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?

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About TheAnonymousOT

Pediatric Occupational Therapist
This entry was posted in Lessons Learned, Occupational Therapy and tagged , , , . Bookmark the permalink.

11 Responses to Therapy Carryover in the Home: Issues and Barriers

  1. Jackie says:

    I always get a kick out your posts! A little humor at the end of a hard day of work does wonder on the soul!
    I wanted to say that I also want to make sure that the CHILD is on board himself, that He knows why we are doing what we are doing. It empowers him and maybe…just maybe…he will remind his parents about home work or whatever technique we had recommended for home!

  2. Kris-Ann says:

    As a parent I truly do struggle with when to complete all the assigned OT homework. It’s not because I can’t find time in my schedule, it’s because I can’t find the time in my son’s. Your gym analogy is a good one and true but if a child sees multiple therapists who all assign at home work, not to mention regular school work and just time to be a kid, it seems like none of the homework gets the appropriate amount of attention. Any suggestions on how to make it all happen would be appreciated.

  3. Rachel H says:

    Hi! I’m a parent to a special needs kid. We’ve been in therapy since he was 18 months old. Speech, OT, PT, sensory diets, vision therapy, and finally Brain Balance (an intense, multi-modal approach – that is wonderful and the program that made the difference!). Quite frankly, home is a place where a child needs to feel the most secure. The barrage of school- and therapy-like “homework”(sounds like more school, right) that is handed out by therapists is a struggle in the environment that is suppose to be the most comfortable. My son has Autism, yet we never chose behavioral therapy. Why? too much work. The at home assignments need to feel like play…so mom and dad (who are completely overwhelmed and exhausted by the diagnosis, prognosis, behaviors, feedback, decisions, grief, stress, and guilt ON TOP OF daily life, work, other children, etc., BTW) can see the child in their child. So they can relax. So they can feel like a person again. Tell me to get my kid out on the playground, spend more time at the pool, do squishy-squeezy crafts to build fine motor skills, do an obstacle course with certain movements, etc. Our children are our life work, please make the time we have together more like life and less like work and it will be easy to exceed your expectations.

  4. TheOTprocess says:

    Brilliant post, adherence to treatment is something that I have been mulling over recently and considering investigating it in my dissertation. I would like to look at integrating exercises/homework into everyday habits and routines to increase adherence. Recent study in strength and balance training has shown this approach is more engaging to participants (LiFE approach, Clemson 2012). Going to do a blog post about it soon once I’ve done my research.

  5. Kris-Ann says:

    Great post! I wonder how you’d address kids with multiple needs who receive multiple therapies. I find that I want to incorporate all of the suggestions and homework our OT gives us, but she’s not the only one doing so. Between the other therapists, regular school work and just time to be a kid, I struggle with making it all happen. Partner those with attention issues and the amount of time we have for work outside of school/dinner hours is very short. How would you suggest working with all therapists to figure out which homework is the top priority for the child, not just the therapist.

  6. pediOT says:

    i’ve started writing a goal that there will be ____% of compliance/follow-through with home activity suggestions so that it’s at least reportable on the progress sheets that go to the physicians. as awful as it sounds, i’ve also discharged patients because they weren’t showing progress and there was no follow-through at home. after a certain point, you just can’t justify billing insurance for therapy that you know isn’t producing any outcome if the missing link is that regular skill practice, right?

  7. Pingback: Developing a professional blog: my story so far | The OT process

  8. Lacosta L. says:

    I have to agree with a previous poster… there is seriously not enough time in my kids’ day for all the “homework.” I will add an additional factor, me and my sanity. Taking care of my special kid and kiddo #2 is exhausting! Every little normal routine of the day can be a serious production, for example, breakfast generally involves a 90 minute negotiation of defiant behavior and sometimes meltdowns. We literally don’t stop ALL day, even naptimes are packed with stuff such as making doctors appointments, screaming at the insurance company and washing all the clothes my kid’s peed on. When we finally make it through the day and all of my kid’s basic care needs have been met, I have no interest in doing anything more but taking some me time. I am sure there are some people smirking right now but the number one thing I have heard from every therapist is to take care of the caregiver. I get about 20 minutes to myself each day (shower included) and I can not see giving that up to do tongue pops and scissor practice. Sounds selfish, I know.

  9. Great post. But you don’t get it though. Sorry to say that and this is not your fault or the parents fault. It’s the way our society works recently. We put a kid in school so he gets an education, we don’t bother educating him, just as long as we remind him to do his homework. We put a kid into hospital so the doctors get him well quick, we don’t think about the fact that the food we put before him everyday might be contributing to his health and illness. We (the parents) don’t have the power to rule our kids life and progress, we’re considered not knowledgeable enough, we don’t have a degree in special ed or healthy nutrition or whatever. And you want us to be involved? Yeah, try building your house on the sand! That confidence in taking charge doesn’t come from being told ‘you should do homework with your kiddo’. It doesn’t come from telling ppl ‘do such and such’.. It takes a while actually to re-train a parent’s mind into thinking like ‘I know my child better than anyone with a PhD, and they should listen to me when I have something to say about what his needs are’. You all know better, at least that’s your sermon. You shouldn’t be asking ‘How come you didn’t do all those worksheets” you SHOULD be asking ‘What do you think your child should be learning at home? What do you think would benefit him the most? What are his problems that you’re stuck with, perhaps I’ll have a few ideas?” You know, it all boils down to motivation. If a parent is not motivated to do what YOU think will benefit their child, then in the parent’s head it’s probably a useless exercise in some academic skill that has no appliance in day-to-day life. When something isn’t working, it doesn’t mean you should just do more of it at home.. Perhaps, you should look for something that works.

  10. Thanks for the great comments and insight everyone! I especially appreciate the parents that have been commenting, because I can completely relate to your issues of carryover.
    I think the biggest issue I have is when a parent confronts a therapist, asking “why isn’t this better?” or “why do we need to keep coming?” when they haven’t been trying anything at home.
    To Oksana- I agree, the parent has to be motivated and involved in therapy in order to really see carry over. There’s no point in working on something that means nothing anywhere else but in the clinic. That’s kind of the whole point of OT, finding motivation through occupation. However, in instances I am describing, I haven’t been able to get a parent on board with anything. (The worksheets were just a simple example, this might happen with other activities that I try to make as family friendly as possible.) This situation creates a pickle, because we have children on our caseloads that aren’t making progress, and thus have to be discharged, because there has been no follow through.
    So no, of course I can’t blame a busy parent that has no time for themselves. By all means, you definitely need to take care of yourself! The real issue is when it becomes a barrier to progress and therapy stalls. Because, as I mentioned, just doing an exercise once a week might be beneficial, but for many children, it’s not going to change much without continuous practice.
    Keep the insight coming, I think it opens a great discussion that we need to be talking about!

  11. TheOTprocess says:

    In reference to my last post about adherence to treatment. I have written my blog post about this now. It would be great if you could come and take a look. http://theotprocess.wordpress.com/2013/09/05/the-power-of-routine-or-why-i-didnt-do-my-physio-exercises/

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