibles with accompanying increases in co-pays and prescription costs - so of course I call the XXX Health Insurance Company and am given the run around that the increases are due to the mental health parity law (which we were supposed to be exempt from). After I point out the illogical statements being made I then referenced the letter that I was sent on June 30th and asked him to read from it. This is what he read:

"Rest assured that XXX Health Insurance Company knows that the current pace at which health care costs are rising is unsustainable. We are working on a number of initiatives and programs to deliver better care to the community, as well as the country."

In other words, the insurance company is now claiming that 'their' version of the letter doesn't make a statement about costs not increasing. They asked me to fax them a copy of the letter that I got - which I did - but I won't be holding my breath for that to change anything. I can't believe that they are trying to lie about what their own letter said.

I am a free market capitalist and I think that people have the right to make as much money as they can - but there is something wrong with our health insurance system that has so much profiteering in it, with such restriction of benefits to people, and with such restrictive reimbursements to most providers. The money and benefits need to flow to the patients and their health care providers (with some reasonable opportunities for profit but NOT price gouging). Again, this could all be solved with open market competition.

End game: we are competitive shopping for health insurance - again - and costs would most certainly be easier to manage if there was cross-state competition as there is in other insurance markets. I am terrified about handling health insurance over to the government because I have very little faith that the government will run a fair and competitive product (again, costs will simply be shifted via other taxes to the whole population and the risks of rationing as in other socialized systems are just not acceptable).

The current system is broken, and the public option is a very broken alternative that is subject to the same power-broking and manipulation as our current system. There is a need for leadership on this issue that includes open private competition and tort reform as the first step at repairing the system. I do not have confidence that we will see it.

Thursday, September 17, 2009

New ABC Therapeutics website goes LIVE!

Please stop by and visit our new site:

Cut to the chase: A simple question that perplexed us today!

At the beginning of each school year I marvel at how big of a challenge it is to get everything organized. Education is not new, drawing school district lines is not new, establishing bus schedules is not new, and determining outcome measures for education is not new - but each year it is as if no one has ever done it before, and people are left floundering around trying to figure out what needs to be done and how it needs to be done!

In my own little OT corner of the universe we came upon the issue of 'what are the best scissors for preschoolers to learn how to cut with?' Well there are no shortage of opinions but there is very little evidence I could find. That was a little surprising given the length of time we have been teaching preschoolers how to use scissors.

Having practiced OT for over 20 years I have some opinions, but they are just opinions and I have no proof to offer that the way I do things is any better than any other way. I am aware of a fine book about scissors training that Marsha Dunn Klein wrote around 20 years ago - but that wouldn't qualify as 'current' information. I am also aware of some interesting book chapters and presentations by Mary Benbow that I have read and attended over the years - but again this is nothing more than expert opinion based on normal fine motor development. We have some good developmental expectations on when skills are typically attained (as per PDMS and HELP data) - but these don't specify any given teaching method or even any specific type of scissors!

I looked through the searchable AJOT database and came up empty. OT Seeker did not have anything on the topic either. So what are the best scissors for preschoolers to use? Have I missed anything out there that anyone is aware of?

This year we will try to begin to answer this question. Since we have convenience samples that essentially parallel each other in demographics and need, and since both methods seem well accepted we will simply use Benbow scissors in one set of rooms and Fiskar scissors in another set of rooms. At the end of the year we will look for some narrative perspective of the therapists and teachers and we will look at actual rates of goal attainment since so many of the kids have scissors goals. If during the course of the year it becomes evident that one scissors is clearly superior we will switch all classes to those scissors.

Or if someone can help us answer this question sooner we would love to see your evidence!

Monday, August 10, 2009

A subjective conversation about the issue of grade retention

My occupational therapy practice is sometimes as much about parents as it is about children - and in fact the two are so intertwined that making the distinction is irrelevant. We get questions all the time about parenting decisions - and as these are directly related to both parenting and childhood occupations we try to help. Summertime is famous for conversations about retention.

I have read all the studies - but won't list them here because they may not apply. Still, the studies state that there is sometimes temporary/immediate benefit to grade retention but that those benefits disappear in subsequent years.

The problem with the studies is that they are done on such a large and heterogeneous group that it is difficult to say exactly who these results apply to. Parents and teachers and administrators get lost in the issue because they inject all kinds of ancillary concerns including
  • what will it mean if he is the physically largest child in the class?
  • is it true that the extra year will allow him to be more 'developmentally mature?'
  • our district does/does not have a retention policy so we don't do it that way
  • at the cost of $xxxxx.xx to educate a child who has a disability each year, we can't afford retention!
Clearly this is an example where large population research needs to be honed down and we need to look at practices on individual district levels. It would be more accurate for a district to conduct internal studies using consistent curriculum and early intervention/remediation/special education practices. That would allow for a valid basis of comparison between retained and non-retained students.

Parents ask me about retention all the time - and I usually shrug my shoulders. There does not seem to be evidence that can universally apply to all children. In general, I fall back to the basic idea that 'developmental readiness' may or may not be a valid concept because there is no way to measure such a construct. Is it possible that 'developmental readiness' is a smokescreen term to hide our lack of attention to specific individual or curriculum based factors?

That leaves us to curriculum or educational methodology (which includes remediation and special education). It certainly makes no sense to retain if we are going to deliver the same curriculum a second year! Rather, a best-practice approach should include intensive case-study to determine the individual factors that contribute to lack of progress and then educational planning based on those individual factors. I believe that this is the best approach to take until we see district-based outcome studies.

I am not sure how soon we will see this - because although we have Individualized Education Plans it is also true that we create curriculum and hope that all the children will fit inside our creations. Curriculum is efficient - but perhaps is a poor way to consider best-practice when administering special education. Is it enough for us to develop special-case curriculum and try to fit as many pegs as possible into the holes we drill? This ultimately boils back down to an issue of resource allocation. Just how far are we willing to go to deliver truly individualized education - and what can we actually afford?

Perhaps it is wrong for us to call it individualized? Would we be willing to admit that it is not?

I sometimes think that if we answered this question that we could begin to have a real conversation about the value of retention.

Thursday, August 06, 2009

tree frogs and coming to grips with a diagnosis of autism

I saw Jason today whose family has not yet acknowledged his autism. They will soon, as society will not allow them to continue explaining away his stereotypical behaviors for much longer. For now, from the perspective of his family, "he loves to jump and wave his hands!" and "he just doesn't like to talk much." and "he loves rocking in that rocking chair!"

It is all fine; it is not my job to cram some doctor's provisional diagnosis down the family's throats. I don't even pretend to know how difficult it must be for parents to come to this kind of acceptance - but I frequently see how long it takes to get there so I can imagine that it is not an easy path to walk along.

Anyway, I was intrigued today while I was listening to his grandmother make many assumptions about Jason's behavior. Jason walked near the refrigerator and the grandmother interpreted this as him wanting a bottle because she believes that he is emotionally regressing since the baby brother was born. It was a complex set of assumptions tied to the simple act of walking through the kitchen.

When he walked out of the kitchen the grandmother perceived that he was mad because he didn't get what he wanted. It is possible that she was correct but there is no reason to believe that her interpretation was correct. It was all created perception, and there was no external reality to support the perception. Again, it was all fine - but the complexity of her interpretation based on limited facts was intriguing.

As I drove home I realized that this was very similar to an article that I read about tree frogs. The author hypothesized that they urinated before they jumped because they were "afraid" of large predators (as if frogs pee their pants when they are scared??). The more appropriate explanation is that the frogs urinate because they lose a significant amount of weight and frogs that urinate before they jump are able to jump farther, thereby giving themselves a significant survival advantage.

The author was guilty of the same anthropomorphism as Jason's grandmother. As humans we have a tendency to interpret all kinds of behavior as cognitively purposeful when indeed it may not be. I am in no way suggesting that Jason is cognitively equivalent to a tree frog; rather, I would just point it out that the grandmother's interpretations of his behavior fall into the same category of fuzzy logic as the author that attributes the emotion of 'fear' to a frog.

Perhaps in the absence of data it is easy for us to 'fill in' information that is consistent with our own cultural beliefs or world view. This is an adaptive mechanism for people who need to make sense out of their experiences. There is no externally valid 'sense' to a child having autism, so this kind of emotional 'closure' most likely serves as an important short term survival function.

Tuesday, August 04, 2009

Reforming funding for school-based special education - at the point of a gun

Nearly three years ago I offered to work for NYS for free to help tackle the problems of Medicaid fraud for special education services (see The system needs reform badly - and although I never expected to be asked to serve I was actually quite sincere in my concern and desire to effect some improvement in the system.

As I predicted back then, there would eventually come a day of reckoning to pay for the fraud and abuse - and it seems that we are at that day. In today's Albany Times Union, reporter James M. Odato informs us that the New York State Education Department is withholding Medicaid payments to school districts in accordance with a settlement agreement that has NY State paying out hundreds of millions of dollars back to the federal government.

Also as predicted, this leaves school districts in quite a pickle - because they are still mandated to provide these services by law - and now the burden for payment may fall to local districts - which equates to higher taxes for all.

I have always viewed opportunities and threats the same - both require action. I think that this particular situation provides an opportunity for districts to begin looking at their models of service provision and see how to provide services more efficiently. That includes setting appropriate entrance and exit criteria for related services, adopting evidence-based or RTI-type models for educational intervention, and improving team building to ensure that services are reinforced in a transdisciplinary way throughout the curriculum. All of these strategies would help improve the efficiency and also the quality of special education services.

Professionals also have new opportunities to improve focus on school-home carryover. Parent involvement is critical for positive educational outcomes and may be the largest underutilized resource in the special education equation.

Because I am inherently cynical I understand fully how someone might think that I am speaking code for decreasing related services and abdicating responsibility to parents - but I am not. I am talking about an open dialogue about educational best practices and establishing responsible and defensible criteria points for intervention. We have had too many years of poor oversight, lack of accountability, and variable interpretation of special education regulations.

Reform is hard but reform can be good when it is done correctly. Reform should not be driven by some perceived benefit of political expediency or in satisfaction of legal settlements. Our special education system and its funding mechanism is broken and now we have a real chance to improve.

Will we make the most of this opportunity?

Thursday, July 30, 2009

Recurring philosophical questions

I have had a recurring question in my mind since the beginning of my occupational therapy career. At that time I was working in an urban acute care psychiatric facility and I was fresh out of college with my head full of lofty ideas about occupational behavior, occupational role, and the potential of occupational therapy to solve societal problems.

I read every word that Mary Reilly ever wrote, and listened as they were explained to me in the classroom by proxy of Phil Shannon and watched in amazement as they were practiced in a hospice home care setting while being mentored by Kent Tigges. Still, after work each day I took the Metro North to the safety of suburban living and I kept rolling over the question: "How can I remember NOT to transpose my values and my concept of Quality when working as an occupational therapist??"

My training told me that I wanted my patients to develop options, decision-making, problem solving, and agency relating to some return to occupational role. This was easy to comprehend if I was dealing with people who were students, homemakers, or workers but most of the patients that I saw were none of these things, nor did they aspire towards them. I was treating chronically ill people, people who were drug addicted, people who were on welfare or who were 'professional' patients.

The concept of helping people achieve occupational role functioning seemed like a very white and upper middle class attitude - which from the perspective of that particular demographic is not a bad way to organize the world with respect to sociology, economics, etc. - but it was anathema to THE SYSTEM and the real experiences of most of my patients. It just wasn't their brand of real.

So the idea of cultural competence comes into play, but for all the chatter about cultural competence it doesn't seem to bridge the gap between our theory base and the lived experience of many people who receive our services. I am not certain that we are improving and despite some of the wonderful advances in theory since the late 1980s I see that the divide remains as a real problem for our profession.

In concept I enjoyed Yerxa's article in the new AJOT, entitled "Infinite distance between the I and the It." I appreciate good philosophy and in many ways I can understand exactly what she is driving at - but the more I read the more I heard the repetitive tha-thunk and whoosh of the Metro North car as it sped toward the safety of the suburbs. The problem is in the basic premise where she writes, "Our purpose is to enable people to become agents of their intentions and to obtain satisfaction through actualizing their unique interests" (p. 491). I think this is often true but it is not always true.

Today I walked into a family's apartment; my responsibility is to provide early intervention services to a little two year old in the home. The family unit is comprised of the mother who works part time and receives welfare assistance, a boyfriend who is developmentally disabled and at least 40 years older than the mother, and the child. They live in abject poverty: there are no toys, there is little food, there is no money. The boyfriend was watching the child, and I immediately noticed the large and oozing hematoma on his forehead when he answered the door. It was hard to get information from him because he was frightened that his girlfriend would be mad but he eventually revealed that she hit him in the head with a pot because somehow the baby knocked the television off of the table. I'm not sure how these events are connected but that was his report. He was planning on going back to his home in a neighboring city, but he wasn't sure if he had the bus tokens to get him there.

Although the details are unique, the flavor of this scenario is not unique. The people in this story are not poised to receive a health service that helps them self-actualize. They need a service that respects their human dignity, provides them with a means of economic survival, and perhaps - if good fortune abounds - helps them develop skills for autonomy and independence that may one day lead to the beginning steps of self-actualization.

Similarly, we get 'thank you' notes from our patients constantly for the fine work of the therapists in our clinic that focuses on hand injuries. The notes always say the same kind of things: '"Thanks so much for helping my hand get better!" and "I am so happy that I was able to go back to work." I have not yet received a thank you letter that states, "Thank you for helping me determine how I will make a contribution with my life." Now in obtuse ways one could argue that the patients are indeed 'saying' this but I don't think so. I don't think that most people really think in those terms. Sure - some do - like Florence Clark's patient that she discussed in her Slagle lecture. But most patients are not asking us to conduct and compose metaphorical and allegorical tales to help them find meaning in their disability experience. In this sense I think that our theory is at risk of missing the mark on the lived experiences of many people who actually receive occupational therapy services. Many folks are happy to move their hands again - or happy to pick up their grandchildren again. For them, occupational therapy is not an "ethical quest, promoting human flourishing" (p. 496).

The 'I' that Yerxa discusses is so critically important - and I really do agree in part with what she is saying.. but not all of those I people live their I experience in the way she describes. Sometimes, people even subjugate their I in consideration of the larger cultural context - because the cultural context is sometimes more important than the I! A very clear example that comes to mind here is literary - the character Okonkwo in the novel Things Fall Apart. Okonkwo rigidly adheres to his cultural traditions - even though they lead to his own exile and eventually bring him into conflict with the introduction of Christianity - a conflict that causes him to commit suicide. There was no I for Okonkwo, or perhaps his I was defined by the We of his clan and its customs. In this case, would occupational therapy help the we flourish or would it help the I flourish? I am not sure.

The overall point here is that there is danger in assigning our personal values to Quality - and I believe it is possibly wrong-headed to believe that the self-actualizing, meaning-pursuing, and Forrest Gump questions of 'What's my destiny, mama?' are reflective of how everyone really experiences their lives.

This kind of philosophizing about the meaning of living kind of works for me, but I am a white upper middle class guy. When I try to think fairly and I think of the guy who has developmental disabilities and who literally has no resources and perhaps fewer options and is scraping up bus tokens to escape the domestic abuse of his girlfriend - it just becomes difficult to imagine his lived experience in terms of the word 'flourish.'

I think that there is something more germane to OT than a highfalutin preoccupation with I. I think it may have something to do with the basic dignity of human experience, and perhaps meeting needs across a broad spectrum of perspective - especially and particularly when that perspective has to do with finding ways to duck from flying pots.


Achebe, C. (1958) Things fall apart. New York: Anchor Press.

Yerza, E. (2009). Infinite distance between tne I and the It. American Journal of Occupational Therapy, 63, 490-497.

Monday, July 27, 2009

Fun-filled game of the day: Guess the CSE chairperson's intent!

Why would a CSE chairperson who has worked in the field for over 20 years suddenly want more information on the Beery VMI?? This chairperson has seen this assessment used hundreds of other times... so why more information now??

Inquiring therapists want to know.

re: Johnny XXX

To Whom it May Concern:

At the request of the district CSE Chairperson, here is additional information regarding Johnny's performance on the Beery VMI. Quite honestly this is an unusual request as this test is perhaps the most commonly used assessment in school-based occupational therapy and I do not understand why special explanations are required for this child. I am hopeful that this information will help to get an appropriate plan for this child into place.

The Beery Developmental Test of Visual Motor Integration 5th Edition is a widely respected assessment tool that is backed by decades of research and clinical use. The Beery VMI screens for visual-motor deficits that can lead to learning, neuropsychological, and behavior problems. The assessment is commonly used by occupational therapists as part of an overall evaluation for school-related performance difficulties.

The Beery VMI helps assess the extent to which individuals can integrate their visual and motor abilities. The tests present drawings of geometric forms arranged in order of increasing difficulty that the individual is asked to copy. The Beery VMI series also provides supplemental Visual Perception and Motor Coordination tests to help compare an individual's test results with relatively pure visual and motor performances. (One or both of the supplemental tests may be used.) The purposes of these additional tests is to allow for a statistical comparison of results from all three tests.

Many therapists use the Motor Free Test of Visual Perception 3rd Edition instead of the Perception component of the VMI. As stated above, the comparison results are helpful to determine if a child's writing difficulties are perceptual or motor based.

In the instant case, the child scored a standard score of 137 on the perceptually oriented MVPT-3 and a standard score of 78 on the Beery VMI. This represents a 59 point difference - almost 4 standard deviations of discrepancy between the scores. This indicates that the child has advanced perceptual abilities but has severe disabilities in operationalizing this perceptual skill into the motor act of writing. This discrepant performance was already clearly spelled out in the child's recent OT evaluation that is being questioned.

As corroborating evidence, the child has extremely poor organizational skills and his writing is only marginally legible.

If any additional information is required please do not hesitate to contact me.


Christopher J. Alterio, Dr.OT, OTR
Occupational Therapist

Thursday, July 23, 2009

We need consumer education and tort reform before handing over health care to our government

There are many conversations swirling about regarding health care reform, proposed 'public options,' and tax/penalty methodology to pay for the programs. The more that gets said the less specificity seems to be revealed. Instead I am hearing a lot of lofty and non-specific theory that the system will pay for itself by 'inherent efficiencies' which I have concern may be code for rationing. When pressed for these kinds of details all I am hearing is a full-frontal assault on 'insurance companies' but occasionally there is a jab slipped in at providers who are accused of making decisions based on reimbursement structure and not on clinical necessity.

There is no doubt that a reimbursement system obviously creates incentives and disincentives to how care is delivered - but to accuse providers of driving decisions solely on financial incentive is a little much. The added insult is to trumpet the 'endorsement' of prominent organizations - like the AMA - which informed people know does not actually represent the opinion of all or even most physicians.

All that aside, I think there are two essential reform components that our health care system needs and I don't hear a lot of conversation about them. These two missing components are education and tort reform. Anecdotes help people understand issues - so rather than list statistics that tend to make people's eyes glaze over I want to tell two very recent stories that help to illustrate these needs.

First is the need for education. This morning I had a patient call me and he was concerned about his bill. The bill was extremely straightforward. He injured his hand and required very short term therapy that included splinting and two weeks of guided exercise, control of inflammation, and a home program educating him on how to promote healing and slowly return to his normal tasks. He had five co-pays and his insurance company only reimbursed half the cost of his splint. His insurance company sets the reimbursable allowance of each therapy visit and of the splint. His cost was actually quite modest and completely consistent with the HMO model of 'cost-sharing' where the insurance company pays part of the cost and the patient pays the 'co-pay.' The patient was upset that he incurred costs at all and although he understood the explanation he stated, "Well I just guess that I didn't expect a bill, and I guess my health insurance just sucks."

Of course no one is happy when they receive a bill, and I am sure that everyone would like to have free health care - but this fellow didn't understand how health insurance really works and had no real appreciation for the concepts of 'co-payments' and cost-sharing as a model for insurance. Based on my experience his opinions are not unique: many people think that if they have insurance that they are then 'covered.' Many people can't understand how insurance works. They don't understand co-pays. They don't understand deductibles. They don't understand coverage limitations. People can consume health care more responsibly if they are educated - and this is a sorely needed component.

A second component is tort reform. Medical malpractice liability forces providers into practicing 'defensive medicine;' in other words, it causes providers to order tests and to perform procedures 'in defense of' potential lawsuits JUST IN CASE they miss something in a patient's case. Here is another recent example - this one personal.

My daughter complained of deep hip pain the other day and since she is an active risk taker my first question to her was "Is there any REASON why your hip would hurt - did you fall, or were you running or biking or ANYTHING??" Of course she said there was no reason for it so that raised my alert level a little. In drum corp she recently started hauling around the large bass drum and that was new so I started to think that her symptoms could be related to her new bass drum playing. Now I don't like overusing the medical system and I am very conservative, but this is where too much knowledge can cause difficulties. Although my daughter is not obese by any measure, she has been carrying around a bass drum for many hours and this adds to her functional weight and strain on her lower extremities. Then I started thinking that she is in the middle of adolescence and growth spurts. Being the therapist that I am I started putting two and two together and began thinking that there was a small chance that her sudden unexplained hip pain could be related to a slipped capital femoral epiphysis. I asked her again if there was ANY OTHER REASON for her pain and she said there was not. So, I broke down and decided to let the pediatrician see her.

The pediatrician, who is extraordinarily and appropriately diligent, ordered an x-ray of the hip which was negative. I am sure that several differential diagnoses were circling around in the MDs mind - although I did not ask her thought process. I am sure she was thinking, strain, hairline fracture, SCFE, hernia, and any other number of possibilities. Then the pediatrician asked again, "Is there ANY OTHER REASON why your hip would hurt?" Dutifully, my daughter then recounted a story where she and her friend were practicing yoga and her friend was stretching her leg. Oh, and this all just happened last night.

Of course I wanted to kill my daughter at this point because by now we had gone to the MD, wasted the MD's time, gotten an xray and perhaps killed off or mutated a few eggs in the process - all for the sake of a probable muscle strain caused by silly adolescent girls doing yoga at a slumber party. If I had this information I would have avoided the MD visit and xray - and just watched it a couple days with the anticipation it was a self-limiting and minor muscle strain. But here is where the doctor and I separated.

Although the MD acknowledged that it was all just likely a muscle strain - she also had to suggest that the only way to rule out everything else was with an MRI. That would mean an additional expensive test, a consultation with a radiologist to read the report, and more follow up with the pediatrician. I politely declined - and decided to just watch her at home. Turns out that it was just a muscle strain after all and she is fine now.

The point here is that you can see how engagement in the medical system leads to an upwardly increasing spiral of interventions - all in consideration of not wanting to possibly 'miss' something. If indeed my daughter had a SCFE or a hernia and that MD didn't order the MRI then they would be liable - and this is no small issue - A SCFE could lead to avascular necrosis of the hip and a hernia could lead to a strangulated intestine. No MD in their right mind would want to leave those stones unturned - especially in this litigious society. Tort reform could limit medical liability to reasonable levels and have a suppressing effect on the excessive use of expensive diagnostic tests. This would save uncounted billions in health care costs but is not a strong component in any of the health care reform proposals.

We need consumer education on how insurance plans work and how they can best function and make decisions in our current system. We also need to relieve practitioners of the pressures associated with practicing defensive medicine. These are examples of two important issues that are nowhere to be found in our current conversations about health care reform.

Thursday, July 16, 2009

The impact of proposed new federal regulation on health care delivery

Proposed new health care regulations may have an extraordinarily negative impact on the way consumers access their health care. The following information is from a September 2005 report from the Small Business Association entitled The Impact of Regulatory Costs on Small Firms.

"The annual cost of federal regulations in the United States increased to more than $1.1 trillion in 2004. Had every household received a bill for an equal share, each would have owed $10,172, an amount that exceeds what the average American household spent on health care in 2004 (slightly under $9,000). While all citizens and businesses of course pay some portion of these costs, the distribution of the burden of regulations is quite uneven. The portion of regulatory costs that falls initially on businesses was $5,633 per employee in 2004, a 4.1 percent cost increase since 2000 after adjusting for inflation. Small businesses, defined as firms employing fewer than 20 employees, bear the largest burden of federal regulations, as they did in the mid-1990s and in 2000. Small businesses face an annual regulatory cost of $7,647 per employee, which is 45 percent higher than the regulatory cost facing large firms (defined as firms with 500 or more employees)."

In other words it is fact that small employers (particularly those with fewer than 20 employees) share a disproportionate burden of regulatory costs. This is important to consider because of the current debate regarding health care reform that will cause additional mandated cost burdens to small health care practices.

A lot of people consume their health care in 'very small businesses' - your doctor, physical or occupational therapist, dentist, mental health counselor, chiropractor, etc. are mostly categorized as 'very small businesses.' Many of these offices employ small numbers of people - but interestingly the payrolls of these operations are high because they are employing a highly skilled professional workforce.

How might the current health care reform proposals impact these employers? In the current text of H.R.3200 as Introduced in House as America's Affordable Health Choices Act of 2009 there are significant penalties for employers who won't be able to afford to offer health care for their employees - as much as 6% for payrolls between $350k to $400k per year.

These payroll sizes are actually quite small, and will likely have a disproportionately negative impact on small professional offices where the average salary is high. Specifically, how many health care workers can be employed under a cap of $400,000??? The answer is "not many" and that is why these salary cap proposals are extremely damaging to small offices that employ these highly paid professionals.

These penalties will be applied to many of these provider offices because they may not be able to afford the proposed mandatory percentage contributions, which are currently proposed as:

72.5% of the premium cost of single coverage
65% of the premium cost of family coverage

The critical factor here will be the cost of the premiums, of course - which is a rather large unknown at this point. Still, the owners of these medical and professional offices will be forced to incur increased costs - either through mandated premium contributions or penalties for not participating. Increased employer expenses drive up the cost to deliver care, which will lead to upward pressures on prices - which ultimately feed pressures on cost to deliver that care -and on and on in a never ending upward spiral.

An alternative is that employers will seek to limit the size of their practices and control their functional growth - which essentially subverts the system by ducking underneath the mandates. The problem with this is that it bypasses the intent of making insurance affordable/available and it forces care to be delivered by increasingly small offices which is not efficient and also can also cause upward cost pressures.

If small professional offices are not able to find ways to work within these systems they will ultimately fail. That can cause consumers to have fewer choices or to force consumers into very large health care systems that are able to work within these models because as stated above the relative cost distribution of these mandates is less on large employers.

This will be a shock for consumers - most don't prefer standing in the waiting room with 50 other people who are all waiting to see the same doctor and who were all given a 9am appointment. This is the model of care in large inner city clinics - and won't sit well with people who are more used to receiving their care in their small community doctor's office.

So the future of health care delivered in small professional offices is at risk - unless the reimbursement structure offered somehow offsets the mandated costs. That will keep the small professional offices in "business" and preserve consumer choice but will certainly not do much to help limit the cost of that health care, which was supposed to be the whole point from the beginning.

From the perspective of a small health care provider, the intent of the proposed legislation seems to be the systematic decimation of our current delivery system. There is no question that we require reform in our system but this proposal is a frontal assault on the doctor, dentist,and therapist in your local community. It will have a chilling impact on what your future health care delivery will look like.

End game analysis: get ready to drive to the big hospital clinic, grab a number, and stand in line. It's the only way that the proposed model can be affordably delivered.

Tuesday, June 30, 2009

School buses and safety belts: Not a simple issue

I was pleased to see the article in the recent OT Practice entitled "School Buses + Safety Belts = Good Idea." (Loveland, 2009). I think it is important for OTs to have a good discussion about ways to promote safety and prevention of child injuries.

There are some additional facts to consider so I wanted to list them here:

1. In the studies cited in the Loveland article, there was an annual average of 17,000 children seen for emergency treatment for school-bus related injuries. However, that number is a little misleading. The study reports that only 42% of those injuries were crash related, so by extrapolation, it is arguable that seat belts would not have made a difference in many of those injuries. In fact, the 17,000 number includes slips and falls outside of the bus, getting on/off the bus, etc (McGeehan, 2006).

2. The National Highway Traffic Safety Administration (NHTSA) reports detailed research on their website about school-transportation related injuries and deaths. School buses remain the safest mode of transportation for children. The actual incidence of injury and death is strikingly low and pales in comparison to data on injuries and deaths from other forms of transportation.

3. Study after study shows that compartmentalization works - but it is true that studies also tend to measure the impact of front impact crashes. There is a reason for this - and that is because there has to be some standard for determining safety. It is not reasonable to study every possible rear and side impact configuration because it is impossible to reliably report the result of those impacts. There are just too many variables - size of other vehicle, point of impact, speed of collision, locations of children related to injury distribution within the bus, and many others. People don't like to say it out loud - but the issue may very well relate to diminishing safety benefit in relation to dollars spent, which leads me to the next point.

4. Of course any child injury or any child fatality is one too many - BUT - if we are going to expend resources (money, time, energy, etc.) into injury prevention will our efforts be better served by focusing on causes where there is a MUCH GREATER NEED and where our efforts will HAVE A GREATER IMPACT on reducing injury and fatality? This is a very difficult conversation, and I expect people might get upset about discussing it this way - but it is just a reality. If we spend millions of dollars to save 20 lives a year, could we have saved hundreds of lives by distributing those resources and efforts in a different direction? This is not to diminish the importance of school bus transportation safety - but rather is an important policy question about allocation of resources.

I have made a few entries on child passenger safety in this blog. I don't have the answer to the question of 'how do we best spend our resources,' but I think it is something that we all have to think deeply about.

Loveland, J (2009, June 29). School buses + safety belts = good idea. OT Practice.

McGeehan J et al. (2006). School bus-related injuries among children and teenagers in the United States, 2001-2003, Pediatrics 118, 1978-1984.

Friday, June 12, 2009

NY Times article is demeaning to elderly people who have Alzheimer's

Here is the offending/offensive article: All-Night Care for Dementia’s Restless Minds

I will be the first one to admit that it gets a little boring to listen to people have complaints about political correctness and terminology - everyone is offended by everything these days... but this article went so far beyond any semblance of acceptability that it has to be pointed out.

I am not criticizing the program - because I have no direct knowledge of what actually happens there. In concept I think that offering night time respite care for caregivers is a great idea. Unfortunately, the authors of this article portrayed the program in a very negative way - and I don't think that they really intended to do so.

Throughout the article the authors repetitively compare elderly program participants to children. For example:

1. The participants were "chattering and giggling like children sneaking out of camp."

2. A caregiver reports relief by stating, "It was like when your baby first sleeps through the night."

3. Another sad comparison about a program participant: " a kindergartner acclimating to school she made new friends, and blossomed."

4. Some of the activities presented to the participants do not seem to be age appropriate: "A children's pool with soapy water was set on a table, and a few people sat around it, playing with the suds, squeezing the soft toys."

5. The authors continued the theme of comparing the elderly participants to children, stating that the therapist is like "a really cool counselor at night."

6. There were also several sexual references - among the worst – “the place suddenly felt like a girlish slumber party: Mrs. XXX was talking, again, about men and sex, causing Ms. YYYY to dissolve into giggles.”

It was horrifying to see that the authors actually posted the names of these program participants. Could they provide informed consent?

In my opinion this whole article was simply disgusting. If you are so inclined, please write a letter to the NY Times and tell them that the article was demeaning, inappropriate, and a very poor example of journalism. Elderly people who have Alzheimer's Disease deserve much more dignity and respect than what was written in this article.

Monday, June 08, 2009

How I became an occupational therapist

Or perhaps more appropriately titled: Too much information. Oh well.

I wrote a blog entry once about 'the things I do.' It has been lost to time - I am not sure where I have the entry stored but I recall that it received many comments and sparked a lot of conversations about the issues of time and time spent - and how one comes to the decisions about the things they do. That entry is decidedly more serious than this one. So, I am not trying to recreate the original - but couldn't think of a more appropriate title for this entry. Maybe I will look for the original sometime.

Today is a hard work day. I am not questioning why I am an occupational therapist but sometimes when I have hard work days I reflect back on what I thought I wanted to do when I grew up.

I took a Strong-Campbell Interest Inventory in high school, and it said that my career interests were matched to a speech therapist, a college professor, and an actor. The fourth match was 'occupational therapist' but I never noticed that until I went back and looked at the document years later. The career that I was supposedly most poorly matched to was 'agricultural business manager.' I remember that because for years after taking that test I would respond to "What are you going to college for?" with "I really want to be an agricultural business manager." There are probably people out there who believed me and thought that is what I really wanted to do. The truth is that when I was in high school I thought that interest inventories were stupid and I was mostly interested in my girlfriend, hockey, and Rush.

My own career development came through a combination of interest and happenstance. In elementary school I wanted to be a football player. I don't know what I was thinking. I am not very good at football. If I was a football player, people would be able to say, "Wow, he is not very good, but he really tries hard."

In middle school I wanted to be a marine biologist (now somehow demeaned by that Seinfeld episode, oh well). It was never anything more than a fantasy, really. I used to be so excited when National Geographic was sponsoring another Jacques Cousteau special. I wanted to ride on Calypso and learn how to dive... When I used to keep aquariums I don't think anyone knew that my love of marine life was carried through from my childhood. I have never eaten fish in my life, except fish-sticks once or twice when forced to as a child - it has always seemed sacrilegious to me. I remembering reading that a new kind of squid was discovered and that it can grow to over 24 feet in length - and I didn't have anyone to talk to about that. Most people just think I hate fish, and I don't bother to correct them.

In high school I had a lot of ideas about how I wanted to spend my life. First I wanted to be a veterinarian. I read all of the Herriot books and I even got a job in an animal hospital. I loved the lab work and the anatomy and the pharmacology - the science appealed to my sense of order. But now I understand that what originally caught my fancy was Herriot's ability to connect with people. If I was a veterinarian, I would want people to say, "I love the way he handles my pet. It makes me think that he really cares about me too."

In high school I also wanted to be a stage actor. I was in all the plays in high school and also have done some community theater. I always loved the task of immersing myself into a character and experiencing those affective shifts so intensely while playing. Over time, I found out that people were dramatic and histrionic in real life which is always difficult for me to manage, and I stopped enjoying it as much. I don't do well with dramatic people, and now I find my participation in theater rather ironic.

Between high school and college I wanted to be a geneticist. Oddly, some of the coolest things I have done in my life involved fruit flies (drosophila). In my first college biology course I got to mate winged with wingless fruit flies, and I had to count the wingless offspring to see if the Punnett Square models of gene expression were true (and determine the genetic heritage of the parents). In a different class I got to remove the salivary glands of a fruit fly and see the chromosomes under a microscope. I know that some people would consider this very strange stuff to get excited over, but having success at extracting salivary glands from a fruit fly is truly accomplishing something. At least I always thought so.

Once I got into my sophomore year I wanted to be a physical anthropologist. I loved the rigor of the anatomy, and I also enjoyed the classification schemes of new vs. old world monkeys, knuckle walkers vs. brachiators, etc. Once I took a comparative primate anatomy course and had to dissect a macaque, a baboon, and a human all within the same semester. Believe it or not, that crazy semester made me even more certain that I would not mind being a physical anthropologist. I think that I especially liked the idea of disappearing into a tropical forest for months at a time to do observational research.

Along the way in college I transferred schools and had to put an 'intended major' on the transfer application. I had no idea what to write, so I opened up the college catalogue and pointed my finger. It landed squarely on "Nuclear Medicine Technology," which sounded intriguing. Then I looked at the classes I would have to take and I saw that it was heavily oriented to chemistry and math. Since I was struggling with orbital paths of electrons and calculating molarity and molality I decided that I couldn't be a Nuclear Medicine Technologist. I flipped to the next page and it said "Occupational Therapist," so that is what I put on my transfer application. The rest is history.

My daughter is currently considering her future career path - she is seventeen and not sure if she wants to be an occupational therapist, child psychologist, FBI crime scene investigator, or perhaps Broadway starlet. From my perspective her occupational development is essentially on track. She has passed through Ginzberg's stage of fantasy choices (for the most part) and is coming into tentative choices now based on her values and interests. In trying to move her forward into the stage of realistic choices I am encouraging her to spend actual time observing the professions that she has interests in.

The problem is that even under conditions of observation there are many vocational activities that are not apparent to the casual observer. For example, when I have a high school student spend a day 'observing' me I try to find fun and exciting activities for them to participate in. On these days I am more likely to have them observe me completing evaluations, providing therapy services, and in general spending time with clients.

What my young observers never see are the 45 minute conversations with my site supervisors as we pore over details and strategies of how to handle staffing concerns. They don't see me fighting the fax machine or trekking to the post office to see how faint the stamp ink can be for them to still honor my postage meter. They also don't watch me answering emails on what the most effective potty training chair is and they most certainly don't get to watch me sit paralyzed by responsibility and fall back to blog spewing for some odd kind of therapeutic tension release.

Observations may not really do much for people. I am not sure what does - in my immediate circle of high school buddies there were career aspirations including an architect, lawyer, doctor, two engineers and a rock star. None quite worked out that way, but from what I can tell people are doing fairly well. I don't worry too much about my daughter's occupational choice process. It seems to be happening.

This stream of consciousness is starting to run dry. I really need to get back to work - I have many things to do. None are particularly motivating me, so if anyone knows of a job posting for a physical anthropologist intern in the jungles of Borneo, please send it my way.

Friday, May 22, 2009

Top 10 ways to identify that it is May!

Usually sometime around April I stop looking at the calendar because I no longer have time to look at calendars. Life in April and May is generally spent running from one responsibility to the next, non-stop. Then something strange tends to happen at the end of May, and I begin to realize that Spring is in full bloom and that there is indeed a light at the end of the tunnel that all pediatric therapists are running through this time of year. Here are some common experience-markers that are making me believe I will soon have a life again...

10. The semester is over for most college students - and my son completed his undergraduate career!
9. Robins have nested in all of their favorite spots around our building and the baby bird chirping is louder each day!
8. Memorial Day Weekend!
7. Pediatric OTs are beginning to look for jobs! (the better ones always finish out the school year first).
6. My landscaping contractor has repaired the lawn damage from winter plowing and has cut the grass at least 2 times!
5. The furnace doesn't seem to be going on any more!
4. Requests for services are up up up! There is a mad scramble to take care of all the issues that SHOULD have been taken care of earlier in the school year!
3. The amount of paperwork from completed annual reviews, early intervention to preschool transitions, and preschool to school transitions is overflowing my office! I think I need to hire another full time person just to keep up with the filing this time of year!
2. Staff is talking to me about summer schedules, and information is trickling in about summer needs at various locations around the community!

And the top way I can identify that it is May...

1. I look at the blog history and realize that despite the richness of my experiences recently I haven't written anything in over a month because I have been TOO BUSY!

(hope to be back soon...)

Tuesday, April 21, 2009

Twenty years of SIPT - where do we go next?

Standardized tests are periodically discarded or updated because the normative group that the test was developed around may have changed characteristics. I am unaware of any 'industry standards' regarding the life expectancy of standardized tests; rather, professionals in a field tend to come to consensus about the relative usefulness of tests on their own. I would be interested in knowing what other therapists think about the Sensory Integration and Praxis Tests - which were published in 1989.

I became certified in the administration of these tests seventeen years ago. At first I found them highly useful but the more I gave the tests the more I understood the limitations. Now it has gotten to a point where I do my best to discourage people when they ask for this test - not just because of the inherent weaknesses of the test construction but also because of how old the norms are.

There have been some legitimate concerns with the tests including extremely poor test-retest reliability for several of the subtests - most notably included postrotary nystagmus, kinesthesia, location of tactile stimulation, and figure-ground perception. The statistical data for these tests is published in the test manual (Ayres, 1989).

Additionally, a complex set of cluster and factor analysis studies include this data that has unacceptable reliability - and 'diagnostic groupings' were developed on a inconsistent data set that included these measures. Mulligan (1998) conducted a very interesting confirmatory factor analysis on the original groupings and found that there was not good fit between Ayres' original groupings and the data of over 10,000 cases in the WPS database. She completed a new exploratory factor analysis and proposed a new model of diagnostic groupings but I am uncertain if anything ever came of her suggestions.

Research is best when it builds upon previous research. Asher, Parham, & Knox (2008) completed a study ten years after Mulligan's analysis. They looked at validity of Ayres original diagnostic groupings as measured on two test cases. When I read this last year I remember thinking that the LACK of reference to Mulligan's work was really odd.

One interesting comment made in the Asher, Parham, & Knox article was that they used a convenience sample of therapists in the Los Angeles area. The significance of this could be lost on people who don't understand the geographic distribution of the SI research knowledge base - which is largely concentrated in a handful of areas around the country. The study made me wonder - would the results have been different if you asked therapists OUTSIDE of Los Angeles area? If anyone asked a certain therapist in Western New York to participate in a validity study on SIPT diagnostic groupings there would have been a loud question about the Mulligan study. It is a pertinent issue - you can't talk about broad validity when you only include people who are all drinking the same Kool Aid, so to speak.

All of this is lost on parents, who read things on the Internet and want their child tested using the SIPT. Sometimes parents come to me for therapy after someone else has tested their child on the SIPT. Many of those parents are confused when I suggest re-assessment using current tools - they already paid hundreds or thousands of dollars for some assessment that their insurance company didn't reimburse - and then I tell them that they need updated assessment that their insurance company WILL reimburse. It is hard to have a good conversation about test reliability and validity with parents who just invested a lot of money out of pocket - so I lose some of those patients to be sure and the parents go off looking for someone who will validate their SIPT investment. That is kind of unfortunate, and I think we are doing parents a disservice by setting them up for this kind of conflict.

Occupational therapists have a lot to offer children regarding assessment of practic, visual perceptual, and sensory motor functions that were measured in the original SIPT. We just need an updated test. This matters especially because there are statements about the SIPT being the gold standard of tests for sensory integration - and if we are relying on a twenty year old test with questionable reliability that failed a confirmatory factor analysis then we are in trouble.

This is all also related to the push for SPD to be included in the new DSM. I think it is inadequate to rely on parent or teacher reports of processing problems as the primary form of diagnostics. The information from these parent or teacher reports is informative but it is not diagnostic. We need an updated or reworked SIPT - and in my opinion we need to shelve this current test. We should all agree that it was an amazing first step - but the second step is long overdue.


Asher, A.V., Parham, L.D., & Knox, S. (2008). Interrater reliability of Sensory Integration and Praxis Tests (SIPT) score interpretation. American Journal of Occupational Therapy, 62, 308-319.

Ayres, A. J. (1989). Sensory Integration and Praxis Tests. Los Angeles: Western Psychological Services.

Mulligan, S. (1998). Patterns of sensory dusfunction: A confirmatory factor analysis. American Journal of Occupational Therapy, 52, 819-828.

Monday, March 30, 2009

Monday morning spaghetti

In 11th grade I took a computer programming class - computers were brand new technology at the time and the teacher knew little more than the students so it was definitely a wide open frontier. The computer was an excellent tool in that programming forced my adolescent brain into a type of linear and logical thinking pattern that I still find useful today.

The teacher often had us work in pairs on larger projects and I had an excellent programming partner. We regularly challenged ourselves with writing complex programs and we were sometimes over-ambitious. One particularly complex program we attempted was to write a 'Blackjack" program. I remember how excited we were when we got the cards to print correctly on the screen. This was high-end stuff for a couple of high school kids hacking away on a TRS-80 Model III computer!

Our Blackjack program became increasingly complex, and as we attempted to make accommodation for ever increasing complexities the programming code became more and more jumbled. What began as a linear progression of thought devolved into endless subroutines of special-case if-then propositions. It became classic "spaghetti programming" and it was a mess.

Eventually the project became so large and so confusing that it couldn't hold the interest of our adolescent minds - and so we moved on to easier programs.

I re-experienced all of these frustrations this morning when a parent walked into my office with her 7 year old child and asked, "Do you think that my child has a sensory integration problem?"

In my linear programming-oriented mind I have learned not to bias myself when I hear this kind of question. Sometimes when you are posed with a clinical problem you can start off by taking the individual strands of uncooked spaghetti and neatly ordering them as you tick off questions and answers. Eventually, you can sometimes reach a perfunctory conclusion based upon the obvious pattern that is evident on the differently ordered and arranged piles of uncooked spaghetti. AHA!! The problem is XXX! I like when the world is ordered and things make easy sense.

I was not so lucky today because I heard the parent say, "My child has congenital adrenal hyperplasia." My hope of neatly ordered piles of uncooked spaghetti disappeared as I imagined the water boiling and having to dump all that pasta into the pot for cooking.

Congenital adrenal hyperplasia, in general, is a condition where there is a problem with the body not producing enough corticosteroids. As a result, many children with this condition have to take replacement hormones. Additionally, there is the issue of impact from long term increased exposure to higher levels of androgens.

The parent described auditory defensiveness problems, difficulties with high activity level, and some behavioral rigidity. His 'symptoms' reportedly vary in intensity and are intermittently problematic. Here is where I felt stuck with the parent's report - is it possible, or even likely that the symptoms are nothing more than a reflection of his fluctuating ability to maintain a functional physiologic coping mechanism because of a complex psychoneuroendocrine disorder? I know enough about cortisol and stress responses to understand that this child has no physiologic basis for stability - and indeed is dependent on Cortef and Fludrocortisone to maintain as much of a steady state as possible. At the same time, I am also aware that most research says that although young girls with this disorder demonstrate more 'masculine' play behaviors and agression that this is not the case for young boys.

Now - does this represent a fundamental gender difference between the way that adrenal hyperplasia can be phenotypically or behaviorally expressed??? Or does this represent something odd about our cultural tolerance for varying levels of so-called 'agresssive' or 'hyperactive' behaviors in boys?

The reason why these questions matter is because we can then have a context for developing some kind of intervention plan. Certainly, if a child has an underlying endocrine problem it is not likely that we will fundamentally alter that condition with external stimuli. However, we might introduce calming activities for parents or teachers to try in case they see that behaviorally things are 'ramping up.' Listening to calm music, petting your cat, etc. all can contribute to lower cortisol levels - these are activities to consider because cortisol level may not be optimal at any time for someone who has adrenal hyperplasia. Conversely, caregivers (including teachers) need to understand what the behavioral markers are for impending adrenal crisis and how to obtain medical intervention when needed. The problems can be bidirectional, and the response from caregivers has to be dependent on the fluctuating signs.

What complicates this is that psychoneuroendocrine responses don't occur in a vacuum - they are also influenced by behavioral patterns and habits that are established following a lifetime of sucessive responses and reinforcers. And sometimes - kids are just kids and don't listen to adults.

Now we have fully-cooked spaghetti, ready to be heaped in a mass onto a plate for consumption. I couldn't even try to answer this parent's question about whether or not the child had a sensory integration problem. That is frustrating.

In the end, I am able to recommend a home program of calming activities and signs to watch for that are indicative of arousal and fight-or-flight responses that are out of balance. I am able to provide some common sense suggestions for activity pacing - and considering ways to make environmental and contextual modifications to limit sensory overload. I am able to encourage an activity configuration that balances structure, goal-setting, and positive socialization in addition to allowing for pedal-to-the-metal raw energy release. I am able to promote what I call high-intensity parenting because their need for educating other caregivers is critical. I am able to express that behavioral expectations can't be tossed out of the window and it is STILL important to maintain some measure of expectation and standard for appropriate contextual behavior. Also, in the long run we need to provide a cognitive-behavioral program where the child is able to increasingly learn how to attune to their own regulatory state and make activity choices to address changing needs.

I am not sure where this spaghetti mess begins or ends, and I do not know that it is a sensory integration problem - whatever that is - but whatever it is the child and family clearly needs some help. From a programming and logical-order perspective the problem represents an epic failure in our ability to 'name' and 'plan' interventions.

I am hopeful, at the least, that understanding the complexity will prevent me from introducing special-case if-then propositions. I learned in 11th grade that these methods don't contribute to a good final product.