Mark’s Minute Volume 3 – Sensory Processing Disorder Is Only a Theory NOT a Real Diagnosis
Hi Team,
The end of the school year is extremely busy full of IEPs, end of the year testing,
gathering of equipment and devices from around the district to place back into the
inventory, and wrapping up treatments with all the students.
I still want to share some philosophy with hopes to better understand the role of
Occupational Therapy in the school system and the many facets of that role.
The primary role of the OT is to address the human occupation of the child being
served. That occupation (hence the title of our discipline) of the child is being a
student.
Often times the OT wears many hats in order to help meet the requirements of the
disciplinary team, the requests of parents, and most importantly the needs of the
child(ren). This leads the OT to frequently draw upon his/her own past experiences
and training, in addition to applying one’s current level of certifications and
professional beliefs into practice. OTs are also known to explore and be creative.
We can do this but need to be careful what we call creative thinking versus valid
accepted therapeutic interventions.
The current “trend” in the realm of school-based occupational therapy seems to
reflect the concern that many kids have problems with sensory processing or
sensory integration, as is the typical vernacular in use today. I have discussed in
Mark’s Minutes Volume 2 about how behavior is a form of communication, so where
is the behavior coming from? What is communicated? Sensitivities? Emotions?
It is becoming more and more common to look at the sensory processing aspects of
a child as a determinate for the type of communication or behavior being manifest.
This is a misperception and can be in error as far as how interventions should be
carried out when particular behaviors are being manifest. Remember the old adage,
“If the only tool you have is a hammer, you’ll view every problem as a nail.” I
caution teachers, parents and OTs alike, please do not go onto the web to selfdiagnose a child. The only tool you will have at the time is a proverbial hammer.
Sensory Processing Disorders are more and more being commonly misused as a
diagnosis for children on the Autism Spectrum, and those with ADD and ADHD.
The best possible advice or suggestions I could offer with this paradigm is that
Sensory Processing Disorders (SPD) and Sensory Integration Disorders (SID)
are only theories. The Diagnostics Statistical Manual Volume 5 (DSM IV) has not
accepted SPD or SID as official diagnoses. The DSM 5 is the manual of all manuals
when it comes to listing diagnoses. It is the professional’s guide to making a specific,
valid, real, recognized, official diagnosis. It is accepted and used by psychiatrists,
pediatricians, psychologists; MDs and DOs, neuropsychologists, and anyone
affiliated with and/or authorized to make diagnoses.
Author Beth Arky (Beth Arky is a Brooklyn-based freelance writer and editor covering
parenting, health and children's learning and developmental issues, including autism.)
- (http://childmind.org/article/the-debate-over-sensory-processing/) reports:
“When a child is identified as having developmental delays, not speaking or walking
as well as other children his age, the first thing parents often hear is SPD. ‘On top of
confirmation of these delays, parents are given this unheard-of diagnosis of sensory
processing disorder,’ she says. One of the reasons it’s often “unheard of” is that SPD
is not included among the conditions spelled out in the Diagnostic and Statistical
Manual (DSM), the guide used by psychiatrists and many other clinicians—including
pediatricians, psychologists, and social workers—in diagnosis. It is occupational
therapists that first theorized that sensory processing issues are a source of distress
for many children, and an explanation for a lot of otherwise puzzling behaviors. And
it is often OTs who identify these challenges, typically in preschool children, and
who specialize in treating them. Despite an intense campaign—waged in part so that
costly private treatments could be covered by insurance—it was not added as a new
diagnosis in the latest edition of the diagnostic manual, the DSM-5.”
The problem with SID and SPD not being an officially recognized diagnosis is the
fact that research is scarce, and what is out there is poor at best. Nancy Pollack, an
OT researcher in this field of study cautions the following
(http://www.caot.ca/otnow/sept09/sensory.pdf):
“Most of the effective research on these types of approaches has been preliminary in
nature. While some positive results have been found, for example, in the use of
specific interventions such as weighted vests (Fertel-Daly, Bedell, & Hinojsa, 2001;
Vandenburg, 2001), the research designs have been less rigorous, such as singlesubject designs, case studies, and quasi-experimental designs. The population being
studied has also shifted with many of these studies being conducted with children
with autism. Case-Smith and Arbesam (2008) in a review of interventions for
children with autism cite some positive findings, but again conclude that the
evidence for sensory integration and sensory-based interventions for children with
autism is weak and requires further study.
These research findings are of course concerning for those therapists and parents
who believe that they see positive changes in the children treated using SIT and for
those who want to base their practices on strong evidence. Sensory integration as an
explanatory framework has intuitive appeal. We have strong evidence that there are
children who present with behaviors and neurological responses consistent with
hypothesized sensory processing challenges. We also have strong evidence that
these children have difficulties in their daily occupations. The question remains,
how do we help these children? The evidence for the types of interventions we have
studied to date is weak, yet a significant proportion of occupational therapists
report that they continue to use sensory integration as a primary intervention
approach (Brown, Rodger, Brown, & Roever, 2007; Rodger, Brown, & Brown,
2005).”
There is a consensus in the field, not necessarily the field of occupational therapy,
but the field of research regarding the study of sensory processing problems that
some children do benefit from a so-called “sensory diet” intervention while yet
others do not. So the question arises as to whether the intervention has any affect at
all over time, and does it work with many other children as well, enough to be called
a valid intervention? There simply is not enough solid research to say yes to this
inquiry.
“Dr. Michael Rosenthal, a pediatric neuropsychologist at the Child Mind Institute and
the son of an occupational therapist, explains the landscape this way: On the one
hand, it’s clear that identifying sensory issues and working with an OT help many
children become calmer and better regulated. By tuning in to a child’s particular
sensory profile, they can find ways to help kids cope and bring them more balance.
“I’ve known many OTs who are really creative and ‘get’ kids very well,” he says.
On the other hand, it’s not clear how much benefit children get from the techniques
and whether it’s possible to generalize enough from the behavior of individual kids
to consider it a coherent disorder. “The thing we don’t really understand is how and
if this approach works for every kid who has sensory issues,” Dr. Rosenthal adds,
“and where is the science in creating a specific sensory diet for a specific kid.”
(http://childmind.org/article/the-debate-over-sensory-processing/)”
We all need to be aware of the interventions we provide to children and not just
follow a trend. We need to be educators of truth and of scientifically valid
interventions that actually work and we have good rationale for why they work, so
we can explain this rationale to others, specifically to parents. If we cannot
rationally explain it, then we need to question ourselves as to whether it is
something that really works or not, and if we should even be implementing it. This
does not discount the fact that somethings might work for one child and not
another, so we need to be astute observers and collect valid data, which just might
then become our rationale in and of itself. We need to help parents understand the
truth about theory versus scientifically based facts. Parents often go on the web and
self-diagnose their child, then tell their physician what the problem is and how it
should be treated. This is scary at best. Let us gather more tools in our toolbox so
we can view things not always as a hammer. Parents need to know this is theory.
Occupational Therapists have the responsibility not only to provide valid
interventions for children, but also to properly educate the teachers and parents-ofthese-children as to the interventions that work specifically for their children.
I believe that we must validate our reasoning and see how scientific research has
changed the perspectives of our interventions over time. As an Occupational
Therapist in the school system, I would encourage the research to turn toward the
direction of using PET and SPECT scans to help identify not just brain structural,
anatomical differences (as seen in an MRI), but the brain’s metabolic, and
neurophysiological process differences. This might help provide more
substantiation to various interventional strategies and even discount some as
misnomers in the field of pediatric interventions in the school system. One
important intervention for all children everywhere is play. Make sure we and our
kids are having fun with learning, with interacting, with developing. Have fun!