More discussion re: the AAP Policy Statement on sensory integration

This was written in response to Dr. Clark's letter to Pediatrics regarding the AAP Policy Statement: Sensory Integration Therapies for Children With Developmental and Behavioral Disorders.  

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Dr. Clark's response included some important points which were good to read, including recognition that single modality interventions tend to be ineffective; I am hopeful that her statements will help to move occupational therapy practice away from these interventions.

I was also glad to see mention of the neurobiological literature as theoretical backing for some interventions.  This is important literature that we should all keep in mind when trying to understand apparent processing difficulties.

Finally I was glad to see mention that occupational therapists use a wide variety of interventions with sensory processing interventions among them but not representing them solely.  I think we need to remind or medical colleagues of this fact lest we become associated with only a single intervention strategy.

I would like to encourage AOTA leaders and my occupational therapy colleagues to carefully consider the comments of Dr. William Carey, located online at http://pediatrics.aappublications.org/content/129/6/1186/reply#pediatrics_el_54252

I believe that Dr. Carey expresses an important point when he states

"Where normal variations leave off and abnormal degrees supposedly begin has not been clearly defined. Clinical problems probably occur most often when the particular level of sensitivity or reactivity makes a poor fit with the demands and expectations of the environment. That dissonance may lead to stress and to some form of dysfunction in the child. In these cases it is helpful to assist the child and parents in finding ways to get along better and reduce the impact of the mismatch. But this does not mean that the child has a disorder." 

I think that occupational therapists have done an incomplete job of making distinctions between truly pathological levels of dysfunction vs. identifying traits and tendencies regarding processing differences.  In part this has been facilitated by over-reliance on parental report measures and the an apparent desire to get this labeled as a disorder first and to develop valid and reliable client factor assessments second.

Occupational therapists remain well positioned, and I would even argue best positioned, to still provide important interventions to children and families where sensory processing differences are causing stress, anxiety, and even performance difficulties.  However, when we take the opportunity to consider that this is not always a primary disorder but sometimes a complex and dynamic relational point of dysfunction between the child and their contextual environment, then suddenly we have a whole different set of tools available to us in addition to the process and structural components that are currently being suggested as preconditions for any kind of effective intervention.

So why do we need to re-frame this so that we are not restricted to calling it a disorder and thinking that we need special equipment and 6 months of therapy (ideally)????  Because of pragmatics and the real world.

Dr. Clark talks about real world applications and so here we need to acknowledge the real world.  Insurance companies do not pay for months and months of therapy - nor should we expect that in this current health care environment.  What good do we do when we state that the only proper studies to consider are those that include a frequency and intensity of therapy that is not reimbursed?  Do we restrict this intervention only to the wealthy who are able to go to private clinics and pay these fees out of pocket?

Ultimately, I believe that the model of sensory integration therapy that calls for specific structural and process elements that are not found in the majority of intervention settings will not serve the public and will be discarded.  The model of sensory integration therapy that calls for high dosage requirements that are not reimbursed anywhere in the country will not serve the public and will also be discarded.  This high intensity and high dose strategy is not a model that will position us to help children and families who experience these difficulties.  

We need to consider the words of Dr. Carey carefully.  His words do not de-legitimize the role of occupational therapy; rather, his words are a clarion call to provide occupational therapy in a way that is more congruent with actual child/family needs and more congruent with a responsible and conservative intervention strategy.

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