Monday, October 30, 2006

DSM and SPD: Are we ready?

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 presumed etiology is included."

Although we have made some excellent progress toward developing tools to identify sensory processing disorders (i.e. The Sensory Profiles) I am not sure that we have completed the research to gather prevalence, familial patterns, or other features. There is some preliminary evidence that we have done about linking measured neurophysiological differences to Sensory Profile scores - which provides some good scientific validation, but I don't know that we have done enough yet.

Finally, we should not rely on a DSM-IV or DSM-V inclusion to support reimbursement. If children who have SPD also have significant impairments in functional performance then short term occupational therapy intervention would be presumably be covered under a related diagnosis code. We really don't know if SPD is a diagnosis unto itself or if it is a clinical feature that is sometimes associated with other conditions. Again, more research is necessary to make this distinction.

In the meantime I strongly recommend that we continue our research efforts to focus on validating neurophysiological markers associated with atypical Sensory Profiles as well as use of tools such as the Children's Assessment of Participation and Enjoyment or the School Function Assessment to measure any performance/function related difficulties of children who presumably have a sensory processing disorder. Gathering additional data related to prevalence, familial patterns, etc. would also be helpful.



References:

American Psychiatric Association (n.d.) FAQs about DSM. Retrieved 10/30/06 from http://www.dsmivtr.org/2-1faqs.cfm

Brown, C., Tollefson, N., Dunn, W., Cromwell, R., & Filion, D. (2001). The Adult Sensory Profile: Measuring patterns of sensory processing. American Journal of Occupational Therapy, 55, 75-82.

Miller, L., McIntosh, D., McGrath, J., Shyu, V., Lampe, M., Taylor, A., Tassone, F., Neitzel, K., Stackhouse, T., & Hagerman, R. (1999). Electrodermal responses to sensory stimuli in individuals with fragile X syndrome: A preliminary project. American Journal of Medical Genetics, 83(4), 268-279.

The KID Foundation (2006, October 12). Advocacy. Retrieved 10/30/06 from http://www.kidfoundation.org/advocacy/

Wednesday, October 25, 2006

on polar bears and autism

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, and these must always be distinguished from normal repetitive play tendencies on infants and toddlers.

This carpet-rubbing behavior was not play-like and would last long past the amount of time it should otherwise last. So we needed to consider other options. Most notably, the behavior would only occur when toys were removed from the immediate reach of the child. The child has motor delays and is not yet functionally mobile, so I considered that the likely cause of this behavior was boredom and a desire for stimulation when there was no stimulation (toys) present in the immediate environment.

There is always risk in bringing up animal models when discussing human behavior but I admit to liking the simplicity of animal models. The child's behavior reminded me of the polar bears at the zoo. I recall visiting the zoo before all the studies came out about enriching zoo environments to improve the health and reproductive interest of the animals for conservation efforts. The polar bears used to pace back and forth in their environments, repetitively, for hours. I recall logging polar bear behavior over the course of several years in different zoos and in non-stimulating environments the pacing behavior was almost always repetitively present. However, when they gave the bears some barrels and floating 'ice cube floats' in the water for them to interact with the pacing behavior immediately decreased. I know that I am not an animal behavior specialist and this is by no means a scientific study but it is my observation.

So when I moved the toys within reach of my young friend his rug-rubbing behaviors stopped immediately and he went right back to appropriate interaction with the toy.

This is not to say that there are not concerns to monitor and issues to address for my young friend, but they are probably not autistic concerns. Rather, this underscores the importance of understanding how motor delays in young infants may lead to non-productive and even stereotypical play behaviors. Seems like an idea for a good study - although I would limit it to children within the 0-2 age range (sensorimotor period of development) because I imagine that long term motor restriction in children who have functional language leads to a different set of sometimes atypical behaviors (relatively increased verbal scores on classic IQ tests) - but that is another set of ideas.

So I hope the mom feels a little better with my description of 'primary' autistic signs and 'secondary' autistic-like behavior. We'll watch and see what happens.

Monday, October 16, 2006

swinger of birches

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's having lashed across it open.
I'd like to get away from earth awhile
And then come back to it and begin over.
May no fate wilfully misunderstand me
And half grant what I wish and snatch me away
Not to return. Earth's the right place for love:
I don't know where it's likely to go better.
I'd like to go by climbing a birch tree,
And climb black branches up a snow-white trunk
Toward heaven, till the tree could bear no more,
But dipped its top and set me down again.
That would be good both going and coming back.
One could do worse than be a swinger of birches.