Sunday, April 28, 2013

Mixing up chickens and eggs: A response to Fleming-Castaldy and Gillen

In the recent AJOT Fleming-Castaldy and Gillen wrote an interesting article entitled "The issue is: Ensuring that education, certification, and practice are evidence based."  In the article, they examine why outdated neurophysiologic techniques are promoted in the profession of occupational therapy as opposed to more current and evidence based motor learning and motor control theories.  They argue that outdated models based on Bobath and Brunnstrom have no place in contemporary practice.

In spirit I agree wholeheartedly.  There are many techniques that are still present in contemporary practice and we hang onto those techniques even in the face of mounting evidence that other models are more appropriate.  I have spent considerable time in this blog discussing this issue as it relates to certain sensory-based approaches and the very limited evidence that exists for their continued promotion and use.

Toward the end of the article they suggest that educators need to critically appraise their curricula, that textbook authors need to thoughtfully consider what they are including in texts, and that NBCOT needs to consider their exam development methodology.

They do not mention any role for the professional association (AOTA) outside of a general reference to ACOTE standards and I think this is a serious error.  This weekend at the AOTA conference I attended a special interest section workshop that promoted three pediatric sensory based interventions that have virtually no supporting evidence.  One of those interventions was a very controversial listening/auditory method that has been labeled experimental by other important professional associations.  I believe that our professional association has a direct responsibility to promote higher quality presentations at the national conference that reflect consideration of evidence - particularly when those presentations are coming out of the special interest sections of the association.

I have experience with certification examinations so I wanted to address several incorrect statements about the role of a certifying body.  These are my own opinions and I am not speaking for NBCOT as I am no longer on their board.

Fleming-Castaldy and Gillen state that outdated material regarding neurophysiological approaches appears on the certification examination and in the reference texts that are used to create the examination.  They further state that educators feel compelled to teach that material because they want their students to pass the examination.  These statements are begging the question based on the incorrect assumption that the certification examination drives educational content.  This is a serious logical fallacy.

In actuality, NBCOT generates its list of references based on a survey of EDUCATIONAL PROGRAMS and TEXTBOOKS THAT EDUCATORS ARE USING IN THEIR CURRICULA.  The list of textbooks is not created out of whole cloth and the point of origin is not NBCOT.

Evidence takes on many forms - including what is written in textbooks and what is anecdotal to practice.  I fully agree that this is not the best evidence but a certification examination has the responsibility to reflect actual practice - even when actual practice is ignoring higher level evidence like research studies.  It is a conundrum to be sure. 

Items appear in the practice analysis and are ultimately reflected in an examination blueprint based on the criticality of responses from entry level practitioners.  In other words, entry level practitioners are using those techniques. If they are using those techniques it is not because they appear on an NBCOT reference book list.  They are using those techniques because that is what they were taught and that is what they see in the field.

Therefore, the correct origination of content is the academic program and the field.  NBCOT uses references based on feedback from programs about the texts they are using and by responses of entry level practitioners.

Furthermore, Fleming-Castaldy and Gillen state that NBCOT practice analysis survey respondents may not have updated their practice and may not be using evidence.  This is a factually incorrect assertion because the 2008 practice analysis was given to practitioners who worked only from 0-36 months.  If practitioners who completed the survey don't use evidence based practice it is not because they haven't UPDATED their methods; it is because they were never educated in those methods OR if they were educated in those methods then they chose to abandon them when they entered practice.  That has nothing to do with practice analysis methodology - that is a problem in the field.

It is important to raise this question about why there is a hesitancy in our profession to abandon methods that lack evidence and I congratulate the authors for raising an important issue.  However, I believe it is important to point out some errors in their analysis as well as to assign greater responsibility to the professional association.  The certification examination is a lagging indicator that is downstream of many other problems including broad professional tolerance for outdated methods, teaching outdated methods in occupational therapy curricula, lack of AOTA guidance about abandoning outdated methods, and poor textbook writing.

There would be an appropriate hue and cry if a certifying body suddenly took it upon itself to unilaterally dictate the standards of what the profession was supposed to teach and practice.  Certification examination development is a mirror of the profession - and nothing more.  The best that a certification body can do is HOPE to indirectly influence practice by promoting evidence (e.g. offering free database access to all certificants).  They can't directly drive that process - that is the responsibility of the profession itself, and that includes its educators and its practitioners.


Castaldy-Fleming, R. and Gillen, G. (2013).  The issue is: Ensuring that education, certification, and practice are evidence based.  American Journal of Occupational Therapy, 67, 364-369.

National Board for Certification in Occupational Therapy (2008). 2007 NBCOT Practice Analysis.  NBCOT: National Board for Certification in Occupational Therapy

Thursday, April 11, 2013

A reminder about human agency and self reliance

There has been some noise and distress in social media circles with the recent advertisement run by MSNBC regarding 'who should be responsible for raising children.'  Here is the video:

This academic/pundit has since walked back some of her comments, stating that people just didn't understand the nuanced nature of what she was saying about 'collective' efforts in raising children.

I suppose that if she wanted her message to be that we need to 'build a world together' that she should have said that in the original message instead of a bizarre statement that we need to 'break through our kind of private idea that kids belong to their parents.'   Most parents I have spoken to about this weren't impressed with being informed that they just weren't nuanced enough to  understand the original message.

This is an issue that directly relates to therapy services for children because we are at a point in time where it is becoming increasingly evident that we don't have resources to support all of the social programs that (as a society) we want to support.  People have values to provide social safety nets, but all the recent posts about the early intervention program in NY State should provide ample evidence that the government just can't support what it has promised.

People don't seem to like that.  I have seen anger and lots of blame being tossed about - and none of it seems to be particularly constructive.

Very liberal voices, represented by this MSNBC pundit, seem to argue that the solution will be to tax people more and to grow our programs more and place more responsibility on the State for providing these services.

But the State can't do this any longer.  And getting angry about that fact is not constructive.

Also, we have to consider what the State's record is in taking care of people who have disabilities.  We need to remember our history.

That does not mean that we eliminate social safety nets.  It certainly does not mean that we don't expect help from each other.  However, we need to rethink our model because although 'It might take a village' in some cases, that doesn't mean this will be the de facto methodology for handling every situation because that philosophy is no longer sustainable and even more importantly that philosophy robs people of the opportunity for dignity through self-reliance.

Dignity through self-reliance is actually important when it comes to occupational therapy theories.  Fifty years ago (!) Mary Reilly asked us if America was the place and if the 20th century was the time to determine if our profession was going to serve what she called 'society's need for action.'  Mary Reilly  believed that our service was meeting needs and facilitating action, productivity, and human agency.  She did not suggest that meaning was arrived at through collectivism, but rather as a result of a person's need to master their environment - to alter and improve it.

Is it not curious that we are so willing to abandon that philosophy now when we are structuring care delivery systems and making recommendations for services?

 We have arrived at a pragmatic point of decision and we have to decide what our care systems will look like and how they will be structured and delivered.  It is a good time to reflect on Mary Reilly's wisdom and to remind ourselves of our philosophical core.

As a start, we need to reject the expectation that our municipalities will be able to be the never-ending source of programming effort and resources.  The pragmatic barrier has been reached and the evidence is that we can't afford that model.

We need a re-designed service delivery model that has at its core a requirement for family investment and that promotes action, productivity, and human agency.

I define investment as requirement for time, energy, interest, participation, and cost-sharing.

In my opinion, entitlement programs as currently constituted do not mandate parental investment.  As such they rob families of agency.  It is common for children to receive OT services in the schools and for therapists to have only nominal contact with the family.  That is not a recipe for shared responsibility for outcomes and it is not a recipe for promoting human agency.  Therapy provided in a 1-2x per week model with little or constricted opportunity for classroom and home carryover is a poor model.

Of course some therapists have release time or make extraordinary efforts to communicate with families but as a whole these are the exceptions and not the rules.  This is not so much the fault of the therapists who I am sure would LIKE to communicate more with families; rather it is the fault of a system that is poorly constructed and does not promote this communication.

As for early intervention and home-based CPSE services, I believe that we should stop perpetuating the mythology that providing a service in the 'natural environment' is the de facto best model.  Last week I did a home visit for a baby who has torticollis - and the condition is complicated by the fact that the child is restricted to a 6x8 carpeted area bounded by a sectional couch, a 55 gallon aquarium, and a 60" TV.  The child sits with a kyphotic posture and head laterally tilted from floor level all day long so he can see the TV and aquarium.  The parent has been instructed in modifying the environment but has been unable to make changes for a variety of reasons including inertia, lack of interest, and blaming the spouse.  For another child, the tiny trailer that the family lived in had clothing, garbage, toys, and Kix cereal strewn all over the play area and there was literally no where to even sit on the floor.  The parent takes the time that the therapist is present to attend to Facebook and cell phone texting.  Both families do not carryover, obtain little to no benefit from the 'natural environment,' and receive their services for free and are clearly not invested in any way.  They have been robbed of human agency through models of collectivism and entitlements that are delivered for free directly to their front doors.

There are some families where the old EI/CPSE models work well but that is not a function of the natural environment; it is a function of the family's investment in spite of the entitlement culture.

I see children and families in my private clinic also.  The children and families that I see come from an extraordinarily diverse socioeconomic and cultural background.  Some receive public assistance and have Medicaid; others have private insurance or have the financial resources to private pay.  No matter what their culture or socioeconomic differences are they all share a common core trait: they WANT their child to receive therapy, they WANT to listen to therapist recommendations, they TAKE THE TIME to make appointments and keep appointments at a community-based private clinic, and most importantly they all FOLLOW THROUGH on recommendations and are highly invested in what I call a 'parental empowerment' model of service.  That model of service is oriented toward LOW FREQUENCY consultation (often only once a week) and HIGH INTENSITY parental consultation and home programs.  This model of service promotes agency and self reliance.

The services that children receive in my clinic are extraordinarily less expensive than home based or school based models.  Additionally, the families who are invested have significantly better outcomes.  THEY set the goals and then THEY invest the time to make them happen.

Because there is no 'investment metric' for families entering into entitlement programs that is why I would not mind if those systems imploded.  That would leave families who really wanted the services to find ways to pursue and obtain the services.  Providing services, or anything for that matter, with no requirement for investment only serves to reinforce ongoing dependency and lack of progress.

Because families may be at many different phases of understanding the criticality of their investment and participation, traditional services (as currently constituted) should be provided on a time limited basis with the primary goal of education regarding the importance of parental investment.  Then it should be up to them to follow-through - and obtain those services under a different model that mandates their participation and promotes their human agency.

I suspect this would be considered radical - but that is only because we have loud voices in our public discourse that state that parents don't need to be responsible and that the village will take care of any concerns.

We need to counter those voices by reminding ourselves of the power of human action and agency - and of the power of self-reliance 

I believe in social safety nets and I believe that we need to help families find ways to become more invested.  To become more self-reliant.

I DON'T believe that we are doing much to  empower families using our current models - and in that sense we are really only serving ourselves by chasing the unsuccessful notion that the village is somehow better positioned to solve problems of individual human agency.

It is time that we all read that Slagle lecture again.


 Reilly, M. (1962). Occupational therapy can be one of the great ideas of 20th century medicine. American Journal of Occupational Therapy, 16, 300–308.