How some OTs are responding to criticism

Sometimes images can convey an action or feeling better than words, so I offer this as representation of the occupational therapy profession's response to the Washingtonian article that some in the profession believed was overly critical:

Like the Spartans, many occupational therapists responded to the message in the article by killing the messenger.  That might not be the best idea.

I made the following comments in the article but since I am not assured that those comments will persist I thought I would document them here.

Some OTs are concerned that the article is unfair and undermines the legitimacy of OT in general and their work in particular.  First of all, a magazine article can't undermine the legitimacy of anything. It is a piece of journalism. As such it has some reporting elements and invariably there are some differing opinions injected. Those opinions exist outside of the magazine article. The article does not undermine legitimacy; the opinions do. Therefore, it is important to look at the opinions that are reflected in the article.

Some defenders made comments that promoting normal development is a good thing to do, particularly since so many children have experiences that are not encouraging school readiness skills.  There was discussion about how the current culture and parenting practices are not always beneficial for children.  In the comments one therapist asked several questions related to "When is it bad to..." and those were all great questions because the answer to all of them is never. It is never bad to promote a child's development - but that is not the opinion here that is problematic. The opinion is a matter of whether or not it is ethically correct to promote and recommend therapy for every level of small deviation from normal that might exist.

So although it is never bad to promote a child's development, the real issue is whether or not it needs to happen in context of a skilled occupational therapy encounter.

Here it is important to take square aim at the American Occupational Therapy Association that promulgates policies and positions that countervail existing practice realities. Current practice realities include the fact that services are reimbursed with municipal money and that it is not in society's best interest to provide a therapeutic service to any child 'just because they might benefit.' Occupational therapists are routinely instructed by their professional association that they should promote wellness and that medical models should be questioned and that new models of prevention by providing 'population based services' should be adopted by all. Those are well intentioned but very misguided instructions.

Now those are all fine ideals and I understand the very good intentions behind those concepts but that is not how the world of municipal funding works and that is not how the world of private insurance works. Those ideas are also incongruent with how services are delivered in early intervention programs and school systems. These systems are not designed to provide services to anyone who might benefit.

So the problem here is not that an article is undermining the legitimacy of OT. The problem is that there are some OTs are providing services that might be unnecessary given the realities stated. They get ideas about providing those services because of misguided but well intentioned association-level dialogue. I notice that an AOTA pediatric representative commented and referenced the Practice Framework. I encourage my colleagues to take a deeper look and examine the expansion of the definition of OT that has occurred over the last three versions of that Practice Framework in the last 12 years. The definition of OT has expanded from being a service for people who have disabilities and it now states that OT is a service that promotes wellness for entire populations.  I documented and discussed this issue extensively in a previous blog post.

Some occupational therapists are abandoning their professional purpose and breaking the social contract of providing services to children who have disabilities and instead they are promoting this notion that 'everyone can benefit.' It might be true that people can benefit but that is not how the system works and that is not what society wants to pay for.

That is why we see articles like this.


In addition to problems with expanded definitions of practice that don't jibe with reimbursement reality there is also the problem that some therapists are providing services that are not evidence based and not reimbursed by regular insurance.   

This is a re-occurring narrative.  This is not the first such article that describes parents being charged thousands of dollars for evaluations and therapies that insurance will not reimburse. The prices quoted in this article are in line with what others have reported in many other venues and they are in line with what happens from some providers in my own community. Some unscrupulous OTs are charging these rates that are double, triple, quadruple, and even more than what any private insurance would pay for the service.

Furthermore, these services are charged for therapies that sometimes have very poor evidence to back them up. That does not mean that this represents ALL occupational therapy but this is a reality and we don't correct the problem by refusing to acknowledge it.

The problem does not solely exist in private practice. This time last year there was collective outrage about a NY Times article that discussed the skyrocketing rates of service provision in public schools. We can have interesting debate about the nature of modern parenting, the shifting culture and lack of outdoor play spaces and opportunities, the changing criteria for autism, and the rates of medication for young children - all of these are factors - but in my opinion responsible professionals should work to educate families about how they can personally work to mitigate these negative influences. Not every child needs to be placed on a therapy program.

My suggestion is "Occupational therapy: Heal Thyself." All the good that is done by so many responsible and ethical occupational therapists is quickly undone by your colleagues who are quick to swipe some concerned parent's credit card or by your colleagues in the school engaging in pseudoscientific quackery instead of evidence based practice or by your colleagues who have abandoned the original purpose of occupational therapy in pursuit of a new wellness service for the whole population.

I ask my colleagues to please stop killing messengers. 


Anonymous said…
Hi Chris,
I came upon your website because as a mom researching
sensory processing issues on behalf of my 2 year, 10
month old daughter. She has been diagnosed with an
anxiety disorder but I also think she has sensory
issues on the hypersensitive side. I have read that
hypersensitivity and anxiety often co-occur and it
makes a lot of sense to me.

She was a very fussy baby. She was extremely
difficult to get to sleep even given every sleep prop
and slept very little. She still only sleeps 8-9
hours max at night.

She notices and complains about all kinds of faint
smells, is a picky eater (prefers bland foods),
sometimes covers her ears when there is a loud noise
and doesn't like things, notices all kinds of visual
details. I've also noticed she becomes very antsy and
grabby. She is particular about physical touch and
wanting physical space; lately she has even been
complaining about DUST being in her space when
sunlight shines on it.

More concerning is that her baby brother is now 11
months old and she still cannot cope with the
unpredictable noises and movements he makes. There are
certain behaviors she has exhibited since his birth
like yelling;once he started crawling and now walking
she also has become physically aggressive. I know it
could be related to her anxiety but I've noticed she
always yells or is aggressive when he makes noises or
touches her/comes close to touching her. She has
started exhibiting these behaviors towards other
children as well. Literally she will scream at a
random child in public places for looking her

I have been trying to find evidence-based strategies
to implement with her at home. I have purchased some
compression shirts, have done sensory bin-type of
activities like sand, water, rice, beans, etc. for a
long time, I try to do heavy work type of activities
but find that she resists them so I do not force it. I
have read a lot of your posts and appreciate that you
obviously care about implementing strategies based on
evidence. As I am not an OT, I really don't know what the literature says. The pediatrician who diagnosed her anxiety seemed reluctant about OT due to lack of evidence. I'm wondering if you have suggestions for evidence-based strategies to utilize for addressing her sensitivities, especially relating to coping with unpredictable noises and physical touch since those are the main issues with baby brother. I would really appreciate your thoughts. Thank you.

Hi anonymous,

I appreciate the time that you spent outlining these concerns; I am sorry that things are tough for your daughter right now.

However, I am not really in any position to provide suggestions because any evidence based suggestions have to follow a thorough evaluation. I am not sure where you are geographically but I encourage you to find an occupational therapist for a full evaluation. If you are local and if I can help in any way just call our office!

Anonymous said…
Thanks so much for taking the time to respond. I would like to have her evaluated but my husband is not confident about it. She does not do well with new people and places due to her anxiety and he thinks she would not participate in an evaluation or therapy and it's not affordable for us to take her to something in which she may not actually participate. I think she would qualify for early intervention but her 3rd birthday is quickly approaching. Some of the treatment activities I've tried to describe to him from my limited understanding sound a little hokey to him and it is hard to blame him given what the pediatrician said. I understand your hesitancy to give recommendations without completing an evaluation and I really appreciate your taking the time to respond.

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