Showing posts from 2009

Luke 2:10

The day before Christmas eve is always busy, and yesterday was no exception. The office will be closed for several days and there were so many things that needed to be done. Payroll had to be audited and sent out, some schools had paperwork deadlines for the end of the second quarter, schedules needed to be coordinated for time off so we were sure to have coverage for those families that wanted services next week, some end of the year banking needed to be done... on and on. It was busy, and the message was delivered this year on cue in the form of Tina. At the very end of the day we had three families jostling past each other between appointments and Tina burst through the front door on a mission. She made a bee-line straight toward me, absolutely disregarding all the social cues that might have otherwise indicated she needed to wait. It didn't matter that other parents were standing near me, that we were engaged in a conversation, or that her own mom was trying to corral he

Conversation with a future OT student

From: A future OT student Sent: Sunday, December 13, 2009 7:07 PM To: Subject: from a future OT student: wanted to say thanks Dear Dr. Alterio, I just wanted to thank you for all of the great stories you posted on your blog... I am writing to you because I have been searching for stories by occupational therapists where they actually help people, where they make a real difference. After going through prerequisites, applications and finally being accepted into two of my top choice schools- I have found terrible posts on [a website] posted by ex occupational therapists and some physical therapists which all revolve around how occupational therapy is an ineffective, terrible profession to go into. They warn people to stay away from the profession. Many people have written in response to those posts saying that because of them, they have changed their mind. You helped me to not change my mind. I started looking into occupational therapy after having worked with s

Questions about AOTA's response to the National Autism Center

The National Autism Center published a comprehensive National Standards report regarding evidence-based practice guidelines for children and young adults who have autism. The report is an excellent summary of research about intervention methods and effectiveness. It was particularly interesting to me that this report referenced and hoped to expand on the New York State Early Intervention Clinical Practice Guidelines for autism spectrum disorders which of course is a document that is familiar to many of the families in my geographic area. The NYS guidelines were published ten years ago so an update to include new research was needed. The new report focuses on quantitative studies and in this sense some important occupational therapy literature may not have met the inclusion criteria. There have been some excellent qualitative studies completed that make important occupational therapy contributions to best-practice considerations so I am really looking forward to the next report th

Sustainable communities and disaster relief for people who have disabilities

In general, people are not inspired to continue monitoring post-disaster relief operations after most of the television cameras leave. So any commentary on this topic may seem to be johnny-come-lately except for those who sustain their interest and understand how big the problem really is. This is an attempt to refocus a little bit of attention on an issue - and I am not as interested in getting preachy as I am in shining a flashlight on issues that are good fuel for action. There is a great competition for students to examine the challenges that people who are elderly or disabled face during and after disasters in their own cultural and local contexts. I hope some students see this and become interested in the topic. If you need some motivation for outrage, read this first.

Student survey: What education level is needed for COTAs?

Please consider helping an OT student by taking this non-scientific survey so she can gather opinions on what education level is needed for COTAs. The survey is at Thanks!

Distinctions between health care delivery problems and social policy problems regarding premature births

Today the March of Dimes released their 2009 premature birth report cards for each state. Premature births are an important issue to discuss for occupational therapists because so many of the children who require OT services have a history of prematurity. Even so-called 'late preterm births' where the children are 34 weeks gestation and older have a higher incidence of learning problems. People will take advantage of the release of this report to politicize the findings as an indictment of the US health care system. This is only partially true because a multitude of social and cultural factors causes this problem, including: MDs practicing defensive medicine and increasingly using 'late preterm' cesarean delivery. Couples opting for fertility treatments that inevitably lead to increased incidence of twin/triple/quad pregnancies (and sometimes more). Poor prenatal care among illegal immigrants and undocumented aliens who do not have health insurance. Poor prenatal he

Good question from a student

From: OT Student Sent: Sunday, November 15, 2009 11:55 AM To: Subject: OT student needs help Hi, I just visited your website and found your blog section very interesting. I am a current MOTS student from XXX that is working on a project looking at whether COTAs should be required to have a bachelors degree rather then just an associates. I am wondering if you are able to post this question on your blog as I need feedback from OTRs and COTAs on how they feel about this issue. I would be most grateful. Thank you in advance, OT Student ************************************************************************** Dear OT Student, If you create an online survey (there are several free survey tools available) I will be happy to put the link on my blog. I am not aware of any evidence that supported graduate degrees for OTRs - and this is an important question that should be raised. If more schooling is required and this feeds competence that is fine - but I don't kno

Feedback on alternatives to the therapy cap

Occupational therapy payment restrictions, typically referred to as 'therapy caps' on Medicare Part B, are daily concerns for all occupational therapists working in private practice, outpatient clinics, and nursing facilities. AOTA is participating in a long-term project aimed at finding an alternative to the current cap system. RTI International, the entity that was awarded the government contract to conduct this research, states that "CMS envisions a new method of paying for outpatient therapy services that is based on classifying individual beneficiary’s needs and the effectiveness of therapy services, e.g., diagnostic category, functional status, health status. Currently, CMS cannot evaluate or implement this type of approach because CMS does not currently collect the appropriate data elements." RTI is proposing assessment tools to describe the characteristics of Medicare Part B clients. The proposed tool for outpatient settings collects demographic data and co

New York toughens child abuse laws, some.

Earlier this year I wrote about Nixzmary Brown and I was happy to learn that Governor Paterson signed the bills into law that toughened possible sentencing for child murderers. Under the new law, an adult who intentionally causes the death of a person under the age of fourteen years old can be found guilty of Aggravated Murder if they tortured the victim prior to death. [Penal Law §§ 125.26] The bill also authorizes a sentence of life imprisonment without the possibility of parole. [Penal Law §70.00(5)]. Tougher sentencing options are good - and if you want to feel good about this outcome then don't look into the history of the case. If you want to feel good about this outcome then don't research any details about the trial. If you happen to do any research into this you will still feel an empty aching in the pit of your stomach. I suppose there should be no rest for the wicked - and we really have not yet done enough.

Cloudy with a chance of ... pine cones?

Here is a picture of the wheelchair ramp on the front of the building. Thanks to a particularly unstable weather cell in our area we had violent winds this morning. While working with a small group of four year old children we heard THUNK THUNK THUNK THUNK outside the building and I immediately thought that I was hearing hail. When you are an adult it is sometimes reflexive to think about boring things like repair bills for damage - the noise was extremely LOUD and I was envisioning the dents all over the roof and hood of my car! Thankfully I don't work in the world of adults and so the self pity over potential repair bills didn't last long. The children were curious so we all ran to the window and they were amazed at what we all saw. "OH MY GOODNESS IT IS RAINING PINE CONES!!" The contextual world of children is currently rich with movie metaphors for odd rain events and so it all made very perfect sense to them. The kids were very excited to return to our pre

How the health insurance industry is price gouging to its own demise

Here is an interesting anecdote of how the private health insurance market is killing itself: Our health insurance costs (premiums + deductibles) for the plan we offer to employees have risen over 20% each year for the past five years. Some years our costs have risen as much as 45% when we were forced into the high-deductible product line. There has been no accompanying increase in reimbursement rates for occupational therapy or physical therapy, by the way. Aside from that, I was interested when I was informed three months ago that our current plan was being discontinued because the letter that we were sent said very specifically: " In the short term, the impact of these changes will not be seen in premiums. Encouraging preventive care and providing new products and programs to empower members to take a greater role in their health care and will help address rising costs. Rest assured that XXX Health Insurance Company knows that the current pace at which health care costs are

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Cut to the chase: A simple question that perplexed us today!

At the beginning of each school year I marvel at how big of a challenge it is to get everything organized. Education is not new, drawing school district lines is not new, establishing bus schedules is not new, and determining outcome measures for education is not new - but each year it is as if no one has ever done it before, and people are left floundering around trying to figure out what needs to be done and how it needs to be done! In my own little OT corner of the universe we came upon the issue of 'what are the best scissors for preschoolers to learn how to cut with?' Well there are no shortage of opinions but there is very little evidence I could find. That was a little surprising given the length of time we have been teaching preschoolers how to use scissors. Having practiced OT for over 20 years I have some opinions, but they are just opinions and I have no proof to offer that the way I do things is any better than any other way. I am aware of a fine book about scis

A subjective conversation about the issue of grade retention

My occupational therapy practice is sometimes as much about parents as it is about children - and in fact the two are so intertwined that making the distinction is irrelevant. We get questions all the time about parenting decisions - and as these are directly related to both parenting and childhood occupations we try to help. Summertime is famous for conversations about retention. I have read all the studies - but won't list them here because they may not apply. Still, the studies state that there is sometimes temporary/immediate benefit to grade retention but that those benefits disappear in subsequent years. The problem with the studies is that they are done on such a large and heterogeneous group that it is difficult to say exactly who these results apply to. Parents and teachers and administrators get lost in the issue because they inject all kinds of ancillary concerns including what will it mean if he is the physically largest child in the class? is it true that the extra

tree frogs and coming to grips with a diagnosis of autism

I saw Jason today whose family has not yet acknowledged his autism. They will soon, as society will not allow them to continue explaining away his stereotypical behaviors for much longer. For now, from the perspective of his family, "he loves to jump and wave his hands!" and "he just doesn't like to talk much." and "he loves rocking in that rocking chair!" It is all fine; it is not my job to cram some doctor's provisional diagnosis down the family's throats. I don't even pretend to know how difficult it must be for parents to come to this kind of acceptance - but I frequently see how long it takes to get there so I can imagine that it is not an easy path to walk along. Anyway, I was intrigued today while I was listening to his grandmother make many assumptions about Jason's behavior. Jason walked near the refrigerator and the grandmother interpreted this as him wanting a bottle because she believes that he is emotionally regressing sin

Reforming funding for school-based special education - at the point of a gun

Nearly three years ago I offered to work for NYS for free to help tackle the problems of Medicaid fraud for special education services (see The system needs reform badly - and although I never expected to be asked to serve I was actually quite sincere in my concern and desire to effect some improvement in the system. As I predicted back then, there would eventually come a day of reckoning to pay for the fraud and abuse - and it seems that we are at that day. In today's Albany Times Union, reporter James M. Odato informs us that the New York State Education Department is withholding Medicaid payments to school districts in accordance with a settlement agreement that has NY State paying out hundreds of millions of dollars back to the federal government. Also as predicted, this leaves school districts in quite a pickle - because they are still mandated to provide these services by law - and now t

Recurring philosophical questions

I have had a recurring question in my mind since the beginning of my occupational therapy career. At that time I was working in an urban acute care psychiatric facility and I was fresh out of college with my head full of lofty ideas about occupational behavior, occupational role, and the potential of occupational therapy to solve societal problems. I read every word that Mary Reilly ever wrote, and listened as they were explained to me in the classroom by proxy of Phil Shannon and watched in amazement as they were practiced in a hospice home care setting while being mentored by Kent Tigges. Still, after work each day I took the Metro North to the safety of suburban living and I kept rolling over the question: "How can I remember NOT to transpose my values and my concept of Quality when working as an occupational therapist??" My training told me that I wanted my patients to develop options, decision-making, problem solving, and agency relating to some return to occupati

Fun-filled game of the day: Guess the CSE chairperson's intent!

Why would a CSE chairperson who has worked in the field for over 20 years suddenly want more information on the Beery VMI?? This chairperson has seen this assessment used hundreds of other times... so why more information now?? Inquiring therapists want to know. re: Johnny XXX To Whom it May Concern: At the request of the district CSE Chairperson, here is additional information regarding Johnny's performance on the Beery VMI. Quite honestly this is an unusual request as this test is perhaps the most commonly used assessment in school-based occupational therapy and I do not understand why special explanations are required for this child. I am hopeful that this information will help to get an appropriate plan for this child into place. The Beery Developmental Test of Visual Motor Integration 5th Edition is a widely respected assessment tool that is backed by decades of research and clinical use. The Beery VMI screens for visual-motor deficits that can lead to learning, neuropsyc

We need consumer education and tort reform before handing over health care to our government

There are many conversations swirling about regarding health care reform, proposed 'public options,' and tax/penalty methodology to pay for the programs. The more that gets said the less specificity seems to be revealed. Instead I am hearing a lot of lofty and non-specific theory that the system will pay for itself by 'inherent efficiencies' which I have concern may be code for rationing. When pressed for these kinds of details all I am hearing is a full-frontal assault on 'insurance companies' but occasionally there is a jab slipped in at providers who are accused of making decisions based on reimbursement structure and not on clinical necessity. There is no doubt that a reimbursement system obviously creates incentives and disincentives to how care is delivered - but to accuse providers of driving decisions solely on financial incentive is a little much. The added insult is to trumpet the 'endorsement' of prominent organizations - like the AMA - w

The impact of proposed new federal regulation on health care delivery

Proposed new health care regulations may have an extraordinarily negative impact on the way consumers access their health care. The following information is from a September 2005 report from the Small Business Association entitled The Impact of Regulatory Costs on Small Firms. "The annual cost of federal regulations in the United States increased to more than $1.1 trillion in 2004. Had every household received a bill for an equal share, each would have owed $10,172, an amount that exceeds what the average American household spent on health care in 2004 (slightly under $9,000). While all citizens and businesses of course pay some portion of these costs, the distribution of the burden of regulations is quite uneven. The portion of regulatory costs that falls initially on businesses was $5,633 per employee in 2004, a 4.1 percent cost increase since 2000 after adjusting for inflation. Small businesses, defined as firms employing fewer than 20 employees, bear the largest burden of fed

School buses and safety belts: Not a simple issue

I was pleased to see the article in the recent OT Practice entitled "School Buses + Safety Belts = Good Idea." (Loveland, 2009). I think it is important for OTs to have a good discussion about ways to promote safety and prevention of child injuries. There are some additional facts to consider so I wanted to list them here: 1. In the studies cited in the Loveland article, there was an annual average of 17,000 children seen for emergency treatment for school-bus related injuries. However, that number is a little misleading. The study reports that only 42% of those injuries were crash related, so by extrapolation, it is arguable that seat belts would not have made a difference in many of those injuries. In fact, the 17,000 number includes slips and falls outside of the bus, getting on/off the bus, etc (McGeehan, 2006). 2. The National Highway Traffic Safety Administration (NHTSA) reports detailed research on their website about school-transportation related injuries and deat

NY Times article is demeaning to elderly people who have Alzheimer's

Here is the offending/offensive article: All-Night Care for Dementia’s Restless Minds I will be the first one to admit that it gets a little boring to listen to people have complaints about political correctness and terminology - everyone is offended by everything these days... but this article went so far beyond any semblance of acceptability that it has to be pointed out. I am not criticizing the program - because I have no direct knowledge of what actually happens there. In concept I think that offering night time respite care for caregivers is a great idea. Unfortunately, the authors of this article portrayed the program in a very negative way - and I don't think that they really intended to do so. Throughout the article the authors repetitively compare elderly program participants to children. For example: 1. The participants were "chattering and giggling like children sneaking out of camp." 2. A caregiver reports relief by stating, "It was like when your bab

How I became an occupational therapist

Or perhaps more appropriately titled: Too much information. Oh well. I wrote a blog entry once about 'the things I do.' It has been lost to time - I am not sure where I have the entry stored but I recall that it received many comments and sparked a lot of conversations about the issues of time and time spent - and how one comes to the decisions about the things they do. That entry is decidedly more serious than this one. So, I am not trying to recreate the original - but couldn't think of a more appropriate title for this entry. Maybe I will look for the original sometime. Today is a hard work day. I am not questioning why I am an occupational therapist but sometimes when I have hard work days I reflect back on what I thought I wanted to do when I grew up. I took a Strong-Campbell Interest Inventory in high school, and it said that my career interests were matched to a speech therapist, a college professor, and an actor. The fourth match was 'occupation

Top 10 ways to identify that it is May!

Usually sometime around April I stop looking at the calendar because I no longer have time to look at calendars. Life in April and May is generally spent running from one responsibility to the next, non-stop. Then something strange tends to happen at the end of May, and I begin to realize that Spring is in full bloom and that there is indeed a light at the end of the tunnel that all pediatric therapists are running through this time of year. Here are some common experience-markers that are making me believe I will soon have a life again... 10. The semester is over for most college students - and my son completed his undergraduate career! 9. Robins have nested in all of their favorite spots around our building and the baby bird chirping is louder each day! 8. Memorial Day Weekend! 7. Pediatric OTs are beginning to look for jobs! (the better ones always finish out the school year first). 6. My landscaping contractor has repaired the lawn damage from winter plowing and has cut the gra

Twenty years of SIPT - where do we go next?

Standardized tests are periodically discarded or updated because the normative group that the test was developed around may have changed characteristics. I am unaware of any 'industry standards' regarding the life expectancy of standardized tests; rather, professionals in a field tend to come to consensus about the relative usefulness of tests on their own. I would be interested in knowing what other therapists think about the Sensory Integration and Praxis Tests - which were published in 1989. I became certified in the administration of these tests seventeen years ago. At first I found them highly useful but the more I gave the tests the more I understood the limitations. Now it has gotten to a point where I do my best to discourage people when they ask for this test - not just because of the inherent weaknesses of the test construction but also because of how old the norms are. There have been some legitimate concerns with the tests including extremely poor test-retest re

Monday morning spaghetti

In 11th grade I took a computer programming class - computers were brand new technology at the time and the teacher knew little more than the students so it was definitely a wide open frontier. The computer was an excellent tool in that programming forced my adolescent brain into a type of linear and logical thinking pattern that I still find useful today. The teacher often had us work in pairs on larger projects and I had an excellent programming partner. We regularly challenged ourselves with writing complex programs and we were sometimes over-ambitious. One particularly complex program we attempted was to write a 'Blackjack" program. I remember how excited we were when we got the cards to print correctly on the screen. This was high-end stuff for a couple of high school kids hacking away on a TRS-80 Model III computer! Our Blackjack program became increasingly complex, and as we attempted to make accommodation for ever increasing complexities the programming code becam