Wednesday, July 25, 2012

Bidirectional bias as ABA and SI proponents fight in the public square

More for the file 'whose kung fu intervention for autism is strongest.'

Lang, (2012) published a systematic review of sensory integration therapy for autism spectrum disorders that at the same time has academically dishonest and potentially useful information.

The review errs in its rather lopsided inclusion of articles that measure the effects of isolated intervention strategies that would probably best be identified as addressing components of sensory processing as opposed to measuring a sensory integration methodology.  This is nothing new; there have been some good articles in the American Journal of Occupational Therapy recently that have contributed to debunking the use of seat cushions to promote attending behaviors and debunking the use of weighted vests to promote attending behaviors.  These findings are yet to filter into practice because a lot of people really like the idea of quick and easy answers to complex problems.  Finally we are getting to a point with our research where we are showing that solutions don't come that easy.

Anyway, the review tells us what we already know with all these other quick and easy interventions - that they are probably largely ineffective.  That's a good thing and potentially useful.  However, to call these interventions 'sensory integration therapy' is essentially dishonest, especially in consideration of all the conversation about fidelity (Parham, et al 2011) and what constitutes SI.  One could forgive Lang and  colleagues for their mis-characterization but they acknowledge fidelity as a problem

...the immense differences in SIT procedures across studies and the lack of a treatment fidelity measure in the majority of studies prevents direct comparison of the studies with positive and negative findings.

They also make some other admissions, such as "It is possible that the application of some other coding system may have yielded different conclusions" but I don't expect that the insurance company reading this study and looking for a reason to avoid paying for some services will highlight that quote.  This is where their dishonesty is at its peak because as researchers are sometimes wont to do, their overall conclusions overstate the data that they have actually collected.

Now enter AOTA with their expected response in opposition to the Lang review.  Jane Case-Smith and Roseanne Schaaf wrote a response that includes the typical AOTA components of defensiveness and more defensiveness.  The AOTA response questions whether or not biased methods were used in the review.  The answer to that of course is yes, in exactly the same way that the AOTA response is biased in the opposite direction.  The legitimate concern (as noted above) is whether or not consumers (aka insurance companies, etc.) will bother to pick through the bias in a search for truth - but they have their own bias and desires so that is not a hard issue to know what they will do with the information.

The AOTA response fails in exactly the same way their responses to these issues in the past have failed.  I am still waiting to see an honest response regarding the following issues:

1. A large marketplace exists that is fleecing families by selling products that are often being used in a single-solution context.  You can dance all around weighted vests and other similar interventions by saying "these prescriptions are embedded in a multi-faceted treatment plan and not offered in isolation."  That is really not true based on practice that I see from the street level perspective.  If all these studies indicate that these weighted vest or brushing or other interventions are not effective then why continue to parse the issue?  The AOTA response does at least state that "single modality strategies that are provided in isolation do not appear to result in positive effects."  Maybe we should celebrate the small admissions?

2. The sensory integration intervention protocol, at least as described by OT researchers presently, is not realistic in most occupational therapy practice.  In order to have adequate fidelity, researchers have promoted a protocol that can only be validated by a handful of self-appointed experts and the structural elements that are required are not found in the vast majority of family homes, preschools, schools, and other places where pediatric occupational therapy is most typically provided.  Additionally, intensity and frequency of such intervention is not realistic given the reimbursement structure or service delivery model available in many settings.  As I have mentioned previously in this blog, what in the world is the point of an intervention that can't be applied in the real world of MOST practice settings?

3. AOTA routinely defends a single intervention protocol and fails to adequately acknowledge that there are many occupational therapists who use a number of different approaches.  This is a disservice because when the professional association fails to acknowledge the limitations of a single approach, and when it fails to acknowledge that it is only ONE approach among MANY that are legitimately used, that defense promotes the notion that sensory integration interventions are synonymous with occupational therapy interventions.  That misrepresents the practice of many therapists.

And here we come full circle where the special interests are 'duking it out' over whose intervention is best.  Well here I will serve both sides of this nonsense some comeuppance:  street level practitioners are not interested in the politics of this; they want to use interventions that are effective and they want people who are in the halls of academe to put aside their respective bias in the interest of what is actually good for the people who ask us to provide services.  The Lang review and the AOTA response are both reflective of ingrained bias.  It is getting boring when I have to pick up professional journals and it feels like I am reading an editorial page of a newspaper.  Shame on both.


Case Smith, J. & Schaaf, R.(n.d.) Response to Systematic Review of Sensory Integration Therapy for Autism Spectrum Disorders.  Retrieved from

Lang, R., O'Reilly, M., Healy, O., Rispoli, M., Lydon, H., Streusand, W., . . . Giesbers, S. (2012). Sensory integration therapy for autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 6, 1004–1018.

Parham, L.D., Smith Roley, S., May-Benson, T.A., (2011) Development of a fidelity measure for research on the effectiveness of the Ayres Sensory Integration Intervention, American Journal of Occupational Therapy, 65, 133-142.

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