Can You “Cure” Sensory Processing Disorder?

Posted on May 10, 2013 by

Can you "cure" SPD?

Here are some of the most common questions I hear when discussing a child’s sensory processing skills with their parent:

“Is he going to be OK?”
“Will he make a full recovery?”
“Will he eventually just grow out of it?”
“Is OT the cure?”

These parents are all essentially asking the same question: Are we going to “cure” their child’s sensory processing disorder?

Short answer: “Kind of…”

Long answer: Keep reading.

Here’s the thing- we ALL have sensory preferences. I can’t stand dry sand under my fingernails and I happen to be highly distracted by auditory input.
But do I have sensory processing disorder?
Not so much.
And how do I tell the difference between a sensory preference and SPD?
Sensory processing disorder interferes with daily functioning.
Any other questions I want to ask myself?
Eh, not right now.

So sure, I love the beach, but I’m probably not going to dig a sand castle with my bare hands. I also know that if I want to read a book or type a report, I either have to have complete silence or listen to a white noise app on my phone. With these simple strategies I can adapt to be a (somewhat) typically functioning adult.

However, what about the child that can’t sit still in their chair because they crave vestibular input? They might be missing out on fine motor skill development because they aren’t appropriately participating in school work.

What about the child that can’t stand the touch of a tag in their shirt? Refusing to wear clothing can make it kind of challenging to get out the door in the morning and participate in life.

Another issue that makes sensory processing disorder different is that I know that I can’t sit still at a conference for 8 hours straight. I bop my leg up and down or I chew gum to keep myself alert. A child doesn’t always have the reasoning skills to say, “Hmm, I had better just chew some gum rather than bite through my neighbor’s pencil.” Their nervous system is driving them to find the input they need, and they might not know the most appropriate or effective strategies to use.

That’s the point when OT comes in handy. We teach children and parents the strategies that are most effective. Essentially, how to get the most “bang for your buck” when it comes to sensory input. A child that pings around from activity to activity might just need some assistance to choose something more appropriate, and stick with it long enough to receive the benefit of the input.

Now, say that OT teaches the child what they need to know, and the parents follow through with appropriate sensory activities at home. Does this mean the child will be “cured”? Not essentially. It means that they will have more control over their bodies. We are working with the idea that the brain is “plastic”, meaning it can change and make new connections. The theory behind sensory integration supports the hope that the nervous system will become better able to handle and modulate sensory input to the point that a child can function appropriately.

However, will a child that is extremely under-responsive to movement input choose a desk job when he grows up? Probably not. This is the child that might choose snowboarding as a hobby, or something that provides the input he still craves. Or on the other side of things, a child that is sensitive to most input is probably not going to pick a job in a factory with a lot of loud, unpredictable noises.

So throw the words “cure” or “fix” out of your vocabulary when it comes to sensory processing disorder, and think more along the lines of “adapting”. Hopefully a child’s sensory processing disorder becomes manageable sensory preferences that allow them to lead their lives the way they want.

Related Posts:

Sensory Processing Disorder: Is it Real?

Sensory Processing Disorder: Is it Real?

Sensory, Behavior, or Both?

Sensory, Behavior, or Both?

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Posted in Lessons Learned, Occupational Therapy | Tagged , | 2 Comments

Putting Cursive on the Chopping Block

Posted on May 4, 2013 by

Putting Cursive on the Chopping Block

The inclusion of cursive handwriting within a school’s curriculum has been debated for a while now. The lovely people over at PediaStaff forwarded me a recent article from the New York Times debating the need to teach cursive ( Is Cursive Dead? ) and asked what my stance was on the subject.

The piece in the New York Times offers four different opinions from various professionals. (Always exciting when they actually include an OT in the discussion!) Before reading the article, my automatic response has always been yes, of course children should be taught cursive. However, after reading and analyzing the different opinions, my stance isn’t so black and white. (Darn you, New York Times, for making me think!)

Why Cursive Matters

Ok, so why is my knee jerk response as an OT to say, yes, you should teach cursive?  In the simplest of terms – because it promotes fine motor and visual motor skill development.

Most OT’s look at cursive as more than just a fancy script. We aren’t pushing for the font of olden-times, we simply see an activity that promotes skills that many children are lacking. So if there is an opportunity to participate in a task that will be beneficial to overall development, we are all for it!

In her opinion piece, Suzanne Baruch Anderson (an occupational therapist) mentions that cursive promotes brain development as well as synapses across the left/right hemispheres of the brain. I haven’t personally read the research on that, so it is hard for me to offer an objective opinion.

However, I am on board with the point of writing speed and efficiency. Now, when I was in school, taking notes by hand, a cursive/print hybrid situation helped me out quite a bit. Although most would argue that kids just take notes on their computer now, so my argument might be shot down.

I think the information from the College Board stating that students who wrote in cursive scored slightly higher on the SAT than those who printed is quite interesting. While Suzanne mentions that some experts attribute this to efficient handwriting that allows for a focus on content, I have my own thoughts.

What about first impressions of someone’s handwriting? I feel that people tend to make snap judgements about a person’s intelligence based solely on their handwriting. Would it be such a stretch to assume that the students writing in cursive receive higher scores based on subjective assumptions of their fancy writing? Just something to think about.

On a different note, sometimes cursive is simply the better choice for a child in a clinical sense. When I work with children with difficulties in visual-spatial relationships, they may benefit from trying a different script. When the letters are connected in cursive, the children don’t have as much of an issue with inconsistent spacing between letters and words. This in itself can help improve their overall legibility.

I also feel that we should all have some sort of signature. Is my signature a perfect example of cursive strokes? Of course not! But it does offer some sort of minimal protection when it comes to someone forging your name.

Why Learning Cursive Isn’t Worth the Trouble

The most ridiculous point made in these articles is that children should be taught cursive because it is beautiful. To teach cursive because it’s pretty…that’s no reason at all. I think pictures of rainbows are pretty, should everyone be taught how to make those?

However, Jimmy Bryant (an archivist) also points out the cultural traditions of cursive. Many historical documents are written in cursive, plus don’t forget all those letters from your grandparents. But again, does that mean we should still be actively teaching it? I don’t know that I see the rationale for it based on that alone. I do agree with Kate Gladstone’s point that every child should be taught to read cursive. Minimal instruction can unlock the ability to decipher many historical documents. That’s a no-brainer for me.

Now, the biggest reason I realize that cursive might not make the cut – time constraints in school. Morgan Polikoff (an assistant professor of education) makes an excellent point that teachers are stretched thin as they try to squeeze their curriculum within the school year. I have teacher friends that have looked at me and said, “I barely have the time to teach the children to print.” I see so many children in my office for OT because they didn’t quite figure out how to form the letter “A” in that one day of instruction, and quickly fell behind.

So, with that said, are there better things to spend the child’s time working on? Perhaps learning a foreign language? Don’t we all have terrible math skills in this country? When you start to think of it that way, should we really be teaching children a whole second way to write, when they struggle with other skill areas of great importance? It’s a tough call.

The Best Compromise?

In an ideal world, yes,  children would learn cursive. I say that even though I know it won’t be used much in their adulthood, but the fine motor/visual motor practice is worthwhile.

However, since we don’t live in an ideal world, I suppose I have to compromise. First and foremost, every child should know how to read cursive. There is no wiggle room for me on this one. What a sad form of illiteracy if a child can’t read an important document, or heaven forbid, what about a fancy wedding invitation?

I think children should at least be given an introduction to cursive and learn a cursive signature. Even if they only get a little practice, they can at least get an understanding of the letter formations. In some schools with more flexibility, they could even offer cursive as an elective course. (I mean, come on, they take the time to teach some kids Latin…)

Clinically, I think some children might need to learn cursive as an alternative to print. In that situation, they might require a referral to an OT for private instruction. I have seen the incredible benefits of writing in cursive for some children; however, it might be the exception more than the rule.

With all that said, I can definitely understand both sides of the argument. But comparing cursive to the abacus and slide rule, as Morgan Polikoff states? That might be a bit dramatic. Learning cursive might not be the most practical use of instruction time, but I strongly believe that there are benefits to learning this archaic script.

Posted in Lessons Learned, Occupational Therapy | Tagged , , , | 2 Comments

Pinned on Pinterest, Tested in Therapy: Test Pin #14 Corn Cob Fine Motor

Posted on April 29, 2013 by

Corn Cob Holder for Fine Motor Skills

To see all Pinterest test pins, click here.

I first heard of this idea at a conference, and made the mental note to give it a try. However, time passes and you simply forget… until Pinterest reminds you, of course: Corn Cob Holders for Fine Motor Practice.

First, track down some corn cob holders. This is actually the perfect time of year to find them for super cheap. I got mine for around a dollar. In order to encourage accurate hole punching, you should pull one of the metal prongs out of the holder. My trusty husband did this with a pair of pliers, and then filed it down a bit to make sure the left over metal wasn’t too sharp.

You can then draw pictures, shapes, or letters, and place the paper on top of a piece of cardboard. The child punches holes along the guidelines using an appropriate grasp on the corn cob holders.

Some things I learned from testing this in therapy:

The effectiveness of this activity depends on the corn cob holder you use. I happened to have a bigger set, which allowed some children to manage a funky grasp on the handle. A smaller corn cob holder would have provided less wiggle room for an inefficient grasp.

You could also simply use a push pin and you wouldn’t have to go through the extra steps of finding corn cob holders and ripping a prong out. The small push pin definitely forced a tripod grasp and provided a more appropriate challenge for the older children.

This activity is actually more difficult than it looks. Even as I punched a few holes in order to take these pictures, my hand quickly started aching like a wimp. Overall, it worked out to be a fun way to promote a functional grasp and strengthen the muscles of the hand in an appropriate position

Corn Cob Holder for Fine Motor 2

I think I’ll give it two cobs up. :)

Have a Pinterest pin you want to see tested? Contact me and let me know!

Posted in Uncategorized | 4 Comments

Pinned on Pinterest, Tested in Therapy: Test Pin #13 Gel Bag

Posted on April 22, 2013 by

Gel Bag tested in OT

To see all Pinterest test pins, click here.

This idea caught my eye as another fun, kinesthetic way to work on letter formations. I’m always looking for out-of-the-box ways for kids to work on handwriting skills, other than just sitting with a pencil and paper. Boring.

You can see the original pin here. It led me with the pretty basic idea of mixing hair gel, glitter, and a few buttons in a bag. Sounds like the ingredients for a good time, right?

The first step was gathering the necessary supplies. For some reason when I was at the store, I just grabbed the biggest tub of yellow hair gel, not really thinking it through. When I got it in the bag it was too transparent, as if the gel wasn’t even there.

I didn’t like this look, so I added a few drops of blue food coloring, and got a much better color to work with. You can still see the letters, but the opaque nature of the gel encourages the children to “find” their name.

I went ahead and added the glitter because I happened to have some around the house. (As everyone does, I assume…) Was the glitter necessary? No. Was it fabulous? YES.

The best part was that I thought it might really stand out on my DIY light box that keeps coming back to earn its keep. And it did. The picture doesn’t really do it justice, so you’ll just have to trust me on the sparkly amazing-ness.

Gel Bag Names

Now, let’s get to the usefulness of this activity. I had the children try to trace their names using the button in the bag, but this was very tricky. Many children wanted to place their finger directly on the button to move it around, but this doesn’t work well. You have to guide the button by placing your finger behind it and pushing it around.

Once the children learned this technique it was easier for them to move the button. However, this tactic didn’t really work well for certain letters. Think of the letter F: you make a line down, then “jump” back to the top, which is impossible to replicate with this activity. The children just slid the button around haphazardly as they tried to move it back to the top of their letter.

To remedy this issue, I just scrapped the button idea and had them trace the letters with their finger. We did this with pre-writing shapes as well. I liked that it worked on finger isolation, providing a bit of resistance as well.

Now, with all of that said, I should point out that almost every single child just preferred to squish the bag as soon as I handed it over. And I mean seriously squish the bag. I’m a store brand shopper, children, so needless to say I was a bit worried about springing a leak. Thankfully, it held up and at the very least, became a pretty popular fidget/sensory activity.

Overall a quick, inexpensive activity. I’ll say it was at least worth the try.

Have a Pinterest pin you want to see tested? Contact me and let me know!

Posted in Pinterest Test Pins | Tagged , , | Leave a comment

Pencil Grip 101

Posted on April 19, 2013 by

Pencil Grip 101

{If you aren’t familiar with pencil grasps or the anatomy of the hand, you might want to check out my post, “When to Fix a Pencil Grasp” as an introduction.}

Suppose you have a child that can’t hold a pencil correctly… what do you do? I see way too many people slap a grip on a pencil and declare, “Job done!”. Yikes. There is actually much more to correcting a grasp than using a grip, but I’ll get to that later.

As I was preparing this post, I had my husband help me take the pictures of each pencil grip. Of course he had to test each one out, finally coming to the conclusion: “These are all essentially the same.” Ha!

I have to give him some credit, because he is right in a big way. All of these grips are designed for the same thing: to put a child in a “correct” tripod grasp. A few can be modified for a quadrupod grasp, but essentially, they all aim for the same goal.

The biggest difference between each grip is the way it gets you there. For example, if a child has a thumb wrap, they might do better in a Grotto than a Stetro because there is a bigger guard. Have I lost you yet? Alright then, let’s just start by identifying a few common grips on the market and the ways they are designed to work.

(I should probably put a disclaimer here that this is by no means an all-encompassing list of grips. These just happen to be the ones that have been accumulated over the years.)

Foam Grip

Foam Grip on pencilFoam Grip: Let’s start with an oldie. Have you ever considered the foam sleeve a pencil grip? This grip comes in many variations: ridges or bumps, plastic or foam. It gives the child a target area to grasp, and the grip is supposed to provide a cushion which can reduce pressure on the joints. However, it doesn’t do much in terms of actively positioning a child’s fingers.

Triangle Grip on pencil

Triangle Grip on pencilTriangle Grip: Here is another classic pencil grip. It can be a stand alone grip, or you might see a lot of pencils, crayons, or markers designed in this triangle shape as well. The three-sided design is supposed to provide a physical cue to promote a tripod grasp by giving each finger a designated spot. Again, it doesn’t do too much to actively change a child’s finger positioning.

Stetro Pencil Grip

The Stetro GripStetro Grip: This grip is small, so it works well for smaller hands. The indents provide cues for finger placement on the pencil in a tripod position. The “Solo” grip is also similar to the Stetro in the level of positioning support, just a larger overall size.

Writing Claw

The Writing ClawThe Writing C.L.A.W.: Hmm, when I think of a correct pencil grasp, the word “claw” definitely doesn’t come to mind. However, C.L.A.W. actually stands for Controlling Letters of Adolescent/Adult Writers. Bet you didn’t know that, huh? (I didn’t either until I just looked it up….)

This pencil grip provides a cup for each of the three fingers. In terms of the amount of positioning support, nobody really slides out of this one… a little tripod straight jacket. However, I do find that it has slightly more wiggle room in terms of actual finger movement than some of the other grips.

Grotto Grip

Grotto grip on pencilThe Grotto Pencil Grip: The idea behind this grip is to limit any odd positioning or movement of the fingers in order to support a tripod grasp. The “Crossover” grip also looks very similar to the Grotto, but I haven’t used that one before. You’ll see the guard in the front is supposed to prevent the fingers or thumb from wrapping over.

Start Right Grip

Start right grip on pencilStart Right Pencil Grip: This grip is designed to keep the web space open, as well as provide barriers to prevent the thumb and fingers from going anywhere they aren’t supposed to. You’ll see that there aren’t any indents on this grip for the fingers to slide into. It’s main job is to prevent any wandering fingers.

The Pencil Grip

The Pencil Grip

The Pencil Grip: Whoever came up with the name for this was genius. Need a pencil grip? Why not get THE pencil grip? I mean, have you read some of the names of these things?

The Pencil Grip is supposed to provide an ergonomic support in a tripod position. It comes in regular size as well as a jumbo size for smaller hands. I also have another use for The Pencil Grip, which I will demonstrate next…

TIP Grip ProtocolTIP Grip 2

The TIP Grip Protocol: I believe the TIP Grip protocol was created by Jan McClesky, an occupational therapist from The Handwriting Clinic/First Strokes program.

It is a way to adapt the pencil using a The Pencil Grip that has been cut in half to promote a proper grasp with appropriate joint positioning. You can look it up online for a tutorial.

I sometimes think of this protocol as the “un-grip” because the child actively grasps around the grip to the rubber band, instead of using the grip to support their fingers.

Pencil Grip Precautions

As I mentioned before, there is much more to correcting a pencil grasp than slapping a pencil grip on a pencil. That’s kind of the equivalent of duct taping a hole in your roof. It might work for a minute, but the underlying issues still remain.

Let’s say you put a grip on a pencil and the child holds it beautifully. Fantastic. However, what happens when you take that pencil grip away? If they were just using the grip as a crutch to melt their fingers into, they probably haven’t developed the proper strength to maintain the position alone.

Another issue to think about is when children have difficulties with motor planning. If you teach them to grasp a pencil only with a pencil grip, it might be very challenging to wean them off. Some children look at a pencil as if it is a foreign object once the grip has been removed.

How about the children that are rigid in their routines? They might not want to give up that grip. With these children I might avoid a grip all together and focus on hand strength/dexterity and provide a visual cue such as a sticker on the pencil to demonstrate where they should place their fingers.

If the child has structural issues that caused an inefficient grasp in the first place, they might not even be able to maintain the position that the grip forces them into. That pencil grip isn’t glued to their fingers in the correct position, you know. That means some children start to compensate around the pencil grip, creating more issues.

For example, this position below is technically a “tripod”, but the thumb has locked itself into hyperextension to keep from collapsing. Think of locking your knees to keep from falling over when you are tired. You don’t have a lot of flexibility or dexterity in this position.

Hyperextension

If the child really has an issue with stability, they might start to fold their fingers or their thumbs over the grip in a fight for control. If someone has simply put the pencil grip on and walked away, a child might find themselves writing in these positions; often steam rolling right over all of the features of the grip that were supposed to keep them in place.

Compensation with pencil grips
Or how about this compensation, can you even tell which pencil grip I am using?

Guess the pencil grip

Alright, a bit of an exaggeration, but my point is that putting a grip on a pencil is not going to magically change a child’s grasp. They can still find ways to compensate or do strange and funky things with their hands.

Another point to think about – is the child going to actually use the grip? A lot of children I know have hidden their pencil at school or refuse to use it because it makes them look “different.” Some children start to cry or avoid homework and writing tasks because they are incredibly embarrassed by the grip. I had one child look at me with puppy dog eyes and say, “You aren’t going to make me use this at school, are you?” I mean, come on, it’s not like these things are discreet.

Making the Pencil Grip Choice

There are two different ways to look at choosing a pencil grip: are you looking to adapt or rehabilitate? That’s right, I’m busting out those occupational therapy frames of reference.

If I am looking at a child with an adaptive frame of reference, I am assuming that they will not hold a pencil in a functional way without adaptive positioning. At that point, I might need to select a pencil grip that works for them depending on the level of support they need.

If I am working with a rehabilitative frame of reference in mind, then a pencil grip might just be a step in the grasp training process. The child first needs to develop strength all in the right places. That means building a stable support by working on proximal stability, (core strength, shoulder, elbow, and wrist stability) as well as assuming a proper seated position. I also work on separating the sides of the hand and developing the palmar arches. All important components of a proper grasp.

With that underlying support, I may alternate writing tasks with a grip on and off the pencil, just so the child understands and feels the correct grasp. Other times I simply use the pencil grip for fine motor strengthening tasks by placing it on tweezers or chopsticks, or by having the children grasp the pencil grip while completing a gross motor task or obstacle course.

Sometimes I have to let parents know that there are situations when no grip is the best grip for their child. I think some parents feel cheated when they come to OT and don’t get a pencil grip. I need them to know that there are so many factors that contribute to a correct grasp that there isn’t always a quick fix. You want your OT to look at all the underlying issues before making a decision.

I do realize that OT’s all seem to have different philosophies on pencil grips, and we can get really judgmental of each other based on our choices. “Ugh, she totally recommended a Grotto. I always go with the Start Right…” I mean, we really argue about these things. However, as long as we all know the reasoning behind our recommendations, go for it. To each his own grip, I suppose.

Related Posts:

The Handwriting Debate: Which Program is Best?

The Handwriting Debate: Which Program is Best?

Evaluating a Child's Handwriting: An Inside Look

Evaluating a Child’s Handwriting: An Inside Look

When to "Fix" a Pencil Grasp

When to “Fix” a Pencil Grasp

Posted in Insider Information, Occupational Therapy | Tagged , , , | 3 Comments

Pinned on Pinterest, Tested in Therapy: Test Pin #12 Water Beads

Posted on April 15, 2013 by

Water Beads in Occupational TherapyTo see all Pinterest test pins, click here.

Water beads: have you tried them? You probably have, seeing as though they are all the rage on Pinterest these days. This was one of those instances when I pinned a hundred different pictures of them before actually deciding to give them a whirl. Honestly, before I investigated them further, I just assumed that water beads were a sensory product that you had to order from a therapy catalog for a ridiculous price. Oh, how little did I know.

Water beads can be found in the floral section of any major store. Technically, these are made to be vase fillers, because the beads expand and absorb water. One thing they don’t advertise on the package: hours of sensory fun.

When you purchase water beads, they come in a small package and look  a lot like regular beads. They are offered in several different colors, so of course I opted for the most fun “Multi Color” pack. These puppies only set me back 99 cents, so even if they were a total bust, I wasn’t going to be mad.

You soak the beads for 4-6 hours and they grow quite a bit as they absorb the water. Thankfully, I only used about 1/4 of the package, since they probably would have exploded out of the bag had I used them all.

Water Beads in Occupational Therapy 2

Lessons Learned from Water Bead Play

They are “messy”.

Not messy in the sense of paint or shaving cream, but these little guys bounced, jumped, and rolled everywhere. Especially when the children were overly excited to get their hands in the bin! (Although, what a great opportunity for fine motor practice to find them and pick them all up!)

Also, if children get overly aggressive with their play, the beads squish and turn into a jelly. This unexpected and quick change in consistency was slightly aversive to some of my clients that have difficulty tolerating tactile input.

They are tempting.

No, those aren’t delicious gourmet jelly beans, small child! Be careful, just like when children see a dry bean container for the first time, sometimes they just have to try to pop one in their mouth. You had better have quick reflexes for some children to keep this from happening.

They should be kept wet.

I definitely recommend keeping these in a resealable container to keep the moisture in. I felt like as the week went on, the beads shrank a bit as the water evaporated. If they do dry out, it just takes a while to get them back to full power by adding more water.

Incorporating Water Beads in Sensory and Fine Motor Play

For some children, I just put the water beads in a clear plastic bin and set them on the DIY light box for sensory play. (I have found so many uses for that thing. Score!)  This turned into a very calming task. A few of my friends just buried their little hands in the water beads and smiled in contentment.

Of course, you can incorporate fine motor tasks with these water beads so that the children get the benefit of skill building with a sensory component. Here are some of the activities I tried:

-Spoon the water beads into cups or bowls as a way to address utensil use.

-Sort the beads by color into different containers (i.e. ice cube trays or the suction cups on the bottom of a bath mat toy) using pincer fingers or tongs. This was a great way to work on force modulation because if the child squeezed too hard, the beads were either crushed or shot across the room!

-Some children just wanted to try to crush the beads one at a time with their fingers, which was a fun way to work on strengthening.

-We got tooth picks out and tried to spear as many water beads as we could. This task required bilateral coordination to hold the tooth pick with one hand while attempting to stick the water bead on with the other.

There seem to be many websites out there with unique ideas for water bead play, because apparently I am VERY late in the game to try these things out. The pin that got me going on this venture was this one here: How to Use Water Beads in Play Therapy. This post also has several links to other websites.

If you haven’t tried water beads out yet, you won’t be disappointed. If you have, please feel free to share your favorite activities!

 Have a Pinterest pin you want to see tested? Contact me and let me know!

Posted in Pinterest Test Pins | Tagged , , | 2 Comments

Ethical Dilemmas in OT Practice: What Would You Do?

Posted on April 11, 2013 by

Ethical Dilemmas in OT Practice

Alright, therapists – let’s play a little game I like to call: “Is it ethical?”

Occupational therapists are good people. I think I can rightfully make that statement, don’t you? Hopefully a therapist can’t make it through school, fieldwork, and daily practice without being a decent person. However, there are still many situations when the right answer isn’t always the easiest answer.

Have you ever realized how many of these situations you might be encountering on a daily basis as an OT? When I really sat down and thought about it, it wasn’t hard to see some ethical blunders that happen quite a bit in our realm.

The following situations are all dilemmas that either I or my colleagues have faced in our jobs around the country. While my moral compass points to “unethical” for pretty much all of these, it doesn’t mean that’s how everyone else will feel. That’s why I would love to hear your opinions… what would you do in these situations?

Photocopying assessments instead of ordering them.

The scenario: (Alright, so this is pretty obviously copyright infringement. Perhaps I should have started with something less obvious?) How many of you have worked in a clinic that photocopied their assessments? Have you ever gone so long without seeing a “real” VMI that you forgot they come on colored paper? Have you been unable to accurately score an assessment because the scoring template couldn’t match up with the image warped by a million trips through the copy machine? Your boss says, “This is what you get. We aren’t paying an arm and a leg for new score sheets.” Do you refuse to use the copied assessments?

Why this scenario occurs: Well, in some situations, it’s just how the clinic owner runs it. Larger therapy clinics are prepared to absorb this sort of cost in their overhead, but in small private clinics, this cost obviously hurts the profit margin.

Should you go on strike until the proper assessments are purchased? Or as one student suggested, “Why don’t you just buy your own assessments if you feel uncomfortable?” Well sure, adorable little OT student, but let me know how long you hold out on that ethical dilemma. Assessments aren’t cheap. A package of 25 VMI full forms is $104, and a clinic could burn through those in 1-2 weeks. But is that a proper excuse? No, of course not.

Giving a parent preferential (or less preferential) treatment for therapy times.

The scenario: You get an open spot on your schedule. Client “A” has been on the waiting list for 7 months, but you know the mother is intense and kind of mean. Client “B” is the little brother of one of your current clients that just decided they wanted to start OT services. So, who gets the spot? Do you show preferential treatment for a family you know, or go by the waiting list?

Why this scenario occurs: Therapists are human! It would be easy to give an awesome family that prime after school spot, not the mean people that have been waiting forever. This also depends on who is doing the scheduling, the therapist or someone in the front office.

Seeing a child for therapy past the point of progress.

The scenario: Billy has been seen for 5 years at a therapy clinic. He hasn’t really made progress in the last 3. At what point does the therapist call it quits? The decision eventually has to be made about billing for services when the child a) doesn’t participate, or b) hasn’t made a stitch of progress in months/years.  Some therapists might attempt to make goals so incredibly low or incremental that the child somehow meets a miniscule goal every 6 months or so in order to document progress. If they aren’t making progress, do you continue to see the child?

Why this scenario occurs: Again, therapists are human. How hard is it to say that a child will never really progress further with intervention? Also, there are times when OT becomes more of a therapy for the parent than the child. The parent needs someone to engage with; a moment of sanity. However, is that a billable service for OT, or is it just good ol’ fashioned “therapeutic use of self”? Regardless, it might be too gut wrenching for a therapist to tell a parent that their child isn’t even a candidate for services.

Administering treatment while waiting for a license.

The scenario: A therapist has just moved from another state. Their paperwork hasn’t come in yet, but they are an experienced and capable clinician. The boss says, “Just go ahead and see the kids; we’ll have one of the other OT’s co-sign your notes.”

Or, in another example, say a new graduate was hired, but either their license hasn’t come in yet, or they haven’t received the results of their national boards. The boss says, “What’s a week or two without a license?” If you are the therapist, do you practice without a license? If you are the name going on the paperwork, do you allow it?

Why this scenario occurs: This could happen due to poor planning. A clinic is in a pinch because they lined up a bunch of new clients, but a paperwork delay causes a kink in the cash flow. It isn’t to say that a therapist wouldn’t do a great job, but wow, would you be willing to risk it?

An OTR signing off on a COTA’s work that they have never met.

The scenario: A COTA works in home health, but has never met her supervising OTR. She turns in her documentation and an OTR signature magically appears. If you are the COTA, do you feel comfortable with this level of supervision? If you are the supervising OTR, are you willing to sign off on someone you have never met?

Why this scenario occurs: Scheduling! Plus, how often is a company going to let an OTR spend a day shadowing a COTA? That’s paying two people to do one job.

States have different requirements for supervision of COTAs, but most of the time they require some sort of face to face meeting or observation of skills. Some states require more supervision if the COTA has been practicing for less than a year. Plus, there are a lot of amazing COTAs that probably don’t need close supervision, but the law is the law. However, that’s what happens when a therapist is under the pressure of a rigorous schedule or high productivity level expectations.

A COTA completes an initial evaluation.

The scenario: An experienced COTA has a time slot open for a child to begin therapy, but the OTR does not. The boss has said, “Just let the COTA do the initial evaluation and you can sign off on it.” Do you allow that to happen?

Why this scenario occurs: It could simply be a way to get a child on the schedule to begin therapy quickly.

A fieldwork student carries their own caseload without direct supervision.

The scenario: Come on now, who hasn’t had at least one fieldwork experience when the Fieldwork Educator said, “Just go for it.” I remember transferring some woman as a student in the nursing home and absently thinking, “Huh, I hope nothing bad happens.” Or how about seeing clients when the Fieldwork Educator is on vacation? Technically, a licensed therapist should be within eyesight of a student at all times. Again, this is regardless of their amazing skill level. As a student, do you request more supervision? As a supervising Fieldwork Educator, do you allow the student to practice alone?

Why this scenario occurs: Profit, scheduling, productivity: take your pick. The high demands of a therapist lead to tight schedules and not enough time to do some things the way they should be done. A clinic might also look at a student as a way to increase their revenue and load them up. However, sometimes the Fieldwork Educator just takes a student as a way to take a “break” from the rigors of practice.

Working on a skill that is outside of the OT scope of practice.

The scenario: This could happen a million different ways, so I’ll just give you an obvious scenario. You notice that Billy isn’t saying his /r/ correctly. His parents can’t afford a second therapy session a week for speech, so they ask if you can just help him work on his sounds during therapy. Do you play the dual therapist?

Why this scenario occurs: Sometimes, therapists just want to help. Parents come to us with off the wall problems, assuming that OT should address it, so we do our best to assess the situation and try to correct it. On the other hand, sometimes an OT decides that they can tackle anything, and refuse to refer out to someone else. The harm comes when a therapist does something that might negatively impact a child, or when the therapist isn’t doing as good of a job as someone else could.

Billing for an entire session, even when the client wasn’t there for the whole amount.

The scenario: You are working with a child, but they barf all over you halfway through the session. Or, what about the client that consistently arrives 20 minutes late? Your boss says, “Bill for the whole hour, you had it blocked on your schedule that way.” How do you bill it?

Why the scenario occurs: Occupational therapy is billed by units. These are time intervals of 15 minutes, beginning with at least 8 minutes. For example, 1 unit = 8-22 min., 2 units = 23-37 min., 3 units = 38-52 min., 4 units = 53-67 min., and so on. Some places round these numbers up by a generous amount due to the fact that if they don’t, it costs them money.

Backdating or altering dates on paperwork.

The scenario: You accidentally forgot that a child’s re-evaluation was due. You missed the deadline by a few weeks, but continued to see them for therapy. Their insurance will not cover therapy unless there is a valid evaluation on file for the current calendar year. Darn, that means there are three visits that the clinic will have to pay back, unless you change that number on your report. Do you backdate the file?

Why this scenario occurs: This sort of dilemma can stem from the pressure a therapist receives from their superiors. A support staff member might just change dates without a second thought, or a therapist might be asked to sign off on a different date than when something actually happened.

So yes, OT’s are good people, but life often throws out a few curve balls, and it can be challenging to always be on the “right” side of every situation. I don’t doubt that every one of us has encountered at least one of these issues in our practice, but hopefully we have all reacted with the most ethical of intentions.

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