ABC Therapeutics Occupational Therapy Weblog

I wrote this four years ago, and since I am recording stories with different endings I thought this would be another scenario that deserves to be dusted off and posted here. _____ Camille called me tonight, somewhat frantic, with an obvious need to tell me some news about her daughter. Camille is an overprotective mom and grandmother who has been disapproving of her daughter's choices. However, as she is ultimately interested in her daughter's well being (and the associated well-being of her grandchild) she mostly keeps her mouth shut for fear of alienating her daughter. About two months ago Camille had to be hospitalized for gall bladder surgery, and that left all the caregiving responsibilities of the new grandchild to Karen, her daughter, as it should be. Because it had been my job to go to their home and help educate the family on caregiving for this disabled child, I was trying to split my time between Camille and Karen. As I said though, since the surgery I have been spen...

On most days people appreciate the things I do, which is a positive reinforcement for me to continue with those tasks that keep my private practice running. However, the reality is that sometimes people don't appreciate or understand what you are doing, even if you take the time to explain. Today seems to be the right day to talk about an experience I had when someone was not able to appreciate my efforts. Collin’s mom is single or divorced – I am not sure which. She has two children by two different fellows, neither of whom believes that their presence is important in the lives of the children. The mom does not work outside of the home; her primary role is as a parent. Their apartment is in a blue-collar town outside of a large metropolitan area. The town is famous for its chemical dumps and environmental toxins. I do not know if it means anything, but I cannot listen to AM radio in their neighborhood – there is just too much RF interference from the high-tension electricity lines...

In a recent comment a reader asked my opinion about the best treatment options for autism. This is inherently a loaded topic because there are so many people who have aligned themselves with particular treatment approaches. Also, there are some people who have experienced significant improvement with a single approach. I form my opinion on this question based on twenty years of clinical experience working with children and families. I don't believe that there is a single approach that works for everyone. Also, just because something works for someone at some point in time has not been an indicator that it will work for everyone else at countless other moments in time. From an evidence-based perspective it seems that behavioral approaches have the best research to support their efficacy. However, behavioral approaches are not unitary and the concept of 'efficacy' needs to be clearly defined. Certainly, there is no overwhelming evidence that any behavioral approaches will cur...

By definition, mediocrity implies ordinary or unremarkable quality. For occupational therapy to achieve the centennial vision that is proposed by AOTA I believe that the profession needs to move far beyond mediocrity. This week I experienced mediocrity in occupational therapy and in educational systems - it was concerning, so I wanted to share it here. A parent asked me to attend a meeting at school in preparation for a CSE meeting. The parent was informed that occupational therapy services would be discontinued for her daughter. I won't even argue the child's needs here - but rather will point out the process by which this determination was made. The child has an IEP but there are no statements on the IEP that indicate her present levels of performance as they relate to her occupational therapy needs or her academic functioning. There are also no goals on the IEP that relate to any needs that might be typically associated with occupational therapy as a related service. Still, ...

If a cone fell on the floor, what is the chance that it would land ‘standing up' on its base?? I wonder this because a family member had a total hip replacement and is receiving occupational therapy in a short term rehabilitation facility. In OT they are teaching her how to pick up objects that have fallen on the floor. That seems like a reasonable point of intervention to me: it is important that people avoid placing undue stress on a new hip joint and I am sure that the OT does not want her to bend excessively. Why, though, does my family member have to pick up cones? I know a little about cones, more from my experience with geometry than from my experience as an occupational therapist. A cone is a three dimensional geometric shape. It is the locus of all line segments between a base and a point outside the plane. I know that the base of a cone can be any shape as long as it connects to an apex at any point outside the plane of the base. As far as I know there is nothing in her h...

Here is an excellent email question I got from a gentleman in India who is considering a career change and would like to practice OT in an English-speaking country. My question is: Even if I got good command over English, would indigenous people prefer a foreign therapist and would I be able enough to know their problems? I had this exact same question when I was completing my fieldwork in a mental health setting in an inner-city environment. I grew up in a suburban mostly middle-class world and when I came into my new worksite I looked around and could not recognize the culture around me. I understood that poverty existed in the world, but I had not seen people trying to get admitted into the psychiatric unit until the monthly governmental check came. I understood that some people were on drugs, and I had even seen some of my friends try drugs, but I never saw anyone needing to be strapped down to a gurney after a bad PCP trip because they thought that they could see the devil if they...

In a recent entry I talked about the issues of pseudoscience and the problems with sensory integration theory from an academic and theory-based perspective. Today I got an email from a parent that illustrates the problem from the street: QUESTION: My child has just been diagnosed with sensory integration difficulties. I must admit the evaluation results are scary and seem overwhelming. I can only imagine what my child is feeling. I am very anxious to get my child help. We had my child tested at A PROMINENT AND WELL KNOWN SENSORY INTEGRATION CLINIC (name redacted). They are excellent - but the treatment is very expensive and not covered by insurance. Do you have any experience with how to get the insurance company to make an exception? It has been recommended that we get 1 hour of weekly therapy for about 18 months and if possible a 3 week summer camp. The hourly sessions cost $165.00 Your response would be appreciated. Thank you NAME REDACTED ++++++++++++++++++++++++++ Insurance comp...

I entered my profession in 1987 and at that time a bachelor’s degree was required to practice as an occupational therapist. At the American Occupational Therapy Association's Annual Conference in 1999, the Representative Assembly passed Resolution J, mandating post-baccalaureate education for entry into the profession. I still have not seen any study that indicates that baccalaureate-trained professionals are in any way less effective than people who enter the profession at the master’s level. The marketplace also never acknowledged the alleged benefit of the master’s degree, as people with advanced credentials did not make any more money than people with bachelor’s degrees. I summarize from this set of facts that the move to post-baccalaureate education served the needs of educational institutions who were able to get more tuition from students who were trying to enter the profession. Students stay in school longer and educational institutions benefit by collecting more tuition. I...

Pseudoscience is defined by characteristics including the use of vague, exaggerated or untestable claims, over-reliance on confirmation rather than refutation, lack of openness to testing by other experts, lack of progress, and personalization of issues (see Wikipedia article which is a nice summary). As the article notes, however, it is important to distinguish protoscience with pseudoscience. At this point in time, 35 years after Jean Ayres wrote Sensory Integration and Learning Disorders, I am willing to consider that this concept of sensory integration theory is no longer 'nascent' and that we have not made appropriate progress toward researching and validating the theory as it is now constituted. For perspective, in 1972 when that book was published, the first hand-held calculator was marketed. Has science not moved forward since that time? This is not to say that children don't have learning problems, or that they don't have problems in processing sensory informat...

Earlier this week Consumer Reports reported on the performance of certain child restraints in side impact crashes. That generated a few calls and emails to me from concerned parents. Now I see that they are retracting the article because of new data they are considering. It seems that the crash velocities used in the Consumer Reports testing far exceeded the 35-38 mph standard that is typically used. Go check out their retraction statement HERE. I like to highlight this information because any pediatric OTs out there who have young children on their caseloads should be sharing this information with parents. When parents hear about these reports they begin to lose confidence in their car seats - it is critical that parents continue to place their children in their car seats. This is particularly true for parents of children who have disabilities. Many of these parents already lack confidence in child restraints. Traditional child restraint devices do not address the unique positioning n...

(I intended to post this over a week ago; life got in the way). Here are some recent questions that I will answer here: Hi Chris, I'm an occupational therapist working in a child development clinic in Israel. I am looking into the validity of the Wilbarger brushing technique. I've come across very little that validates the intervention. I thought I read on your blog some sort of critique of the lack of evidence. It might have been on a different blog, but would appreciate your feedback nonetheless especially after reading your thoughts on evidence based practice. Thanks and have a happy new year!-dena Hi Dena! Happy New Year to you too! I have blogged about the Wilbarger protocol here ( http://abctherapeutics.blogspot.com/2006/04/wilbarger-approach-how-patient-should.html ). Nothing has really changed since I wrote that last April. There has been nothing new published that I have seen. People use the search terms ‘Wilbarger protocol’ frequently, based on hits to this blog. I be...

Folie à deux is a psychological term referring to the situation when two or more people share the same delusion. Delusions are funny things, and difficult to disprove, particularly when more than one person starts seeing them. This all relates to Mary, who taught me about love, and trust, and delusions, and perceptions - and ultimately what matters most. **************************************** It seemed strange that the doctor didn't request physical therapy as well, I thought, as I watched Mary limp down the hallway in a traditional hemiplegic gait pattern while using a quad cane. I remembered practicing that Trendelenberg gait in college with my classmates, accentuating the weakness of the hip abductors. The difference here was that Mary certainly wasn't faking or pretending with her newly acquired gait pattern. A serious look was on her face, and her arm was clenched tightly to her side in an angry and tense position. In college I guess we really didn’t stop to think about ...

I wanted to write some Christmas-theme entries this month but I ironically have not had the time. Life can sometimes get very busy. Being busy is precisely the topic I wanted to discuss. Adult occupational behavior around the holidays is fascinating to study. I don't want to get into a lengthy treatise about the meaning of shopping - but let's face it - is holiday shopping a healthy or unhealthy occupational experience? Watch adults in the mall and you will understand the question. Western societies are consumer-oriented. Corporations spend untold billions of dollars based on our classification as consumers. Consumer-focused messages are reinforced by cultural practices that remind us what grouping we are in and how that fits in with our status as occupational and social beings. So, I am sent messages that this is my 'prime' as a human being on the planet. These are my 'productive' years - I am past the tumult of young adulthood and this time is prior to the tum...

For various reasons I have been called to task regarding an analysis of what I believe in - and I thought that the philosophical definitions are important so I wanted to yell them to the rafters, so to speak. Issues of internal consistency are important to me, so I was interested to find that my work vs. non-work need for evidence was quite different. I'm still not entirely sure how to resolve that issue – perhaps it is not important. Anyway... Superstitions often stem from folklore or historical reinforcement of confusion between causation and correlation. Common response experiences and confounding variables contribute heavily to confusion that is then reinforced through repetition. In this sequence of events, superstition translates to mythology and there is high risk for it to be further transmitted into tradition. I am aware of the debate, but count me among those who believe that 'folk psychology' is real. I know that eliminative materialists will take me to task, but...

It will be interesting to see how far and wide this issue travels - I expect that my answer will make some people angry and other people very happy - but either way I view this as a question that comes along that is just too good for me to ignore - Today I was asked for my opinion on the following question: "I am a COTA and I have attended a couple of workshops on Anadyne Therapy. It is an infrared treatment modality used to treat patients with peripheral neuropathy. Treatment will initially consist of a pre-sensory test (Semmes-Weinstein monofilaments), treatment with the Anadyne and fine motor exercises. The question is: Does an OTR have to do the initial evaluation which would be the pre-sensory test prior to the treament? I am able to conduct the test and the treatment but I don't know if legally I can." Here is my response: According to the NY State Board of Regents, occupational therapy assistants as a rule have not demonstrated competence to perform evaluations, so...

I am not in a life-saving profession - at least not in the traditional medical interpretation of life-saving. I was never really interested in wielding that kind of power, although in many ways I think that I have learned that traditional life-saving power is easily reducible to a little chemistry, a little anatomy, a little slight of hand and technical know-how. Little else. This is not meant to downplay that technical expertise though. Actually I am humbled by those who perform such acts on a daily basis. I saved someone's life once. That is what I have been told anyway. I like to tell this story because the moral is that sometimes you might be in a position to make a difference, even if you did not put yourself in that position, and even if you had no intention of making a difference. I think that is important information to have tucked away for reference purposes. One day my phone rang and it was my buddy John. John was an itinerant therapist in the truest sense ...

...because street-level occupational therapists sometimes need a break.

I don't typically pass around web sites that I think people should go visit although I have done so lately. I hope that when people see that I am referring a web site that it is not the equivalence of junk mail or spam. I would only send you somewhere that I really think you need to visit. I got involved in child passenger safety sometime in the late 90s. I was forced there out of necessity and parent demand - a parent whose child had a spica cast chastised the hospital I was working in because there was no appropriate restraint to send her child home in. I am thankful to that parent to this day; I am not sure if she is aware of the changes that were made because of her concerns. I educated myself on the issue and learned that a nationwide education campaign resulted in increased use of child restraint devices in automobiles but many children are still restrained improperly (Glassbrenner, 2003). National studies demonstrate that the misuse rate of child restraint devices in automob...

Lots and lots of questions these days and I am doing my best to answer them... What I would like to try here is to throw my problem solving methodology to the winds and perhaps if someone finds this useful there will be fewer questions in the world. Is that likely? There is a difference between a primary problem and a secondary behavioral attribute but people constantly confuse the two. So when someone says, "My child won't pay attention," or "One kid on my caseload won't eat any solid foods" they will often look for a direct and concrete answer to their 'problem' and completely misunderstand what the 'problem' really is. Let's take one example and walk through it. First of all, if you have a clinical/presenting problem, place it in a circle at the top of the page and then make 5 circles underneath it. Five is a random number, but these circles will represent the POSSIBLE causes of the problem in the circle above: PROBLEM REASON 1____REAS...

Today I had contact with three families who were all dealing with problems relating to encopresis. Encopresis can be essentially defined as a lack of fecal continence and it is a huge problem for families. I have to admit that there was no training in my occupational therapy curriculum relating to encopresis, although occupational therapists spend a lot of time talking about helping people with self care activities of daily living. I suppose that my educational programs assumed that intervention ends when a child can let their pants down and sit on the potty? The lack of any mention of pediatric encopresis in the occupational therapy literature certainly doesn't stop occupational therapists from weighing in on this subject when it comes to giving parents advice. I read an evaluation once where a therapist talked about a child's constipation and encopresis being related to a craving for deep pressure stimulation, and it was a reflection of poor sensory processing. The recommende...