Time to throw in the towel on sensory processing assessment
Today's Wall Street Journal includes the standard article in its Life/Health section on Sensory Processing Disorder that we are all accustomed to seeing published every six months or so.
The general idea of these journalistic offerings includes the standard trope of expert occupational therapists who can identify a disorder that the medical community can't quite agree on. It also includes the standard ethical bombshell that occupational therapists can't bill insurance for this therapy and that the costs are $175 per session and are needed for 18 or 30 sessions, depending on who you ask. Maybe it depends on credit card limits in different geographic localities, I am not sure. The fact that the cost for this therapy can range from $3000 to $5000 is in itself a red flag that should make most parents squeeze their wallets shut and run for the hills. The fact is that there is no consensus on frequency of these interventions and there is also no consensus if this 'intensive sensory' approach has any merit.
None of this is to say that some children don't have difficulties that can impact their behavioral regulation or motor skills. The problem is with the never-ending profiteering off of the 'problem' when there is no evidence to support the intervention. In the interest of full disclosure, I see some children in my practice with behavioral and motor difficulties. The difference is that we only bill what the insurance will pay for, which is generally $50 or so a session. We also only see most families once weekly for a few months for consultation, home programs, and education. We use cognitive-behavioral and motor learning strategies that are evidence based. We use this model of consultative empowerment and evidence based practice because we find it to be accessible to families and we also find it to be effective. We also use this model because in the absence of good evidence for sensory-based interventions this seems to be reasonable and conservative.
The occupational therapy profession is wholly responsible for perpetuating a message about sensory processing assessment and interventions that in my opinion is irresponsible and unethical. An example is noted in the just published article "A Review of Pediatric Assessment Tools for Sensory Integration" that was published in the American Occupational Therapy Association's SIS Quarterly Practice Connections.
The purpose of the article was to "provide clinicians with a current, comprehensive list of robust pediatric assessment tools specific to sensory integration." A case example was included in the article.
Of the nine assessment tools listed in the article, four are either 'in development' or 'used in research/not clinical settings.' That takes us down to five.
Of the remaining five, two are parent report instruments that are subjective and not an actual measure of child performance. That takes us down to three.
Of the remaining three, one is not a measure of sensory processing at all, and in fact is described by the publisher as a test of functional motor skills. That takes us down to two.
Of the remaining two, one is a criterion measure based on a convenience sample of only 130 children in a single geographic region. The other was normed on 85 children in 2005.
The biggest offense in this article is that the case study discusses the use of one parent report instrument, a questionnaire not listed in the article, and also the Sensory Integration and Praxis Tests, which was also not listed as a recommended assessment. Maybe it was not listed because it was published over 25 years ago and has outdated norms which are no longer appropriate for clinical use. It is confusing that it would be used as an exemplar of sensory processing assessment in the case study.
Nine years ago I blogged about how the SIPT was outdated. In that post I commented that I had hope that the partnership between USC and WPS would lead to new norms and a more robust certification process. Now that those two organizations have severed ties it seems that won't happen. I figure that a school like USC can't really associate itself with a product that is so outdated, but the reasons given for the split were kind of vague.
People may argue that science takes time and that there is a compelling reason to be patient but the fact is that there is no current mechanism to assess for sensory processing disorder, even if such a construct exists separate from other identified disorders. Clinicians have been very patient. More importantly, so have families who are relying on clinicians for guidance. Research into a distinct sensory processing disorder construct has been going on for over 40 years and the best that we have in 2016 is a list of clinically irrelevant tools, continued promises that more things are 'in development,' and exemplars of outdated assessments. Time to throw in the towel.
Most clinicians, even those skeptics in the medical field, understand that some children have anxiety, dysregulation, and even some motor planning difficulties to varying degrees. Those problems undoubtedly can impact functional skills. That is not what is controversial.
What is controversial is the idea that there is some distinct sensory processing disorder construct and some specific sensory-based intervention. The reality is that we do not even have a way to assess for what some occupational therapists are claiming exists. The scarier reality is that we do not even have a consensus on what 'sensory processing disorder' even means. At best all we have is the belief that something exists because parents describe concerns to us on standardized questionnaires.
We have seen enough articles in the popular news press discussing the problem that only occupational therapists know how to identify and treat. We have seen enough of the $175 per treatment session that can only be paid privately because insurance doesn't reimburse for experimental or controversial interventions.
Now it is time to turn the page, examine the research on anxiety and regulation and motor learning that is not so controversial, and find conservative evidence based interventions that insurance companies pay for and our medical colleagues accept.
References:
(embedded links, and...)
Mori, A.B., Clippard, H., del Pilar Saa, M., and Pfeiffer, B. (2016 August). A review of pediatric assessment tools for sensory integration. SIS Quarterly Practice Connections, a supplement to OT Practice, 1(3), 7-9.
The general idea of these journalistic offerings includes the standard trope of expert occupational therapists who can identify a disorder that the medical community can't quite agree on. It also includes the standard ethical bombshell that occupational therapists can't bill insurance for this therapy and that the costs are $175 per session and are needed for 18 or 30 sessions, depending on who you ask. Maybe it depends on credit card limits in different geographic localities, I am not sure. The fact that the cost for this therapy can range from $3000 to $5000 is in itself a red flag that should make most parents squeeze their wallets shut and run for the hills. The fact is that there is no consensus on frequency of these interventions and there is also no consensus if this 'intensive sensory' approach has any merit.
None of this is to say that some children don't have difficulties that can impact their behavioral regulation or motor skills. The problem is with the never-ending profiteering off of the 'problem' when there is no evidence to support the intervention. In the interest of full disclosure, I see some children in my practice with behavioral and motor difficulties. The difference is that we only bill what the insurance will pay for, which is generally $50 or so a session. We also only see most families once weekly for a few months for consultation, home programs, and education. We use cognitive-behavioral and motor learning strategies that are evidence based. We use this model of consultative empowerment and evidence based practice because we find it to be accessible to families and we also find it to be effective. We also use this model because in the absence of good evidence for sensory-based interventions this seems to be reasonable and conservative.
The occupational therapy profession is wholly responsible for perpetuating a message about sensory processing assessment and interventions that in my opinion is irresponsible and unethical. An example is noted in the just published article "A Review of Pediatric Assessment Tools for Sensory Integration" that was published in the American Occupational Therapy Association's SIS Quarterly Practice Connections.
The purpose of the article was to "provide clinicians with a current, comprehensive list of robust pediatric assessment tools specific to sensory integration." A case example was included in the article.
Of the nine assessment tools listed in the article, four are either 'in development' or 'used in research/not clinical settings.' That takes us down to five.
Of the remaining five, two are parent report instruments that are subjective and not an actual measure of child performance. That takes us down to three.
Of the remaining three, one is not a measure of sensory processing at all, and in fact is described by the publisher as a test of functional motor skills. That takes us down to two.
Of the remaining two, one is a criterion measure based on a convenience sample of only 130 children in a single geographic region. The other was normed on 85 children in 2005.
The biggest offense in this article is that the case study discusses the use of one parent report instrument, a questionnaire not listed in the article, and also the Sensory Integration and Praxis Tests, which was also not listed as a recommended assessment. Maybe it was not listed because it was published over 25 years ago and has outdated norms which are no longer appropriate for clinical use. It is confusing that it would be used as an exemplar of sensory processing assessment in the case study.
Nine years ago I blogged about how the SIPT was outdated. In that post I commented that I had hope that the partnership between USC and WPS would lead to new norms and a more robust certification process. Now that those two organizations have severed ties it seems that won't happen. I figure that a school like USC can't really associate itself with a product that is so outdated, but the reasons given for the split were kind of vague.
People may argue that science takes time and that there is a compelling reason to be patient but the fact is that there is no current mechanism to assess for sensory processing disorder, even if such a construct exists separate from other identified disorders. Clinicians have been very patient. More importantly, so have families who are relying on clinicians for guidance. Research into a distinct sensory processing disorder construct has been going on for over 40 years and the best that we have in 2016 is a list of clinically irrelevant tools, continued promises that more things are 'in development,' and exemplars of outdated assessments. Time to throw in the towel.
Most clinicians, even those skeptics in the medical field, understand that some children have anxiety, dysregulation, and even some motor planning difficulties to varying degrees. Those problems undoubtedly can impact functional skills. That is not what is controversial.
What is controversial is the idea that there is some distinct sensory processing disorder construct and some specific sensory-based intervention. The reality is that we do not even have a way to assess for what some occupational therapists are claiming exists. The scarier reality is that we do not even have a consensus on what 'sensory processing disorder' even means. At best all we have is the belief that something exists because parents describe concerns to us on standardized questionnaires.
We have seen enough articles in the popular news press discussing the problem that only occupational therapists know how to identify and treat. We have seen enough of the $175 per treatment session that can only be paid privately because insurance doesn't reimburse for experimental or controversial interventions.
Now it is time to turn the page, examine the research on anxiety and regulation and motor learning that is not so controversial, and find conservative evidence based interventions that insurance companies pay for and our medical colleagues accept.
References:
(embedded links, and...)
Mori, A.B., Clippard, H., del Pilar Saa, M., and Pfeiffer, B. (2016 August). A review of pediatric assessment tools for sensory integration. SIS Quarterly Practice Connections, a supplement to OT Practice, 1(3), 7-9.
Comments
You might identify me as a professor and in some sense that is correct but the greater truth is that I am a street level clinician. I don't think that it is undermining the profession to provide constructive criticism and to express that we need better practice models. I don't see much value in pursuing the SI model as it is constructed. I believe that the people who come to us for help will be better served by us increasing our focus on temperament theory, cognitive behavioral approaches for situational coping, motor learning approaches, and conservative parent empowerment consultation that is short term as opposed to long term. All of this needs to happen in a broad occupation frame, of course.
"On the latest SIS Practice Connections, a significant and unfortunate error occurred on the article "A Review of Pediatric Assessment Tools for Sensory Integration" where the Sensory Integration and Praxis Test (SIPT) was omitted from the listing of assessment tools in sensory integration. Corrections will be included on the online version of the article and printed on the November edition of the Quarterly Practice Connections. The SISIS feels strongly about sound and scientific measurement in occupational therapy. The Sensory Integration and Praxis Tests, a significant contributor to our practice area, is considered the gold standard in assessment of sensory functions as well as occupational therapy's current and only standardized assessment of pediatric tactile and praxis functions. Please accept our apologize (sic) in this significant oversight.
The SISIS Committee and authors of the article
Annie Baltazar Mori
Heidi Clippard
Maria del Pilar Saa
Beth Pfeiffer"
+++
For what it is worth, I would like to see a response to the specific issues that were outlined. This statement about how the SIPT is "current" only raises more concerns.
I appreciate your willingness to speak out about an area of OT that many people have strong opinions/emotions about. In my OT program I brought up similar concerns - in particular the fact that this is one of the most researched areas of OT but the methodology of many studies is questionable at best or based on such small sample sizes that it's not fit to be generalized. I received a lot of push back from classmates and professors alike, and heard comments similar to what you received here. It's an emotional topic for many people - no one wants to hear that they're dedicating time and energy to an approach that doesn't have support. Plus, many therapists anecdotally insist that it works. My hope for the future is that therapists who use the approach can acknowledge the lack of research without feeling personally affronted. I think it's bizarre to suggest you are undermining the profession by calling for evidence based practice. OT would only be more legitimized by research showing our interventions work. In a health care environment where there's overlap between fields it's a good thing to be recognized as the sole provider of a certain service, but it's troublesome if that service isn't supported by research and if the diagnosis it treats isn't even formally acknowledged by medical or psychological bodies. I sincerely hope research continues to improve in quality and there is evidence for the existence of SPD and the utility of SI interventions. Until then, I think it's wise to be cautious when advocating its use
He is almost 7 and has no hand dominance. Writing is extremely difficult. Reading is lagging. During the evaluation he fell over during all of the balance tests. The therapist also noted his motor planning is poor. He had difficulty with putting pennies in a dish, for example, but always improved on the next round.
After reading your blog, I'm concerned that the OT is pointing us in the wrong direction I'm wondering if you have advice on how to find an evidence-based, conservative practice. I'm also wondering how you address these children with clear motor delays. Thank you!
First of all, it is important to understand that a child can't be diagnosed with spd because it is not a valid diagnosis. That said, if he is having difficulties with writing, reading, balance, etc then 'something' is likely a problem. You need to locate a team of evidence based practitioners who can help you get to the root cause of his difficulties.
A psychologist or neuropsychologist would be very helpful and should administer IQ tests and achievement tests - in addition to other behavioral screens for attending difficulties, anxiety, etc as needed.
An OT would also be very helpful and should administer a visual motor test, a motor free visual perception test, a fine and gross motor test, and also a full developmental and occupational history.
Call a local university that has an OT program and tell them that you are looking for an evidence based OT practitioner. Tell them specifically that you are not interested in pseudoscientific approaches.
If you happen to be local to NY then let me know and I would be happy to help.
As for how these problems get addressed - it all depends on what the root nature of the difficulty is. After you have thorough evidence based assessments you can pinpoint your child's learning needs with accuracy. Then a treatment plan can be devised. If you get to the point of identifying the problem I can begin to give you general ideas about what a treatment approach would look like.
Motor learning and cognitive behavioral strategies are the best general approaches for children who have learning difficulties. However, specifics will vary depending on the nature of the problem.
Best of luck in getting good evaluations. That really is your best chance for being able to develop a good plan.
Your pediatrician may also be the best source for advice and referrals to good evidence based practitioners. If not, they should be!
Your points are valid and it's heartening to see a voice of reason in the profession as I feel like SI has reached the status of a kind of religion. I sense there's a lot of politics involved which forces everyone to be locked into a consensus in this area, when we really need independent, critical thinkers. There has been much done to promote SI, presenting a skewed, unrealistic view of what it can accomplish. Parents and teachers who don't know the evidence are left with an impression that SI has all the answers and these high expectations can actually hurt the child by diverting time and resources away from other strategies that may prove more helpful. The ambiguity concerning identification of SI problems and the expected outcomes of the intervention makes it a challenge to move away from this approach when it is clearly, at least to me, not effective for a particular child; and it gets dragged out for years as a focus. SI has a lack of falsifiability that is troubling - everything can be explained as an SI issue.
My impression of the research, is that it's mostly conducted by people who already believe SI is effective. To me, this lack of objectivity is the source of many of the problems.
I don't have specific 'names' for these interventions - most of the time 'named' interventions are commercialized/marketed/sold. The methods that I use are related to evidence on those models in general and informed by research studies. I am not sure I am fully understanding your question, so perhaps if you could re-phrase it I could try to answer more specifically. Thanks!
Various movement programs: Ready bodies, learning minds; or S.M.A.R.T. (stimulating maturity through accelerated readiness training) (it's a series of various movements targeted at reflexes, balance, vestibular, gross/fine motor, auditory, visual efficiency, visual perception, instruction, etc...) OR balametrics perceptual program, OR yoga, the list goes on and on...
I am all for doing the EBP believe me... however when I try to find out what that is exactly, I google layers and layers and layers of information with no clear cut answers. It's disappointing and frustrating. So in your blog, if you could educate us on what it is you do that works so well, that would be greatly appreciated. I do not have the time to do all this leg work in finding out what treatment modalities are properly researched with favorable results. Or results that you see fit and legitimate. It's clear to me that you really have a flair for understanding research. So if you can give it to us in simple terms, I would forever be grateful. I am more interested in knowing and learning what works (backed up by research)... not just what doesn't work. I hope that helps... if not, please let me know.
thank you!
Let's just take handwriting as one example. There have been several interesting studies on handwriting methods that have been published in AJOT recently. Many of those studies have been small but they provide a nice beginning level of evidence for methods that might be more effective. For example, there were three studies that included a consultative method of handwriting training embedded in the classroom. One was for the Size Matters method, one was Handwriting without Tears, and the other was for a locally-created 'Write Start' method. Students in each of the 'experimental' groups out-performed controls. Based on these studies, it seems reasonable to conclude that implementing a variety of practice-based consultative handwriting methods seems to have positive effects on development of handwriting. I call that "evidence-informed" because in order to be truly "evidence-based" I would rather have even larger-scale studies on a single method. Another way you might use this kind of information is to say that at least these methods have some beginning support, whereas the SMART program does not appear to have any studies published in peer-reviewed journals.
It does not take much time to search databases, but like all skills you will become more skilled at it the more that you practice. You have access to ProQuest databases if you are current with your NBCOT certification, and there are also many publicly available databases to search for evidence. If you need to brush up on your evidence-searching skills, I recommend the 'PICO' game on the NBCOT Navigator site to help you practice developing research-able questions. I hope this helps, some.
Chris
References:
Case-Smith, J., Weaver, L., & Holland, T. (2014). Effects of a Classroom-Embedded Occupational Therapist–Teacher Handwriting Program for First-Grade Students. American Journal Of Occupational Therapy, 68(6), 690-698. doi:10.5014/ajot.2014.011585
Donica, D. K. (2015). Handwriting Without Tears®: General Education Effectiveness Through a Consultative Approach. American Journal Of Occupational Therapy, 69(6), 1-8. doi:10.5014/ajot.2015.018366
Eckberg Zylstra, S., & Pfeiffer, B. (2016). Effectiveness of a Handwriting Intervention With At-Risk Kindergarteners. American Journal Of Occupational Therapy, 70(3), p1-p8. doi:10.5014/ajot.2016.018820