Thursday, December 18, 2008

Empirical vs. innate knowledge in sensory integration

I received an email from the Sensory Processing Disorder Foundation about today's NY Times article discussing the process of how disorders are included in the DSM.

The email expressed excitement that awareness of sensory processing disorder was growing. I think that awareness of any problems that children have that can impact their ability to function is good - but I remain unconvinced that we are anywhere near ready for DSM inclusion of sensory processing disorder, if such a unitary disorder even exists. I have blogged about this topic before here.

As the title of this entry suggests, my primary sticking point is the problem of empiricism vs. innatism. Empirical analysis suggests a process where there is NO prior knowledge and everything learned is written upon the 'blank slate' of consciousness. One could argue that the seedwork of sensory integration research completed by Ayres was the closest that we may come to a truly empirical approach to the issue of sensory integration. Her diagnostic typologies were reported along with the publication of the SCSIT in 1972 and later the SIPT in 1989. Even the SIPT typologies were likely 'polluted' through statistical factor and cluster analysis but still this represented excellent sophistication at the time.

Fast forward 20 years from the SIPT - and we have done too little. We have been waylaid with pseudoscience of brushing and Brain Gym and auditory interventions and other professionals have confused Ayres' concepts with everything from Doman-Delacato approaches to Snoezelen. It has been a mess.

Parham, et al (2007) began the excellent discussion on the fidelity problem and I really thought that this represented a turning point. Ayres' original typologies drove us toward fidelity, but there are problems with the test - and there was a need to re-think and evolve the concepts. Unfortunately, this is where the field has fallen short: instead of developing the theory and developing clinically useful tools that could inform us for refinement of appropriate clusters and factors - we fell into a much lower level of evidence based development - and instead came up with the so-called empirical analysis completed by Miller et al (2007). There is little doubt in my mind that sensory processing difficulties exist, but I don't see any evidence that helps me understand how to tease these difficulties apart from other diagnostic entities or even from simple childhood behavioral difficulties. We just don't have the measurement tools to do this with any degree of statistical reliability much less clinical validity.

So experience is great and developing typologies based on many expert opinions is interesting - but it seems like such a giant step backwards from test development and clinical diagnostics. I believe that the DSM folks would be much more impressed with sound diagnostic tests and an evolved SIPT. If I was considering sensory processing disorder for inclusion I would want some real clinical tools to diagnose it and that actually provided some evidence that such a disorder exists and actually occurs outside of other conditions.

My point here is that I don't think we are really using empirical methodologies when it comes to identifying so-called sensory processing disorders. Rather, we are relying on the conceptual innatism that has been passed on to us from our forebears - and as inspirational as those fountains were - it really is time to move on to more evidence based methods.


Ayres, A.J. (1972) Southern California Sensory Integration Tests, Los Angeles: Western Psychological Services.

Ayres, A.J. (1989) Sensory Integration and Praxis Tests, Los Angeles: Western Psychological Services.

Miller, L. J., Anzalone, M. E., Lane, S. J., Cermak, S. A. & Osten, E.T. (2007). Concept evolution in sensory integration: A proposed nosology for diagnosis. American Journal of Occupational Therapy. 61, 135-140.

Parham, L.D., Cohn, E.S., Spitzer, S., et al. Fidelity in sensory integration intervention research. American Journal of Occupational Therapy, 61, 216-227.

Tuesday, December 16, 2008

Assistants, aides, and the importance of certification

We have been advertising for physical therapist assistants recently, and I have been a little shocked at the high volume of calls we received from non-licensed people who believe they are qualified for the position. It is quite common to hear callers state "Well I worked as a physical therapist assistant and am not licensed but I am qualified for your position." I have never received similar calls when we advertise for occupational therapist assistants.

New York State regulations that govern PT practice on this issue are quite clear. They state:

  • New York State law restricts the practice of physical therapy to licensed physical therapists or certified physical therapist assistants. Individuals who are not licensed or certified may not provide physical therapy services. Aides may perform non-patient related activities such as secretarial, clerical and housekeeping tasks. Additionally, aides may act as an extra set of hands for the physical therapist or physical therapist assistant who is actually providing the treatment.
The occupational therapy regulations are quite similar and we don't get confusion about OTAs - so why is there such confusion from PTA candidates who believe that they are qualified and report that they have job experience as assistants?

My working assumption is that so many people calling for the job are not lying - and they must have been used in illegal capacities in previous jobs. That is concerning for the PT profession.

I went to the Bureau of Labor Statistics site to do a little research on this issue and found contributing confusion. BOTH the pages for OT Assistants and PT Assistants are entitled "XXX Assistant and Aides." I was a little shocked at some of the salary and work site data that was listed for 'aides' and it makes me wonder. Either people confuse the terms 'aides' and 'assistants' when they are reporting their job titles, or there are an awful lot of unlicensed people doing the jobs of assistants and making a pretty reasonable salary. That is unfortunate for the true assistants who are licensed.

So what is the truth - as it is not discernible in the statistics??? Is there a lot of illegal use of aides to do assistant work? Do regulatory bodies care about the confusion and are they 'looking the other way' and allowing non-licensed people to do work that was previously protected for licensed professionals? And as there is no similar confusion at the occupational therapist and physical therapist levels is this a sign that the public does not believe that the assistant level is important to certify or regulate?

I believe that as long as we have educational programs, certifications, and laws that we should follow them. But if there is a latent disinterest in upholding the laws - isn't it appropriate to throw this issue on the table for discussion?

Thursday, December 04, 2008

HIPAA and FERPA: The opinion of a street level OT

I am not a lawyer, so stop reading my opinion and go talk to one if you are having a real problem. Please.

But here is my OPINION that I want to rant about:

Everyone needs to go and read the recently published Joint Guidance on the Application of the Family Educational Rights and Privacy Act (FERPA) and the Helath Insurance Portability and Accountability Act of 1996 (HIPAA) to Student Health Records.

This is the most recent guidance document in a string of legal opinions and guidance documents that have been kicked around since HIPAA came into effect and schools were left trying to figure out what it meant. The bottom line problem is that we have created a system in the United States where a public health program (Medicaid) morphed into a broad funding stream for a variety of educational programs. The original stated purpose of Medicaid was for medically based interventions (and thus its common designation as a 'health insurance' system of sorts) - except that now it also pays for health related services in schools - but those health related services from the school's perspective have to be 'educationally related.'

For background purposes, FERPA came first and is a law governing privacy of educational records. HIPAA came second and is a law governing privacy of protected health information - except that the legal eagles cross-referenced and excluded FERPA from HIPAA in some situations. The confusion exponentially grows since schools are now in the business of billing insurance companies (including Medicaid) for some services. What is left in the confusing aftermath is a pair of legs devoid of a brain, each wondering who is supposed to take the first step forward.

School officials, from my experience, have no idea how to solve the problem - and what ends up happening is that on a regular basis I am witness to information being released to people and places that it should never be released to. The overwhelming majority of the time this release is not malicious but nevertheless it is problematic. Also, parents are infrequently aware of FERPA exclusions to need for consent - and when so-called protected health information is morphed into an educational 'treatment record' that is then FERPA controlled it is interesting to see who can get access to very personal information that someone initially thought was simply a private medical record.

So we have a new guidance document straight from DHHS and DOE. It is quite clear - to lawyers probably and those who like to rant about such things on blogs. People who are on the front lines of this issue will still grapple with the complexity of educational vs. medical records and make many unintentional mistakes. Individuals or parents can always address confidentiality breaches after the fact, but that will invariably leave people dissatisfied and wondering why the system was so vulnerable in the first place.

Our practice: we get consents from EVERYONE for EVERYTHING. We NEVER re-disclose information and only release our own documentation. We also educate families to exercise EXTREME caution in who they decide to give information to. We also don't release ANYTHING unless we have a direct and specific consent or a court order. Sometimes we have even cleared the court orders with our attorney just to be safe.

Let's just call it all broken and start over. Privacy rights should not be so complex and I can absolutely guarantee that individuals are not served well when the waters are this muddy.