ABC Therapeutics Occupational Therapy Weblog

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...

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...

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...

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...

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...

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...

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...

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 ...

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...

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...

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...

We had a family function recently and my Great Uncle Joe brought his artwork for everyone to look at. It was such a treat to be able to see his work, and now it has surfaced again on the web. Please indulge my family photos here - this is my sister Stephanie admiring his artwork. I am so glad that I had this picture - now I don't have to risk copyright infringment by using the one in the paper... Here is link to a very nice article in the Albany Times-Union about my Great Uncle Joe . Under most circumstances I wouldn't use this forum to link to news articles about relatives, but I admire my Uncle Joe so much that I want to spread this around. I figure he wouldn't mind since it is already out in the public domain. I don't know if my Uncle knows about occupational therapy and I don't think I have ever discussed it with him. However, this story illustrates the bi-directional power of occupation - in this case both for him as a teacher and for the people who sign up fo...

We are growing again! We have openings in the Fall for the following positions - please spread the word to anyone you know who may be interested in employment: COTAs OTRs PTAs PTs The positions are pediatric - preschool and school based in Erie County, New York. Thanks for spreading the word! If anyone is interested in applying for a position they can call (716) 759-8634, or stop by and visit at ABC Therapeutics , or email at chris@abctherapeutics.com We would love to hear from you...

Advance warning: this is not for the faint of heart. If you are easily offended, please move on. I don’t want to discuss too many details because this is a sensitive situation, so I will try to focus my discussion on the issues of sociobiology, sensory processing and behavioral analysis, disability rights, and of course the carceral archipelago. I get the most interesting referrals. A recent one was for a young adult who has mild to moderate developmental disabilities who was removed from his community vocational placement because of inappropriate sexual behavior. A psychologist had the idea that perhaps some of the behaviors were generated from a ‘sensory seeking’ type of profile so I was asked to assess this area and provide some input for the team to consider. I would like to offer an analogy for purposes of beginning this discussion. I am not equating human and animal behavior by giving this example, but rather trying to find a means of opening a discussion on instinctive sexual a...

I can't seem to add pictures - and don't know why. Oh well. I recently received an email announcing AOTA's Annual Capitol Hill Day Kick-Off . I went to this event last year and am now deciding if I will participate again this year. The primary issue I discussed last year was the legislation to repeal the Part B cap on therapy services. My senator's aide agreed that this was an important issue to residents of New York State but asked us if we had approached CMS with this issue. As a group we explained that this was an issue that had to be addressed legislatively, and I am not entirely convinced that the aide had a full understanding of this issue. She expressed that Part D Medicare legislation was on the forefront of all health care legislation for the upcoming session and she expressed sincere doubt that any other Medicare legislation would come to the floor for a vote prior to the Part D legislation being addressed. Now we see that there is a cap exception process - ...

New York State decided this week to agree on some methods to address fraud as it relates to the $46 billion dollar Medicaid program. Don't for a moment think that the discussion was all high-minded and oriented toward saving the taxpayers money; one of the sticking points that the Dems finally had to let go was letting their trial lawyer buddies get a whack at the money pinata by allowing whistle-blower suits. So now we have a more fully funded Medicaid Inspector General's office, which has been pinched by the feds to pony up on several billion dollars worth of payments. Of course this means that the state turns around and pinches the counties that administer the Medicaid program, asking for proof of all the services that were provided. Then counties turn around and pinch the municipalities and school service providers for their paperwork. The problem here is that municipalities and school providers probably didn't keep good enough records because they don't know how to...

There was a very nice article in Parenting magazine about children's sensory development but as is typical of such articles it could have said so much more. So, in the interest of broadening the dialogue, I submitted the following for them to consider publishing: Making Sense out of Child Development When we bring our six month old children to the pediatrician’s office we can usually expect the doctor to ask if they are rolling over or sitting up. When our children are one year old the doctor asks about what words our children are saying and if they started walking. Now with new research that helps doctors better understand child development, you may begin hearing different questions during your well-child visits. In addition to understanding how children develop typical motor and speech skills, researchers are learning about other aspects of development that make a big difference in children’s lives. Sensory skills are not a totally new area of scientific study, but developmental...

Today I had the opportunity to recall the 1980 presidential election. Perhaps this was the first election where I was politically cognizant. I recall watching debates and listening to candidates speak, but at that time I had no ability to understand how two different people could give two radically different perspectives on the same issue, both citing facts and figures during their explanations. At the time I assumed that certainly one of them had to be right, and the other had to be lying. Certainly one position was the 'Truth.' I struggled through the entire campaign, not knowing what to think. I don't have the same problems in trying to understand politics today. I understand now that people 'cherry pick' their facts, and that there are so many facts floating around nowadays that it is not difficult to find those that support your position. So, this picking of facts does not necessarily bring you any closer to Truth - and as soon as you realize this it is much ea...

Greg was pushed into my office, sitting in a wheelchair, and he didn’t make much eye contact. “Hi Greg,” I said, trying to find a way to elicit some response. He still didn’t look at me, but nodded his head in acknowledgement to my greeting. Although Greg had limited eye contact he willingly shared the details of his story. Greg had hopes that he could make sense of things. Talking helped him, and he had hopes that things happened for reasons. He told me that he struggled with this on a daily basis. From my vantage point, at the time when we first met, I didn’t have many answers for him. Greg joined the army when he was 18, hoping to find some structure and discipline in his life. He was a part of the wild crowd in a rural high school. In his opinion, the army was a form of escape - and an opportunity to change things. It was a blank slate, a do-over. Most importantly, he would earn money so that he could continue his education. It was never important to him in high school, superficial...