Tuesday, March 03, 2009

Sensory Integration: How occupational therapists are stuck in the long tail

I am working with a student who is completing a literature review on the concept of fidelity in sensory integration. At the same time I am completing a book chapter on entrepreneurship and today came to an interesting perspective on the state of sensory integration theory and practice models.

Reality dictates that people purchase goods and products and will pay for them based on some value formula. Occupational therapists have famously made references to the value of their services - from Mary Reilly's belief that OT could be one of the great ideas of 20th century medicine to the more recent AOTA branding campaign on how OT helps people live life to its fullest. If both of these statements were true people would be flocking to seek out and pay for our services. Is this the case?

Certainly people are receiving occupational therapy services. Certainly insurance companies and others are paying for occupational therapy services. Despite these facts, it is true that the vast majority of payment for occupational therapy services comes from public health entitlements and less comes from the willful parting of everyday people and their health care dollars. This equates to less of a consumer-driven 'flocking' and seeking out of services and more of a 'herding' by legislative mandate.

For those of you that practice every day, this is why you find yourselves explaining what OT is to your patients or families, and why you have to fight against higher powers-that-be who are feeling 'forced' to keep you hired and offer the service. This also lies at the crux of the recent debate on branding - consumers don't know what the service is and those payers that DO know what it is are only viewing it as a mandated cost and not as a health or lifestyle product that has value.

Sensory integration theory and practice models provide an interesting example of this issue.

Without descending into a values inquiry of Pirsig-like proportion - we can ask the basic question "Does sensory integration have value as a practice model?" To begin with, although there is a growing body of research (some supportive and some not) about sensory integration - there is longstanding lack of acceptance for the intervention from the medical community. Many doctors and insurance companies believe it lies somewhere between Doman-Delacato patterning and swimming with dolphins - and have responded by issuing policy directives that it not be reimbursed. Now whether the assessments were fair or correct is a separate issue - but the fact remains that it is not a valued practice model in the medical community.

On the street level, parents have children who are not learning in school. This isn't new - and over time our society has responded to this population with terms like 'minimal brain dysfunction' and 'soft neurological condition' and 'learning disability' and 'attention deficit disorder' and 'central auditory processing disorder' and 'sensory integration disorder.' The names change - the conditions are constants. This means that there is evidence that there is a problem that needs to be addressed - it is just the intervention method that is the largest question.

Schools don't value sensory integration intervention as a practice model because it lacks face validity to the wider perspective of educational-behavioral methods and the intervention model itself is mostly incompatible with the structure of a school day.

The fact that educational and medical systems don't value sensory integration as a practice model has not dissuaded occupational therapists - and instead some therapists have participated in legal battles and infighting that have led a group to actually trademark the KIND of sensory integration intervention they espouse.

Others in the profession have responded by participating in some good research around the concepts of sensory integration - but only at the level to get it identified as a DISORDER. This doesn't even really touch the issue of what the best way is to TREAT the disorder.

So while people debate whose kung fu sensory integration is the best and others complete research to find out if it is even a disorder - there are a lot of clinicians struggling with how they should or should not integrate this information into their practice - and struggling with the reality that it is not valued by medical or educational communities.

What has happened is that a value question was posed and answered. Sensory integration as a practice model is not valued. The logical response would be to re-tool the model or abandon the model and move toward something that has greater value. Behavioral and mental health professionals were faced with a very similar value question when cost factors made people question the worth of long term psychotherapy. The behavioral and mental health people were very quick to respond and change their interventions to direct behavioral methods with short term interventions. In short order they completely redefined the nature of their practice - and now are tackling larger issues like parity with physical medicine.

Occupational therapists instead chose the long tail - and now frequently 'market' to the very few parents who are willing to look outside of the medical and educational communities. By 'market' I refer to the conscious and unconscious portrayal of the nature of our interventions. Rather than find a practice model that provides value to broad constituencies, therapists instead find long-tail parents who will pay privately for the service or who are willing to push for the service with their MD or school. Those therapists who are practicing within the educational and medical systems find themselves mostly marginalized and undervalued - because the larger systems already answered the value proposition.

Ultimately, this is unhealthy for the profession. Practicing therapists who cling to the model are dismissed by their educational colleagues and referring physicians. The service remains (for now) because it is legislatively mandated - and occupational therapists continue to operate within their own private Idaho of practice - wanting to help people live lives to its fullest - but at the same time only having niche believers who value the intervention. As a practice model, sensory integration is not meeting the demands of the largest population/short tail of consumers (broad medical and educational communities).

This observation is not meant to detract from the excellent efforts to define sensory processing problems as a disorder - because there is value in further definition and understanding of why children have difficulty learning. However, it should give practicing occupational therapists something to think about regarding how they INTERVENE with the problem - at least if they want to avoid going the way of Freudian psychoanalysis.


Margaret said...

With regards to your comments on a target market of parents, a company just recently created a line of "sensory friendly" clothing i.e. no seams, pocket for weights, permanent fidgets attached to pants, etc. Seems so ridiculous to me especially at $99 for a pair of children's pants!!!! There are so many gadgets now for weighted anything - blankets, lap pads, vests, shoelaces, pencils. I would love to see some significant research supporting all of this. To date I have not found much. Please inform me if I have missed all the hard data on weighted items. I am not saying that some children do not respond to it but the amount of products out there seem a bit much to me.

Chris said...

There isn't a lot of evidence beyond anecdote and small scale studies. Some of the studies done on deep pressure and calming are listed in another blog entry at http://abctherapeutics.blogspot.com/2008/08/effectiveness-of-howdahug-seat-in.html We found that a chair that delivers 'pressure stimulation' might just as easily achieve improved attending by its conforming design that cues children to remain in one position.

As you mentioned, this isn't to say that anecdotal evidence lacks value - the question is if there is enough evidence there to justify incurring expenses. I'd say that the jury is still out. If a weighted vest or similar product is available for free trial then it might be something to try in addition to a solid cognitive-behavioral intervention program. If it works - great! But I would not recommend that people just go out and buy them at this point.

Thanks for your comment Margaret. Anyone charging $99 for a pair of pants is taking advantage of a desperate parent. It saddens me to see that. Truth is that I don't know any adults who need to buy seamless pants at exorbitant prices so they can avoid having a sensory meltdown at the Monday morning sales meeting. Kind of makes the whole premise look a little foolish.