It’s no secret that there is a huge increase in the number of new clients coming into outpatient pediatric clinics with emotional regulation concerns. Like I’ve mentioned before, every single child on the “incoming patient” list at my clinic is coming in for emotional regulation. Of course I ask, “Why in the world are our kids falling apart so much that our clinics are overrun with emotional dysregulation issues?”…I have some strong theories, but that’s for a different day.

Today I want to ask these questions: Why is OT the new go-to service for this concern? And what makes us competent at addressing this?

When I was thinking about how OTs got pegged as the “regulation experts” in the last couple of decades, I think it all comes back to our initial push for Jean Ayres’ Sensory Integration Theory. Jean Ayres came up with this theory (which is still in fact just a theory all these decades later) about sensory processing and integration, and she attempted to create a manualized, concrete method for making neurological changes in the brain that would improve a child’s sensory processing skills, and thereby improve occupational functioning in everyday life.  

The sound of a lot of it makes sense, and it’s obvious that Jean Ayres was incredibly intelligent. I think she did good work, and I commend her for pursuing this theory, ready to prove or disprove it as a scientist does. But did she ever prove her theory that we now push so hard? 

The short answer is “no”, and I will be discussing my research around this in a separate post. Given that the answer is “no”, I find it very interesting that we have pushed this theory SO far that everyone is crying “Sensory! Sensory!”. Teachers, OTs, parents, everyone. It’s the most popular buzzword in the world of pediatric occupational therapy. 

I think we pushed this concept so far, that now all areas of “regulation”, not just “sensory” regulation, have bled into the world of OT, and I’m not convinced that we’re equipped for that. I’m not sure that we should be such go-to’s for the behaviors, emotional difficulties, and family dysfunctions that come into our clinics seeking our services. In OT school, we receive instruction in some basic concepts around the theory of Sensory Integration. In my personal experience, we then learned a very watered-down, vague version of the protocol that Jean Ayers designed. From my own work experience and watching OTs around me, we don’t even know the difference between all of the “sensory” approaches, and we undervalue the fact that it is an unproven theory. 

I don’t want to talk too much on the validity of our sensory integration claim to fame, because that will be a different post. I want to return to the fact that the sensory processing piece of “self-regulation” is what we claimed to be experts on as OTs. Now we treat the umbrella terms “emotional dysregulation” and “self-regulation” with things like social stories, Zones of Regulation, and the ALERT Program. Did you know that the latter two were to be used in designing and implementing sensory diets (another concept I seriously question the validity of), and not to address the complexity and variety of behaviors we see all lumped under “emotional regulation”?  

And while social stories and storytelling in general are beneficial and used across different cultures amongst OTs and everyday parents…when do we decide to refer clients to professionals directly trained in emotional-behavioral concerns? I think we see that yes, chronic and severe emotional dysregulation impacts a child’s ability to engage in their everyday occupations, but what specific training do we truly have from grad school that makes us competent in this area? Where do we draw the line between our scope, and mental health professionals’ scopes? Do continuing ed courses and the fact that it (amongst literally everything) affects “occupational performance” make the everyday OT competent in this? Remember, everyday OTs received a Master’s degree in the term “occupation”. Mental health therapists received Master’s degrees or more specifically in mental health, then often specialized further. Just because we can connect something to occupational dysfunction does not mean we are well-equipped to treat that specific thing. 

I have done continuing ed after continuing ed within the OT field, and none have given me enough substance to treat what walks into my clinic. I have then turned to so many “parenting” books written by these mental health professionals (i.e. psychologists with Ph.Ds and extensive experience in working with emotional dysregulation) to gain any tidbits of information and strategies that may be more useful than these curriculums we’re given (Zones, ALERT, etc.). 

“But Interoception is a sensory system, and it’s important for emotional regulation”. 

Another can of worms that we’ve opened. Can someone please explain why someone should go to an OT instead of a trained pediatric therapist conducting dialectical behavior therapy, play therapy, or exposure therapy? Again, most therapists are not formally trained in the actual Sensory Integration Therapy protocol, which may lack some serious validity anyway. I would assume this would be the primary way for us to treat a child’s difficulty managing sensory input. Essentially I think what we try to do is a sort of exposure therapy, or offer deep breathing strategies, or distractions (i.e. fidgets) that are loosely based on a child’s “sensory needs” (do we know what we mean when we say “a child’s sensory needs”, and are we basing that knowledge on a highly biased Sensory Profile??)…DBT without being trained in DBT…

Oftentimes “sensory” is NOT the primary cause of a child’s anxiety or behaviors, let’s all admit that right now. Why can’t a professional distinctly trained in childhood mental health throw out the same strategies that we do, and more? 

I think we are in over our heads and overcomplicating a lot of things. To take it further, we then blame their dysregulation on things like “retained reflexes”. Someone please show me the research on this right now. 

My goal with this blog is to ask questions that I very deeply feel need to be asked and discussed. You may feel angry and wildly disagree with everything I have to say. That is perfectly ok. I want to hear your perspective and see all the research that you’ve done. 

Click the “Contact” button on this site and educate me! Or tell me if you were struck by these questions, or have had the same questions yourself!

Until next time,

The Inquisitive OT 🙂