Showing posts from 2006

Folie à deux

Folie à deux is a psychological term referring to the situation when two or more people share the same delusion. Delusions are funny things, and difficult to disprove, particularly when more than one person starts seeing them. This all relates to Mary, who taught me about love, and trust, and delusions, and perceptions - and ultimately what matters most. **************************************** It seemed strange that the doctor didn't request physical therapy as well, I thought, as I watched Mary limp down the hallway in a traditional hemiplegic gait pattern while using a quad cane. I remembered practicing that Trendelenberg gait in college with my classmates, accentuating the weakness of the hip abductors. The difference here was that Mary certainly wasn't faking or pretending with her newly acquired gait pattern. A serious look was on her face, and her arm was clenched tightly to her side in an angry and tense position. In college I guess we really didn’t stop to think about

Christmas messages as considered by a pediatric occupational therapist

I wanted to write some Christmas-theme entries this month but I ironically have not had the time. Life can sometimes get very busy. Being busy is precisely the topic I wanted to discuss. Adult occupational behavior around the holidays is fascinating to study. I don't want to get into a lengthy treatise about the meaning of shopping - but let's face it - is holiday shopping a healthy or unhealthy occupational experience? Watch adults in the mall and you will understand the question. Western societies are consumer-oriented. Corporations spend untold billions of dollars based on our classification as consumers. Consumer-focused messages are reinforced by cultural practices that remind us what grouping we are in and how that fits in with our status as occupational and social beings. So, I am sent messages that this is my 'prime' as a human being on the planet. These are my 'productive' years - I am past the tumult of young adulthood and this time is prior to the tum

random thoughts on superstition, tradition, conviction and evidence-based practice in occupational therapy

For various reasons I have been called to task regarding an analysis of what I believe in - and I thought that the philosophical definitions are important so I wanted to yell them to the rafters, so to speak. Issues of internal consistency are important to me, so I was interested to find that my work vs. non-work need for evidence was quite different. I'm still not entirely sure how to resolve that issue – perhaps it is not important. Anyway... Superstitions often stem from folklore or historical reinforcement of confusion between causation and correlation. Common response experiences and confounding variables contribute heavily to confusion that is then reinforced through repetition. In this sequence of events, superstition translates to mythology and there is high risk for it to be further transmitted into tradition. I am aware of the debate, but count me among those who believe that 'folk psychology' is real. I know that eliminative materialists will take me to task, but

physical agent modalities and competency in occupational therapy

It will be interesting to see how far and wide this issue travels - I expect that my answer will make some people angry and other people very happy - but either way I view this as a question that comes along that is just too good for me to ignore - Today I was asked for my opinion on the following question: "I am a COTA and I have attended a couple of workshops on Anadyne Therapy. It is an infrared treatment modality used to treat patients with peripheral neuropathy. Treatment will initially consist of a pre-sensory test (Semmes-Weinstein monofilaments), treatment with the Anadyne and fine motor exercises. The question is: Does an OTR have to do the initial evaluation which would be the pre-sensory test prior to the treament? I am able to conduct the test and the treatment but I don't know if legally I can." Here is my response: According to the NY State Board of Regents, occupational therapy assistants as a rule have not demonstrated competence to perform evaluations, so

The Day I Saved Andy’s Life

I am not in a life-saving profession - at least not in the traditional medical interpretation of life-saving. I was never really interested in wielding that kind of power, although in many ways I think that I have learned that traditional life-saving power is easily reducible to a little chemistry, a little anatomy, a little slight of hand and technical know-how. Little else. This is not meant to downplay that technical expertise though. Actually I am humbled by those who perform such acts on a daily basis. I saved someone's life once. That is what I have been told anyway. I like to tell this story because the moral is that sometimes you might be in a position to make a difference, even if you did not put yourself in that position, and even if you had no intention of making a difference. I think that is important information to have tucked away for reference purposes. One day my phone rang and it was my buddy John. John was an itinerant therapist in the truest sense

Why I am not writing entries for a while.

...because street-level occupational therapists sometimes need a break.

child passenger safety

I don't typically pass around web sites that I think people should go visit although I have done so lately. I hope that when people see that I am referring a web site that it is not the equivalence of junk mail or spam. I would only send you somewhere that I really think you need to visit. I got involved in child passenger safety sometime in the late 90s. I was forced there out of necessity and parent demand - a parent whose child had a spica cast chastised the hospital I was working in because there was no appropriate restraint to send her child home in. I am thankful to that parent to this day; I am not sure if she is aware of the changes that were made because of her concerns. I educated myself on the issue and learned that a nationwide education campaign resulted in increased use of child restraint devices in automobiles but many children are still restrained improperly (Glassbrenner, 2003). National studies demonstrate that the misuse rate of child restraint devices in automob

Clinical problem solving in occupational therapy and the need to eliminate special case thinking

Lots and lots of questions these days and I am doing my best to answer them... What I would like to try here is to throw my problem solving methodology to the winds and perhaps if someone finds this useful there will be fewer questions in the world. Is that likely? There is a difference between a primary problem and a secondary behavioral attribute but people constantly confuse the two. So when someone says, "My child won't pay attention," or "One kid on my caseload won't eat any solid foods" they will often look for a direct and concrete answer to their 'problem' and completely misunderstand what the 'problem' really is. Let's take one example and walk through it. First of all, if you have a clinical/presenting problem, place it in a circle at the top of the page and then make 5 circles underneath it. Five is a random number, but these circles will represent the POSSIBLE causes of the problem in the circle above: PROBLEM REASON 1____REAS

Pediatric encopresis and occupational therapy

Today I had contact with three families who were all dealing with problems relating to encopresis. Encopresis can be essentially defined as a lack of fecal continence and it is a huge problem for families. I have to admit that there was no training in my occupational therapy curriculum relating to encopresis, although occupational therapists spend a lot of time talking about helping people with self care activities of daily living. I suppose that my educational programs assumed that intervention ends when a child can let their pants down and sit on the potty? The lack of any mention of pediatric encopresis in the occupational therapy literature certainly doesn't stop occupational therapists from weighing in on this subject when it comes to giving parents advice. I read an evaluation once where a therapist talked about a child's constipation and encopresis being related to a craving for deep pressure stimulation, and it was a reflection of poor sensory processing. The recommende

Smiles from Nicholas

I knew a boy named Nicholas, and I don't think that it needs to be confidential any longer. Nicholas had cerebral palsy and I was randomly chosen to be his occupational therapist. That's the way referral patterns go sometimes - and it just amazes me - because on any given day as an occupational therapist you just don't know what your life might be thrown toward. I am not going to attempt to re-tell Nicholas' story because his parents have already documented it far better than I ever could. I would like to ask everyone to go visit their web site and Foundation Smiles from Nicholas . I learned a lot from Nicholas and his family So although there were tears, there was laughter more. And although there was pain, there was joy more. And when things seemed bleakest, they lived. I have been thinking about them a lot and I don't know how a world can right itself after the death of a child, but I trust that it will in one way or another (with a a little help from above of co

DSM and SPD: Are we ready?

October 25-31 is National Sensory Awareness Week and The Knowledge in Development (KID) Foundation is working to obtain inclusion of Sensory Processing Disorder in the DSM (Diagnostic and Statistical Manual). DSM classification would presumably raise awareness of the disorder and contribute to appropriate diagnosis and recognition. The press information from the KID foundation also states that the addition of SPD in the DSM will help reimbursement for treatment. I fundamentally agree with this effort but I really wonder if we have enough information about sensory processing disorders to present a cogent argument for inclusion. According to the American Psychiatric Association "each disorder included in the manual is accompanied by a set of diagnostic criteria and text containing information about the disorder, such as associated features, prevalence, familial patterns, age-, culture- and gender-specific features, and differential diagnosis. No information about treatment or presum

on polar bears and autism

Parents are bombarded with messages about autism and that unfortunately fuels worry and speculation. It also fuels early diagnosis which is never bad. I was recently observing an infant who has some motor delays and the parent was very worried about some atypical repetitive behaviors. The baby would sit and stare at the carpet while running his fingers through the carpet pile. Over. And over. Repetitive and non-purposeful behaviors always need to be assessed. However, this child has excellent play and social interaction skills - so the parent did not understand why he would engage in this very autistic-looking type of behavior. To some degree children thrive on repetition and adults will become bored by an activity long before a child will. So, a child may repetitively place a ball through a series of ramps and watch it over and over as it rolls to the bottom - but this is just a way that they learn about cause and effect. This doesn't mean that they have autistic-like behaviors, a

swinger of birches

We had a little snow here late last week that extended my hiatus away from the computer. This is a view of my backyard from the deck. The bowed trees are a clump of four river birch that are approximately 30 feet tall (well, when they were standing). I planted the trees there on purpose, so I could look at them from my office window in my house. Anyway, there are still many people in the Western New York area still without electricity, heat, etc. and we are very fortunate. Much of the snow is melting now and my birches are struggling to stand again. I think they will. I don't mind that this happened; it reminds me of important lessons that I like to think of as I go about my daily work. Thank you, Robert Frost: So was I once myself a swinger of birches. And so I dream of going back to be. It's when I'm weary of considerations, And life is too much like a pathless wood Where your face burns and tickles with the cobwebs Broken across it, and one eye is weeping From a twig'

more on transparency: CSE meetings, second opinion and fair use

Another CSE meeting recently, another issue with transparency. Professionals can sometimes disagree, which is bound to happen because children's performance is subject to variability. When test performance varies across different tests that are supposed to measure the same construct both professionals should be open and concerned enough to try to explore and understand the difference between test scores. I have never had a problem releasing raw test data to occupational therapy colleagues. I understand that there are issues with randomly releasing test materials and manuals to the general public, but most people agree that in the case of 'second opinions' it is not objectionable for a professional to release raw data to another similarly credentialed professional upon request and upon consent from the family. The materials pass directly between professionals, and should never involve parents, lawyers, etc. unless there is some court order to do so. Today a (non-OT) professi

occupation in action

So much of what we read about in our occupational therapy journals has to do with models of medical illness. Disability models are traditional practice for health care professionals. Therapists feel 'comfortable' when working within these systems. In 1985 I took an undergraduate Community Health course. At that time the concept of community health was in its infancy and we were just seeing the beginnings of a move away from inpatient and institutional care. I recall that the course gave me the idea that one day we would not be in hospitals, developmental centers, and large state institutions for the chronically ill. We have made some progress since that time, but I often wonder why more OTs are not in private practice or doing more work in the community. OTs still prefer the safety nets of institutions and agencies. Practice is decidedly more community based than when I first graduated: there is a lot more home care - both for infants and adults. More services are provided in H

Things I think about on tough days

This is a story about a little boy from Africa. His parents recently immigrated to the U.S. and he was only a little over a year old. L. contracted a bacterial infection, leading to a cold, leading to a systemic infection, all of which landed him in the pediatric intensive care unit. It was a one in a million complication actually. Kids get bacterial infections all the time. The parents take them to doctors who prescribe medication, and modern medicine has taught us to expect that the infection will go away. Every once in a while the medicines don't work. The bacterial strain multiplies, is immune to the medication, or who knows what. So L. was hospitalized and lying in the PICU as the infection ravaged his little body. I believe at this early stage that the doctors did everything they could possibly do. The infection was particularly virulent though and his heart began to fail. And then his kidneys began to fail. In order to properly deliver medications he had arterial lines inser


I have spent some time thinking about the concept of transparency lately. This is one example of how it has come up recently - I like to have parents sit in on my evaluations. I find that most children are not distracted by their parents at all. Very rarely I will have to ask a parent not to coach if we are doing a standardized test, but this is very uncommon. Having parents sit in on evaluations allows them to see what is being done and it enables them to be better advocates for their children. Parents who have seen occupational therapy evaluations are better able to discuss a child's needs at a CSE or CPSE meeting. Also, having a parent 'right there' allows me to interact with them as contextual behavioral issues come up and it also allows me to observe the nature of the parent-child interactions. The one exception to this rule is that I generally don't like to have parents present in the room if I am doing the SIPT. I can't tell you how many parents have fallen a

Insurance companies and doing business in New York

Although I have a lot to say about health insurance and occupational therapy I will save it for another day. That is a topic that deserves several entries. Instead, since people email me and tell me that they may be interested in starting their own private practices I thought that this 'other insurance' information would be interesting for people to read about. In the last month I have had interesting interactions with my professional liability insurance provider, my general liability insurance provider, and now the NY State Department of Labor who administers the FUTA tax, also known as ‘unemployment insurance.’ I dutifully pay our professional liability (malpractice, etc.) each year and have never had a claim thank goodness. It is common for large contracts to require listing on the policy as an ‘additional insured.’ This is fine, but the underwriting department of the professional liability insurance company has strict rules about the technical wording of who is listed as th

Lesion studies as a methodology for researching sensory processing disorders

OTs are trying to better understand the neurophysiological basis of sensory processing disorders. Several sites are conducting research using the Sensory Challenge Protocol . Preliminary studies (McIntosh, Miller, Shyu, & Hagerman, 1999) support the presence of a physiological basis of sensory modulation disorder (SMD), finding that electrodermal responses were larger in children with SMD, excepting those who were non-responders. Additionally, Schaaf, Miller, Sewell, & O'Keefe (2003) found that cardiac vagal tone index was significantly decreased for children who had identified sensory processing difficulties. These studies provide preliminary evidence that there is a physiological basis for SMD. Another method of researching the nature of sensory processing is to look at sensory processing in people with known neurophysiological problems. Lesion studies are a classic method for understanding function and dysfunction of the human nervous system. Of course precautions must

More on the need for more rigorous evidence-based practice in pediatric OT

Today a colleague pointed out to me that there was such a thing as 'Sensory Stories.' During a conversation on the ABC Therapeutics discussion board she asked about 'Sensory Stories' and I thought she was talking about Carol Gray's Social Stories. Turns out that some folks have tweaked the Social Story concept and are now marketing products. For more information on Sensory Stories you can buy them here or read information from the authors here . It seems that these are customizable stories that employ sensory-based strategies to help children learn to cope with hyper-responsivity to certain sensory information. In addition to the sensory strategies the authors suggest repetitive reading of the story, perhaps setting up a cognitive-behavioral script to help establish a coping routine to an upsetting situation. The authors provide recommendations for how often the stories should be read, and make statements about their research - although this is all just weasel-wor

A book recommendation

This is a lot of information to get to a book recommendation at the end, but I hope the information along the way will be helpful. In occupational therapy, context refers to a variety of interrelated conditions including cultural, physical, social, personal, spiritual, temporal, and virtual factors that influence performance (AOTA, 2002). Performance contexts are taken into consideration when determining function and dysfunction within an environment. The concept of “contextual factors” was not explicitly stated in the occupational therapy literature until the profession adopted Uniform Terminology III (AOTA, 1994). This document included the earliest named references to contextual factors that occupational therapists consider. Specifically, it mentioned temporal aspects including chronological age, developmental stage of maturation, point of location in the life cycle, and disability status. Additionally, the definition of cultural contexts includes customs, beliefs, and activity patt

Book review: The curious incident of the dog in the night-time

The curious incident of the dog in the night-time. M. Haddon. New York: Vintage.226 pp. $12.95.Paperback In this mystery novel the protagonist narrates through his journey into awareness of adult relationships. The story is at times engrossingly accurate and at times painfully pedantic. Ironically, in a story about a protagonist who perhaps has Asperger’s Syndrome or some other form of high functioning autism I imagine that is supposed to be the point. Unfortunately, the story ultimately fails because the author can’t resolve the fact that the real ending is already known, despite the ‘mystery’ being revealed on page 120. Christopher is an interesting character and his quirkiness is probably what drew critics to praise the book. I don’t imagine that the critics have ever met someone like the protagonist, so his ‘differences’ are captivating enough to keep an uninformed reader glued to the pages long enough to finish reading. Sadly, the author reinforces the disability-as-magic-power my