Monday, August 15, 2016

Time to throw in the towel on sensory processing assessment

Today's Wall Street Journal includes the standard article in its Life/Health section on Sensory Processing Disorder that we are all accustomed to seeing published every six months or so.

The general idea of these journalistic offerings includes the standard trope of expert occupational therapists who can identify a disorder that the medical community can't quite agree on.  It also includes the standard ethical bombshell that occupational therapists can't bill insurance for this therapy and that the costs are $175 per session and are needed for 18 or 30 sessions, depending on who you ask.  Maybe it depends on credit card limits in different geographic localities, I am not sure.  The fact that the cost for this therapy can range from $3000 to $5000 is in itself a red flag that should make most parents squeeze their wallets shut and run for the hills.  The fact is that there is no consensus on frequency of these interventions and there is also no consensus if this 'intensive sensory' approach has any merit.

None of this is to say that some children don't have difficulties that can impact their behavioral regulation or motor skills.  The problem is with the never-ending profiteering off of the 'problem' when there is no evidence to support the intervention.  In the interest of full disclosure, I see some children in my practice with behavioral and motor difficulties.  The difference is that we only bill what the insurance will pay for, which is generally $50 or so a session.  We also only see most families once weekly for a few months for consultation, home programs, and education.  We use cognitive-behavioral and motor learning strategies that are evidence based.  We use this model of consultative empowerment and evidence based practice because we find it to be accessible to families and we also find it to be effective.  We also use this model because in the absence of good evidence for sensory-based interventions this seems to be reasonable and conservative.

The occupational therapy profession is wholly responsible for perpetuating a message about sensory processing assessment and interventions that in my opinion is irresponsible and unethical.  An example is noted in the just published article "A Review of Pediatric Assessment Tools for Sensory Integration" that was published in the American Occupational Therapy Association's SIS Quarterly Practice Connections.

The purpose of the article was to "provide clinicians with a current, comprehensive list of robust pediatric assessment tools specific to sensory integration."  A case example was included in the article.

Of the nine assessment tools listed in the article, four are either 'in development' or 'used in research/not clinical settings.'  That takes us down to five.

Of the remaining five, two are parent report instruments that are subjective and not an actual measure of child performance.  That takes us down to three.

Of the remaining three, one is not a measure of sensory processing at all, and in fact is described by the publisher as a test of functional motor skills.  That takes us down to two.

Of the remaining two, one is a criterion measure based on a convenience sample of only 130 children in a single geographic region.  The other was normed on 85 children in 2005.

The biggest offense in this article is that the case study discusses the use of one parent report instrument, a questionnaire not listed in the article, and also the Sensory Integration and Praxis Tests, which was also not listed as a recommended assessment.  Maybe it was not listed because it was published over 25 years ago and has outdated norms which are no longer appropriate for clinical use.  It is confusing that it would be used as an exemplar of sensory processing assessment in the case study.

Nine years ago I blogged about how the SIPT was outdated.  In that post I commented that I had hope that the partnership between USC and WPS would lead to new norms and a more robust certification process.  Now that those two organizations have severed ties it seems that won't happen.  I figure that a school like USC can't really associate itself with a product that is so outdated, but the reasons given for the split were kind of vague.

People may argue that science takes time and that there is a compelling reason to be patient but the fact is that there is no current mechanism to assess for sensory processing disorder, even if such a construct exists separate from other identified disorders.  Clinicians have been very patient.  More importantly, so have families who are relying on clinicians for guidance.  Research into a distinct sensory processing disorder construct has been going on for over 40 years and the best that we have in 2016 is a list of clinically irrelevant tools, continued promises that more things are 'in development,' and exemplars of outdated assessments.  Time to throw in the towel.

Most clinicians, even those skeptics in the medical field, understand that some children have anxiety, dysregulation, and even some motor planning difficulties to varying degrees.  Those problems undoubtedly can impact functional skills.  That is not what is controversial.

What is controversial is the idea that there is some distinct sensory processing disorder construct and some specific sensory-based intervention.  The reality is that we do not even have a way to assess for what some occupational therapists are claiming exists.  The scarier reality is that we do not even have a consensus on what 'sensory processing disorder' even means.  At best all we have is the belief that something exists because parents describe concerns to us on standardized questionnaires.

We have seen enough articles in the popular news press discussing the problem that only occupational therapists know how to identify and treat.  We have seen enough of the $175 per treatment session that can only be paid privately because insurance doesn't reimburse for experimental or controversial interventions.

Now it is time to turn the page, examine the research on anxiety and regulation and motor learning that is not so controversial, and find conservative evidence based interventions that insurance companies pay for and our medical colleagues accept.


(embedded links, and...)

Mori, A.B., Clippard, H., del Pilar Saa, M., and Pfeiffer, B. (2016 August). A review of pediatric assessment tools for sensory integration. SIS Quarterly Practice Connections, a supplement to OT Practice, 1(3), 7-9.