Wednesday, January 31, 2007

pseudoscience and sensory integration theory

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 information that leads to functional and behavioral problems. What it means is that we need to toss out the proverbial bath water without throwing out the baby when it comes to sensory integration theory.

Why do we need to revisit this? Sensory integration theory does not EXPLAIN why children behave the way they do. Sensory integration theory does not help us PLAN intervention. Sensory integration theory does not PREDICT how behavior will change as a result of intervention.

The most recent textbooks still state that "sensory integration cannot be observed. (Bundy & Murray, 2002, p.3). When I went to school as an undergraduate in the early 1980s I was told that there may be a neurochemical basis to sensory integration difficulties. It was an exciting concept that I was interested to see develop. Twenty five years later after completing my doctorate there is still no definitive cause for the disorder that can be identified.

This matters because there is a credibility gap when an occupational therapist states that a child has SI problems. Therapists have mistakenly believed that if we change the names to SID, or DSI, or SPD that this will somehow change people's minds about the theory. In reality we can call it chicken soup or anything we want - if the theory can't be validated then the name is irrelevant.

Occupational therapists are continuing to dialogue about classification and naming in sensory integration theory. Now we are making distinctions between sensory-seeking vs. sensory avoiding typologies. Or distinctions between active vs. passive coping styles. Ad nauseum. Less attention is paid to neurophysiological underpinnings and basic science research that would actually DO something to elucidate the nature of the disorders.

There is NO LACK of basic science that applies. Why aren't we studying neuronal migration (see Chang, et.al. 2005) or undetected brain damage (see Looney, et.al., 2007)?? Instead we focus on endless classification and naming of some 'unseen process' that we can't define. Then we state that by engaging the child in a series of experiences that they will somehow improve - but here we begin to disagree, with some people advocating passive and prescriptive sensory input and others advocating child-directed approaches. So as a consumer (parent, insurance company, etc) imagine their confusion and hesitancy when they go to some OTs who tell them that their child has some alphabet soup disorder (DSI, SID, SPD, whatever) that can be treated by either active or passive strategies - depending on who you talk to - and that we can't define what is REALLY wrong but we just know that these active or passive strategies will help the brain to function normally.

I wouldn't buy it either.

What I would buy is going to a therapist who tells me that learning disorders often have a physiologic or genetic component and that these causative factors can vary between children. Some of our research points to brain damage, some to neuromigration deficits, and some we just don't understand yet. Either way, the distinct problems that the child has as a result of the organic neurologic problem can be quantified by performance on standardized testing that looks at motor, perceptual, and other cognitive factors that impact occupation. When children have known deficits that we can quantify or measure, we can gather baseline data so that we can measure the effect of our intervention and training attempts. Intervention can involve participation in sensory-based and other activities, but we still need to quantify our progress with a behavioral measure.

After we proceed this way we are left holding data that quantifies the nature of the problem. We have basic science that could be analyzed to determine if there is a 'fit' between the identified organic problem and the clinical signs that are seen. We also have intervention strategies that can be evaluated in terms of progress on standardized measures.

Contrast this to our current state of affairs where all we have is a loosely defined set of behavioral observations, no real science to back it up or validate our intervention strategies, and a pile of people (OTs and non-OTs alike) with products rushing to market music CDs, weighted vests, brushes, and yet another sensory integration book that parents will buy because they are desperate to find answers for the problems that their children are having.

We can do much better.

This is why I now purposefully label sensory integration theory as pseudoscience.



References:

Ayres, A.J. (1972) Sensory integration and learning disorders, Los Angeles: Western Psychological Services.

Bundy, A.C., & Murray, E.A. (2002). Sensory integration: A. Jean Ayres' Theory Revisited in A.C. Bundy, S.J. Lane, & E.A. Murray (2002) Sensory integration: Theory and practice, 2nd ed., Philadelphia: F.A.Davis.

Chang, B.S., Ly, J., Appignani, B., Bodell, A., Apse, K.A., Ravenscroft, R.S., Sheen, V.L., Doherty, M.J., Hackney, D.B., O'Connor, M. et al. (2005) Reading impairment in the neuronal migration disorder of periventricular nodular heterotopia. Neurology, 64, 799–803.

Looney, C.B. et al. (2007). Intracranial hemorrhage in asymptomatic neonates: Prevalence on MR images and relationship to obstetric and neonatal risk factors. Radiology, 242, 535-41.

Friday, January 19, 2007

another look at child passenger safety

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 needs of children with disabilities (AAP, 1999). Premature babies and children who are smaller or larger than average are not well protected in typical child restraints. Children who have tracheotomies require special consideration for protection of their airways. Children who have muscle tone abnormalities require specialized external support to accommodate for their positioning needs. Because of these and other complexities, parents and school personnel make inadvertent installation and securement errors when the children are riding in their families' cars and on their school’s buses.

Providing education to parents and professionals regarding options for safe transportation of children with disabilities helps to improve children's health and well-being and prevents injuries and deaths.

The parents of children with disabilities have unique occupational needs associated with the safe transportation of their children. Parents must accommodate their children’s physical disabilities as well as their own adaptive habits and routines of caregiving. Many experienced child passenger safety professionals do not know how to evaluate and intervene in these complex scenarios. Conversely, many occupational therapists who understand the multi-factorial issues associated with childhood disability do not have any experience with crash dynamics, securement systems, and legal mandates of safe transportation.

So this is a good opportunity for OTs to have conversations with parents about child safety restraints. Stay tuned for new information once Consumer Reports re-evaluates its crash testing on infant seats.

References:

American Academy of Pediatrics, Committee on Injury and Poison Prevention (1999). Transporting Children With Special Health Care Needs. Pediatrics, 104, 988-992.

Monday, January 08, 2007

answers to questions

(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 believe that people like the idea of an intervention that is so concrete in its application for such a troubling problem.

All that being said, just because something isn’t fully researched doesn’t make it worthless. A lack of evidence just means that we need to be judicious in the way that we present information to consumers (families, insurance companies, other professionals, etc.). A lot of statements have been made about this intervention as if there was evidence to support a deep pressure protocol being done a certain way, or with a certain brush, or with a certain schedule. I don’t believe it is fair to say that we really know that much about this intervention at all.

In my opinion the problem with lack of evidence for a Deep Pressure Protocol is troubling primarily because of the conviction with which it has been presented to consumers.


Here is another one:

My Grandchild does not seem to react well to transitions ie. He keeps repeating phrases over and over, almost stuck of them and he gets fixated on certain toys. The only thing he likes when he gets upset is I give him BIG hugs and sort of rough house with him, for some crazy reason he is much calmer AFTER I play hard with him. WHY? I don't even know if you can help me with him but we are open for suggestions.


I get a lot of questions like this, asked on the website or in a comment on the blog. The problem is that there is NO CONTACT INFORMATION! So, I would love to help, but so much more information is needed. The best I can say is to see an occupational therapist for an evaluation. Also, please leave contact information so we can contact you if you have this kind of question!

Happy New Year to everyone!