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.