Saturday, September 28, 2013

Evidence update: Pediatric fecal incontinence and best practices for intervention

Almost seven years ago I wrote a blog entry on pediatric fecal incontinence which is archived here.  In that review I briefly discussed psychological and physiological and regulatory factors that might contribute to the problem.  The evidence at that time indicated that dietary, activity, and cognitive behavioral interventions were most likely to be successful in helping families.

I also discussed a common occupational therapy mythology that sensory processing factors such as preference for deep pressure stimulation might contribute to fecal retention.  There has never been any evidence to indicate that this is a relevant factor.

In the current issue of the American Journal of Occupational Therapy there is an article by Bellefeuille, Schaaf, and Polo (2013) that describes OT intervention for a child with retentive fecal incontinence.  The authors hypothesize that a 3 year old child's difficulty with passing stool is related to overresponsivity to sensory stimulation.  By report, toilet training started at 2.8 years of age when he had to attend a preschool.  The parents were concerned after 4 months of unsuccessful training and according to the article they felt 'pressured' because he needed to be toilet trained for preschool participation.

An assessment included the Sensory Profile which indicated overresponsivity to sensory stimulation.  Occupational therapy intervention began at 3.7 years using an Ayres Sensory Integration Approach.  The authors report that the Ayres Sensory Integration was a useful framework that contributed to the child's improvement.

I have several questions about this article because I believe it represents a rather serious departure from conventional evidence and knowledge on the topic.

To begin with, fecal incontinence is not generally diagnosed in three year old children. At a minimum this diagnosis is not applied until the age of four, at which time a child may be reasonably expected to have completed toilet training and have the ability to exercise bowel control (Mayo Clinic, 2011; American Academy of Pediatrics, 2013). Additionally, at least 20% of developmentally normal children 18 to 30 months of age may refuse stool toilet training at some point (Taubman, 1997). Therefore the core premise of the article that the child had any actual diagnosable condition as would be identified under conventional medical standards is dubious.

A second concern is that the 'objective' data collected as reported in the article is a parent questionnaire about sensory processing difficulties.  Parent reports may be important to help obtain narrative understanding of a clinical problem but they do not represent any direct measure of a child's actual capability in an objective sense.  Additionally, Dickie, Baranek,, (2009) indicated quite clearly that parents don't automatically frame children's activities in sensory terms. Specifically, they state

 "that sensory aspects of experiences are often not noted unless they are unusual (as in having a child who is hyperresponsive to certain sensory situations), or attention has been drawn to them (e.g., through education about characteristics of autism, or by an occupational therapist reframing a child’s behavior in sensory terms)."

Certainly, and as indicated above, childhood fecal retention is hardly an unusual phenomenon and it  does not automatically link to sensory overresponsivity.  It seems reasonable to wonder if the interpretation of the problem was reinforced by the frame of reference of the occupational therapist.

Of additional note is that there was no report of direct assessment of the child that would support the hypothesis that the child had any sensory processing difficulty.  Additionally, no other developmental atypicalities were reported.  If a child had a sensory overresponsivity, wouldn't we expect to see other developmental consequences of the problem?

I am concerned about the concept of providing skilled occupational therapy intervention to three year olds simply on the basis of slow toilet training.   There is no questions that fecal incontinence and struggles to develop toileting skills are a significant point of stress for families, particularly in relation to enrollment in institutionalized day care.  However, individual child readiness has to be assessed across a multitude of factors including child developmental factors, contextual demands, and cultural norms (Brazelton, Christophersen, Frauman, et al (1999).  There is simply no evidence that a sensory overresponsivity construct is an important factor to consider for this problem, particularly in otherwise typically developing children.

It seems irresponsible to suggest that application of a treatment program to an otherwise typically developing child is responsible for progress that one would expect under any circumstance within that developmental period.

Families should always consult with their pediatricians about these concerns to rule out medical difficulties.  The recommendations I made from seven years ago still stand.  Occupational therapists might help families with these difficulties through basic education about healthy activity and nutrition, providing support and information about normal development, and implementing simple cognitive behavioral plans that can be applied across care contexts. This intervention can be provided in time-limited consultation models.


American Academy of Pediatrics (2013, July 9). Soiling (Encopresis). Retrieved at

Bellefeuille, IB; Schaaf, RC; and Polo, ER. (2013). Occupational therapy based on Ayres Sensory Integration in the treatment of retentive fecal incontinence in a 3-year-old boy.  American Journal of Occupational Therapy, 67(5), 601-606.

Brazelton, T.B., Christophersen, E.R., Frauman, A.C., et al (1999).  Instruction, timeliness and medical influences affecting toilet training. Pediatrics, 103, 1353-1358.

Dickie, V. A., Baranek, G. T. Schultz, B. Watson, L.R., and McComish, C.S. (2009). Parent reports of sensory experiences of preschool children with and without autism: A qualitative study. American Journal of Occupational Therapy, 63, 172-181.

Mayo Clinic (2011, Jan 4). Encopresis.  Retrieved at

Taubman, B. (1997). Toilet training and toileting refusal for stool only: A prospective study. Pediatrics, 99, 54–58.

Thursday, September 26, 2013

Are NYS Medicaid audits improperly destroying care systems?

Follow up to earlier post:


New York State Medicaid regulations are a dizzying and complex ruleset that most providers in good faith attempt to follow in their care of people who are Medicaid recipients.

There is an appropriately strict set of rules that most people don't disagree with because naturally we want our State monies to be distributed appropriately and we certainly don't want people fraudulently gaming a reimbursement system.

Undoubtedly, there are examples of fraud and abuse that require strong auditing response and hopefully even referral to the criminal justice system.  We have all heard of stories of providers submitting documentation for services that were never provided, or providers claiming all kinds of illegitimate program costs, and even providers creating no-show Medicaid funded administrative jobs for friends and relatives.  These are the kinds of cases that everyone agrees should demand the attention of the NY State Comptroller's Office or the Office of the Medicaid Inspector General (OMIG).  Every right thinking person wants this kind of real fraud ended.

However, NY State does something much more insidious with its Medicaid auditing that often gets lost or misconstrued when these audits come to public knowledge in the press.

In a recent OMIG audit of preschool services I witnessed overzealous auditing practices that threatened community agencies and a County with several hundred thousand dollars of alleged 'fraud' and 'overpayment.'  The issue had to do with complex supervision requirements of therapists and what constituted evidence of said supervision.  OMIG was not satisfied with co-signature of treatment notes and quarterly review; they were demanding a level of face to face supervision that was not actually required by regulation.  Wanting to be a compliant Medicaid provider, I asked them to please indicate exactly where in the regulations this kind of supervision that they wanted was required, and they referenced the NYS Education Law that describes the legal practice of occupational therapy in NYS.  Thankfully I know that law rather well, and was able to point out that what they were claiming was nowhere to be found in the law or the regulations.

Flustered by the evidence, I recall the auditor stating, 'Well, if I was a parent I would want more supervision' to which I was able to reply, 'Although I highly respect what you would want if you were a parent, what you want is not in the regulations and therapists are required to follow the regulations when they participate in the Medicaid program.'

So it wasn't that the therapists were not being supervised - the issue was how that supervision was documented and how frequently it occurred.  Supervision is never a bad issue to visit or even re-visit, but it is beyond the scope of OMIG to put itself in the position of dictating professional practice on whims of what individual auditors THINK should be happening.  Based on all of this information, the agencies and County did not have to make any 'repayments'

Unfortunately, OMIG has made this claim regarding supervision all over NY State, and who knows how many agencies and Counties rolled over and paid the improper OMIG tribute.  THAT is something that requires some investigation.

I revisit all of this because there is another story in the news today about Medicaid 'overpayments.'  I know enough to understand that you can't take the OMIG report at face value as I have some understanding of the OPWDD adult day treatment population.  I have some concerns about these 'overpayments.'

I want to focus on the largest issue, which as reported is lack of physician signature on an overall treatment plan for day treatment participants.  According to the article (linked) it seems that this is the largest issue uncovered in the audit.

This lack of signature could mean several things.  It could mean that there is absolutely no physician oversight and that the UCP of Ulster County is taking random people off of the streets and billing Medicaid for the services that are being provided.  In this possibility, the UCP of Ulster County is intentionally bypassing the requirement for MD authorization because they were hoping that no one would notice their nefarious scheme to defraud NYS of its Medicaid money.

Someone reading the article might come to that kind of conclusion because they know nothing about the structure of UCP agencies, they know nothing about OPWDD, and they know nothing about adults who have developmental disabilities and how services are provided.  I actually know nothing about this particular UCP agency but I would practically bet my life that this couldn't possibly be occurring.

It is more probable that there is sloppy documentation or perhaps systemic barriers to obtaining the authorization in the way that the regulation requires.  Perhaps there was a period of time when the agency did not have a 'medical director' willing to sign off on all of the care plans for these people.   That would have left the UCP in the position of having to ask the community doctors to sign a mountain of paperwork.  As many of these Medicaid participants receive multiple medically related services (OT, PT, Speech, etc.) it is likely that there is a lot of physician oversight of their participation, but maybe it was not documented on the correct form.  Or maybe they could not get the signature within the specified time period but in fact it is there, or many other possibilities.

Based on my own experience, it could just be that the OMIG auditor didn't like the way that the agency was getting physician signatures or did not like that the signature was present on a face sheet instead of an actual document.  OMIG has a history of being overzealous.

Here is the reality that the OMIG auditors and the general public are not considering.  People who attend OPWDD day treatment facilities are extraordinarily disabled.  They have significant intellectual disabilities and there is NO CHANCE that if you met one of these people that you would not be able to IMMEDIATELY figure out that they were disabled.

In NY State we have made a public covenant to provide meaningful active treatment for people who have developmental disabilities.  We made this covenant in response to NYS malfeasance in its care.  That is so we don't allow people to remain locked away in developmental centers in the so-named SNAKE PITS of Willowbrook and other institutions.

Now we have community agencies like UCPs that provide (hopefully) meaningful active treatment that respects the dignity of human beings, despite their developmental disabilities.  How ironic is it that we have NY State through its OMIG enforcement arm acting as some arbiter of justice regarding care of these people?  Why is UCP being threatened with severe financial losses and perhaps shutdown if they have to pay back all of this Medicaid money?  Was that money REALLY ill-gotten - or is this indicative of administrative and technical difficulty with complying with complex Medicaid rule sets?

Listen, maybe a head needs to roll at a UCP if there is a dereliction, or maybe they need to get smacked with a fine or an oversight process, and DEFINITELY there needs to be some more correct understanding of what exactly the problem with the physician signatures is.  However, there DOES NOT need to be a confiscatory removal of funds that jeopardizes the program for these people - who undoubtedly NEED IT - whether the physician signature was on the correct form or not.

Here is the solution to the problem: I propose that for every day treatment program that OMIG shuts down on technicalities and NOT on actual malfeasance, that those individuals in the programs be bussed to the OMIG offices so THEY can provide a day treatment program and comply with all of the technical rulesets.

Does NY State really want to shut down community agencies that provide care to people who have developmental disabilities?  If there is actual fraud and abuse then I have no quarrel - but based on my experience I am very concerned that this has more to do with an ill-conceived revenue generating scheme that is being perpetrated upon the most vulnerable people in our State and on those providers who are attempting to provide care.

People with developmental disabilities need your voice.  Ask your representatives if OMIG is shutting down agencies for real fraud - or if they are just beating upon vulnerable and politically weak groups that can't fight back.

We want OMIG focusing on the real fraud, and we want a legitimate process that ensures regulatory compliance without threatening the care systems of vulnerable populations unnecessarily.

Wednesday, September 18, 2013

The influence of William Morris and the Arts and Crafts Movement on Occupational Therapy

n.b. ongoing series related to a study of George Barton, founder of the Occupational Therapy Profession.

By my reckoning, it is probably impossible to conduct a study of an event without studying the context in which that event occurred.  Here I suspect that occupational therapy colleagues reading this will understand the bias of the author as he attempts to become a historian.  As clinicians we have well established practice frameworks like the P-E-O model (Law, Cooper, Strong, Stewart, Rigby, & Letts, 1996) that explicitly state that the behavior can’t be separated from its contextual influences. Additionally, this model re-introduced the importance of history-taking for establishing personal contextual relevance for clinical reasoning. Similarly, the Lifestyle Performance Model (Velde & Fidler, 2002) takes a congruent approach by completely embracing phenomenology as being the only possible method for understanding the personal contextual relationships between an individual and the occupations that they engage in.

So it is with this bias that I approached this task of re-constructing fragments of information so that I could better understand why George Barton was the man that he was.

As indicated in the last entry, we know that Barton was born in 1871.  We know that his father was a banker and that his family had some connection to other famous Boston families.  He studied in the Boston public schools and at that time architectural education was accomplished primarily through apprenticeship as formal training programs in Universities were just beginning to be formed.  At that time it was common for parents to secure an apprenticeship for their children and that model of pupillage, in combination with emerging organized architectural education, was a primary means for entry into the field (Crinson & Lubbock, 1994).

Several sources document that Barton was sent to London, England where he was apprenticed to William Morris and other notable Victorians including Sir Hiram Maxim and Henry James (Gifford, 1989; Licht, 1967).  At that time, the effects of industrialization on local artisans was profound in that machinery was replacing the handiwork of craftsmen and textile workers.  William Morris was a leading figure in the Arts and Crafts Movement which was a response against industrialization and its impact on Victorian interior design.  A classic Morris quote that captures the spirit of the movement and is oft-repeated is

If you want a golden rule that will fit everybody, this is it: Have nothing in your houses that you do not know to be useful, or believe to be beautiful.

When considered within the context of classic Victorian interior design, it is easy to understand the simple messages embodied within this statement.

William Morris was passionate about Illumination Manuscript and apparently introduced Barton to this art form.  This is a sample of original Illumination artwork created by Barton that was found amongst some of his possessions:

On the back of this artwork are some notes written by his wife, Isabel (Newton) Barton:

I was unable to find any evidence of Barton artwork or design that has ever been previously published.

George Barton was strongly influenced by Morris, and when he returned to America he became the first secretary of the Boston Society of Arts and Crafts.  The purpose of this Society as reported by Eaton (1949) was as follows:

The Society of Arts and Crafts is incorporated for the purpose of promoting artistic work in all branches of handi­craft. It hopes to bring designers and workmen into mutually helpful relations, and to encourage workmen to execute designs of their own. It endeavors to stimulate in workmen an appreciation of the dignity and value of good design; to counteract the popular impatience of Law and Form, and the desire for over-ornamentation and specious originality. It will insist upon the necessity of sobriety and restraint, of ordered arrangement, of due regard for the relation between the form of an object and its use, and of harmony and fitness in the decoration put upon it.

The Society was incorporated June 28, 1897. It is still in existence today.

Upon completion of his apprenticeship, George Barton worked in the architectural firm of Cram, Wentworth, & Goodhue, of Boston.  Around 1895 he went on a tour of England and France, with the special purpose of studying the domestic and church architecture of the smaller cities and towns (Brochure Series, 1895).

Early in his career he won the Shattuck Prize for Industrial Homes (Barton, 1947).  In 1902 Barton partnered with R. Clipston Sturgis and together they formed the architectural firm of Sturgis and Barton which continued until 1907 (AIA, 1914). 

This is the known history of the beginning architectural and design work of George Barton.  His interest was nurtured through apprenticeship in England and he was significantly influenced by Morris and the Arts and Crafts Movement that he brought back to the United States, where it still persists today in both the occupational therapy profession as well as in the Boston artisan community.


American Institute of Architects (January, 1914). R. Clipston Sturgis, President of the Institute.  Journal of the American Institute of Architects, v.2, 5.

Barton, I.G. (1947, May 16). "Talk Given Before the Western New York Occupational Therapy Association at the Clifton Springs Sanitarium."

Crinson, M. & Lubbock, J. (1994). Architecture: Art or Profession - 300 years of Architectural Education in Britain. Manchester, UK: Manchester University Press.

Eaton, A.H. (1949). Handicrafts of New England. New York: Harper and Brothers Publishers.

Gifford, F. (1989, May 23). Historian's Corner: George Barton - The Man Who Wouldn't Give Up. The Community Trader, p.7.

Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996).  The Person-Environment-Occupation Model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63, 9-23.

Licht, S. (1967). The founding and founders of the American Occupational Therapy Association. American Journal of Occupational Therapy, 21 (5), 269-277.

Morris, W. (1880, February 19). "The Beauty of Life," a lecture before the Birmingham Society of Arts and School of Design.

The Brochure Series of Architectural Illustration (1895), Personal, p. 109, Boston: Bates and Guild. 

Velde, B., & Fidler, G. (2002). Lifestyle Performance:  A model for engaging the power of occupation.  Thorofare, NJ: SLACK, Inc.

Saturday, September 07, 2013

When the fishing is good but the catching is bad.

I personally always fished with worms, or occasionally newts - but I am no fisherman and my knowledge of this occupation is restricted to the things a young boy would gain by spending summers casting into the Hudson River more for a way to commune with friends than for the sport.  Back then it never really mattered what we caught or even if we caught because the occupation was directed toward the social experience.  Besides, there is nothing worse than having to get a river eel off of your line.  Gross.

Anyway, I was preparing a lecture and the concept of 'emerging practice area' ran across my radar screen.  This is certainly nothing new in OT.  The word 'emerging' seems to be an interesting buzzword in occupational therapy right now and it is applied across many contexts.  There are 'emerging leaders' and there are 'emerging practice areas' and there are 'emerging fieldwork sites' just to name a few.  It must be important because there are even ACOTE standards that demand that accredited educational programs promote 'emerging' practice areas.

Sometimes words are used so frequently that there is a risk of just accepting the word without really doing much diligent investigation into why we are using the word.  I think that might be true with the concept of 'emerging' things.

'Emerging' sounds good, mostly, and generally evokes images of forward thinking or being innovative.  In the OT literature the word is often accompanied by 'niche' which makes me think of ideas that are small but valid.  So the concept of emerging niche actually seems kind of appealing, at least from the perspective that it might be kind of nice to find some things that are not easily noted but might be growing in significance.  Being 'cutting edge' is generally a positive attribute, so these words evoke some connections to other words that might seem to be good things.

If you try to trace back the use of the word 'emerging' as it relates to OT I think it is mostly fair to state that the AOTA Centennial Vision process really kicked off the use in its present context.  That is not to say that OT hasn't talked about future-thinking before - but just that the use of the word 'emerging' in so many contexts was spurred largely by that visioning process.

I have indicated previously that I am a pragmatist in my heart.  I spend time looking at the 'emerging practice' information because I am always wondering how we wed the intention of future planning to the realities of what we are demanded to do on a daily basis in our work.  It interests me that the Centennial Vision document specifically identifies misalignment between priorities and the external environment as a point of barrier.

As an example, under the Children and Youth heading of the AOTA website there is a tab for 'Emerging Niche.'  That tab has topics under it like childhood obesity, use of RTI models, bullying, and other topics.  All of these are interesting topics and they impact the occupational performance of children, but they really don't represent the efforts of what most practitioners are doing in their daily jobs.

So who determined that these areas were 'emerging' and others were not?  Are we using evidence to determine what is emerging?  Are we using evidence to determine if practicing OTs are really that involved in these areas? 

I recall an interesting conversation on the OT Connections site where the notion of strategic planning and the Centennial Vision was being discussed.  The issues discussed were whether or not it was correct to strategic plan on needs or to strategic plan solely on where you want to go.  It is a legitimate debate, but I believe that the best strategic planning has an important element of pragmatism.

You see, without that element of pragmatism, we run headfirst into misalignment between priorities and the external environment.  This creates a large problem, in my opinion.  Specifically, while we cast our line out and fish around for issues related to obesity and bullying we are actually catching severe problems with reimbursements and service delivery structures.  So the fishing is good but the catching is bad.

I have been trying for about two years to get the river eel of New York State's failed early intervention program off of my fishing line.  It is slimy and gross.  When I look over to my AOTA buddy's efforts all I see are 'emerging niches' of bullying prevention.  Are some folks catching bullies and doing great work???  They sure are!  But what are we doing about the slimy river eels on our lines?

It is not just AOTA though.  For months I would look over to see what NYSOTA is doing about the early intervention problems I have documented for a couple years now and although there are some johnny-come-lately efforts you were more likely to see tons of pictures about some marketing effort of taking pictures of some branded multicolor hand thingie as you were to see even a single picture and a story of some sad therapist turning the sign on the front of her early intervention business to where it reads "CLOSED."  That has changed recently, and that is good, but now it is too late.

This is misalignment between priorities and the external environment.

We all have responsibilities for this.  Outcomes are not measured by the integrity of our intentions.  Outcomes are measured by what actually happens.  I am acutely aware that banging the drum on a blog is not solving the problem either, so I am taking other steps to try to solve problems.  I have been meeting with my legislators myself.  I am educating parents about these issues even more directly.  I am trying to collaborate and team with others in my community that are facing the same issues.  I am even changing my lecture topic content.

We can walk and chew gum at the same time.  So, I can talk about 'emerging' practice but I can also talk straight about what is real and happening in the field now.  If educators fail to talk about what is real then all we will accomplish is promoting a bunch of disconnected graduate and doctoral projects on childhood obesity or bullying that have no traction beyond the demonstration project level.

The point is to serve the needs of people, not to endlessly prop up our own good intentions with non-viable ideas.  Honestly, how many AOTA poster sessions and student projects will we actually see about the role of OT with homelessness or domestic violence shelters before we realize that virtually no one is actually working in those areas?

Again, I want to point out that this kind of visioning about emerging areas is not bad in itself, but it really does increase the risk of distracting us from really important everyday concerns that are right in front of our faces.

I think there is great risk in this posting because I don't know if the notion of how fishing is good but catching is bad will resonate.  I was thinking instead of writing this around the Aesop's parable of the milkmaid and her pail.  She daydreamed endlessly and spilled her milk before she ever got to market - the moral being the same as my fishing analogy.  It is a little simplistic so I hope the fishing analogy is more apt.  You can legitimately think about it either way.

We just need to have some pragmatism.  Or at least a little more than what we are currently employing.