Posted July 21, 2008

Q: I practice EI in a state where they are using non-health care personnel to treat babies. They work on two cases I have: a child with Down syndrome another very low functioning child with chromosomal damage. What do you think of this practice?

A: Fifteen years ago when I started working in EI, I was shocked to find a teacher working with one of the most impaired children I saw. What was a teacher doing with a child who couldn't focus, who we weren't sure could hear, who barely responded to touch and who was fed through a nasogastric tube.

She was working to stimulate auditory and vision with toys. She didn't really handle the baby.

At the time, the EI program I worked for was administered through the county, not private agencies. I asked the director of EI about the teacher, called a SEIT ("see it"), a special education itinerant teacher. They were used when OT was unavailable, and for cases with a low or very guarded prognosis. And they cost the county $9,000-12,000 less than an OT. EI was taking 75 percent of the county's whole health budget, which was limiting services to all others over 3 years old!

Budgets and fees are public records. I think it serves us to learn about them. I think if we understood costs and could offer ideas as to how to manage them better, we could make a respected impact in all the programs we serve.

I have always believed that before OTs work with small children they should work with the oldest ones. They would see full-grown children who will always be intellectually limited, who will always need public funds for support, who will always need life guidance. Some of them will have had years of therapy, costing hundreds of thousands of dollars over time, while others with similar diagnoses have only had special ed teachers. They are indistinguishable.

Years ago these children lived in institutions for their whole lives. I worked in a general hospital and evaluated babies referred according to disability: ortho, neuro and MR/DD. I visited an MR/DD facility. Clients there ranged from very low -functioning and totally dependent, to ones who would walk from their living areas to shop independently. They made the most beautiful embroidered linens I had seen outside of a museum. They responded with ease to the repetition of time and design of the craft. They had been patiently taught by "shop teachers." The goods were sold to the public a few times a year. The clients knew it because they were given special treats. And they were proud-when asked what they were working on, they held up the cloth with great big smiles.

I was taught to triage cases early in my career. I was taught that we demean ourselves if we tried to treat patients who can't respond to therapeutic interventions. If patients were unable to respond meaningfully to OT treatment, they would be evaluated with the explanation of: "patient is performing at maximum level within the reality of diagnosis and condition. OT is not indicated at this time." This allows for a re-evaluation and future treatment if the client changes.

I think what OTs should think about doing, rather than fight a battle that probably will not be won, is focus away from the very disabled child and give treatment to those who have a chance in leading full or nearly full functional lives as adults.

Right now, with heroic measures to save preemies and others with the problems that are cropping up with in vitro children, we have "new" infant disabilities, different from Down syndrome and the pre-birth impaired. I think we might be wise to focus on them.

Let the less-skilled personnel focus on the least functional patients with the poorest prognoses. I think we would be more creative, could get more attention and respect as a profession if we would treat babies who will eventually enter into and take part in the mainstream of our society.

Jane Sorensen, PhD, OTR, ND, practiced in all traditional OT areas over 32 years and wellness for 25 years in private practice. She currently has a supervisory and consulting practice. She has written A Therapist's Tales (www.lulu.com/drjane) and was ADVANCE editor E.J. Brown's co-author for A Guide to Early Intervention (www.proedinc.com). You can reach her at 212-744-5836 or drjane@hvc.rr.com. <% footer %>