The American Academy of Pediatrics Takes Aim at Occupational Therapy

 I wasn’t entriely surprised to receive the item above in my inbox this morning.  The headline, Pediatricians doubt effectiveness of sensory integration therapy, smacks a bit of yellow journalism when you consider that the Reuters article on which it is based is titled Pediatricians raise caution on sensory-based therapy.  The issue here is a Policy Statement published online yesterday in Pediatrics, the official journal of the American Academy of Pediatrics, titled Sensory Integration Therapies for Children With Developmental and Behavioral Disorders.

In a nutshell, the recommendations of the Policy Statement are this:

1. At this time, pediatricians should not use sensory processing disorder as a diagnosis.  When these sensory symptoms are present, other developmental disorders – specifically autism, ADHD, developmental coordination disorder, and anxiety disorder – must be considered first, and be thoroughly evaluated by a developmental/behavioral pediatrician, child psychiatrist, or child psychologist.

2. Pediatricians should advice families about the limited data on the use of sensory-based therapies for childhood developmental and behavioral problems.

3. If the pediatrician is managing a child whose therapist is using sensory-based therapies, the pediatrician can play an important role in teaching families how to determine whether a therapy is effective.

4. Pediatricians should inform families that OT is a limited resource, particularly the number of sessions available through school and through insruance coverage.

We are familiar with these kinds of Policy Statements by the AAP, cloaked in a mantle of scientific concern, but usually with a hidden agenda.   Developmental and behavioral optometrists have been countering the AAP’s misrepresnetation of vision therapy for decades.  This policy statement has all of the same ingredients: OT is covered on a limited basis by third parties (as if the parent doesn’t have an option for paying privately!), it’s research base is questionable, and what it claims to treat is better treated elsewhere.  It even casts aspersion by citing a small study (involving four children on the autistic spectrum) cautioning that SI therapy by OTs can do more harm than good!  I say that none of this surprises me because I have heard directly from OTs during my seminars that pediatricians have been giving them a tough time.  I suspect that in the drive to establish primary care pediatrics as the child’s medical home, pediatricians have become more aggressive in cherry picking cost containment issues.  It’s expedient to point fingers at other professions, such as OT, rather than turning the magnifying lens inward.  The irrationality of the Policy Statement is evident in just one of its recommendations.  If one looks at the body of evidence in support of treatment for developmental coordination disorder (DCD), which the AAP is endorsing, it is clearly not better than sensory processing disorder (SPD) which it is disputing.

I am sure that we’ll be hearing from the AOTA about this.  In the interim, I’ll side with colleaguse such as Dr. Fortenbacher who advocate for collaboration between OTs and ODs on sensory integration therapy and vision therapy.  We would all do well to take this latest AAP policy statement with the grains of salt it deserves.  I know that most parents will.

21 thoughts on “The American Academy of Pediatrics Takes Aim at Occupational Therapy

  1. What are the Pediatricians afraid of? Most Pediatricians today are specialized GPs. Next they will demand that all children (under 18) not be seen by Nurse Practitioners.

    • It’s always been more about protecting the turf, than the merits of the issues. We know firsthand that these “Policy Statements” by various medical organizations are selective reviews of the literature to support a pre-conceived agenda. They’ve never had the intellectual honesty or professional integrity to address the many rebuttals of their policy statements against VT by Optometry.

      • They have nothing to rebut with, except for saying that they are the experts and everybody should listen and believe what they say. Like the BIG LIE, they think that repeating it over and over it will become the accepted truth. They do not believe tyne power of the internet, and social media. They are lost in the 20th Century.

  2. “Pediatricians should inform families that OT is a limited resource, particularly the number of sessions available through school and through insruance (sic) coverage.”

    They should also rightfully advise parents that pediatrics is also limiting, and easily more hazardous to children’s health than behavioural methods. OTs and ODs are a great mix, agreed.

    • Hazardous? How so? Might you be referring to the easy Rxing of various psychostimulants for ADHD and anxiety? You mean off label Rxing of meds with far less evidence-based medicine that what is required for other professions to claim efficacy? If so, I’m in total agreement.

      • Yes, these are some common causes of morbidity, and some evidence of mortality as well (i.e. increased suicidality with antidepressants) – with an associated lack of evidence to support any positive learning outcomes with pharmaceutical use. I was also referring to risks and costs associated with pointless medical (imaging) and psychometric (WISC etc) interrogations which have real but undocumented physical and psychic effects.

  3. Optometry should advertise in the AAP Smart Brief as I believe grass roots Pediatricians do not believe
    all that the American Academy of Pediatrics writes. I also agree that they should remove their motto, ”
    Dedicated To The Health of All Children”. Their unchanging message in a changing world leaves them far behind OT and Optometry. There viewpoint on their capability to try and justify their thoughts exemplifies the Orwellian double think necessary to defend the indefensible. Their intent is money based and a calculating form of activist-speak, a cynical exercise on the rhetoric of the big lie. That is wrong. And,
    it is a wrong compounded by the fact that it attacks those who need it least, the young and the unsophisticated. We can not afford counterfeit comparisons for our children. We will continue to move our profession forward, after all, medicine has made other mistakes in telling people that eye glasses weaken eyes (Ophthalmology), that staring at the sun is good (Dr. Black; Ophthalmologist), that people need to see a real eye doctor (Bob Hope advertising), and of course now, that visual training is useless.
    They continute to be wrong. We continue to be smarter doctors, as we must know what they know plus
    additional facts involving vision, which they think occurs in the eyes. We know vision occurs in the brain, so we call amblyopia lazy brain, and they call it lazy eye. Sorry for getting on my soap box

  4. You have the right to get on a soapbox, and with good reason, August. I have a feeling that the AAP has no idea how much this “caution” about OTs in general, and SI in particular calls they objectivity and credibility as an authoritative source into question.

  5. I agree with August re ‘we must know what they know, plus…’.
    Forgive my taking the personal case-study line, but our son’s best support has been through modes that paediatricans, OTs, ODs and VTs CANNOT provide, but are accessed through paediatric referral. Re-examining the status of an SI approach may be timely in all three fields.
    In the heat of battle we need to remember that some children’s broken brains are broken for life, need accurate medical diagnosis to minimize social stigma and maximize acceptance, and need a management, not a treatment approach for them to face life and live well.

    My son (one-time friends with Dr Bob Hohendorf) with a lifelong history of sensory issues had 5 years of vision therapy from 8-13 yo – in part a success – and OT for 6 months at 8 years of age. We paid in excess of $10,000 (largely unfunded) for his overall care.
    At age 13, my son developed severe Tourettes which has continued this past 2 years (and the latest news from neurology is ‘no, it is not a disorder of puberty and 90%+ of patients do not ‘get better’ – just change over the years’).

    Now we have team-based management approach: we (as parents) considered the risks of medication options, Clonidine or Respiridone, and supported our son’s decision not to be medicated for the sake of others’ psychological comfort, he had EEG and full MRI/neurology assessment, physical therapy monitoring, support with pain, orpthoptics, optometry, cognitive behaviour therapy and support, increasing knowledge of developmental movement and access to as much as anyone can tell us or our son can discover for himself about self-moderating neurotransmitters through activity and diet. And since the condition further robbed his sight and then some hearing, he now depends on glasses and hearing aids. All the above is now free to us/fully funded.

    VT was a ‘way in’ for him to conscious eye movement control and binocular vision, certainly, but the stressors in the therapy may have also exacerbated the underlying condition. Previous vision testing and resulting prescriptions were likely distorted by involuntary movement mistaken for lack of movement control. The OD’s diagnosis at 8 yo included ‘sensory integration disorder’, and they chose to overlook a paediatrician’s early observations of hand-clawing and other signs of neurological etiology and documented but did not refer for a host of other subtle symptoms including early large tics.
    An earlier diagnosis of Tourettes may have avoided the eventual severity of the condition. If children in VT have un-diagnosed movement or neurological disorders, the onus is on the ODs and OTs to see that they know the signs and when to refer.

    As an ex-VT who worked with sensory therapy and developmental movement, every second I spend with my son I know that we know almost nothing about the underlying cause of the conditions we work with. We know what the condition is not. E.g. the neurologist was adamant that no symptoms were due to involvement of the parasympathetic nervous system (and as an aside: our experiences indicate that syntonics needs more research before ODs continue to promote it). The problems the paediatrician and OD thought could be due to PSNS issues turned out to be appendicitis.
    The way forward for us has so far been found somewhere in our son’s brain and personality. Nothing I learned as a therapist (apart from neutrality and a glimmer of hope from Dr Paul Harris’s talk on the gestalt approach) prepared me for the horror of the early days of holding, dressing and bathing my twisting and shuddering teen.

    We have learned to use (and avoid) specific sensory cues (all of his senses can be used to trigger tics or stop them) to assist him when he is paralysed, dribbling, collapsing or swearing.
    Observing and managing sensory inputs? Yes. Sensory integration – on what planet? When every large tic leaves him clinging to something until he regains some sense of gravity or the nystagmus slows down… Volitional movement is improving. He can close his eyes sometimes, play the ukelele rhythmically and dance a little without ticcing.

    An orthoptist and ophthalmologist (through the hospital, three visits per year) have been invaluable in monitoring phorias and nystagmus and recommending prism bar work (not usually done in VT in our office, but definitely the least risky VT for our son) and seating positions in the class to allow best vision (nystagmus in left gaze, so sit toward the left of the class). Interestingly, the orthoptist is encouraging me to manage my son’s therapy to avoid his missing class weekly, and she is finding it interesting working with a teenager rather than the little ones she usually sees. The ophthalmologists openly praised the documented eye movement gains during past VT.

    After a recent WISC he is now coping better with learning and anxiety at school and has extra time and separate accommodation for school tests and examinations. VT does not tell parents or teachers the specifics of how to help their neurodiverse child study in college. A WISC analysis can.

    ODs and VTs should not discount the possible contribution of a psychological or psychiatric assessment. A single 30-minute psychiatric nurse assessment resulted in our son (then barely able to walk) being prescribed pretending to be a science-fiction character 4 times a day with us for 5 minutes at a time and it was the best ‘way in’ to reducing the involuntary movement and transferring that intense ‘special interest’ mode of thinking into all his other activity through learning self-alteration of neurotransmitter function. The years of ‘making him more normal and less intense and compulsive’ and trying to get him to ‘eat normally’ stopped right there. His ‘abnormality’ turned out to be his only treatment, including helping him claw his vision back from 6/60 to reading book-print with +0.75 and BI/BD OU in just 5 months. The lenses are from a great OD who figured out how to test him without triggering tics.

    Every profession has offered something new and valuable for our son.

    Perhaps Sensory Integration therapy should be renamed movement training. With tears I recall Dr John Streff’s powerful demonstration that vision is movement. I remember my first experience of chain retinoscopy. I also recall his own tears as he said, again, that we so often make children wrong. When I thanked him for his time and energy spent in discussion with me he almost shouted, ‘Energy! Can’t you see how much energy I have for these things!’

    There is so much more to think about than SI.

    I’m also curious to know what V.S. Ramachandran says about the ongoing debates between paediatrics and ODs/OTs? And what does he say about sensory integration and its place in the wider field of function?

  6. Len, I’m currently lecturing to a group of wonderful Occupational Therapists in Atlanta, GA. They are “in the trenches” working with children whom have developmental challenges and delays. Their specialty is to evaluate and treat sensory issues in children; they are good at it, it is their profession. If Pediatricians were on the floor for an hour with the kids that they evaluate rather than spending 10 minutes with the child sitting on a table and coming to a diagnosis, I would consider their opinion more. Taking a “thin-slice” from little data is definitley belittling the profession of OT.

  7. Pingback: Incorporating Sensory Breaks For Autistic Kids | Parenting Coach For Parents Of Special Needs Children

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