Friday, February 08, 2008

Do you believe???

One of the best questions that people ask me is if I 'believe' in sensory integration. I haven't really answered that directly, so I will try. I am motivated to do so because I just got the question again today - and I don't want to post the comments that were left because there was too much identifying information - and the person did not leave an email. So I hope the commenter sees the response here.

I suppose that people see my commentary and questioning about sensory processing and the need for evidence as being 'critical' or 'unbelieving' in the diagnosis. I commented recently about the concept of 'fidelity' when talking about sensory integration because one of the problems is that it is being so poorly defined by so many groups, including researchers. Even our 'state of the art' assessments are horribly intertwined between asking behavioral questions and sensory questions. I believe that it is getting increasingly difficult to distinguish sensory from behavioral difficulties based on the data that we get from self-report or parent-report assessment tools. There is a real need to improve these assessments so we can again begin to factor out sensory issues. There are some scholars who are 'beating the drum' over the fidelity problem and I am encouraged by their actions. The neurophysiological research is also a step in the right direction, as I have previously stated.

Anyway, the bottom line here is that in my practice I see many people come asking for 'sensory' evaluations. This week I evaluated a child who has an exclusive aversion to clothing and who will only wear 5 outfits. The child is normal in EVERY other way and there are no developmental delays. After a thorough evaluation I concluded that what may have started as some kind of tactile preference has mushroomed into a behavioral issue that requires a behavioral intervention approach.

I also saw another child who has a known neurological disorder and who is taking medications to control tics. The combination of medication instability and ineffectiveness, the interfering nature of the tics, and the associated emotional and behavioral state of the child are all combining into a gigantic sensory and regulatory mess. I have no idea where the 'spaghetti' begins and ends on his 'plate' but it is obvious that there are some very real problems there.

What I am saying is that people come looking for sensory or regulatory interventions, and clinically it is just not always easy to tease out the nature of the problem. This is because we have defined sensory integration so poorly, researched it ineffectively, and then perpetuate the problem by promoting 'cure-all' techniques that in actuality have dubious effectiveness.

I am certain that sensory and regulatory and behavioral problems exist in children. I also am certain that occupational therapy can be an effective intervention to promote improved function in children and in providing families with effective strategies to promote typical development and participation. Our best interventions to solve sensory and regulatory difficulties are functional and behavioral and contextual and educational. Other interventions may prove to be effective, such as 'deep proprioceptive protocols' or 'therapeutic listening' but we don't know that yet, and it is certainly inappropriate to pronounce something as being effective when we are not yet certain.

So to the person who left the comment I recommend a FULL occupational therapy evaluation to determine if there are any developmental difficulties. A spirited child who likes to spin might just be a spirited child who likes to spin. It is only a problem if there is some corresponding deficit in adaptive functioning or an inability to participate in normal activities.

However, if you go to a therapist who claims to be a 'sensory integration specialist' I would be wary. Instead, find an evaluator who is willing to 'suspend' their belief systems in the interest of determining whether or not a child has any functional or developmental difficulties. Perhaps there is a behavioral problem. Perhaps there is a sensory problem. PERHAPS THERE IS NO PROBLEM!

Consumers need to understand that if they are looking for answers, the answer they receive will often depend on who they ask. If you are having marital difficulties you will get different answers to your problem if you ask a lawyer, a counselor, or your clergy for advice. The same holds true for health care, and this is why consumers need to choose their health care practitioners very carefully.

I recommend avoiding practitioners who 'believe' too strongly in any particular interventions. We need more practitioners who are concerned because they want to see better evidence; we don't need practitioners who blindly 'believe' in single interventions.

I believe that some children have functional and occupational difficulties because of a constellation of physical, sensory, regulatory, cognitive, social, and other contextual difficulties. It is the job of an occupational therapist to determine if functional problems exist and how to direct an appropriate intervention program regardless of the root cause of that problem.

Friday, February 01, 2008

Documentation of deceleration from completing a doctoral program, v.1.0

I decided recently that I have an issue to face: what to do with my post-doctoral time?

Participating in the doctoral program at Nova Southeastern University effectively consumed every moment of my waking (and in strange ways sleeping) consciousness. This process carried me through approximately 5 years. Somewhere and somehow in the course of that time period I transitioned back to full time clinical practice, grew our private practice to 15 employees, started this blog, and watched my two older children grow through their high school years.

I have a doctoral degree now. So now what?

My initial response to this extra time was to immerse myself in what was supposed to be mindless leisure pursuit of video games. It was an odd transition off of a distance learning program. I was accustomed to living my life in asynchronous debates via WebCT, researching and reading in the vast online resources of NSU, and writing writing writing writing papers. I was used to being ON THE COMPUTER, so my initial point of transition was to play computer video games.

While playing computer games I still found myself thinking about OT, as I started thinking about the use of virtual context to promote occupation. Then while playing these games I started thinking about the meaning of the occupation and the role of recapitulation in transitioning from childhood to adult occupations. This was all reinforced when I read an article about use of online virtual context to promote social skills for people who have Asperger's syndrome.

So anyway all of this is interesting, but I think the message is that I need to separate my work from my leisure.

I am now in the middle of Version 2.0 of the deceleration that will hopefully be a little more successful. Details to follow...