Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Thursday, February 19, 2015

Occupational Therapy in New York Schools: Expensive, But Not Evidence-Based

An article in yesterday’s New York Times bore the headline “Occupational Therapy Increases Sharply in New York’s Schools: Methods Improve Focus and Motor Skills” (www.nytimes.com/2015/02/18/nyregion/new-york-city-schools-see-a-sharp-increase-in occupational-therapy-cases.html). [There’s a curious contrast right there, as the article actually concentrates on the use of OT methods, not the number of “cases” that need them.]

The Times article, by Elizabeth Harris, begins by describing the “tools” of occupational therapy being used in a first-grade classroom. These were small plastic armchairs, a tight vest that provides pressure to the child’s chest, and a weighted, velvety blanket. Accompanying photographs showed a child on a trampoline and others playing Jenga, a game involving stacking wooden rods and keeping them balanced. Bumpy cushions that demand efforts to balance were mentioned later, as were other methods of strengthening specific muscles and practicing perceptual skills.

The techniques were described as a possible alternative to medication like Ritalin that may be helpful to children with real attention problems. In addition, the article quoted an educational consultant as saying that parents who were applying to private schools for their children were sometimes putting the children into occupational therapy programs as preparation. She commented, “Here [in New York] you have accelerated or demanding curriculums, so they put them in O.T.to bring them up to speed…. They want to enhance their basic skills. New York is a fast-paced city, and sometimes they don’t want to wait for the child to develop the skills they may need.”

Do children develop improved skills as a result of these or other occupational therapy methods? As evidence of the effectiveness of these methods, another photograph in the Times displayed a nine-year-old’s handwriting samples from February 2014 and May 2014, describing the second one as “after occupational therapy”. The samples looked pretty much the same, except that on the first one the child had written not only between small lines, but in much larger letters in an unlined space; the second sample showed only letters written between lines. The first sample did show a larger number of tall letters that crossed the lines above them than the second one did.

It’s not very surprising that a 9-year-old could develop somewhat improved handwriting over a two month period, whether receiving “treatment” or not, and neither is it surprising that a child might write somewhat differently at different times, even if the times were on the same day. But when people conclude that treatment must have caused any changes that occur, we see the post hoc, ergo propter hoc error so common in educational thinking--  the belief that whatever changes have occurred in a child after some experience, they have occurred because of a treatment or because of instruction, not because of the natural course of maturational change. It’s not surprising that teachers think this way, because after all it’s their job to provide instruction that is intended to bring about large, important cognitive changes, and their focus is on what they do to contribute to the child’s development. Parents too tend to concentrate on what they should or should not do.

But if we’re really to understand how development works, and what interventions are effective, we have to differentiate between the effects of treatment or instruction, and the changes that occurred during a time period because maturation continued along its normal lines whether  a treatment was taking place or not. That means that in order to know whether bumpy cushions, vests, weighted blankets, etc. change a child’s abilities and behavior, we have to investigate this in a systematic way, not just display a couple of handwriting samples. Because human beings are different from each other, we need our study to include a large number of children. Because people can respond differently to treatments they have chosen than to other treatments, we need to have children randomly assigned to treatments, not just given the ones a parent or teacher wants. Because special attention or activities may have a positive effect on a child, we need to be sure that the children in our study who are not receiving occupational therapy do get some comparable set of experiences of attention and play. Only by following these guidelines will we be able to tell whether changes that follow occupational therapy, if any, are actually caused by the treatment.

As it turns out, there have been very few studies that have met these requirements. As a result, the occupational therapy techniques discussed in the Times article have never been demonstrated to be effective. This does not mean that they have been shown to be ineffective. Nor does it mean that they have been shown to be harmful (although indirect harm is certainly done if a child is given ineffective treatment when effective treatment exists). However, the absence of supportive evidence does raise serious questions about the 58 million dollars apparently spent by the city of New York for 42,000 students, often under circumstances where a child might cope well if not required to behave like someone a year or more older.
I should point out that the techniques discussed in the Times article are not the entirety of occupational therapy. Occupational therapists do a wide variety of tasks, ranging from helping prematurely-born infants learn to nipple-feed, to working with stroke patients. The techniques mentioned above, like pressure vests and weighted blankets, are part of a treatment called Sensory Integration Therapy (SIT).

SIT is based on a theory of sensory integration offered in the 1960s by the occupational therapist A. Jean Ayres. Ayres posited that many cognitive and motor problems result from difficulty with organizing the many sources of sensory stimulation each of us experiences. She saw the organizational difficulty as resulting primarily from problems of vestibular and tactile sensitivity, which she considered to be the foundation of perceptual and motor organization. Ayres felt that providing extra or modulated tactile and vestibular experiences could guide the developing perceptual and motor system toward better integration. This was the basis of the use of weighted vests, swings, trampolines, and so on as treatments for children with various handicapping conditions. Awkwardly for SIT, the vestibular and tactile systems are the first to become myelinated and thus to have mature communication in the nervous system, and as a result are not shaped by experience in the same way as vision is. SIT is not a plausible intervention for that reason. In addition, there is little empirical evidence to support such treatments for autism, for cerebral palsy, or for attention problems--  and certainly none to support the use for attachment disorders found on some Internet sites.

One more point: the educational consultant quoted by the Times article spoke of OT methods being used to “bring children up to speed”. She presumably was referring to children well within the normal range, whose parents wanted them to match a curriculum, rather than looking for a curriculum to match the child’s needs. Can a normal child’s development be hastened in this way? There is no good evidence to suggest that it can, and if we look at other aspects of development, there seem to be suggestions that it cannot. For example, giving children extra Vitamin C has no useful effect, as the extra is excreted in the urine. Poor nutrition slows growth in height and can reduce adult stature, but extra good nutrition does not speed growth beyond the rate seen with adequate nutrition. Just as children only need “good enough” parents, they only need “good enough” nutrition or “good enough” instruction to allow them to develop at their own best rate. Children can be harmed by an environment that is not “good enough”, but if they are developing normally, extra food or instruction will not result in “extra” development.    



14 comments:

  1. Dr. Mercer,

    You write here that, "SIT is not a plausible intervention" for sensory processing problems and that "there is little empirical evidence to support such treatments for autism..." I'm wondering what interventions or treatments, if any, have been shown to be effective in addressing the motor delays and sensory differences typical for children with autism?

    My son (at age 4 1/2) has a provisional diagnosis of ASD; he is very high-functioning, if he is indeed "on the spectrum" and not simply a bright, shy, quirky boy. But he was born 6 weeks early and we have struggled with his sensory differences his whole life--many food textures make him gag and vomit; he is very clumsy/wiggly and seems to not know where his body is in space; he is hypersensitive to loud noises, which impacts his ability to play with other children his age; he is behind his peers in his fine- and gross-motor development, etc.

    The only treatment to address these challenges suggested to us by the medical professionals we've met on our autism journey was occupational therapy; the only approach used by the occupational therapists we've seen has been some variation of SIT.

    Is there something we're missing? What else could we pursue?

    Thanks,
    Kelly

    ReplyDelete
    Replies
    1. I am very sorry to say that there are no evidence-based interventions for the problems you're describing. And like you I would not care to say whether this is just a big set of individual differences or whether treatment is really needed. I know you'd like to have some way to help him with the things that interfere with fun and learning, like the oversensitivity to sounds.

      Unfortunately, I think, OTs doing SIT have moved in to fill the gap where parents want treatment for both mild and serious problems of the kind you describe. This has become sort of like Gresham's law ("Bad money drives out good") for child development. Medical professionals know SIT exists, they know it's probably not harmful, they have nothing else to suggest, so they recommend it when parents ask for help .

      Have you had experiences with SIT? If your son enjoys it, there's no reason to stop. But some of the eccentricities you describe may just be part of who he is, although they may moderate with age and you and he may find some workarounds-- you probably have already done so about the food issues. Other than that, I can only think that perhaps physical therapy would be helpful for the motor development, but it may be difficult to find a PT who is skilled in that kind of work and willing to deal with a wiggly child.

      Wish I could be of more help!

      Delete
    2. I am, also, very interested in this. As you know, my daughter (22 months) is delayed and while we have not gotten a diagnosis yet, she definitely had sensory issues. She share hyposensitive to pain, although thankfully not to the point of serious injury. She just send like a really tough little cookie lol. She is very motor driven and send to seek out sensory stimulation. Since she started walking the only time I've seen her sit and focus on one activity was at the beach, in the sand. I never thought they'd be a day I'd say the beach with a toddler was relaxing. But that was wonderful, not having to chase her everywhere. More concerning, though, is she seems to have pica. So I'm wondering what I can do to help her slow down a little, not eat everything, and maybe learn to talk lol

      Delete
    3. Hi Ginger-- I think that of all the issues you mention, the speech development is primary. Do you think she understands what is said to her most of the time? You may already have told me this and I have forgotten, but have you had her hearing checked? Young children who don't hear or understand well can seem to be "rammy" and "hyper" or inattentive, just as adults might seem if spoken to in a language they didn't understand. The pica could be related, in that she may not hear you caution her about what to put in her mouth. Of course, these things may also result from the general delay you mention.

      I would suggest that you work toward speech by severely limiting screen time, and that also means time you spend on the phone while you are with her. Make sure she experiences speech sounds as part of interactions with interesting people rather than as just some noise that happens to occur. Try talking to her in attention-getting ways-- louder and then softer, higher-pitched and then lower. If you don't already do this, give her a running commentary on what's going on, what's about to happen, what happened before, etc.

      I think if you can get the speech understanding and use going, that will be a step toward getting the other issues under control. If she likes to jump on trampolines or do other SIT things, there's no harm in them, and if they help you have a pleasant social time that's great.

      I wonder whether you have looked into Floortime. This is not an evidence-based treatment, but it is fun and interactive for parents and young children. There are a lot of examples on youtube that you might follow.

      Delete
    4. First, I'm sorry for my typos. Using a phone name it difficult at times lol.
      Second, she's getting some speech therapy but EI isn't sufficient. Hopefully as soon as she sees the developmental pediatrician she'll get more intensive speech therapy and some OT. The speech therapist tried to check her hearing as part of the school evaluation but Bella wouldn't have any part of it. She doesn't seem to be hearing impared though. She definitely understands more than she says. She can follow simple instructions and she will look at things when they are labeled. For example, if I say where's the dog she'll look at our dog. Although according to the evaluations she's delayed with receptive language too. We do a lot of what you were talking about. We spend a lot of time outside so there's not a lot of screen time.
      I have not tried any SIT things although I'm not opposed to it if she will tolerate it. I think she'd love a trampoline. Her speech therapist suggested putting a weighted backpack on her to see if the extra stimulus will calm her down. Idk though, I'm skeptical lol. I don't know much about floortime. I'll have to look into it.

      Delete
    5. The weighted backpack or vest is another SIT thing. Seems to me there's a natural experiment testing this-- are grade-school children who are always schlepping heavy backpacks calm while they carry them?

      What happens if you say where's the dog, and YOU don't look at the dog? There are lots of ways that people can pick up a little information from speech,or make good guesses, without necessarily hearing everything. (Those with late-middle-aged husbands will know what I mean...) But I'm just trying to eliminate things-- it may not be her hearing at all.

      Delete
    6. I suppose one could argue if a child doesn't have sensory issues then a weighted back pack would have no impact on them (other than they end up with bad backs lol) but if one has sensory issues then the extra stimulation from the back pack is enough for them to stop seeking it out. Again, I'm not sure I buy it, but I'm not sure putting a little back pack with a couple small books in it on my toddler is going to hurt her either.
      As for her hearing, again I think it's fine and I think she understands us as well.

      Delete
    7. The idea of sensory issues is completely entangled with the idea of sensory integration therapy-- it's not a concept used much outside OT. Anyway, no doubt it won't hurt to have her wear a little back pack, or to jump on a trampoline or other things like that-- unless you are paying for this advice, in which case you are the loser, and harm has been done, if the treatment is not effective.

      Delete
  2. Thanks so much for your quick and thorough reply!

    It's interesting--until we had him formally assessed at our children's hospital two years ago (upon the recommendation of our OT, whom we had been seeing since our breastfeeding days for help with latching and feeding), we didn't view any of his "eccentricities" as problems. But after meeting with professional after professional, we have this laundry list of sensory problems to work on; I wonder if some/most of it is just a matter of everything looking like a nail to a hammer?

    Yet--the fact remains that some of his quirks are significant, and I'm concerned about his future success in school, where children are expected to fit a certain range of "normal" social, academic, and behavioral standards. We can, as you say, come up with workarounds at home, but I can't expect his teacher (or his peers!) to create a whole program of compensatory approaches for him when she has 20 other kids to deal with and a curriculum to teach.

    We have been doing feeding therapy and some SIT-type therapy for about a year and I can't say that they are making a huge difference, although his annual assessment did show some gains. But--as you point out--he may have made those gains anyway through his normal development trajectory.

    I guess what I wanted to follow up with you about is to ask you what you think about the idea of sensory processing, generally? It sounds like you don't believe sensory processing disorder is a "real thing," and certainly not its own diagnosis, but do you believe (or I guess it would be more accurate to say does the research reflect) that children on the autism spectrum are more likely than neurotypical children to have those kinds of issues (hypersensitivities to sensory experiences, problems with fine and gross motor coordination that can be attributed to problems interpreting sensory input, etc.)? If so, how can there be no good therapeutic intervention for these problems? (Sensory issues are, after all, mentioned as criteria for diagnosis of ASD under the DSM V?)

    We're just so confused: we know early intervention is so important, so we're pursuing the recommendations we're receiving from doctors and psychologists, but the professionals can't seem to agree on what's going on. (Does he have high-functioning ASD, or only sensory processing problems, or nothing at all except being a bright, shy kid who doesn't necessarily fit in any of their boxes?) They all keep saying none of the interventions we've pursued (ABA, speech therapy, social skills groups, OT) will hurt if it turns out he is in fact a neurotypical kid, and while it's true that it doesn't hurt him/us, they conveniently fail to mention that it certainly does cost something. Not just financially (which itself is not an insignificant concern), but in opportunity costs and emotional costs! Its just incredibly frustrating (and a little bit crazy-making, just ask my husband!!) to be told that there may be significant problems for him at some point in the future, problems which we should now be getting therapy to prevent.... At what point does quirkiness become pathological??

    Anyway, if you have any further insight or thoughts about our situation, or even more generally about the diagnosis and treatment of ASD at the high-functioning margin, I'd be very happy to hear them.

    ReplyDelete
    Replies
    1. Your comments here are so important: the financial, emotional, and practical costs of pursuing every therapeutic alleyway can be overwhelming to parents, and in my opinion have the possibility of interfering with their ability to give the child what's needed at home.

      There are several issues here. One is what has been called "the myth of the first three years"-- the idea that unless intervention occurs very early, it can't be useful. This is certainly true in some areas. Malnourished children with small heads and brains can have their conditions corrected by improved diet before they reach school age, but better diets later on don't undo damage that has occurred. Crossed or deviating eyes need to be corrected early in order for normal depth perception (or sometimes even vision in one eye) to occur. But does this mean that every ability or desired behavior has to be addressed in the early years? I'm not at all sure that it does in every case, and if it doesn't, maybe early intervention is not always important. .

      It makes sense that when a behavior makes ordinary experiences like playing with peers less likely to happen, it has the potential for interfering with development. But can later experiences make up for that? There's no research to test this-- but certainly there are people who grew up in social isolation, on remote farms or with mentally-handicapped parents, and although they may have had a rough entry into ordinary social life, most of them manage to learn later what they might have learned earlier.

      As to whether there really are sensory processing disorders, my opinion is that there is a wide range of sensitivities and many individual differences. Plenty of kids dislike tags on the inside of their shirts or find cooked vegetables nauseating (I have a problem with okra myself), but unless some other difficulty leads them to evaluation, I doubt that anybody pays attention.

      I do think that reports of problematic sensory issues are much more common among kids who are being evaluated for ASD. I don't know whether that means they have more of them than other people, or that they fuss more about them, or just that their parents are asked, so they mention it.

      As to why there are no effective treatments-- well, for one thing, maybe there don't need to be any treatments. When children get older, we cut them a lot more slack. If you know that your 14-year-old can't stand certain food textures, you don't give them to him; if he doesn't like loud sounds, you let him choose whether he wants to go to the football game or not. I have a son who can't stand ticking clocks, and if I accidentally leave one in the room where he's going to sleep, I find it outside the door in the morning (which he couldn't manage to do if he were 4 years old, so he'd probably act agitated).

      I feel as if I'm not being much help here, but I'd encourage you to think carefully about whether you want to go with every possible treatment. After spending years as a college professor, I'm very familiar with people who are bright but quirky, sociable but not "salesmen", and sometimes peculiar in their eating and other choices. It's always seemed to me that if something interests these guys, they can manage to deal with the way it pushes their buttons-- when they're not interested, everything bothers them. Maybe that's the key to "treatment".

      Delete
  3. "I should point out that the techniques discussed in the Times article are not the entirety of occupational therapy."

    This is a very important point. These therapies as described are fringe therapies which have unfortunately taken hold in New York, apparently. There is much work being done by OTs to help children with genuine fine motor and handwriting difficulties. Other methods do indeed have an evidence base, I refer you to the work of Jenny Zivianni as an example.
    Occupational therapists help people to manage the activities they need and want to do, whatever that is and that includes handwriting. I object to the implication that all OTs working with children who have handwriting difficulties are allusing pseudoscience as a basis for therapy. Many OTs are committed to evidence based practice.

    ReplyDelete
    Replies
    1. I thought I had made it clear that this did not apply to all OT work-- sorry if I did not, and thanks for your comments.

      Do you have any thoughts as to why New York seems to foster pseudoscientific approaches, when perhaps other large cities do not?

      Delete
  4. Thanks for your reply Jean. I do not know why this type of therapy has taken hold in New York or other places. I think there is way too much of it going on everywhere! I would support a greater science component in OT (and possibly other health professionals') training.

    ReplyDelete
    Replies
    1. The lack of background in science/research design seems to be troubling many health professions today, as witness "Science and pseudoscience in clinical psychology" by Lilienfeld et al., now in its second edition.

      I taught a research methods course for OT students a few years ago, and although they all did well, I had the distinct sense that they did not want to be taught how to ask questions, but just to be trained in the right hings to do. But again, this problem is hardly unique to OTs and may be related to the economic crunch of recent years.

      Delete