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I thank Dr. Moyers for her comments, but would like to say that there are several important issues in this debate that few recognize. A guest editorial in our Sept. 1 print edition by a highly respected and honored member of the profession in practice for many years will tell the whole story on what this issue really means in current and future practice.

E.J. Brown, Editor, ADVANCE for Occupational Therapy Practitioners	August 18, 2008
King of Prussia, PA

I know that we all share Mrs. Sorenson’s concerns about meeting the needs of the many children who have significant disabilities and their families. Mrs. Sorenson’s article, “Who Should We Be Treating in EI?” was an attempt to highlight the question of non-professionals working with children, an important question AOTA members – including the Representative Assembly – have addressed in recent years.

Yet, I am sorry to say that this article did not deliver a positive message about occupational therapy’s potential, and moreover, the potential of children with disabilities, to grow and learn and live. This is, in part, because of Mrs. Sorenson’s choice of words. Her comment that “OTs should….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” conflicts with the basic tenets and foundations of our profession.

Prioritizing clients based upon the greatest opportunity for independence implies that some lives have greater worth or value than others. Occupational therapy should be provided to any individual, their family, and caregivers who can benefit from skilled services for remediation, prevention, and development of skills necessary for engagement in occupation and participation in daily living. Individualized goals should be established for each client, based upon their needs and potential for achievement of those goals, regardless of the severity or type of disability.

Occupational therapy practitioners can, and do, provide intervention to individuals experiencing severe physical and psychosocial deficits. Furthermore, there are indications that occupational therapy has a positive impact, in contradiction to Mrs. Sorenson’s statement that the differences between young people who have had therapy and have not had therapy “are indistinguishable.”

The AOTA Statement on Health Disparities and Paper on the Core Values and Attitudes of Occupational Therapy Practice are two important documents that support the rights of individuals to receive service. The Commission on Practice is currently finalizing an important paper on the importance of natural and “least restrictive” environments in proper treatment. It is our ethical responsibility to incorporate altruism, equality, freedom, justice, dignity, truth, and prudence within our service provision. Our clients deserve no less.

Penelope A. Moyers, EdD, OTR/L, BCMH, FAOTA
President
American Occupational Therapy Association

Penelope Moyers, President, American Occupational Therapy Association	August 18, 2008
Bethesda, MD

To Whom It May Concern:

It would seem to me that as an occupational therapist or occupational therapist assistant, one of our primary responsibilities, indeed privileges, is to advocate for the welfare of the children that we serve. Furthermore, it would seem that the less likely a child is able to advocate for themselves, the more they require our compassionate advocacy and care. How sad that Ms. Sorensen seems to have forgotten this, if indeed she ever knew it.

Jim Newcomb, COTA/L

Jim Newcomb, COTA/L, Cottage Hospital	August 05, 2008
Woodsville, NH

There is nothing wrong with disagreement, but it is unfortunate for a professional dialogue to degrade into personal attacks, and I don't participate in mud-slinging contests.

I strongly disagree with your position on this topic, and hope that I have been able to put voice to that disagreement in an appropriate way.

I don't believe that I have misread or misinterpreted anything. This is the power of the public forum - because every comment is laid out for all people to evaluate.

I am comfortable with letting all this stand exactly as is - and people can continue to evaluate the words of your article, your links, and my responses as well as the responses of several other professionals for themselves.

Chris Alterio, Owner, ABC Therapeutics	August 04, 2008
East Amherst, NY

The Advance article had the intention of drawing attention to the cost of EI. The hope was to stimulate more ideas about cost control besides my own ideas.

The article on the Child Abuse Prevention and Treatment Act was intended to present another cost to some parents. It was written by an early intervention team with whom I had no involvement.

Cutbacks have been announced in NY state for all agencies and programs. I hoped my input would stimulate creative discussion about how OTs might influence them rather than get blindsided again as we have in the past.

I am sorry I have been misinterputed by a few of you.

Jane Sorensen, Dr.	August 03, 2008
New York, NY

I had to read this article several times, as I thought I must be misunderstanding the point, but I think that my opinions are just very different from the author's. I work at a private school for children with severe/profound disabilities. The lowest-functioning students, who do not show any response to OT interventions (or those who plateau after years of direct OT) receive OT services on a consultative basis, to address concerns with hand and elbow splints, feeding, and sensory needs. On this point, I would agree with that it is not appropriate to directly treat children who cannot respond to intervention. However, I strongly disagree with the statement that OT should focus only on those children who will lead fully functional lives as adults. None of my students will be fully functional adults. Some will not even live to adulthood. Most will always be completely dependent on others to take care of them. But whatever happened to quality of life? In my mind, the goal of OT in this setting is to help children participate as fully as possible in all areas of their lives. For those children who do make progress in response to OT interventions, no matter how small or slow this progress may be, we can help them develop the skills to lead more meaningful and fulfilling lives. If I can help a child learn to tolerate and then to enjoy small tastes of food by mouth, even if she will always remain dependent on a G-tube for nutrition, this will allow her to participate in a valuable sensory and social experience, improving her quality of life as well as that of her family members. If I can help a child learn to hit a switch to activate sensory-based toys, then this has improved his ability to control his environment. He may never progress beyond hitting a single switch, no complex computer access or communication devices, but this may be the only opportunity he has to be in control, which is so valuable on many different levels. If I can help to decrease a child's tactile defensiveness enough that she becomes willing to explore different textures and materials, this greatly increases the number of sensory and learning experiences in which she can participate. These experiences are important and necessary in helping these kids to develop to their full potential, and in my opinion OT is the profession best suited to address them. Special educators (who I wouldn't necessarily call "less-skilled", as they often have masters degrees as well) play a valuable role in collaborating on these goals to ensure that they are carried over through all aspects of the child's day, but they cannot and should not be the only ones working on them. The primary focus of teachers is educational and academic progress, while OT is able to focus on all those areas that will help the children participate more fully in their school day and educational experiences. The final sentence, that "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" really bothers me. Is that really what OT is all about? Sure, it would be great publicity if a successful adult went around telling everybody that he owes everything to the OT he received as a child. But when a mother goes around excitedly telling her friends, relatives, child's doctors, other parents, etc. how an OT got her child to taste foods, OT gets publicity then too. At an IEP meeting, when a father talks about how he wishes his child wouldn't cry every time she touches something, and all the professionals at the table look to the OT because they know that OT might be able to make that happen, that shows respect for the profession. One of the things I really value about OT is that it has something to offer nearly everybody regardless of their level of functioning, because the idea is to address the areas that are most important to the individual.

Stacey Lehrer, MED, OTR/L, ATP	August 02, 2008
RI

Mr. Altiero,

You exhibit great skill in mis-reading, mis-interpreting and, even worse, mis-quoting me.

Please footnote your further references to me in your self agrandizing blah-blah.

And, again, I refer you to my book with EJ. Brown, "Overview of Early Intervention" Pro-ed. You can get it right here from the Advance. It will give you many case studies to rip apart.

Jane Sorensen, Dr.	August 02, 2008
New York, NY

My response to this is long - so if Advance can't publish the whole thing please reference the full response at http://abctherapeutics.blogspot.com/2008/08/more-on-who-should-be-be-treating-in-ei.html

For the second time this week I am deeply disappointed in Dr. Sorensen's opinion.

This article cited is a gross misrepresentation of what happens on a daily basis in neonatal intensive care nurseries. The article suggests that parents who have premature babies secretly wish that they would just die, and that the professionals are forced by the government to provide care that they know is futile, painful, and ultimately cruel. I worked in a neonatal intensive care nursery and this is not what I saw at all.

Rather, I saw parents who were devestated that their child was born early and who desperately did anything they could to stay on bedrest, take prescribed medications, and pray that their baby wouldn't be premature. When their babies were born the parents were terrified at their fragile state and unable to grasp the enormity of what was necessary to keep them alive. They wanted their babies to live and to be healthy.

Doctors and nurses and therapists who love babies and love families did everything they could to provide highly technical and sophisticated care to save lives. They cycled the lights on and off in the nursery, tried to minimize unnecessary stimulation that was damaging to the baby's immature nervous systems, and tried to cluster their care so that the babies were not disturbed more than was needed.

Many premature babies come from at-risk families. Sometimes the baby's mother was a teenager who had taken drugs. The mother would be scared and wouldn't know what to do so the hospital staff worked extra hard to teach the young girl what it would mean to be a parent and how to care for their baby.

Although it was infrequent, sometimes a baby would be too sick and just have too many problems. Doctors and parents conferred. Cases would be referred to the hospital ethics committee. Agonizing decisions would be made by parents. Sometimes parents and hospital staff would hold each other and cry together when a final choice was made to withold treatment.

The article that Dr. Sorensen quotes also states that all these children are a burden to their families and that the burden is worse because of a lack of governmental support. Since the so-called 'Baby Doe' Laws were passed there has also been significant legislation passed to create support networks - in fact the laws that mandated early intervention services were passed after the Baby Doe Laws. Undoubtedly the services to support child development are expensive and I have mentioned previously we do need to use our resources wisely and efficiently - but to say that these children are an incredible burden and that there is no support for families is grossly incorrect.

Rather, parents of premies or of other babies who have developmental problems still love their children. Just like every other parents they want the best for their children and will generally go to any length possible to do whatever their children need. My experience in early intervention is that parents feel blessed with their children - not burdened.

Some families have fewer resources and need more support and education. It is our responsibility as a compassionate society and as compassionate therapists to provide that support - not spread false information about how the children would be better off dead.

Early intervention services are important for children and families. The services are expensive and as responsible professionals we need to advocate for efficiency and conduct research so that we know what methods and service delivery models deliver the best results. Many studies have already been done and every day therapists use this information to provide the most effective and efficient services possible.

Improving delivery systems is always a need and of course it is a frequent topic in my blog. Dr. Sorensen's approach is to solve the problem through amputation - literally throwing out the baby instead of changing the bath water. At any time there will be a sad anecdotal story of an overwhelmed parent who is unable to cope with an overwhelming situation. I suppose it might also be easy to find a professional who feels like Sisyphus after spending long and frustrating days of trying to teach parenting skills to seemingly disinterested teenagers.

The answer to the tired parent and the frustrated professional is usually found the next day after a good sleep. The next day the parent will see the baby smile and reach a little farther and finally be able to play with the toy. The therapist will hear a mother say, "Today you really helped me understand things - thank you for caring and for helping my baby." And at the end of that day, even though there is no knowledge of what the next day will bring, a little bit of hope is created. Maybe it is enough to last just an hour. Maybe it will carry through the whole next day.

But it will be hope. And it will be good. And that is why we work with children and their families.

Chris Alt, Ow, A	August 01, 2008
E, NY

Hostility and ad hominem attacks are not expected nor appropriate from professional personnel, especially who think they are compassionate....yet can't take the personal responsibily of giving full names. It would be more creative and enlightening to offer other treatment protocols and suggestions of how to buffer EI program funds that are limited and will become more limited in operating monies. You may be paid to treat individuals, but your pay comes from taxpayers who are questioning our entire health care system. Our role in homecare has already been drastically cut. Screaming to maintain the status quo in EI? Get ready to be cut with no control over it.

Sad, that you should judge a 500 word article you read briefly ( obvious by too many mis-understanidng and mis-appropriations) as the end word of a respected fellow professional on the subject without reading "An Overview of Early Interverion", co-written with E. J.Brown which reflects over 20 years of clinical practice with infants and children.

Here is an article that you may find of interest. If you are working well psychologically with your mothers in EI it should validate your clinical experiences.

http://www.pediatricservices.com/prof/prof-01.htm

Dr.Jane Sorensen, OTR, ND
New York

Jane Sorensen, Dr.	August 01, 2008
New York, NY

This article was sickening. I was suprised to see this article was published. I would hope that Advance will screen which articles get printed.
First of all, all children are important. Where does Ms. Sorensen get her facts from? To state that a
special ed teacher gets the same results as an OT is far fetched. There are too many factors to consider. Also, since when are we as OT's in the business of playing GOD? How does Ms. Sorensen determine who is worthy of treating and who is not? And who will enter into society and who won't? (all at a young age of birth to three)Who said we as OT's do not have respect? I can not imagine only treating the mildly disabled in order to gain respect. If anything, those who are severely disabled have more needs.
What a very very upsetting article! I am sorry to see such a lack of compassion. It was as though she suggested we discard the severely disabled. Tsk..tsk.. I thought our society had advanced more than that. Glad to see others are equally as outraged as I was.

kathleen dupont, occupational therapist	July 31, 2008
ft.lauderdale, FL

It made me sick to read this article. You can definitely tell that the age of the writer had a strong influence. Her opinions are highly outdated and do not accurately reflect best practice. Everybody has their place on the team for providing services to children with special needs. Teachers are a valuable resource for addressing cognitive, social, language, and other areas of development. In our state we have an individual who is assigned the primary home visitor(could be an OT, PT, ST, teacher, etc) but there is a team of others who provide consultation such as PT, ST, vision, OT, and early childhood special education. It is truly a team approach with everbody working with the family to meet the needs of the child.

We know that children experience an extreme amount of growth the first 5 years of life. How can we tell through a few weeks of interaction with a child who will make progress and who will not. The big question is "why aren't they making progress?" It most likely isn't the child as it is that we need to change our approach or goal to meet the child's needs.

Advance needs to be more cautious about what they approve to be published or they will lose subscribers. This article is entirely opinion and should not be regarded as what is practiced.

Wendy , MS, OTR/L	July 30, 2008
ND

This is a disappointing opinion to see from an occupational therapy colleague. My full response to this can be viewed at

http://abctherapeutics.blogspot.com/2008/07/response-to-who-should-we-be-treating.html

I am sorely disappointed in this opinion, and in the decision to print this opinion.

Christopher J. Alterio, Dr.OT, OTR
ABC Therapeutics

Chris Alterio, Owner, ABC Therapeutics	July 30, 2008
East Amherst, NY

Reading your article in the most recent issue of Advance forced me through a tumultuous range of emotions. First came disbelief at the brass nature of your 'opnion'. I was then appalled at the blatant disregard for families of severely disabled children. Lastly I was saddened for the loss of compassion so clearly depicted by your close-minded view.

Perhaps this vast discrepency in 'opinion' is the result of my personal journey; however, I have to believe that others would share in my disgust. My involvement in Family Centered Early Supports and Services is rooted in a passionate belief in the delivery of services implied by the title. Utilizing my resources as an occupational therapist not only affords me the opportunity to offer skilled intervention to the most disabled children, but also the ability to guide their often fearful caregivers as they embark on a journey to provide the best care to the one they love the most, their child.

To imply that treating only those with a shot at leading 'normal' lives is the best use of our professional resources is ludicrous. Caring for a child with complex needs is a specialty in and of itself. Allowing untrained replacements to take the place of the specialized developmental expertise of occupational therapists is a detriment to our children and their families. All in the name of saving a few dollars?

Perhaps you are willing to turn a blind eye to these children but as a profession we have a responsibility to provide opportunity to all. Each and every child, no matter the 'prognosis' or 'diagnosis' has something to offer. If not to you, to their family and all that love and care for them.

I do hope Ms. Sorensen that you reflect on your article and revisit its' implications. For those of us with compassion and dedication to all children it is disheartening to know that such a reputable professional in the field of OT could possess such a view.

Some opinions are better left out of print.

Sara Lang, OTR/L	July 28, 2008
Woodsville, NH

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