Monday, March 29, 2010

The role of occupational therapy for children who have behavioral difficulties

Behavioral problems in children are sometimes difficult to solve. Caregivers and even professionals often search for what I call an 'easy button' to solve complex problems. I have always believed that using a general systems methodology prevents the inappropriate reduction of complex system problems to single-point causes.

Human beings are meaning-making creatures, however, and that causes us to sometimes reduce complex data into single-points even though it doesn't make sense to do so. As an obtuse example - if you ask the average person what caused the shuttle Challenger to explode they will tell you that it was Morton Thiokol and faulty O-rings. Although that is true, it is more true that there were other factors including cold temperatures, design errors, lack of redundancy, and flawed human communication.

Anyway, my point is that humans like to find single-point answers to problems and that sometimes causes people to come looking for occupational therapy evaluations. Occupational therapists have contributed to this phenomenon by suggesting that some behavior problems can be reduced to sensory processing concerns. Many people look toward 'sensory diets' or some other prescriptive sensory stimulation program (brushing, weighted vests, auditory interventions) as single-point solutions to problems.

I was recently asked to complete an evaluation on a child and this is an edited snippet of my findings:

Priscilla is a ten year old child referred to occupational therapy to determine if she has sensory processing difficulties. Although she does have sensory processing difficulties this should not be considered the only driving force behind her behavioral difficulties or overall developmental profile. In addition she also has apparent intellectual/cognitive impairment, impaired language and communication skills, fine and gross motor delays, and she has a history of multiple foster home placements. She is functioning at a four year level in all of her developmental and adaptive skills. Priscilla requires a comprehensive developmental program to address her multiple disabilities.

1. Review this evaluation with Priscilla's family.

2. Occupational therapy services 3 times weekly addressing motor planning and sensory processing deficits. Consultation should be provided to the classroom staff for developing a team behavioral intervention plan.

3. A strong behavioral management program, informed by use of a team functional behavioral assessment. Some of Priscilla's behaviors are driven by need for escape, others are driven by tangential reward, others are driven by impaired sensory processing. Detailed FBA will assist the team in developing appropriate interventions for targeted behavioral concerns.

4. Consider more in-depth psychological evaluation to elucidate the nature of her intellectual impairments.

After giving the evaluation to the program that made the request, I was a little disappointed to receive a phone call asking me to send a 'sensory diet' to address the child's behavior problems. Although it is true that the child had severe sensory processing problems, in my opinion it would be inappropriate to send along such a 'sensory diet' that was developed out of context from the other team members.

I asked the person making the request if the team had actually read my evaluation, because I thought it was rather clear in recommending a team-oriented FBA approach that would include multiple perspectives on the cause of behavior difficulties. I suggested a 'non-easy button' approach that would require a team meeting to review the behavior problems.

I am acutely aware that I have colleagues who would have been more than happy to suggest that the child needed a prescriptive sensory diet. That would have satisfied the single-point desire of the meaning-making humans who want a quick solution, but I fear that it wouldn't have really helped the child. Sadly, I have found over time that my unwillingness to provide a single point solution has caused people to state "he doesn't believe in sensory integration!" I am not really sure what that means, but it is a criticism I sometimes receive for not providing the single point solution on demand.

I hope that this team agrees to a meeting where we can discuss the sensory processing concerns in addition to all the other complex multi-factorial issues that are impacting this child. In my opinion this child and her family deserve this greatest possible consideration and effort.

Thursday, March 04, 2010

Pediatric occupational therapists: Please check your outrage at the door

I received a lot of email regarding this recent article in the NY Times about occupational therapy. The email I received and online conversations I have scanned included comments like "I can't believe they would say that OT is only for rich people!" or "We need to let people know that this article does not represent what we do!" Although the article got a lot of occupational therapists upset I would like to suggest that we need to perform a reality check on this outrage.

The article comments about how occupational therapy is being used by some more affluent people to promote children's development and how this can be contrasted to a more traditional application of the profession to children who have more severe disabilities. The article offers some incisive opinion that perhaps this kind of trend is a reflection of a larger problem with schools or even a problem culturally with how childhood is being experienced.

Although the online discussions following these articles falls along predictable themes of class warfare - I think that we need to take a closer look at this issue to identify some truths. Maturity, be it personal or professional, includes listening carefully to criticisms and commentary.

I will not spend time feeding the fires of fake outrage. Of course occupational therapists work with children of all ages and impairments. Some even work with healthy children to promote normal development. It is simply the truth.

But let's talk turkey about the realities of pediatric occupational therapy practice:

1. It is absolutely true that there is a population of parents who seek out services for their children who wouldn't otherwise qualify for those services given the entrance criteria for receiving public funded therapies. It is not reasonable and it is not expected and as a society we can not afford expensive therapy supports for every single child. Parents choose all kinds of activities for their children to participate in - sometimes baseball, sometimes martial arts, sometimes summer camps of all shapes and sizes - and YES! sometimes even therapy. Occupational therapists hold themselves out as being experts in child development and they offer evaluations and interventions to help promote that development. This is all true.

2. It is absolutely true that normal market/economic principles apply to occupational therapy. Now here is a real area for some honest professional conversation. People who have resources (and resources should be broadly defined to include access to health insurance, personal finances, time, knowledge, transportation, etc.) are much more likely to spend those resources on products that they perceive hold value. Is it a surprise that you are more likely to find greater access to occupational therapy services in areas where people are willing to part with their resources in order to obtain the service because they believe it to be valuable?

3. It is absolutely true that for all the talk about tolerance and community service on college campuses and even in society a lot of it is simply just talk. As an employer I can tell you with certainty that it is very easy for me to hire occupational therapists if I tell them that they will be working in an affluent suburban area but the moment that I start talking about working in poor urban areas the job applicants scatter and run for cover. Of course there are many therapists who are willing to work in any environment (and I hope I hire them all) but it is very true that multiculturalism is usually only fine if it is restricted to what many people can see happening elsewhere on their flat screen TVs and from the comfort of their own living rooms after work hours. I understand that this is a harsh criticism but I am just going to call it out because I experience these prejudices every day. Please don't deluge me with the exceptions because I already said I know they exist and I hope I hire them all - but I am calling out the fact that this problem does actually exist.

4. It is absolutely true that some occupational therapists feed the access disparity by not participating with insurance plans and by insisting on private pay arrangements only. There are sectors in our pediatric practice where prices are hyper-inflated and feed specifically off of the willingness of parents to 'do anything' that will help their children. From a purely economic perspective it can be argued that there is nothing wrong with this - but I suppose that is up to the ethics of individuals.

5. It is absolutely true that there are cultural forces at work that have changed the nature of childhood play - and consequently have changed the nature of early child development. Although I haven't had in depth conversations with my high school friend about this book that he just wrote I will take the time to give him a plug - I need to take the time to have a conversation with him because I am interested in what drove his interest in the topic. He captures so much truth in these pages that I know will resonate with pediatric occupational therapists everywhere.

So I do not share the collective outrage over the NY Times article. It speaks a lot of truth even if it does not reflect all of pediatric occupational therapy practice. We should be willing to listen to this kind of commentary because then maybe we will mature as a profession and be in a better position to address the points raised in the article.