Do you believe???

One of the best questions that people ask me is if I 'believe' in sensory integration. I haven't really answered that directly, so I will try. I am motivated to do so because I just got the question again today - and I don't want to post the comments that were left because there was too much identifying information - and the person did not leave an email. So I hope the commenter sees the response here.

I suppose that people see my commentary and questioning about sensory processing and the need for evidence as being 'critical' or 'unbelieving' in the diagnosis. I commented recently about the concept of 'fidelity' when talking about sensory integration because one of the problems is that it is being so poorly defined by so many groups, including researchers. Even our 'state of the art' assessments are horribly intertwined between asking behavioral questions and sensory questions. I believe that it is getting increasingly difficult to distinguish sensory from behavioral difficulties based on the data that we get from self-report or parent-report assessment tools. There is a real need to improve these assessments so we can again begin to factor out sensory issues. There are some scholars who are 'beating the drum' over the fidelity problem and I am encouraged by their actions. The neurophysiological research is also a step in the right direction, as I have previously stated.

Anyway, the bottom line here is that in my practice I see many people come asking for 'sensory' evaluations. This week I evaluated a child who has an exclusive aversion to clothing and who will only wear 5 outfits. The child is normal in EVERY other way and there are no developmental delays. After a thorough evaluation I concluded that what may have started as some kind of tactile preference has mushroomed into a behavioral issue that requires a behavioral intervention approach.

I also saw another child who has a known neurological disorder and who is taking medications to control tics. The combination of medication instability and ineffectiveness, the interfering nature of the tics, and the associated emotional and behavioral state of the child are all combining into a gigantic sensory and regulatory mess. I have no idea where the 'spaghetti' begins and ends on his 'plate' but it is obvious that there are some very real problems there.

What I am saying is that people come looking for sensory or regulatory interventions, and clinically it is just not always easy to tease out the nature of the problem. This is because we have defined sensory integration so poorly, researched it ineffectively, and then perpetuate the problem by promoting 'cure-all' techniques that in actuality have dubious effectiveness.

I am certain that sensory and regulatory and behavioral problems exist in children. I also am certain that occupational therapy can be an effective intervention to promote improved function in children and in providing families with effective strategies to promote typical development and participation. Our best interventions to solve sensory and regulatory difficulties are functional and behavioral and contextual and educational. Other interventions may prove to be effective, such as 'deep proprioceptive protocols' or 'therapeutic listening' but we don't know that yet, and it is certainly inappropriate to pronounce something as being effective when we are not yet certain.

So to the person who left the comment I recommend a FULL occupational therapy evaluation to determine if there are any developmental difficulties. A spirited child who likes to spin might just be a spirited child who likes to spin. It is only a problem if there is some corresponding deficit in adaptive functioning or an inability to participate in normal activities.

However, if you go to a therapist who claims to be a 'sensory integration specialist' I would be wary. Instead, find an evaluator who is willing to 'suspend' their belief systems in the interest of determining whether or not a child has any functional or developmental difficulties. Perhaps there is a behavioral problem. Perhaps there is a sensory problem. PERHAPS THERE IS NO PROBLEM!

Consumers need to understand that if they are looking for answers, the answer they receive will often depend on who they ask. If you are having marital difficulties you will get different answers to your problem if you ask a lawyer, a counselor, or your clergy for advice. The same holds true for health care, and this is why consumers need to choose their health care practitioners very carefully.

I recommend avoiding practitioners who 'believe' too strongly in any particular interventions. We need more practitioners who are concerned because they want to see better evidence; we don't need practitioners who blindly 'believe' in single interventions.

I believe that some children have functional and occupational difficulties because of a constellation of physical, sensory, regulatory, cognitive, social, and other contextual difficulties. It is the job of an occupational therapist to determine if functional problems exist and how to direct an appropriate intervention program regardless of the root cause of that problem.


GinnyDreamin' said…
Chris-->great to see an OT BLOGGING about OT!! :) I'm enjoying your blog! I'm an OT practicing in Houston, TX. Take care and happy blogging!
Anonymous said…
I am an OT student at the University of New England in Maine finishing my Master's degree. My graduate focus is on OT and at-risk adolescents with an emphasis on foster care. I really enjoyed your post on OT's and foster care (I posted here since it is more recent) I wanted to thank you for posting your ideas and i hope you dont mine me using you as a source :)
Marcelle said…
Hi Chris I am also an OT for 23 years and I agree with you. I believe OT is a profession that initiated with the need to rehabilitate functional skills. A single strategy to reach the cause of an issue is hard to determine. Our little patients are more than one issue and we need to use our experience, evidence base practice, families history and context and evaluate the plan of care on a regular bases. Sometimes I feel our profession has become SI or NDT or specific therapeutic Intervention forgeting our functional bases.

Thanks for your blogg,
Anonymous said…
I could not agree more with your statements regarding "perhaps there is not a problem". I just finished calming a mother down whose pediatrician mentioned that that her 6 month old baby may need PT because he was not sitting up yet. As soon as I observed her son playing and moving (who happens to be 28lbs at 6 months of age) I told her to relax. His size was obviously influeincing his motor abilities. Mom has since relaxed and he is now 10 months old, sitting, reaching, playing, rolling and starting to crawl and super big! To me that is a star baby rather than a baby that needs to be referred for PT. Parents are so focused on raising a perfect child (sadly myself included) that we worry too much about what is normal versus not normal. As therapists, we need to be careful not to feed into this. The bottom line is someone has to be picked last in gym.

With regards to your comments on a strick focus on one treatment, I agree as well. We need to get back to basics and use techniques that have been proven to work - muscle strengthening and practice, practice, practice.

Thanks for the informative blog. Great writing style.
Margaret Rice - online resource for pediatric therapists

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