Sensory integration: More evidence that OTs have lost control of the narrative
There are quite a few opinion pieces in this blog about the state of sensory integration as a model for occupational therapy - the reader is particularly referred here and here for quick background if needed.
Continued evidence that occupational therapists have lost control of the 'sensory integration' narrative can be found in the October 2010 Scientific American Article by Nancy Shute entitled "Desperation drives parents to dubious autism treatments."
Sensory integration therapy is described in the article as ranging from "wrapping children in blankets or placing them in a hug machine to having them play with scented clay..." They also note in the article that this intervention costs families up to $200 per hour or $6000 per year. Sensory integration is listed in a chart as Temptations: Dubious Therapies.
These kinds of articles always seem to generate responses from people who disagree from them, but before anyone responds I think this is a good opportunity to pause and reflect on why we are finding ourselves in this position. The 'Fidelity' problem has been discussed forever and our field has not come together to find a solution. We still have different 'camps' of people supporting different iterations of what should be included in sensory integration models and the result is ongoing confusion in the public square. We have too much mythology and too little evidence when it comes to our interventions. The public is confused because we have confused them.
What do parents want? Perhaps OTs should listen closely to Jim Laidler who was interviewed in the article: "Obviously, the goal of my family, and most families, is to lead as normal a life as possible. Normal is going out to dinner as a family."
We can use our knowledge of sensory processing to help us understand why children who have autism have difficulties in these environments, and make suggestions to families on how to help mediate those difficulties. We can also use training methods, direct practice, and skill development to help children learn to function in those environments.
Or we can let people continue to think that we are putting blankets on children and letting them play with scented clay, charging them exorbitant prices for this 'expertise.'
What kind of occupational therapy are you promoting?
Continued evidence that occupational therapists have lost control of the 'sensory integration' narrative can be found in the October 2010 Scientific American Article by Nancy Shute entitled "Desperation drives parents to dubious autism treatments."
Sensory integration therapy is described in the article as ranging from "wrapping children in blankets or placing them in a hug machine to having them play with scented clay..." They also note in the article that this intervention costs families up to $200 per hour or $6000 per year. Sensory integration is listed in a chart as Temptations: Dubious Therapies.
These kinds of articles always seem to generate responses from people who disagree from them, but before anyone responds I think this is a good opportunity to pause and reflect on why we are finding ourselves in this position. The 'Fidelity' problem has been discussed forever and our field has not come together to find a solution. We still have different 'camps' of people supporting different iterations of what should be included in sensory integration models and the result is ongoing confusion in the public square. We have too much mythology and too little evidence when it comes to our interventions. The public is confused because we have confused them.
What do parents want? Perhaps OTs should listen closely to Jim Laidler who was interviewed in the article: "Obviously, the goal of my family, and most families, is to lead as normal a life as possible. Normal is going out to dinner as a family."
We can use our knowledge of sensory processing to help us understand why children who have autism have difficulties in these environments, and make suggestions to families on how to help mediate those difficulties. We can also use training methods, direct practice, and skill development to help children learn to function in those environments.
Or we can let people continue to think that we are putting blankets on children and letting them play with scented clay, charging them exorbitant prices for this 'expertise.'
What kind of occupational therapy are you promoting?
Comments
Nice to meet you! Came here via a tweet from LizDitz. Nice to meet another (great) same mind.
Here is an early post I did on this topic:
http://www.therextras.com/therextras/2008/07/shotgun-therapy.html
I have several posts on 'all things sensory' linked in a box in the middle column of my blog.
Recently I guest-posted here:
http://thinkingautismguide.blogspot.com/2010/07/what-to-ask-of-occupational-therapist.html
Hope that answers your question.
Barbara
An early post I did on this topic:
http://www.therextras.com/therextras/2008/07/shotgun-therapy.html
More recently:
http://thinkingautismguide.blogspot.com/2010/07/what-to-ask-of-occupational-therapist.html
Hope that answers your question.
Barbara
I'm very relieved that I'm not the only one who questions the effectiveness of classical SI interventions. While I do provide and suggest certain calming activities that can help a child function better in his context, I spend the bulk of my time teaching functional skills to my kids and helping their families discipline them.
To be honest, I sometimes feel "weird" that I don't make my patients finish "obstacle courses" that are suppose to provide them with the enhanced sensory input that they need because that's what a lot of Filipino OT's do. I frequently feel like I'm the odd one out. Reading your blog entries on SI and evidence-based practice gave me the assurance that I am on the right track. Keep up the good work! :)
Maria Anya Paola P. Sanchez, OTRP
I have been following your posts on this topic for a while now and as an OT, I completely agree with all you've had to say about it.
You might be interested in this article from the August 2010 edition of the Australian Occupational Therapy Journal which covers many of the points you've previously made. Sorry I can't make it a live link but copy and paste should do the trick.
http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1630.2010.00877.x/pdf
Keep up the good work!
Karen
It is gratifying to see that colleagues in Australia are leading the way with publishing these opinions in journals. I hope that this spurs more conversation and open discussion here in the States!
Thanks again,
Chris
Barbara
I'm an OT in the states and have thought this same thing since day one. When I was in school, they taught us to critically look at articles before we bought into them; the first thing I noticed was that 99.9% of SI articles are done by OTs! (Similar to the cigarette companies telling you that tobacco doesn’t cause cancer).
The sensory system affects EVERYTHING. You cannot be alive without at least one of your sensory systems being affected by the environment, so isn’t that convenient explanation for any behavior? It’s a catch all diagnosis and it’s sad that my profession promotes this snake oil to desperate families.
Sorry for the rant and thank you for telling the truth.
In the realm of sensory processing, seven studies showed positive outcomes including changes in tactile function/discrimination, decreases in sensory defensiveness, and overall changes in sensory processing. The study also reviewed behavioral outcomes. A study by Miller, Coll, and Schoen (2007) found significant gains in attention, cognitive skills, and social skills among children with sensory processing difficulties compared with a no treatment group and an alternative activity-based treatment group (May-Benson, T. A. & Koomar, 2010). The article also highlights three more recent studies which examines changes in functional occupational performance. Individualized goals and significant gains were demonstrated, including changes in sleep patterns, improved ability to manipulate fasteners, improved ability to pump a swing, improved ability to participate in meal preparation activities, and improved ability to participate in homework activities. A study by Roberts, King-Thomas, and Boccia (2007) showed gains in functional, behavioral, and attention related goals in children with sensory modulation problems.
Joy
May-Benson, T. A. & Koomar, J. A. (2010). Systematic review of the research evidence examining the effectiveness of interventions using a sensory integrative approach for children. The American Journal of Occupational Therapy, 64(3), 403-414
In the realm of sensory processing, seven studies showed positive outcomes including changes in tactile function/discrimination, decreases in sensory defensiveness, and overall changes in sensory processing. The study also reviewed behavioral outcomes. A study by Miller, Coll, and Schoen (2007) found significant gains in attention, cognitive skills, and social skills among children with sensory processing difficulties compared with a no treatment group and an alternative activity-based treatment group (May-Benson, T. A. & Koomar, 2010). The article also highlights three more recent studies which examines changes in functional occupational performance. Individualized goals and significant gains were demonstrated, including changes in sleep patterns, improved ability to manipulate fasteners, improved ability to pump a swing, improved ability to participate in meal preparation activities, and improved ability to participate in homework activities. A study by Roberts, King-Thomas, and Boccia (2007) showed gains in functional, behavioral, and attention related goals in children with sensory modulation problems.
Joy
May-Benson, T. A. & Koomar, J. A. (2010). Systematic review of the research evidence examining the effectiveness of interventions using a sensory integrative approach for children. The American Journal of Occupational Therapy, 64(3), 403-414
I am an occupational therapy student, about to recieve my masters, and your blog really caught my interest. At this stage in my education we are learning all about sesnory integration techniques and the use of evidence based practice. What you are saying I saw on my fieldwork; we are confusing the public and not using enough evidence.
We are learning how to use our skills and knowledge of sensory processing to help children function the best they can in their environment.
I think my generation of future OT's will help clear up the confusion,"gain control" back and focus more on client centered care using SI. We are being taught to use evidence, focus on occupation based interventions, and advocate for what my profession does. this is the kind of therapy I hope to promote.
I applaud your interest and hope that you continue to study this important issue!
Chris
Your last comment brought me back:
"varied in what they are doing and how they are doing it that it can hardly be claimed to represent a single intervention strategy. I am comfortable with the statement that the studies indicate some support for occupational therapy, but I am less convinced that they represent any cohesive adherence to a single intervention method."
My responses at the Your Therapy Source blog on this post are related to what you just said. (But Margaret hasn't published my last comment yet, so you might wait a bit before going over there.)
http://yourtherapysource.blogspot.com/2010/11/motor-learning-versus.html
Barbara
As I said in my other comment to you, I have been working for more years than I care to say. I have found my own way, if you will, but I have always stayed true to function and occupation, and working in schools I have always stuck to "academic relevance" in what I am doing with children, my goals and treatment. I also always concern myself with student and parent desires, as they match up with the above. What teachers see as student needs is also always a concern of mine in determining treatment goals.
I continue to look at children's function in gross motor and postural control, ability to functionally sit erect with hands free for use for example, fine motor ability, UE and hand development, ability to functionally use tools of the academic environment (scissors, pencil, tape, etc.), pencil control and how it impacts speed and quality of handwriting, visual motor and visual perception as it impacts academic skill specifically handwriting and reading, visual testing specifically ocular motor control, screening for strabismus and other problems, sensory testing such as tactile testing and kinesthetic testing as it directly impacts hand function, vestibular function as it impacts the postural reflex mechanism and functional balance. Behavioral observations and play behavior is another area I always consider, as well as oral motor, eating, ADL, AT, Musculoskeletal exams as they are pertinent to the child.
There is so much for us to do in schools, that is functionally and occupationally based, that I don't know how OT's have the time to waste on "sensory diets." I worked for an SI therapy group, and they NEVER solved a functional problem. They had some fancy charts in their reports, but never helped a child functionally. Very sad - and because the schools and Committees on Special Education never made them accountable for a lack of progress, they continued.
Great developmental progress is possible! I make impressive progress with students every school year. It is sad that the OT profession, and AOTA in particular, has gotten "lost" in all of this. Our reputation as a profession is sadly suffering badly. Often I can say I am embarrassed to be a part of the profession.
I think that the advice given by the American Academy of Pediatrics to physicians to ask for goals and monitor progress is a good step in making people accountable. Years ago, when I had to obtain my own MD Rx’s and justify my treatment to physicians on the phone by answering specific questions about what and why I was doing something, things were better. If physicians were more involved, and asked for pre and post-testing results, the profession would be accountable and we would not be in this mess now.
I think that AOTA should be making themselves accountable. They made a bad turn when they bought into SI hook, line, and sinker for all types of problems and populations. When they eliminated the actual "specialty certification" and changed it into an academic task instead of a clinical competence measure they lost my confidence greatly. It seems if you are not in academia, but you are "only" a clinician, you are not respected by AOTA any longer. I don't know the politics of what happened, but it hasn't been good for the profession. The magazine gets smaller and smaller, doesn't it, and the advertising in it is mostly by AOTA itself for its products.
Good for you for doing such detailed work to tell the truth about SI. If we are to remain as a profession at all, especially in pediatrics and in the schools, we had better start doing something practical for those entrusted to our care.
Anyone charging for their services, which all OTs do either through insurance companies or other means, is making a living off of what they do for work. To talk about people who are doing a lot of work and research in this area in the way being done here is highly concerning.
Please do your research before talking poorly about fellow colleagues. Also, unless you are doing research that is peer reviewed and published to show any given approach is not beneficial you cannot state that it is not as you would have no evidence to support your claim and by the way be sure to use the fidelity tool to be sure how you define ASI is in fact accurate - that would be a good start!
Did you read this entry or are you just making angry comments?
The purpose of this entry was to discuss how (in 2010) an article was written in Scientific American that demonstrated how the public (and the article author in particular) still did not know what ASI was, despite all of the work of those who were attempting to clarify this topic. The purpose was to show how OTs still did not control the narrative, or the definition, on what ASI was.
I am not sure what all of your comments are referring to as it relates to the article, but I will try to address them:
1. I invite you to provide evidence that Ayres SI is evidence-based practice - because if you can do so perhaps some insurance companies could be informed. As it stands, virtually no insurance company that I deal with in the state of NY will cover these services. I suspect that is also true elsewhere, based on information and belief.
2. As for fidelity criteria, they are so stringent as to make the model inapplicable to the vast majority of practitioners and their work environments.
3. I understand that sensory-based modalities are not formally a part of the ASI model, but try telling that to many clinicians around the country. There is a problematic lack of adherence to the tenets of ASI - that is precisely why the fidelity tool was and still is needed. That is the whole point of this entry - to show how variably these definitions still were.
Can you please explain what is concerning about discussing the ethics of charging money for experimental and unproved interventions?
I encourage you to read the entirety of the over 50 blog entries here that discuss the SI model. If you object to something then you should be able to debate it intelligently - not just hurl random insults and hide behind an anonymous moniker when you make comments.
I invite you (or anyone) to critique my opinions, back up your statements, and print your real name. With so much information in this blog on the topic of SI you have a lot of material to comment on.
Start your critique this way: if ASI is so clear in everyone's mind, why do we continually see articles like this even though the fidelity tools were supposed to address the problem?
As a final point, it is the responsibility of the people promoting the intervention to provide the validation for the intervention. Clinicians and scientists are certainly free to evaluate the evidence that has been presented, to critique it fairly, and to render an opinion. A critic does not have to 'prove' that something is wrong. The proof needs to be provided by the people making the claims.
In that regard, many OT researchers have failed.
Constructive criticism and an expectation for evidence after so many years of this theory is not belittling. Charging families money for unproven and experimental interventions might be.
I encourage you to read the over 50 entries in this blog about the SI model. I have tried my best to lay out the case completely - and in doing so it is my hope to improve our profession.