Monday, March 30, 2009

Monday morning spaghetti

In 11th grade I took a computer programming class - computers were brand new technology at the time and the teacher knew little more than the students so it was definitely a wide open frontier. The computer was an excellent tool in that programming forced my adolescent brain into a type of linear and logical thinking pattern that I still find useful today.

The teacher often had us work in pairs on larger projects and I had an excellent programming partner. We regularly challenged ourselves with writing complex programs and we were sometimes over-ambitious. One particularly complex program we attempted was to write a 'Blackjack" program. I remember how excited we were when we got the cards to print correctly on the screen. This was high-end stuff for a couple of high school kids hacking away on a TRS-80 Model III computer!

Our Blackjack program became increasingly complex, and as we attempted to make accommodation for ever increasing complexities the programming code became more and more jumbled. What began as a linear progression of thought devolved into endless subroutines of special-case if-then propositions. It became classic "spaghetti programming" and it was a mess.

Eventually the project became so large and so confusing that it couldn't hold the interest of our adolescent minds - and so we moved on to easier programs.

I re-experienced all of these frustrations this morning when a parent walked into my office with her 7 year old child and asked, "Do you think that my child has a sensory integration problem?"

In my linear programming-oriented mind I have learned not to bias myself when I hear this kind of question. Sometimes when you are posed with a clinical problem you can start off by taking the individual strands of uncooked spaghetti and neatly ordering them as you tick off questions and answers. Eventually, you can sometimes reach a perfunctory conclusion based upon the obvious pattern that is evident on the differently ordered and arranged piles of uncooked spaghetti. AHA!! The problem is XXX! I like when the world is ordered and things make easy sense.

I was not so lucky today because I heard the parent say, "My child has congenital adrenal hyperplasia." My hope of neatly ordered piles of uncooked spaghetti disappeared as I imagined the water boiling and having to dump all that pasta into the pot for cooking.

Congenital adrenal hyperplasia, in general, is a condition where there is a problem with the body not producing enough corticosteroids. As a result, many children with this condition have to take replacement hormones. Additionally, there is the issue of impact from long term increased exposure to higher levels of androgens.

The parent described auditory defensiveness problems, difficulties with high activity level, and some behavioral rigidity. His 'symptoms' reportedly vary in intensity and are intermittently problematic. Here is where I felt stuck with the parent's report - is it possible, or even likely that the symptoms are nothing more than a reflection of his fluctuating ability to maintain a functional physiologic coping mechanism because of a complex psychoneuroendocrine disorder? I know enough about cortisol and stress responses to understand that this child has no physiologic basis for stability - and indeed is dependent on Cortef and Fludrocortisone to maintain as much of a steady state as possible. At the same time, I am also aware that most research says that although young girls with this disorder demonstrate more 'masculine' play behaviors and agression that this is not the case for young boys.

Now - does this represent a fundamental gender difference between the way that adrenal hyperplasia can be phenotypically or behaviorally expressed??? Or does this represent something odd about our cultural tolerance for varying levels of so-called 'agresssive' or 'hyperactive' behaviors in boys?

The reason why these questions matter is because we can then have a context for developing some kind of intervention plan. Certainly, if a child has an underlying endocrine problem it is not likely that we will fundamentally alter that condition with external stimuli. However, we might introduce calming activities for parents or teachers to try in case they see that behaviorally things are 'ramping up.' Listening to calm music, petting your cat, etc. all can contribute to lower cortisol levels - these are activities to consider because cortisol level may not be optimal at any time for someone who has adrenal hyperplasia. Conversely, caregivers (including teachers) need to understand what the behavioral markers are for impending adrenal crisis and how to obtain medical intervention when needed. The problems can be bidirectional, and the response from caregivers has to be dependent on the fluctuating signs.

What complicates this is that psychoneuroendocrine responses don't occur in a vacuum - they are also influenced by behavioral patterns and habits that are established following a lifetime of sucessive responses and reinforcers. And sometimes - kids are just kids and don't listen to adults.

Now we have fully-cooked spaghetti, ready to be heaped in a mass onto a plate for consumption. I couldn't even try to answer this parent's question about whether or not the child had a sensory integration problem. That is frustrating.

In the end, I am able to recommend a home program of calming activities and signs to watch for that are indicative of arousal and fight-or-flight responses that are out of balance. I am able to provide some common sense suggestions for activity pacing - and considering ways to make environmental and contextual modifications to limit sensory overload. I am able to encourage an activity configuration that balances structure, goal-setting, and positive socialization in addition to allowing for pedal-to-the-metal raw energy release. I am able to promote what I call high-intensity parenting because their need for educating other caregivers is critical. I am able to express that behavioral expectations can't be tossed out of the window and it is STILL important to maintain some measure of expectation and standard for appropriate contextual behavior. Also, in the long run we need to provide a cognitive-behavioral program where the child is able to increasingly learn how to attune to their own regulatory state and make activity choices to address changing needs.

I am not sure where this spaghetti mess begins or ends, and I do not know that it is a sensory integration problem - whatever that is - but whatever it is the child and family clearly needs some help. From a programming and logical-order perspective the problem represents an epic failure in our ability to 'name' and 'plan' interventions.

I am hopeful, at the least, that understanding the complexity will prevent me from introducing special-case if-then propositions. I learned in 11th grade that these methods don't contribute to a good final product.

Friday, March 27, 2009

NY Governor Paterson plans to re-institutionalize people who have developmental disabilities?

Is this about saving money on facilities with empty beds? Or is it the confused problem solving coming from politicians who have empty heads?

In a Rochester, NY Town Hall Meeting on March 11th, Governor Paterson was asked about his plans for adults who have developmental disabilities who are on long waiting lists for residential programs. Currently, many are living with their families because NY State lacks housing options for this population.

Politicians should know that this is not a new problem - New York has a long and storied history of problems in providing residential services to people who have developmental disabilities. I blogged about the history of the Willowbrook State School several years ago; I encourage you to click this link for a background study of the situation http://abctherapeutics.blogspot.com/2005/11/new-yorks-disgrace-30-years-later.html

Certainly options are different since Willowbrook was closed. Residential treatment programs in the years following 1987 changed from large institutional facilities into smaller Intermediate Care Facilities (which are still quasi-institutional), Individual Residential Alternatives, and even Supported Housing. The much heralded NYS-CARES program was supposed to finally end the residential housing shortage, but it has been a disappointment. On August 19, 1998 Governor George Pataki announced NYS-CARES; this program reportedly met and exceeded goals but the long term problem remains, despite the implementation of NYS-CARES II. Families are still experiencing long delays for residential placement options.

NY State faces unrelated problems with UNDERutilized juvenile youth facilities - there have been some rather infamous arguments and examples regarding the Auburn Residential Center and other facilities that are being kept open and staffed for virtually no one's benefit except the Union jobs that are being maintained for members of the Public Employees Federation. The union argues that NY State is trying to 'privatize' residential programs (same argument they used against NYS-CARES, incidentally) but the reality is that local community-based initiatives for the juvenile population are more effective and less expensive than maintaining these residential centers. OCFS now places most children in programs that are less expensive and more local, but the unions won't let go of the older and more expensive institutional/residential models.

This is where bureaucratic and political cowardice comes roaring forward. These two problems remain intractable unless two things happen: first, NY State would have to honor its commitment made to a vulnerable population because of the historic Willowbrook atrocities, and second, NY State would have to take on the AFL-CIO/PEF and tell them to take a very long walk off of a short pier. In a world that makes sense, we would provide appropriate housing opportunities to adults who have developmental disabilities and we would provide similarly appropriate intervention and care models for children who are skirting around the justice system. This is not an issue about Union jobs - it HAS to be an issue about what is best for these populations who require services and programs.

In NY State things rarely make sense though. Instead, Governor Paterson recently let it slip that he would convert the existing facilities, retrain the staff (in other words he will suck up to the Unions and let them keep their jobs), and use the institutions to warehouse adults who have developmental disabilities and have been waiting for community placement. If you can't believe it, go to this audio recording of the Rochester, NY Town Hall Meeting on March 11th and listen for yourself. The Governor's comments can be found at 37 minutes into the recording.

So Governor Paterson proposes to send the adults who have developmental disabilities back into the antiquated institutional residential options of the Snake Pit - a reversal of nearly thirty years of progressive NY State policy. And like a coward he will do it with a smile while he maintains his good favor with PEF.

According to the Governor, those workers (who previously worked with children who have social, emotional, and conduct disorders) just need 'a little retraining' - as if this would then qualify them to provide safe and competent care for adults who have developmental disabilities.

When we see politicians engaging in conduct that is potentially harmful to vulnerable citizens they must be stopped. Write a letter to Governor Paterson, include a copy of this blog post if you want, and tell him that he needs to come up with better informed solutions. Our most vulnerable citizens deserve better plans than this.

Saturday, March 21, 2009

An occupational therapist's perspective on patient elopement from nursing homes

Mrs. Kim was one of my first patients when I was a young occupational therapist. She was an 89 year old resident of the nursing home and lived there for the previous seven years. Prior to her admission she was living at home with the support of her only son. She had diagnoses including hypertension, chronic obstructive pulmonary disease, and Alzheimer's disease. She had a history of depression and severe anxiety.

Mrs. Kim was a known 'flight risk' and tried to leave the nursing home facility on several occasions. The nursing home responded appropriately by installing window limiters and door alarms. Out of an abundance of caution they also made sure that Mrs. Kim always had her identification bracelet and she had an alarm that would sound whenever she wandered outside of a designated perimeter around the nursing station.

Despite all of these precautions she still managed to find her way out of the facility on at least three occasions in the preceding seven years - which resulted in the firing of several staff for their lack of attention to the detailed plan that was put in place to keep her safe.

Having seen friends and co-workers fired over this 'high-maintenance' patient, many of the staff at the nursing home viewed her as a 'problem' and a 'burden.' Some of the direct care staff were thrilled at the prospect of the occupational therapist taking Mrs. Kim off of the unit for therapy because that meant that they wouldn't have total responsibility for her continued monitoring.

In addition to the elopement risk, Mrs. Kim's behaviors caused other difficulty on the unit. Despite her advanced age and some physical frailty she was still very mobile and active. She would frequently run into other patient's rooms, frantic and screaming, trying to pull them out of their beds. Although the nursing home's policy was to minimize use of restraints, there were times when the physician ordered both chemical and physical restraints with the intent of maintaining Mrs. Kim's safety as well as the safety of other patients on the unit.

Mrs. Kim's communication skills were severely impaired, generally limited to a fast paced string of syllables that no one could interpret. The staff thought that she might be sometimes speaking in her native Korean language. The nursing home arranged for a Korean interpreter to meet with her once and it was determined that she was not speaking in Korean.

The Activities Director noted that Mrs. Kim enjoyed watering plants, watching television, and that she used to participate in a weekly Bingo group several years ago. Even then she required moderate to maximal assistance but it was the last functional group activity that anyone at the nursing home remembers her being able to participate in.

I read Mrs. Kim's chart thoroughly before I went to get her, so I knew that she had a history of depression and anxiety and I knew about her elopement risk. During the evaluation she bolted away from me and headed straight for the facility's side door. Fortunately I was well-trained by my supervisor to know how to handle the situation - I followed the facility procedure, paged "Dr. Walker" to the 'B' unit which prompted the rest of the staff to converge on the area. I was able to catch up to her in the parking lot not far beyond the side door. Mrs. Kim was frightened, and scratching at my arms, trying to get away - but she eventually calmed and I was able to complete the rest of the assessments that needed to be done.

Although the social and medical history in the chart seemed relatively complete, I asked my supervisor if I could try to contact the son to talk to him about his mother. It wasn't part of the standard OT evaluation to contact family members but Mrs. Kim's lack of communication and the way she grabbed at my shirt made me want to find out more about her.

*************************************************************************

I will never forget the son's explanation of his family's experiences as survivors from a civilian prison camp. When soldiers from Communist North Korea retreated from Taejon in 1950 they intended to leave no one alive from the camp. Although his father was executed, he and his mother survived - pretending to fall over dead as they were bound with wire to other members in their family who were strafed with machine gun fire in a mass execution.

Some years later the family emigrated to the United States, but the psychological scars never left. The son recounted a recurring nightmare that haunted his mother her entire life:

In her dream they were running. It didn’t matter where they had come from – but where they were going did. Forward. She pushed them ahead, as instinctively as breathing.

So many weeks, months, or years ago she would have needed his directive to move. Her husband taught her how to move forward, afraid of the day that he would no longer be with them. That day came a long time ago – so long ago that he was barely a distinct memory now. But his message was clear to her. Run! Run! His words roared in her ears; the muscles in her legs contracted, and she ran.

Thunderous shock waves buffeted them from all sides as they ran. Then on the horizon there was a flash of light: magnesium burning white light that lasted just a second. A column of earth and smoke plumed, mushrooming miles into the sky. She heard her son ask, “Is this the kind that we are not supposed to look at?” These were the final words that any of them would ever speak again.

Mortified, paralyzed, wondering how and why someone could hate someone so much to use such a weapon, and nodding to her son all at once, she made them run in the opposite direction.

Running didn’t matter, but she did not have time to realize this. Time and space instantaneously became irrelevant. In real terms they were incinerated immediately, but the moment in time was stretched out infinitely. Every horror that had driven their survival merged into a single event horizon. In the end, as she hallucinated that her children were drowning and melting into the Earth in front of her, hearing the horrible whir-chop of military helicopter blades as they ran, they all unmercifully died in a moment that lasted for an eternity.

*************************************************************************

Ever since the son told me about his mother's experiences and nightmares, I never quite looked at patient elopement the same way.

Friday, March 20, 2009

Stepping into politics: Obama comments on Special Olympics

I very rarely step into politics in blog format because of the inherent landmines that one encounters. People hold tremendously polarized worldviews that make coherent debate difficult - but sometimes an issue stands out in a way that makes NOT commenting wrong.

President Obama went on Jay Leno's show last night. I am not a huge fan of television so I rarely watch these shows. Still, I knew that I wanted to see 'what he said' when I checked the news this morning.

Apparently, in reference to his own poor bowling skills he made what is now being spun as a 'self deprecating comment.' Obama's comment about his bowling skills was "It's like -- it was like Special Olympics, or something."

In presumably light hearted banter he also allowed himself to be drawn into comments about "water-heads." This is an unbelievable lack of dignity from a President.

The political spinmeisters who think that deflecting the comment as a statement about Obama's lack of bowling skill are missing the point. The problem with this kind of statement is that by labeling something as 'self deprecating' the comment is still reflecting a comparison and a negative perspective on people who have disabilities. Obama is still holding a very negative perspective on the abilities of these people.

Standards for appropriate speech are raised for people who are in political office. If someone makes an obnoxious comment in their daily lives they can be corrected and educated. When a politician makes a comment they need to be more aware of what they are saying because the audience is larger and the impact is greater.

I am not going to engage in a prolonged conversation about the Sapir-Whorf hypothesis but the fact is that people generally speak from their own culture and world-view. It is sad if this is a reflection of his actual world view.

I would go so far to say that you can only make that comment if you really don't even know what Special Olympics is about. He needs to spend some time educating himself. The purpose of Special Olympics is to recognize that all people have a right to succeed if they are given the opportunity.

I am not looking to be outraged and in general it is difficult to offend me - but this statement by my President was just plain ignorant.

There is an awful lot of hub-bub flashing across the President's teleprompter about creating opportunities for all Americans these days. It is sad to see what comes out of the wizard's mouth the moment the curtain is pulled back and he is unscripted.

Thursday, March 19, 2009

Health insurance administration: From pragmatic haggling to preposterous hilarity

There was a time when people paid their MD with chickens or apple pie. It was a bartering economy that made sense between the participants.

For many years doctors resisted governmental efforts for universal health care and insurance companies did not want any part of trying to develop risk models that would make health insurance a money-making product. Houses were easy to make insurance models for - but no one wanted to deal with the vast complication of risk assessment for human health.

Lots of things happened throughout the 1920s and 1930s that pushed insurance companies into the health insurance market: the Flexner report called for and prompted improved standards in medical education, small union groups began negotiating fixed-cost hospital coverage plans, and demand for medical services increased as medical technology improved and large populations of people moved from rural to urban centers.

Health insurance grew through the 1960s and then government entitlement programs were established (Medicare and Medicaid). This leads up to today where many people are viewing universal health care as a right. The systems are so large and complex now that the insurance companies themselves don't even want to administer them, so they farm out the administration to separate corporate entities. This all adds to the cost of health care.

What prompts this little history review is a funny letter I received from NGS which is a Wellpoint subsidiary that was recently awarded the Medicare administration contract for NY. The letter was so hilarious I will just reprint it in whole here:


Per Centers for Medicare & Medicaid Services (CMS) regulations, when Medicare contractors send an overpayment second demand letter to a provider, they are required to attach a copy of the overpayment initial demand letter. Prior to January 5, 2009, contractors were responsible for attaching the initial demand letter to the second demand letter and had their own processes for doing so. With the publication of CMS Change Request 5986, this is now a system-automated process. With the implementation of this change on January 5, 2009, the system will now automatically print and attach the first letter created on the case. However, it has come to the attention of National Government Services that the first letter generated to a provider is not always an overpayment initial demand letter. Another type of communication, such as a redetermination letter, may be the first letter generated through the system, and therefore may be attached to the second demand letter.

Providers need to be aware that when they receive an overpayment second demand letter and a letter other than the overpayment initial demand letter is attached, they should ignore the attached letter, as it may no longer be accurate. However, in these situations, the second demand letter is valid, and offsets will begin for the provider if the overpayment is not repaid within the mandated time frame (41 days from the date of the initial demand letter which had been mailed previously). Providers who have questions regarding the overpayment second demand letter can contact the Provider Contact Center for assistance. Provider Contact Center telephone numbers are located in the Resources section of the National Government Services Web site at www.NGSMedicare.com.

We are continuing to work with Electronic Data Systems (EDS) to determine the date this issue will be corrected.


Thank you,
National Government Services, Inc.
Corporate Communications


Would Doc Baker be able to make any sense out of the crazy system that we have today?

Tuesday, March 17, 2009

Nixzmary Brown was murdered over three years ago. Do you remember?

Three years ago Nixzmary Brown's murder had everyone talking about child abuse and how 'the system' fails. There was no shortage of commentary about how broken the child protective system was - after all, child protection workers were already involved in the case and stated that claims of abuse were 'unfounded.' Tragically, it took a child's death to provide enough substantiated evidence - and even then the so-called parents were only found guilty of manslaughter.

Suspected abuse that is reported to child protection workers is often 'unfounded' - you can find a few such cases that I have ranted about in these blog pages. Once I reported cigarette burns on a child's legs that were determined to be 'unfounded.' Another time cigarette burns on a different child's arms were 'unfounded.' In another case I had, a caretaker was cramming food down a child's throat who could only eat via g-tube but that wasn't a problem . Having a flea-infested home with the child covered in flea bites was also unfounded in another case. I got a lot of email and attention about the blog entries on the kerosene-vapor home recently - all of which was also brushed aside as long as the parents agreed to a foster home placement. I also recently blogged about how a toddler handing over a dime bag of pot to a therapist was 'unfounded' and even the police report identified the substance as a 'green leafy material.'

Only the most severe cases ever reach the public's attention - and then the outrage lasts for a few news cycles and we all forget again until the next tragedy is splashed tabloid-like across our consciences.

Today is a good day to remember Nixzmary Brown, because it is not good enough to only pay attention when a tragedy is unfolding. We need to demand more from our child protection system, and we need to enable law enforcement and our legal system by advocating for severe punishment when a child is injured or killed.

Here is the link to the bill that is currently in the NY State Assembly - it is currently sitting in a Code Committee: http://assembly.state.ny.us/leg/?bn=A05080

Here is the link to a nationwide petition regarding federal legislation that mandates harsher penalties for these crimes: http://www.thepetitionsite.com/1/nixzmary-brown-law-nationwide

If you can, please remember Nixzmary Brown today. Call your legislators and tell them that you demand more out of child protection systems and that perpetrators of child abuse and murder need to be severely punished.

Tuesday, March 10, 2009

The mass of moms lead lives of (not so) quiet desperation

I need to turn Thoreau on his head a little here - I made mention of 'desperate parents' in a blog note last week and on cue I had a discussion with a mom recently and she looked me squarely in the eye and said

You do realize that you are talking to a desperate parent, don't you?

Of course I knew that. It is the time of year for reviewing Individualized Education Plans. This particular mom's story was not so different from the hundreds who have preceded her. She wanted to know if she was crazy, or if she had odd expectations of her school system, and why she was having such a difficult time interacting with her child's educational team.

I began my private practice with the naive notion that I would function as a private therapist for approximately 2-3 years, work with families and school districts to help them bridge gaps of misunderstanding, and likely put myself out of business after engaging in several years worth of advocacy and educational efforts. That was a pretty funny thought, looking back on it now.

I used to have a real fear of marginalizing myself with the educational community by walking into meetings with parents who want more out of their districts. In the beginning it may have been more of a real concern but after doing this for nearly 10 years it seems most of the districts have come to figure out what I am trying to accomplish - that I am just trying to help families learn how to interface with the educational system. Sometimes that means that the family needs to alter their expectations. Sometimes that means that the district needs to modify their intervention plan a little. In the end I hope it leads to better IEPs for kids. That's my bottom line, actually. I have figured out that most districts understand my actions because we have been able to secure contracts with quite a few districts and educational programs, even though I show up at meetings sitting at the parent's side sometimes. I like the fact that we have these contracts and I like that I show up in these districts helping parents on a private basis. It has never been a conflict of interest, because my role in both situations is to best serve the needs of the child who requires services. When I am in a district I try to accomplish that through program development, staff development, and excellent service. When I am helping a parent privately it is through education of the family and advocacy. The only consideration in either situation is the outcome for the child - and this keeps me laser-focused on the objective and (in my opinion) very intellectually honest and unbiased. I hope it comes across that way more often than not.

The interaction is dicey, though - parents (mostly represented by moms) feel varying degrees of desperation over their child's educational plans. What makes IEP meetings akin to a powder keg is that the parent rarely enters the meeting with JUST the educational issue on their mind. So even though the meeting is about developing goals for a behavior intervention plan in third grade, the parent is still thinking about whether it was a good idea to repeat kindergarten, whether it was the correct choice to spend a full year in a self contained classroom at the CSE's recommendation, WHY IS THERE NOT ENOUGH SPECIFICITY IN THIS BEHAVIOR PLAN, whether or not the child will ever develop real friendships, and whether or not they will be able to attend the Senior Prom. These are all absolutely acceptable and normal parent concerns but of course the CSE tends not to think on this scale as it is not their purview to do so. Thus, powder keg meets match.

Parents do not go gentle into that good night. Nor should they - but they need to know what the school is required and not required to do. I try to help with that. Some schools approach the encounter kicking and screaming - even though we have new concepts in education like RTI where we are supposed to be accountable for our interventions. Of course schools come around to these emerging educational models at varying paces, and have mercy on those schools who are not as up to speed as the parents want them to be!

So each Spring I insert myself directly between desperate parents and their CSEs, trying to navigate the stormy seas between them. I hope I help.

Tuesday, March 03, 2009

Sensory Integration: How occupational therapists are stuck in the long tail

I am working with a student who is completing a literature review on the concept of fidelity in sensory integration. At the same time I am completing a book chapter on entrepreneurship and today came to an interesting perspective on the state of sensory integration theory and practice models.

Reality dictates that people purchase goods and products and will pay for them based on some value formula. Occupational therapists have famously made references to the value of their services - from Mary Reilly's belief that OT could be one of the great ideas of 20th century medicine to the more recent AOTA branding campaign on how OT helps people live life to its fullest. If both of these statements were true people would be flocking to seek out and pay for our services. Is this the case?

Certainly people are receiving occupational therapy services. Certainly insurance companies and others are paying for occupational therapy services. Despite these facts, it is true that the vast majority of payment for occupational therapy services comes from public health entitlements and less comes from the willful parting of everyday people and their health care dollars. This equates to less of a consumer-driven 'flocking' and seeking out of services and more of a 'herding' by legislative mandate.

For those of you that practice every day, this is why you find yourselves explaining what OT is to your patients or families, and why you have to fight against higher powers-that-be who are feeling 'forced' to keep you hired and offer the service. This also lies at the crux of the recent debate on branding - consumers don't know what the service is and those payers that DO know what it is are only viewing it as a mandated cost and not as a health or lifestyle product that has value.

Sensory integration theory and practice models provide an interesting example of this issue.

Without descending into a values inquiry of Pirsig-like proportion - we can ask the basic question "Does sensory integration have value as a practice model?" To begin with, although there is a growing body of research (some supportive and some not) about sensory integration - there is longstanding lack of acceptance for the intervention from the medical community. Many doctors and insurance companies believe it lies somewhere between Doman-Delacato patterning and swimming with dolphins - and have responded by issuing policy directives that it not be reimbursed. Now whether the assessments were fair or correct is a separate issue - but the fact remains that it is not a valued practice model in the medical community.

On the street level, parents have children who are not learning in school. This isn't new - and over time our society has responded to this population with terms like 'minimal brain dysfunction' and 'soft neurological condition' and 'learning disability' and 'attention deficit disorder' and 'central auditory processing disorder' and 'sensory integration disorder.' The names change - the conditions are constants. This means that there is evidence that there is a problem that needs to be addressed - it is just the intervention method that is the largest question.

Schools don't value sensory integration intervention as a practice model because it lacks face validity to the wider perspective of educational-behavioral methods and the intervention model itself is mostly incompatible with the structure of a school day.

The fact that educational and medical systems don't value sensory integration as a practice model has not dissuaded occupational therapists - and instead some therapists have participated in legal battles and infighting that have led a group to actually trademark the KIND of sensory integration intervention they espouse.

Others in the profession have responded by participating in some good research around the concepts of sensory integration - but only at the level to get it identified as a DISORDER. This doesn't even really touch the issue of what the best way is to TREAT the disorder.

So while people debate whose kung fu sensory integration is the best and others complete research to find out if it is even a disorder - there are a lot of clinicians struggling with how they should or should not integrate this information into their practice - and struggling with the reality that it is not valued by medical or educational communities.

What has happened is that a value question was posed and answered. Sensory integration as a practice model is not valued. The logical response would be to re-tool the model or abandon the model and move toward something that has greater value. Behavioral and mental health professionals were faced with a very similar value question when cost factors made people question the worth of long term psychotherapy. The behavioral and mental health people were very quick to respond and change their interventions to direct behavioral methods with short term interventions. In short order they completely redefined the nature of their practice - and now are tackling larger issues like parity with physical medicine.

Occupational therapists instead chose the long tail - and now frequently 'market' to the very few parents who are willing to look outside of the medical and educational communities. By 'market' I refer to the conscious and unconscious portrayal of the nature of our interventions. Rather than find a practice model that provides value to broad constituencies, therapists instead find long-tail parents who will pay privately for the service or who are willing to push for the service with their MD or school. Those therapists who are practicing within the educational and medical systems find themselves mostly marginalized and undervalued - because the larger systems already answered the value proposition.

Ultimately, this is unhealthy for the profession. Practicing therapists who cling to the model are dismissed by their educational colleagues and referring physicians. The service remains (for now) because it is legislatively mandated - and occupational therapists continue to operate within their own private Idaho of practice - wanting to help people live lives to its fullest - but at the same time only having niche believers who value the intervention. As a practice model, sensory integration is not meeting the demands of the largest population/short tail of consumers (broad medical and educational communities).

This observation is not meant to detract from the excellent efforts to define sensory processing problems as a disorder - because there is value in further definition and understanding of why children have difficulty learning. However, it should give practicing occupational therapists something to think about regarding how they INTERVENE with the problem - at least if they want to avoid going the way of Freudian psychoanalysis.