How “Evidence-Based” is Your Therapy?

Evidence Based PracticeTherapy lives, breathes, and dies by one simple phrase: “evidence based practice.”

Those three words encompass all therapeutic disciplines, from pediatrics to geriatrics. In the simplest of terms, it means that the decisions we make as clinicians must be founded in research. The kind of stuff that makes families willing to shell out their hard earned money on co-pays, or that prompts insurance companies to reimburse for all that hard work we have done. This is how each of our professional organizations fight for us to prove that we provide services that work. Services that make us better than some untrained, unskilled person off the street.

So yes, you get it already. Evidence based practice is important. Now, all you therapists out there, I need you to think about your daily treatment sessions. Is it fair to say that at least some of what you do is “because you’ve always done it that way” ? Did you pick something up from someone, who picked it up from someone else, who maybe went to a course a long time ago? Are you working off of anecdotal evidence that just kind of “makes sense”? Of course; it happens all the time. You probably just don’t sit there and question everything you are doing, especially if your clients are making progress and meeting goals. The beauty of being a clinician is that you can use your clinical reasoning to work through many problems. But what about when you are stuck and frustrated because your clients are plateauing, or you just aren’t sure where to go next. Is there something you might be missing?

In an ideal world, we would all be reading and contributing to the latest research, sharpening our skills and staying on the edge of what’s next. However, anyone that’s out there practicing knows that this isn’t always possible. There are many factors that impact our consistent use of evidence based practice in therapy.

Availability and Access to Research:

It would be wimpy of me to just whine that there isn’t enough research out there, because that’s not entirely true. What is true is that we don’t all have access to the latest research. In graduate school, they allow students access to databases that house tons of full research articles. If I tried looking something up now, I would most likely have to pay to get the full article. Yeah, I’m probably not going to do that.

This is why I think it’s nice to have a student at a facility, because as a part of their fieldwork, they typically have to complete a project about whatever their instructor decides upon. This is a great opportunity to breathe some fresh evidence based practice into your clinic or practice setting.

Also, don’t knock those new graduates that are so bright-eyed and bushy-tailed. They probably hold a lot of the latest information due to the fact that they just spent so much time in school scouring research papers for their thesis projects.

Motivation:

I can’t avoid the other obvious here, who really wants to go home from a long, hard day at work and read through tedious research articles? Those things aren’t meant to be thrillers. Don’t blame me if I just want to read a trashy magazine or the latest vampire romance novel. Therapists often struggle to find a work/life balance, and I’ll let you know, most business aren’t going to provide the opportunity to peruse research articles on company time. That’s for billing patient contact hours, people.

Now, the obvious solution to this issue is continuing education. We are all required to complete a certain amount of hours in order to keep our licenses. The problem here? Courses are expensive. I could spend anywhere from a couple hundred to a couple thousand dollars on a course. On top of that, you often have to use vacation time or your weekends to complete these courses, and might even have to travel far away for a course that’s any good. The cheaper courses are sometimes a joke or a complete waste of your time…pretty much a crap shoot. Plus, you may only complete 1 or 2 courses a year; not nearly enough to keep up with an ever-changing caseload.

Personal interpretation of research:

You have to let the research guide your clinical decisions, and interpret it with a critical eye. Look for the limitations and how they apply to your practice setting. Let’s say that one study found that pencil grasps do not ultimately impact handwriting legibility. Does it mean that you should never look at a child’s grasp again? No; it means that you weigh the impact of the grasp on a particular child’s handwriting and determine if it is worth changing (i.e. biomechanical joint stress, weakness, etc). Just reading the articles isn’t going to change your practice unless you interpret it and learn how to incorporate it in your day to day treatment.

Therapist personality types:

I find it interesting that in my time as an OT, I have met many different types of therapists. Some that are flighty, doing a few activities here, a few activities there, without a real “plan” in place. I’ve met people that are insanely rigid in their practice, OT rock stars that are quoting AOTA framework and ICF models. (Yes, these people often track me down on the website and let me know what I’ve been doing “wrong”.) Yikes.

These different personality types are ultimately going to contribute to the therapy they provide. Remember that whole “therapeutic use of self” thing? We can’t change who we are and how we naturally go about solving problems, but we can always try to improve.

So I guess it’s a pretty fair to say that we can never know it all. We really just have to do the best with what we have available to us. Also, we should never be afraid to ask questions and collaborate with those around us.
After saying all of this, am I going to go out and create some ground breaking research? Sadly, probably not. However, I am going to continue to try my best to make sure I can always back up what I’m doing. Stop yourself during a session and think, “Why am I doing this?” In your mind you might think: We are working on proximal stability as well as development of the palmar arches, all while addressing letter memory and sequencing. Bam! Skilled intervention!

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Posted in Lessons Learned, Occupational Therapy | Tagged , , , | 5 Comments

The OTR/COTA Relationship

The OTR / COTA RelationshipWhen your child receives occupational therapy, their therapist could either be an Occupational Therapist (OTR) or an Occupational Therapy Assistant (COTA).

First, I would direct you to review my post: “A Who’s Who of Occupational Therapy” so that you get a firm idea of the exact differences between these two therapists as far as credentials and job expectations.

Basically, when a COTA is treating a client, the OTR and COTA must work together to create an optimal treatment plan for a child. In the end, the OTR is in charge of supervising and signing off on the COTA’s work. This supervisory relationship can be great, indifferent, or just really, really bad.

Here are some of the issues that influence the OTR/COTA relationship in a negative way:

 -A Duel of Education Versus Years of Experience
So technically, insurance reimburses the same amount of money for a COTA or OTR completing a therapy session. If that’s the case then why is the gap between therapists a whopping 4 years? (Associate degree vs. Masters degree) It makes the idea of getting a graduate degree and falling an extra $30,000 or more in debt seem a little less appealing now a days, especially in some settings when the gap in pay between the two might be negligible.

Regardless of why the gap in credentials so large, it can definitely create a rift between therapists. Say two 30 year old therapists work at the same clinic. One is a COTA with 10 years of experience, and one is a OTR with 6 years of experience. The only difference comes from the time it took both of them to finish school. When a parent calls and wants “whoever has the most experience.” I’ve seen an uncomfortable moment when the two might battle it out over which means more… education or actual years of practice.

As I’ve mentioned before, I think it takes a whole lot more than the letters after a name to make a therapist a good fit for a child. And for this reason I encourage parents to try to look past this as they find a therapist for their child. But on that same note, I know it’s hard not to feel a little defensive in this situation when you’re the therapist being judged.

-Straight Up Superiority Complexes
This can come in two forms. On one hand, some OTRs just want to exert their “power” and let a COTA know who is in charge. They might shoot down the COTA’s ideas and substitute them with their own. They might put the COTA on the spot and make them fight for their stance. They might just be plain ol’ mean and condescending. Sadly, I’ve seen all of these situations.

On the flip side, sometimes a COTA will want to put an OTR in their place due to the fact that they have been practicing for a much longer time. I mean, imagine being a COTA with 20 years of experience, only to have a new graduate OTR come in to your office and tell you what to do. Yeah, that can’t be fun.

-Unequal Caseload Expectations
Due to the extra paperwork responsibilities of an OTR, in some settings they have a lower caseload expectation. For example, a COTA might need to complete 35 hours of therapy a week and an OTR might have to complete 30. Even though the difference is justified by the additional responsibilities, this in and of itself can create a rift between the professionals, and a COTA might feel as if the expectations are unfair.

-Paperwork Battles
Since all of a COTA’s paperwork needs to be signed by an OTR, their “approval” of work can go down in many different ways. Sometimes it’s just looking over a document for grammatical errors and proper goal progression. Sometimes it’s an uncomfortable overhaul of an entire document. I know when I am reviewing a report of a COTA, I try to not put too much of my own preferences into their writing style. I might read a sentence and say, “that’s not how I would have said it,” but if the content is there, then I have learned to leave it alone. I’m not sure if every OTR feels this way.

-Disagreements over treatment progress
Sometimes there are just honest to goodness disagreements over the course of treatment. I might look at a set of goals that a COTA has for a client and ask, “why are you working on that?” With any therapist, I think it is important to be able to explain the reasoning behind your interventions versus just doing something that you’ve seen other people do. This has also been a learning process for me to accept that something isn’t automatically wrong just because it’s not the way I would do it.

 -A Lack of Any Relationship
Sometimes an OTR might never really interact with the COTA that they are supervising. They sign off on paperwork, but don’t have the time or resources to appropriately supervise a COTA. Granted, there are many COTA’s out there that don’t necessarily require that direct supervision, but by law, there needs to be some sort of processes in place to assure that proper supervision is happening.

From my experiences, the ideal OTR/COTA relationship consists of adequate face time together, and a sense of trust and mutual respect for two different professional opinions. When therapists actually work together, the families benefit so much more, and it can create a much happier and productive work environment.

Posted in Insider Information, Occupational Therapy | Tagged , , , | 2 Comments

Tested in Therapy: Ergonomic Stylus Review

Ergonomic Stylus Review

Let’s face it- tablets, iPads, smart phones… they are pretty much everywhere these days, even in the therapy world. While these gadgets are obviously the new normal, it is very important to remember the importance of good ol’ fashioned fine motor skill development. (A parent once told me that their school therapist said there was no reason to teach tasks with a pencil and paper, since kids would eventually only be using electronic devices. Whoa, now…)

Some tablet games are great for promoting pinch, finger isolation, and even visual motor integration. Of course, you can’t forget that the motivation for these activities is through the roof! However, I’ve found that one of the greatest things I can incorporate with the iPad is pencil grasp training using a stylus. Basically the ultimate in sneakiness.

Say a child refuses to do a writing task, but can’t wait to play a game on the iPad. Well, hand over a stylus, and magically they are practicing their pencil grasp. Plus, they don’t seem to mind corrections or adjustments as much when it comes to playing an app.

So when I was approached by The Pencil Grip to review their Ergonomic Stylus, I was more than happy to give it a go. (Full disclosure, they sent me the product to review for free, but this is in no way a sponsored review. Then I couldn’t be as brutally honest as I love…)

I thought I would put this product up against my regular stylus that I typically use with children in therapy. You can buy 3 of these generic ones for like $1.50 online. The Ergonomic Stylus retails for $12.99 on Amazon.

Stylus comparison

The first obvious difference is the thickness/weight of the Ergonomic Stylus. It has much more of a presence in your hand as you use it. Also seems much more official. This helped some children with proprioceptive and/or tactile issues have greater control of the pencil. Now, this isn’t a ton of weight, but I also liked it for a child that has a very mild intention tremor. He seemed to be more successful with this stylus in terms of control.

Many of my clients with autism preferred to grasp this stylus with a fisted grasp, and would maintain the proper position on the grip for only a few moments. I’m not sure if this had to do with the increased thickness of the stylus, or the grip itself. Just to be sure, I would switch between each stylus during a task, and sure enough, there was much more fisted grasping with the thicker stylus.

Now, if you are really looking for the adaptive positioning benefits of using The Pencil Grip, you can just slide that puppy on a regular stylus without a problem. When I did this, children focused a bit more on their grasp.

Stylus with grip

Another plus of the smaller stylus was that I could interchange different grips for different issues. One of my favorites being the CLAW grip, the one that most little fingers don’t slip out of quite as easily.

Stylus with CLAW grip

Overall, the Ergonomic Stylus might be a good choice for some of the older children that use a similar grip on their pencil successfully. Watch out for compensation while using the product, and as always, I would make sure to follow up with additional exercises and fine motor strengthening. Also, it might be a good choice for adults that do a lot of work on their tablets and need joint/pressure relief.

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Waiting Room Chaos in Pediatric Therapy

Waiting Room Chaos

Ah yes, the waiting room: The very bane of my existence.

Parents? Kids? Therapists? Are we all in agreement here? It’s just the worst.

The concept itself is crazy- Here kids, sit in this chair, be quiet, and wait patiently for your turn. Ha!
It gets loud, it gets busy, and it gets challenging to walk around without knocking someone over. And that’s just at 10AM… wait until the afternoon rush hits!

The waiting room has been an issue everywhere I’ve ever worked- whether the clinic was tiny or huge. However, one clinic had the unique opportunity to move into a bigger facility. There was much debate about arranging the waiting room in the new place. Should there be more space? Perhaps an “L” shape for extra nooks and crannies? We could stagger the therapists’ schedules so that everyone isn’t in the waiting room at the same time. Or, how about no waiting room at all?

The consensus was that the waiting room is horrible regardless. More space = kids literally running around. Less space = louder noises. More toys = more of a mess, kids fighting, and germs spread. It’s a lose/lose situation.

Within the first week at the new facility, a parent looked at me as the tornado of children and parents surrounded us, hands over her ears, exclaiming… “I thought this was going to be better!?” Or at least that’s what I think she said… It was awfully loud in there.

So what exactly makes the waiting room such a stressful experience? Here are just a few things I’ve noticed…

-Lack of proper adult supervision.  

Of all the places in the world, a therapy clinic should be a safe place for parents of children with special needs. I completely understand that and want people to be comfortable with their children.

However, there have to be some rules or expectations in order to keep the situation from getting out of hand or causing other children to meltdown in a horrific domino effect.

I often see parents allowing their children to knock the chairs over, rip books apart, or throw things from one side of the waiting room to the other. (And most of the time it’s the sibling that is the guilty party here as they wait for their brother or sister to be done with therapy.)
These kids can get out of control, and will even get into fights or scream at each other as a parent sits silently on their smartphone. I even had one parent that was so sick of other kids being out of control that she yelled at them from across the room. Awkward.

Now, I hate when parents feel overwhelmed in the waiting room, so if their child is having a particularly hard time, I tell them to take the child back to my office immediately upon arrival, or to arrive right at their scheduled time so they don’t have to wait around.

- Getting a little too cozy in the waiting room.

Hey, therapy is a big time suck for a lot of families. They have to drive there, wait around, and then drive back home. They have things to do, and I totally get that. However, there is a point when the activity you’ve chosen to complete is inappropriate in the waiting room setting.

One parent dragged an end table in front of her chair, set up a laminator and large paper cutter (you know, with the giant blade that chops large stacks of paper) and seemed annoyed when I had to step over her.

There are other instances when siblings bring bags full of toys, Legos, or whatever, and spread them all out on the floor, only to be upset when others come to play and check out the fun. Just know that if you have something cool, other kids are going to be interested. If you don’t think your child will be able to share, you might want to think of another activity to bring along. (Oh, and if you bring a video game or some electronic device, make sure to bring headphones or keep the volume waaaay down.)

I’ve also witnessed several parents attempting to home-school in the waiting room, and I have to say, some can pull it off well. Others? Well, it seems to end up to be a bit counterproductive and they get frustrated by other people making noise in the waiting room.

 -A complete loss of “inside voices.”

Wow, the noise of a waiting room. It’s a therapist, child, siblings, and parent, all talking over each other, times ten. Most of the time I can’t even process what I’m saying to a parent due to the noise level, so how can I expect them to understand what I’m telling them? The worst part is trying to move to a new location, only to be bombarded by other therapists attempting to do the same thing.

 -Judgement and stares from other parents.   

Remember how I said a waiting room should be a safe place for a parent of a child with special needs? I really dislike when some parents sit and openly stare or gawk at another child with autism as they make a strange sound, or possibly hand-flap or “stim” off of something. I can get really defensive when I see this happening, as if they are comparing their children’s challenges. We’re all here for the same reasons, people, so please calm down the judgmental stares.

-Finding a new client in the crowd.

Why does this hardly ever seem to go smoothly with me? You can either walk around to every group of people you don’t recognize and creepily ask if they are there for an OT evaluation, or call out a first name to a crowd that just stares back at you. Sometimes another therapist can describe the child or parent right beforehand, or maybe the receptionist can point me in the right direction if she has a spare moment. Regardless, I apologize if this is a strange situation.

-The transfer of the child from parent to therapist, or back again.

Here’s a fun situation. Maybe it’s only me, but when I take a child back out to the waiting room, as soon as the mom or dad is in view, I assume that the child is back in their care. If your child runs out the door into the parking lot, runs into an adjacent office building, or starts hitting the child next to them in the waiting room, please step in. I’ve chased my share of kids out the front door before, and will continue to do so in order to keep them safe; however, I do appreciate it when the parent steps in to try to help.
Now, if you have your hands full with other children or are trying to load everyone in the car, that’s a different situation all together, and I am more than glad to help. This is mostly an issue when the parent seems to ignore a situation that calls for their attention.

-Attempting to have a meaningful conversation with a parent.

There is this little thing called HIPPA that all therapists and medical professionals must abide by. These laws protect you and your child’s private health information. So ideally, you wouldn’t be talking about a child’s therapy in a crowded waiting room. While most parents give consent to talk openly in the waiting room, it can still be challenging to do so in a meaningful way when there is a circus surrounding you. I feel so terrible when a parent is trying to tell me something important, and my next client is literally tugging on my arm. Or perhaps I am so excited to tell them what their child did in therapy, but the sibling is having a meltdown. In these situations I try my best to find a quiet place to talk in the back or at the car, or I’ll ask to call the parent at another time.

-Keeping things clean.

Please don’t judge a clinic by the cleanliness of the waiting room. I promise, it’s really the hardest place in the world to keep clean. People throw trash on the ground, leave toilet paper all over the floor, spill drinks, vomit, you name it. Again, I know it is a challenging place to keep everyone happy and on their best behavior, but man, I’ve seen some gross stuff left behind.
The worst part is that typically many small or private clinics can’t afford to hire someone specifically to clean. It’s usually a duty that is spread between therapists and other support staff. And throughout the day it’s hard to keep things clean and well stocked when you have a full caseload. However, I will always stop what I’m doing to make sure you have toilet paper. That’s kind of like life’s necessity.

-Finding a waiting room alternative.

So when the waiting room is just too much to handle, what else can we do? For many parents, I recommend taking the child to the car and talking there. The downside to that plan is that I often end up sweating in the heat, or freezing in the cold or rain.

Also, without the watchful eye of the next parent staring you down, people can get lost in the 5 minutes or so allotted to talk before the next session starts. I’ve been stranded in the parking lot on more than one occasion, looking for a pause in the conversation to say, “I gotta go!”
I admit, there’s a point when I stop listening and start thinking, I’m late, I’m late, please stop talking, I’m late… But that’s hard to say when a parent is opening up about something personal or difficult for them, or even just chatting about their day. I would advise bringing up big problems before the last few minutes of the session because you’re more likely to have the full attention of the therapist. Or, if time is running out, suggest having the therapist call you later when they have more time to talk.

And yes, I’ve been yelled at for being late because a parent kept talking to me. (Probably why I’m so paranoid about being late to my next appointment.) One parent literally watched the clock to make sure I wasn’t “stealing” any of her child’s session. Or, how about watching one parent yell at another parent for making their therapist late to their child’s session. Yikes. I have to say, never a dull moment in this job!

So to parents that hate the waiting room, just know that a lot of therapists are right there with you. And if anyone has come up with an amazing solution, please feel free to send it my way.

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

Therapy Carryover in the Home: Issues and Barriers

Therapy Carryover in the Home

The copies run through the machine, one after another, using paper, toner, and a few spare moments I found before my first client. I’m printing out handwriting practice sheets as homework, but can’t help wondering… am I wasting my time?

I used to assume that people followed all of my instructions back in my idealistic “I can fix everything” phase of practice, fresh off the grad school wagon.  But it doesn’t take long to spot a parent that brushes you off, expecting the change to happen in your time together with their child, not at home.

There are some people that are apologetic about it all, like a babysitter that came in week after week- “I’m SO sorry we didn’t do the homework this week, time just got away from us.” Her honestly was refreshingly surprising; after all, it’s not often that someone will fess up to blowing off assignments.

Others are sneakier about it, like one parent that asked every session- “What are we supposed to do at home this week?” I loved it, and felt like she was really on board. I copied handwriting sheets and sent home fine motor ideas each week. We were a team, therapist and parent, conquering letter formations!

That was until one week that the mom was running late. She had to pull up really quickly as her son jumped in the front seat. And that’s when I saw them -  weeks and weeks of homework sheets, crumpled, stepped on, uncompleted, and strewn about the car floor. What should I have done? Pointed my finger accusingly, “Hey! You didn’t do those worksheets! Liar liar pants on fire!” Or what I actually did – avert my eyes and pretend to see nothing. Maybe that day I just needed to pretend like what we were doing was important.

So here is the question of the day: how do we get carryover in the home?

I like to introduce the idea of therapy to parents with a scenario: Would you go to the gym for one hour a week with a personal trainer, never return between sessions, and then gripe at the trainer because you don’t have a six pack? No, because that sounds ridiculous. However, the expectations of therapy are practically that high. “Why can’t he tie his shoes?” “Why isn’t he writing his name?” “His teacher says he still runs around the classroom, this sensory stuff you do isn’t working.”

For many of these situations I respond with a question of my own, “Have you tried my suggestion to do ________?” Parent responses range from “Well… no, not yet.” Or a quick brush off of, “Nah, that didn’t really work.” So many times I find that I bang my head against the wall trying to scour my brain for answers, only to realize the ideas aren’t even attempted.

When I had a string of clients with tricky sensory processing issues, I realized I needed to try something different. The parents were saying, “He hasn’t changed.” or “He is still all over the place.” each week and I was feeling hopeless. One mom admittedly did nothing at home, so I decided to send home a journal for her to track what she did and how the child responded. I tried a very strict approach with her in attempt to get her on board, clearly laying out the rules that she needed to bring back a completed entry every week.

The result? I never saw that journal again.

I’ve seen the same thing with fine motor practice; some therapists attempt to send home a binder of work to be returned and reviewed each week, or perhaps a simple checklist or grid sheet with room to chart exercises. While there are parents that thrive on this approach, I have to wonder if they are the ones that would have been doing the homework regardless.

It becomes frustrating as a therapist when you spend the money and time to create something special for a child, knowing very well that: a) it might never be used, and b) you might never see it again. I have found that even when homework is considered a “requirement” of the therapy program, there isn’t always follow through.

But what makes the difference between a parent that follows through and a parent that doesn’t? Sometimes it boils down to money; those that are paying a LOT for therapy seem very interested in homework, mostly because they want to be done with the added expense ASAP. Others don’t blow off homework intentionally, they just barely have time in their schedules to get their child to and from the office. Then there are still some people view therapy as a break from their child, or perhaps they simply feel like the therapist should be doing all the “work.”

I get it though. Lives are busy, especially when families have more than one child. They have work, school, and extra curricular activities. But if a parent invests in coming to therapy, they should invest in the time to make the most of it, if they really want to see progress.

That’s why I feel that it is critical to make sure the parent knows exactly what is being worked on and WHY. I have found that if a concept or task doesn’t make sense to someone, they are more likely to just not follow through at home then to ask for clarification from their therapist.

There is obviously a delicate balance between becoming an authoritarian that says, “You must do this for your child!” and creating that therapeutic bond. The trick is to find the middle ground. Maybe I should just say “pretty please” and see what happens?

Posted in Lessons Learned, Occupational Therapy | Tagged , , , | 11 Comments

DIY Therapy Putty

DIY Therapy Putty 1

The majority of my test pins have a common theme: how to make therapy products that don’t cost a ridiculous amount.

In my latest quest I set out to find a recipe for DIY therapy putty. I use this stuff all the time- hiding objects inside, pushing pegs into it, cutting it with scissors – It’s a great (and always entertaining) way to develop hand strength for kids. My only issue is that it costs more than it probably should, so I figured a homemade recipe would be worth a try.

While searching on Pinterest, I found a link to this website with the recipe I was looking for: DIY Studio: Homemade Therapy Putty

It looked easy enough, just liquid starch and school glue in a 1:1 ratio, and then food color for added pizzazz. I ended up using about 8 oz. (2 small bottles) of glue and 8 oz. of liquid starch. A batch was under $3 total, with plenty of liquid starch left.

First I added the liquid starch and glue in the bowl (1), and started mixing it together with my hands. It started out very stringy (2), and I thought I had done something wrong already. However, the more you mix it, the more those fibers start to stick together (3). My biggest mistake was waiting too long to add the food color. I guess I had little faith that it was going to work out or something. Anyway, adding it at the end was a bit like mixing food coloring into a mostly done omelet (4).

DIY Therapy Putty

Side note #1: I gagged several times while mixing this little project together, and I didn’t even think I had tactile issues. The consistency in the beginning can be a bit gross, and might be something to consider if you are going to make this together with a child that has sensory processing issues. Even with the finished product there were a lot of children that wouldn’t come close to touching this, even if they didn’t mind regular therapy putty.

Side note #2: I thought it would be fun to play with the ratios of glue to liquid starch to see if I could make the mixture a bit firmer, like regular therapy putty. Adding more starch made the putty a bit more dense, but then chunks would simply rip off instead of being pliable, essentially rendering it useless for what I wanted to use it for. After a few tries, I decided to stick with the 1:1 ratio.

Once I had mixed it all together, I decided to compare my creation to actual therapy putty. The result? No comparison.

Putty comparison

Notice the difference in the overall stability of the two globs of putty? The DIY putty eventually spread out to fill the entire paper plate, while the regular putty (medium resistance) kept its shape. The DIY putty reminded me more of that Nickelodeon Gak I used to play with when I was a kid. Even Silly Putty is firmer than this creation.

However, since I had braved the gagging and messy hands, I decided to see what I could do with this putty.
-I hid some small beads in the mixture, but they were only hiding under a thin film. Not too much digging required here.
-I then tried to stick some “Lite Brite” pegs into the mixture, but they barely stayed in place. It was more fun just to take the pegs and poke a bunch of holes in the putty.
-This eventually just became more of a sensory task with the children. They liked the feel of playing with it and squishing it in their hands. While it could still be used for some fine motor strengthening, you aren’t going to get the resistance of the real therapy putty.

DIY putty activitiesSo no, I didn’t find a substitute for therapy putty. However, I will still say that I found a recipe for a fun sensory “goo.” I might not be making this for myself again any time soon, but I will definitely recommend it as a good activity to try at home.

Posted in Occupational Therapy, Pinterest Test Pins | Tagged , , | 4 Comments

Making Sense of Occupational Therapy Goals

Making Sense of OT Goals

Therapy revolves around one central theme: meeting goals.

It seems straightforward – goals are the way therapists track progress and determine necessity of services. They should be objective, measurable, and attainable. However, a lot more goes into the goal making process than you may realize, and it can be complicated by a number of factors.

Step 1: Determine areas of skill development that the child needs to work on.
Therapists will look at evaluation results and determine which skills need to be addressed.

Complications with this process:

Parents don’t agree on skill areas to be worked on:
Just because I want to work on a goal doesn’t mean the parent wants to, and that can cause tension with some therapist/family relationships. I had a colleague that lost a client on her schedule simply because the mother thought that her goals were inappropriate.
This particular therapist was gung-ho on working on core strength as a foundation for fine motor skills, posture, and stability. The mother felt it was irrelevant to her child’s issues and they just couldn’t agree.
While I think it’s critical for parents to be on board with the goal writing process, there is always going to be a delicate balance. If there is an area that the therapist thinks must be addressed, it’s up to them to fully explain their reasoning to the parent. However, if the parent refuses to work on something, the odds of the goal being met have just been greatly lowered. In this example I might have removed the formal core strength goal and incorporated this foundational skill area in our weekly sessions without blatantly spelling out.

Parents don’t agree on the skill level of the goals:
Yes, some 10 year olds still need to work on pre-writing strokes like vertical and horizontal lines. This can be challenging for a parent that wants their child to be working on things that they just aren’t ready for. Underlying skills have to be built up before progress can be made. A child that can’t imitate a vertical line most likely doesn’t have the motor skills to be able to copy their name.
This gap in expectations can also cause a struggle between therapist and parent goals.  One parent told me “Well, he should be in first grade this year, so I want to work on more challenging things.”
My knee-jerk reaction to statements like that are that we need to work on the level that the child is functioning, and hopefully one day we will get to where we need to be. Unfortunately the changes in the calendar don’t automatically change what we should be working on.

Step 2: Writing out the goals.
It’s more difficult than it sounds: going from “they need to work on promoting a more mature grasp” to an actual goal that can be measured and tracked.

Complications with this process:

Therapists can’t find an objective way to write goals:
Sometimes it’s just challenging to word what you are working on in a measurable way. Especially when you are an OT working on sensory processing issues. How about: “Child will demonstrate improved sensory processing skills to tolerate transitions with minimal distress in 75% of opportunities.” Sounds measurable, right? Not quite… poor parents are left trying to estimate how much of the time their child is melting down in a “minimal” way. Therapist have to try very hard to set their parameters in a way that makes goal tracking easy.

Therapists cram way too many skill areas into one goal:
“Child will utilize a tripod grasp to copy pre-writing shapes (circle, square, and triangle) with good formation and consistent sizing in 4/5 trials with an appropriate seated posture and minimal verbal cues.”

Yikes. The sad thing is that I’ve actually seen this goal and goals like it way too many times. Sure, it sounds fancy and important, but how in the world are you going to track that goal? What if the child copies a circle and square with good formation, but not the triangle? And what about moderate cues for posture, but the functional grasp is spontaneous?
The worst part is when a therapist inherits a child on their caseload from a colleague that has written goals like these. (Can I just discontinue this goal and write three more in its place??) There is nothing wrong with writing several simple, easy to track goals that address all of these areas. A goal doesn’t need to make the therapist look like a super-hero.

Therapists write too many goals:
I believe the longest list of goals I saw was around 46. FORTY SIX. As I’ll touch on later, the therapist essentially wrote a goal for every single testing item that the child was unable to complete upon initial evaluation. That means if a therapist saw an average of 25 clients a week and they all had 46 goals, they would have 1,150 goals that they need to track. Not possible people. There is a beauty in prioritizing.

Therapists only write goals related to testing items:
Therapists: Please, PLEASE, don’t simply write a goal that states, “Child will imitate a bridge design in 3/4 trials.” (A testing item straight from the Peabody assessment.) This drives me insane and makes it look as if no thought was put into goal attainment.

Now, there are some areas on a standardized assessment that can be generalized into appropriate goals. For example, when the child can’t copy a circle or other pre-writing shape. But when it is a super specific, standardized test related item, I question the motive behind the goal. Can the therapist say why they want to work on that? In this block goal example, if the therapist was worried about the child’s imitation skills, then they could potentially write a goal to imitate simple 3-4 block designs. But if they sat there and taught the child one block design until they finally mastered it, they essentially taught them the test. So next year when they are re-tested, did their visual motor integration really improve, or did they “cheat” into a higher score?

Step 3: Track goal progress in weekly notes.
Therapists have to keep diligent notes during sessions to make sure we track progress towards goals.

 Complications with this process:

Therapists work on activities related to goals:
Sometimes I envy my speech therapy friends that keep these beautiful, consistent percentages in their notes. “Child imitated /r/ in 80% of trials.” That’s it, easy to track. But if I’m trying to work on pencil grasp, one day I might write that the child manipulated therapy putty, transferred items with tongs, or inserted pegs with a tripod grasp. It can be difficult to track a goal when you supplement with other activities. Then I end up hating myself when it’s time to write a progress note and can’t find what I want in my notes.

Therapists get side tracked by unexpected areas of concern:
Say I made a goal for feeding this quarter, but all of the sudden we realize the child is reversing their 6’s and 9’s consistently at school, and that becomes the new priority. It’s an appropriate skill to work on, but then when I go to write the progress note I realize we didn’t even touch that lovely feeding goal. Whoops. Once again, as long as a therapist is working on something appropriate, it shouldn’t be that much of an issue.

Step 4: Write a progress note demonstrating progress towards goals.
Therapists must report a child’s progress in a document for both the parents and their insurance companies.

Complications with this process:

Difficulty guessing the rate of progress:
It is really challenging to guess how much progress someone will make in three or six months. Not every child is the same, and not every rate of progress is the same. Yes, it happens to the best of us- we write some goals that a child meets in two sessions, and some goals that get carried over for way too long. While therapists always need to determine how appropriate their goals are, I wouldn’t get bent out of shape over a few that just don’t make the cut as expected.

Parents aren’t aware of their child’s goals:
I won’t judge if you can’t recite your child’s goals from memory, but hopefully parents know the general areas of intervention. I know several parents that would have absolutely no idea what their child is working on in OT. This also means that there isn’t a whole lot of carry over at home, and therefore, progress is going to be slow.

So while the process of writing goals seems simple, there can be many complications along the way. While it might not be a perfect system, the master plan is to promote progress and change in a positive direction for the child.

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