Monday, August 15, 2016

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.


(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.


Susan Livingston said...

Can't wait until this author has someone near and dear to them identified with SPD.....then you will understand.

Christopher Alterio said...

Hi Susan, Thanks for commenting. I hope you re-read my post because actually every aspect of my position is directed toward the concern I have for families. I fully understand the concerns and frustrations - I have been working in this field for thirty years and even focused my doctoral studies on pediatrics and sensory processing issues. I am advocating for effective and evidence based interventions that are accessible to all through their insurance - not just to those with high credit card limits. Families deserve much better than what the occupational therapy profession has done with this vagabondish pursuit of a sensory integration practice model and treatment approach. My comments do not negate any concern that a parent has for their child. My comments only serve to underscore the inefficient and often ineffective methods that have been offered to meet people's needs.

Michelle said...

Christopher- I am concerned about your article. Sensory progressing goes hand and hand with motor planning, life skills, and being purposeful and engaged in your environment. You stated you have concerns with all having access to therapy; however you seem to have more of an issue with diagnosis of SPD and the limited research. I think you are in an unique position as a professor to address your above concerns through ongoing research. Please do not undermine your wonderful profession, but support it with ongoing research on a topic you feel is undeveloped.-Michelle

Christopher Alterio said...

Hi Michelle - thanks for commenting. Can you explain what you are concerned about? I agree that sensory processing is related to motor skills, etc. The problem is that we have relatively reliable and valid ways to measure motor skills and we have methodologies to promote motor learning that are evidence based but we certainly do not have reliable or valid methods of measuring a sensory integration construct. We also don't have evidence that the proposed sensory model, with all of its structural and process elements as described, is effective. So we have many elements of our understanding that are solid but we have other elements (like the idea of assessing a sensory processing construct or using an SI intervention model) that are scientifically weak.

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.

Anonymous said...

Interesting article and discussion! I am a school-based OT. My supervisor encourages us OT's to learn as much as we can about sensory processing, because it is uniquely "our" area within the school team. However, we are not equipped to provide SI therapy; we only see students 30 min. a month, at most; few of us have designated therapy rooms (much less heavy duty SI equipment); and I don't know if any of us have SI certification. We also cannot refer parents to outside therapy, as that might make the school district liable for the bill; regardless, pediatric OT services are very limited in our community. So our role is mainly to consult and offer suggestions pertaining to how uncomplicated sensory equipment (i.e., fidgets, wiggle cushions) and/or strategies (i.e., use of heavy work activities) might help a student be more calm, or more alert, and more engaged. Frequently, we get referrals on students demonstrating serious behavior problems-- i.e., prolonged tantrums, with screaming and verbal and physical aggression-- with the hope that a weighted vest or a sensory diet with specified movement breaks will turn the child around. How could it be that simple? While it is important to try to identify antecedents to problematic behavior, those answers are often a hypothesis at best, and the bottom line is that we need to help students cope, focus, and participate. To that end, I think "Zones of Regulation" is a good and helpful (cognitive/behavioral) framework and resource, presenting self-regulation as a "normal" activity and challenge, rather than simply an area where some people demonstrate dysfunction. Thus, certain sensory tools can benefit most people, along with other kinds of tools in the kit... That said, I think there are individuals whose neurological systems function far beyond the norm, who might benefit from therapy aimed at a kind of "makeover" that changes the way they process sensory information (just as there is a difference between those of us who periodically experience "the blues," and people who are clinically depressed). In that case, as Christopher suggests, we are left with the questions of how we can diagnose those individuals and how we can offer treatment that is evidence-based.

Christopher Alterio said...

Several people sent this link and information to me. The link can only be accessed by AOTA members:

"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.

Anonymous said...

Hi Christopher,
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

mrsschiavolin said...

Hello, I have been obsessively looking for information on spd since my son was diagnosed with it last week, along with retained reflexes.

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!

Christopher Alterio said...

Hi mrsschiavolin...

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.

Christopher Alterio said...

Also, and perhaps most importantly, discuss your concerns with your pediatrician. I neglected to mention that above.

Your pediatrician may also be the best source for advice and referrals to good evidence based practitioners. If not, they should be!