Monday, August 21, 2006

Insurance companies and doing business in New York

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 the ‘additional insured.’ It took about five phone calls to haggle between the contract’s attorney and the insurance company before there was agreement on how the additional insured should be listed. It was quite a process.

For general liability, I received a letter from my insurer (who covers ‘slip and fall’ issues, fire, theft, etc.). Based on an alleged review of my website they have determined that I am at too high of a risk for them to insure. I never even knew that they reviewed websites and looked for reasons to terminate policies! They never asked me a single question, our business activities have not materially changed, we have never had a claim, and they have been our general liability insurer for this entire time. The best I can figure is that they think I am overdue for something? Do they actually apply statistics and probability theory to their decision making? This is quite disruptive because in addition to getting a new insurer I have to get additional insured written in for some purposes on this policy as well. Ugh.

Lastly, New York State’s unemployment system is in the red and it hasn’t paid back its loans from the federal government. So what happens when you don’t pay back your loans? Well if it is you personally you get whacked with a poor credit rating and you have to pay higher rates and higher fees. The same is true for New York State, except they happily pass the increased costs on to the employers. FUTA is something that every employer has to pay for the benefit of employees and the costs can’t be directly passed on. That means profits are lower, and employers are less able to hire. That means some people get laid off and have to USE unemployment insurance. Then the more that it is used the higher the state ratchets up the rate – it can go as high as 9.9%. Thanks for staying on top of your payments, New York.

Anyway, if you are going into private practice, these are some of the non-health insurance issues you will face. It is complicated, time consuming, costly, and you will have to learn things that you never imagined you would have to learn.

It is still worth it, in my opinion. I just like to rant about it once and a while.

Thursday, August 17, 2006

Lesion studies as a methodology for researching sensory processing disorders

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 be taken when using lesion study methods: the presence of a lesion in a location may not represent the primary site of a nervous system function, despite the fact that actual function could be severely impacted at that lesion site. Circuit redundancy and multipath parallel processing can make lesion studies a little muddy.

Complex regional pain syndrome (CRPS) is a disorder characterized by chronic pain that is disproportionate to the trauma that caused the pain (NINDS, 2003). Sensory modulation disorders are identified as altered neurological thresholds to sensory information that impact on daily life functioning (Dunn, 1997). Although the exaggerated state of sympathetic arousal in people who have CRPS is not clinically identical to hyperarousal in people who have SMD, these two conditions may constitute a continuum of pathology that is reflective of sympathetic nervous system dysfunction. A more thorough understanding of these conditions, including their apparent similarities and the impact that they have on function, will provide information that can be useful when developing therapeutic interventions.

ABC Therapeutics is finishing up a small scale study that is looking at the Adolescent/Adult Sensory Profile test scores of adults with CRPS. This study will explore the sensory processing abilities and occupational performance of adults who have CRPS.

On another front, we are also completing some preliminary literature review on "Type T" personalities. We hope to use a similar design (as above) using the Adolescent Adult Sensory Profile to explore if there are measurable differences in test scores in adolescents who have this profile or those behavioral characteristics. Another interesting twist is to see if we can find a tool that has been used to measure what I am calling 'inverted-T' personalities. I am interested to see if we can find a tool that will behaviorally identify these people and then see how they self-rate on the Adolescelt Adult Sensory Profile.

Please feel free to contact me if anyone is interested in learning more about the work we are doing here on this topic.


References:

Dunn, W. (1997). The impact of sensory processing abilities on the daily lives of young children and their families: A conceptual model. Infants and Young Children, 9, 23-35.

Farley, F. (1991). The Type T personality. Chapter in L.P. Lipsett & L.L Mitnick (eds), Self-regulatory behavior and risk taking: Causes and consequences. Norwood, NJ: Ablex Publishers.

McIntosh, D.N., Miller, L.J., Shyu, V., Hagerman, R.J. (1999). Sensory-modulation disruption, electrodermal responses, and functional behaviors. Developmental Medicine and Child Neurology, 41, 608-15.

National Institute for Neurological Disorders and Stroke (2003). Complex Regional Pain Syndrome (also called Reflex Sympathetic Dystrophy Syndrome) Fact Sheet. Retrieved May 14, 2004 from http://www.ninds.nih.gov/health_and_medical/pubs/rsds_fact_sheet.htm

Schaaf, R.C., Miller, L.J., Sewell, D., & O'Keefe, S. (2003). Children with disturbances in sensory processing: A pilot study examining the role of the parasympathetic nervous system. American Journal of Occupational Therapy, 57, 442-449.

Wednesday, August 09, 2006

More on the need for more rigorous evidence-based practice in pediatric OT

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-worded - there is no published research on Sensory Stories - there isn't even much research yet on social stories (scroll to bottom of page of this link).

I was really hoping to find some reference to Carol Gray - even a tip of the hat, or perhaps a statement of permission to use the concept. I couldn't find anything. I am certain that Carol Gray does not need me watching her back, but not seeing the references to her original work kind of bothered me.

Of course the argument to be made is that Sensory Stories are different enough in concept that they should not be confused with Social Stories. But if I confuse them in concept, and automatically attribute the concept to Social Stories, isn't the question of intellectual property a valid question?

Besides all that - do we need another sensory-based intervention program out there that will make my phones ring off the hook - but never really conduct and publish the research to support that these ideas even work? Parents will hear about this. They will call and want us to implement these strategies. Sometimes they will work and sometimes they won't. When they don't work we will have angry parents who think we don't know how to implement the stories successfully. Then we will also receive ridicule from other professionals who will question why we make such bold statements about our interventions without having supporting research. Then, in the final link of this chain of events, I will have no response to the insurance company when they deny occupational therapy services for children because the interventions are still 'experimental.'

I am tired of the never ending stream of new interventions that are marketed heavily and never researched. Brain Gym, Therapeutic Listening, Wilbarger Protocol, etc., etc..

I volunteer my clinic to anyone who wants to conduct research on social stories, sensory stories, or chicken soup stories. Call the stories whatever you want. Just please lets do research before they become the latest craze on the money-making OT continuing education lecture circuit.

Tuesday, August 08, 2006

A book recommendation

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 patterns; although these contexts may be culturally transmitted they are personally acted on and could be classified under a broader scheme of personal contextual factors. Although other authors discussed these factors, prior to this time there was no cohesive set of principles that outlined occupational therapy’s domain of concern regarding context.

Winnie Dunn was Chairperson of the taskforce that developed UT-III and at the same time she was developing her Ecology of Human Performance model (Dunn, Brown, & McGuigan, 1994). This model was designed with the purpose of accounting for the influence of the environment on human performance because Dunn believed that there was a lack of consideration for complexities of context in occupational therapy. Under the assumption that “occupational therapy is most effective when it is imbedded in real life,” temporal and environmental contextual factors are identified that allow practitioners to interpret behavior and choose appropriate and meaningful therapeutic interventions. She stated that ecology (the interaction between person and environment) affects human behavior and performance, and that this performance can’t be understood outside of context. Most importantly, she stated that contextual factors include physical, social, and cultural elements, and are considered to be broader than environment as they also include the experiences of the person. Dunn’s specific statement about the individual’s phenomenological perspective on their own situation was germane to the AOTA’s uniform terminology document, and had a broad impact on how future occupational therapy theorists incorporated contextual factors.

Although I have outlined this before, I will repeat it here as it is ‘contextually appropriate’ to do so: some recent practice models explicitly identify the relationship between the individual, the occupation being performed, and the environment. The P-E-O model (Law, Cooper, Strong, Stewart, Rigby, & Letts, 1996) explicitly states that the behavior can’t be separated from its contextual influences. Additionally, this model re-introduced the importance of history-taking for establishing personal contextual relevance for goal setting. Similarly, the Lifestyle Performance Model (Velde & Fidler, 2002) takes a congruent approach by completely embracing phenomenology as being the only possible method for understanding the personal contextual relationships between an individual and the occupations that they engage in.

How has the profession operationalized contextual concepts? Occupational therapists generally intervene at the level of the individual, although there is some growing discussion about population-based interventions (Scaffa, 2001). Still, for occupational therapists, contextual study generally doesn’t move too high up the complexity scale in a linear general-systems theory framework. Occupational therapists (in practice) tend to consider broader concepts of social and cultural context as they impact the individual. There are some noteworthy exceptions to this pattern – namely Reilly (1974) and to some extent Wilcock (1998) – but then again these referenced books had more to do with grand ideas and a little less to do with street-level occupational therapy.

Here is an example of how OT has traditionally considered contextual factors: Occupations, by their very nature, are interpreted within the context of personal meaning. Without this saturation of meaning, occupations are reduced to simple tasks that are foreign. Hasselkus (2000) describes her experiences of feeling stripped of her occupations when being immersed in an unfamiliar culture with unfamiliar routines. Deprived of her familiar context, she began to question her own identity. She expresses that her ability to participate in even simple but familiar routines provided a grounding foundation for her other experiences. Contextual relevance imbues meaning into occupation and occupation-centered practice requires the consideration of context. Occupational therapists consider contextual relevance by adopting narrative-based approaches in addition to or in substitution for performance component/bottom-up intervention approaches. Occupational history, occupational storytelling, contextual observations, and service provision in naturalistic settings all provide opportunities for collecting data regarding contextual factors.

This makes me wonder – is there a model for operationalizing the grand ideas of Wilcock and Reilly? I have been recently spurred into this question by reading Guns, germs and steel: The fates of human societies (Diamond, 1997). You can also find a nice website here that apparently corresponds to a PBS series that I have not yet seen. Diamond’s argument is that historical context as shaped by geographic factors is useful for understanding the shaping of societies. If his argument has merit, it should be able to be twisted down to looking at how historical and geographic context impacts the shaping of an individual.

Interestingly, Blanche & Henny-Kohler (2000) started looking at issues of cultural geography directly as they relate to occupational therapy knowledge – but their work just begins to scratch the surface of this very large question. Even though the initial question is not answered, the follow-up question is “To what degree is knowledge of these contextual factors helpful in street-level occupational therapy practice?”

I know that this discussion can degrade into a debate of basic vs. applied inquiry – and I am really not convinced that the profession or the scientists have really gotten the issue straight yet. Specifically, why are most undergraduate degrees in occupational science and the graduate degrees in occupational therapy? Does anyone else beside me see that this may be turned on its head?

Anyway, I encourage people to think about these issues – and Diamond’s book will take your brain to some interesting places regarding broad historical context. Does it matter to the people in the street? Let me know what you think… and happy reading!



References:

AOTA. (1994). Uniform terminology for occupational therapy, 3rd ed. American Journal of Occupational Therapy, 48, 1047-54.

AOTA. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609-39.

Blanche, E.P. & Henny-Kohler, E. (2000). Philosophy, science, and ideology: A proposed relationship for occupational science and occupational therapy. Journal of Occupational Science, 2, 99-110.

Diamond, J. (1997). Guns, germs and steel: The fates of human societies. New York: W.W. Norton & Company.

Dunn, W., Brown, C., and McGuigan, A. (1994). The ecology of human performance: A framework for considering the impact of context. American Journal of Occupational Therapy, 48, 595-607.

Hasselkus, B.R. (2000). Habits of the heart. American Journal of Occupational Therapy, 54, 247-248.

Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The Person-Environment-Occupation Model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63, 9-23.

Reilly, M. (1974). Play as Exploratory Learning: A Study of Curiosity Behavior, Beverly Hills, CA: Sage.

Scaffa, M. (2001). Occupational therapy in community-based practice settings. Philadelphia: F.A. Davis

Velde, B., & Fidler, G. (2002). Lifestyle Performance: A model for engaging the power of occupation. Thorofare, NJ: SLACK, Inc.

Von Bertalanffy, L. (1968). General Systems Theory: A Critical Review. In W. Buckley (Ed.), Modern Systems Research for the Behavioral Scientist. Chicago: Aldine.

Wilcock, A.A. (1998). An occupational perspective of health. Thorofare, NJ: Slack, Inc.

Thursday, August 03, 2006

Book review: The curious incident of the dog in the night-time

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 myth in order to achieve his goals. For the informed, the character typing, or perhaps stereotyping, underscores the real tragedy that the author never really explores.

This is not a coming-of-age story in any sense, despite some mimicry of the bildungsroman genre. The basic formula of a bildungsroman is that it is easily understood by people within that culture and time, where the kinds of opportunities presented to the protagonist were the same as the actual experiences of common people. In some sense the events are common – but the protagonist is uncommon. Christopher can never grow through the experience in the classic bildungsroman way; his disability impedes his growth. The author doesn’t provide a contrived ending – he just expresses Christopher’s tragically constricted perception that the world will right itself. I imagine that the collective readership is more than willing to accept Christopher’s fantasies, despite the previously asserted facts of his requirement for guardianship and supervision.

One could argue that an artist simply paints a picture and can’t be held responsible for how others can come to view the work. I still think that Haddon should have been more responsible. Christopher is not a super-hero in this novel, although I understand how he has been misunderstood as one. The reality of this story does not lend itself to the comic-book ending that Christopher perceives and the reader wants to believe. I am a little disappointed that the author didn’t see how that might happen.

Haddon’s error, then, is in sin of omission. The story doesn’t really end so happily. The real story is that the family is broken, and the imperfect adults in the novel are left struggling to define and redefine their relationships and roles in the wake of raising a child who has a disability. The real story is also that given the nature and degree of the portrayal of Christopher’s disability, it is not so certain that he will be able to accomplish his dreams. Art does not imitate life in this book. This omitted fact is the real tragedy.