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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About TheAnonymousOT

Pediatric Occupational Therapist
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5 Responses to Making Sense of Occupational Therapy Goals

  1. We, PT and OTs, must do a better job of documenting progress. I agree that there are many road blocks at times, but if we don’t start showing better results that therapy makes a difference we are not going to be reimbursed for our services.

    One tip – document progress regarding each goal at least every two weeks. It usually only takes a few moments to check on a goal and this way you have a clear record of how the child is progressing. Also, if the child is not progressing inform the parents and teachers. A teacher would never send home a ‘F’ grade without some sort of warning or request for help.

    This is my personal opinion but for school therapists , try not to write goals with less than a 60% achievement rate. Would a teacher ever write that a failing grade is a success? No way, so why are therapists setting goals that would get a ‘F’ grade?

    Agree 100% with your sentiments that goals need to be measurable!

  2. Behind the scene OT says:

    I agree that goals need to be measured all the time. I think it should be part of the whole OT process where you Subjectively and Objectively need to evaluate what progress was made. After that you analys

  3. Behind the scene OT says:

    After that you analyse what happened and determine the positives and the negatives and then plan to see how one can enhance the progress of the client.

  4. Pingback: Classroom Integration, Part 4 – An Authentic and Natural Environment | Pediatric Therapeutic Services, Inc.

  5. Meghan says:

    How do you measure goals with minimal verbal cues? How would you keep track of that?

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