Sunday, January 31, 2010

Things that stop you in your tracks

I was doing an evaluation recently - and I should know better than be shocked at the things that come from the mouths of children...

It is important for therapists to be observant: it is a skill that I drill into my staff and my students on a regular basis. There is always a lot to observe with preschoolers beyond the typical issues of how many blocks they are stacking or how they are holding their pencil.

As is usual my mind was operating on two different levels during a recent evaluation. While we were stacking blocks I noticed the double whorl pattern in the hair of the five year old I was seeing and I was drifting away into some articles I read about the controversy over whether or not this was a phenotypical expression of altered neurological development and hemispheric lateralization or if it was just an incidental finding. I think that I need to read more because of the recent challenges to this concept that I am now aware of.

Anyway, then I looked at the hands of the youngster, and he had a rather notable injury to one fingernail. I was wondering if the fingernail injury would be causing him to use that hand less than typical - and then I was considering that if he was using that hand less than usual that I could make an error in the assessment regarding reporting what hand he used to do tasks - and that in total my findings could be in jeopardy because also I had to make sure I wasn't tainting this whole picture with inconclusive opinions based on the double whorl pattern in his hair. At the crescendo of my cognitive crisis in how to interpret all this data that part of my mind that operates 'in the moment' asked in a very caring way "Oh my, what happened to your finger??"

I thought he said that he injured it in a bar, and I wasn't sure I heard him correctly because my brain was so muddled with thoughts of lateralization, Geschwind and Galaburda, etc. that I just had to ask the follow up -

"What do you mean, 'It happened in a bar??!??"

Without missing a beat the preschooler says, "I hurt my finger in a bar. You know what a bar is. The place where you drink beer?"

Now I am certain that there is a simple and innocent truth behind all this, but sometimes the way things come out of kid's mouths just stops me dead in my tracks.

Tuesday, January 19, 2010

Folk taxonomies and sensory processing disorders

At least once or twice a week I get email or comments on the blog from people asking me if I think they or their children have a sensory processing disorder. The range of concerns most commonly includes one or more of the following: difficulty with attention, difficulty tolerating clothing textures, dislike of certain tastes or smells, or social anxiety.

The problem with diagnosis of these symptoms is that the field of learning disabilities or psychology or even psychiatry has a very poor record of diagnostic stability over time. Diagnosis tends to take on the flavor of 'current thinking' - so for example if you had these problems in Freud's time you would likely come away with a very different diagnosis than what you might receive today. That doesn't instill confidence in a person like me who is looking for a more universal and longstanding point of accuracy about these matters. A compelling example of this is the diagnosis of pediatric bipolar disorder, effectively described in this blog post.

Another example of this diagnostic problem is an article written a couple years ago by Ben-Sasson, et. al. (2007). The article described the diagnostic/labeling differences employed by occupational therapists and psychologists when considering toddlers who had sensory over-responsivity (from the OT perspective) or anxiety (from the psychological perspective). This article effectively demonstrates how professional training and item wording can strongly impact the way that different diagnosticians interpret common behavioral attributes.

When people think that a disorder is present I believe that it is most important to begin with actually determining if there is a functional behavioral problem that is interfering with ability to carry out everyday tasks. That can help us avoid falling into the trap of labeling every nuanced form of trait or characteristic difference that people may express. Humans are natural 'meaning-makers' and we don't advance the cause of understanding our patient's concerns unless we improve our ability to become armchair anthropologists about our own professional culture.

It might be interesting to write a blog post and call it "The Elementary Forms of Sensory Processing Disorder" and see how many occupational therapy researchers get the joke.



References:

Ben-Sasson, A., Cermak, S. A., Orsmond, G. I., Carter, A. S., & Fogg, L. (2007). Can we differentiate sensory over-responsivity from anxiety in toddlers? Perspectives of occupational therapists and psychologists. Infant Mental Health Journal, 28(5), 536-558.

Neuroskeptic (January 14, 2010). A brief history of bipolar kids. Retrieved from http://neuroskeptic.blogspot.com/2010/01/brief-history-of-bipolar-kids.html

Saturday, January 16, 2010

Revisiting predictions from the past.

I regularly try to find justification to feed my children on why they need to listen to me - so today I will co-opt this space for personal use. Over four years ago I made a prediction and a wish - and today it came screaming to life as I watched CNN in the airport on my way back home from Chicago.

All day they have been focusing their reports on how technology is being used for fundraising and to help connect and reconnect displaced people in Haiti with their families. That reminded me that I wrote about using the technology for this purpose well over four years ago - long before it was ever really used in that way!

After I posted those comments in 2005 I watched social networking for two years and wondered which social networking service would emerge on top, and then I joined Facebook in 2007 - even though it was still primarily a college student phenomenon at the time. I was promptly ridiculed by my son who told me I was 'too old for Facebook!' I remember I showed him this article and told him that soon all the old people would be on Facebook so he better watch out!

So I am glad to see the world is catching up with the crazed rantings of dynamic systems thinking. In my way of perceiving things this model of thinking is at the core of most good occupational therapy.

Occupational justice, as taught by Mrs. J.


I got an interesting email asking me what my current views of occupational justice were - this blog gets a lot of hits on that term thanks to Google page rankings and the fact that I wrote an article on the topic several years ago. I have been long disappointed that no one ever wanted to dialogue (in public) on what I wrote several years ago but that blog post sure does get a lot of hits and tends to generate 1-2 private email responses a month.

For the most part I have tried to lose the concept of occupational justice from my thinking and practice. The primary reason for my purposeful disconnect is that the term has been somewhat politically co-opted in the last two years and now holds a lot of political connotation along with 'social justice.' I also have been re-thinking the difference between occupational need and occupational right. At this time I am a little more interested in occupational needs. Rights need to be considered alongside responsibilities, but the existing political climate is less interested in responsibilities as it is interested in justice in general. That makes me tune out.

The driver for tuning out came from my kid's babysitter (strange place to obtain wisdom - but let me explain).

I remember vividly when my daughter would scream at her sister, “Casey, quit whining!” Older sisters like it when they can boss their younger siblings – at least that is what I noticed in my house. The problem that caused the whining was that my daughter Casey clearly was not impressed with what was being offered for dinner.

“You get what you get, Casey,” her sister continued. “You know what Mrs. J. always tells you.”

The relationships that the kids formed with people outside the family were always something that I have enjoyed studying. Mrs. J. knew both younger girls for several years as their after school daycare provider. Mrs. J. was a third grandmother to the girls and I always felt fortunate to have her care for the kids.

It is a simple philosophy, actually – meant to initially apply to after-school snacks. Neither of the kids were ever raw vegetable crunchers but this is what Mrs. J would regularly offer them. Although they would initially rebel against what was offered, Mrs. J. would always answer them consistently when they asked for some other kind of snack, “You get what you get.” It has become something of a rallying cry for learning how to graciously receive what is offered.

The kids learned how to generalize this lesson without my intercession. Sometimes simple messages are the ones that are most easily received. And applied

The larger application might sound somewhat fatalistic, but I try not to think of it that way. We all want things. Sometimes there are things that I want so badly that my heart feels like it is falling out of my chest. I talked before about how we are a society of people who are largely controlled by feelings of entitled immediate gratification. But sometimes we get what we get, and it is not anyone’s fault. It just is. What we make of the things we get is what matters, in the end.

I pray, regularly, so I can understand where I am, who I am, what I am supposed to do. In my own times of questioning I try to pause myself and invoke a quiet acceptance. “You get what you get.” When I hear the echo of this message through the voices of my children I realize how much that actually is.

So anyway I guess that in my thinking it is more about need, and then how we respond to the need and whether or not the need is met and how this generates meaning for our patients. Talking about rights and justice takes it all into a political spectrum that really takes us beyond the initial issue. OTs can certainly engage questions of rights and justice - but I would rather see that we first engage in better understanding and meeting needs and meaning-making.