Wednesday, November 30, 2011

Is therapy working?

Did the therapy really help my son?

A parent once asked me, "How do you know that a certain therapeutic method is working?  What if the problem got better spontaneously?  How can you really tell?"  I thought it was a really good question.  Don't you?

I certainly wouldn't want to waste my time with methods that weren't working.  I want to make sure that my efforts are not in vain.  So how do I know?

When I'm treating a client, I always have very specific goals.  Every activity I do with a child has a specific purpose.  A parent watching may think it just looks like fun and play, but it's therapy disguised as play.  Every task is graded to be at just the right amount of challenge: easy enough to accomplish, but hard enough to push to the next level.  This is the basis of sensory integration treatment.

What does this look like in practice?  Let me give you an example.

Allan (not his real name) was a six year old boy diagnosed with moderate-severe Autism.  He did not use words or gestures to communicate.  He had severe sensory problems which interfered with his family, social, and school life.  He frequently used flicking saliva with his fingers as a self stimulatory behavior.

When I evaluated Allan, he ran around the room in circles.  He appeared fearful and anxious.  When I observed him in class, he appeared to have difficulty sitting still and focusing on tasks.  During recess he did not attempt to engage in social contact with either teachers or other students.  He spent the entire time trying to find a way to flick saliva without getting stopped by a staff member.

In my professional opinion, I thought Allan's sensory issues and his inability to communicate his needs or desires prevented his full participation in school activities.  I began to see Allan twice a week for occupational therapy.  He also received speech therapy twice a week, play therapy once a week, and music therapy once a week.  Allan was enrolled in a special ed. class, with a 3 to 1, student to teacher ratio.

In 6 months, Allan was able to participate actively in circle, his self stimulatory behaviors decreased, he occasionally made social contact with staff members, his anxiety appeared significantly reduced, and he could speak in two to three word sentences!  He was also able to tolerate more outings and new experiences! 

How did I help Allan to reach his goals?  I had to find and use his inner motivation.  I had to start at his level.  In the beginning, he's only comfort was the visual and tactile stimulation of flicking his saliva.  I had to give him a replacement behavior that gave him more satisfaction and the means to communicate his desire for it.

After trying water, I tried bubbles to entice him.  It was a success!  He absolutely loved it!  But how would he request for it?  Since communicating his sensory needs was vital to his progress, I began to work on recognizing and communicating his needs.

The first time I used bubbles, I used it freely without expecting him to request it.  During other tasks, I would bring out the bubbles when I could see that he needed it (i.e. fidgeting, frustrated, decreased attention, attempt to run, etc.).  It was important to show him that bubbles was more effective than flicking saliva.  It's usually ineffective to try to explain why a behavior is inappropriate to a child that isn't using words to communicate and who doesn't know any other way to satisfy his sensory needs.

It was also important to show him that I understood his sensory needs and that I wouldn't try to prevent appropriate sensory seeking.  It was also a way to build his trust in me.  This trust would become the foundation of therapy.  I always take time to build this trust, so my client will try things they wouldn't normally try.   

The second time, I placed the bottle within sight, but not within reach.  This time I waited until he looked at the bottle, before saying, "You want bubble!"  Then I would reward him with extended bubble time.  I would still give him bubble time without request, if he needed it, but the amount of time would be shorter.  Eventually, he learned that requesting bubbles got him greater satisfaction.  "Ah-ha!  Communicating gets me what I want or need!"

At the fourth session, he began to reach for the bottle.  I would immediately affirm what he wanted and give him extended bubble time.  By the sixth session, I put the bottle right in front of me.  This made it possible to make eye contact before rewarding him.  Eventually, he would initiate eye contact and I would reward him with extended bubble time.

When he was consistently able to make eye contact to initiate communication, I would ask him to approximate the "b" sound.  At first I would reward any attempt because it was obviously difficult.  He would use his whole body to try to get the sound out. 

When he was consistently able to approximate the "b" sound, I would ask him to say "ba-ba".  Every time he mastered a request, I increased the difficulty.  Every initial attempt was rewarded with extra time.

Eventually, he was able to say "bubbles", "want bubbles", and "I want bubbles".  The first time he was able to say the full sentence, I rewarded him with bubbles for the rest of the session.  It turned out to be a turning point.  He began to communicate his needs and desires in words.  He began talking all the time!

This wasn't the only thing we worked on in therapy, but it was a focal point.  Obviously, speech therapy and classroom staff also worked on communication as well.  But in OT, the focus was on recognizing and communicating his sensory needs and using appropriate sensory stimulation.  AS the results show, we reached these goals. 

How do I know it was the therapy?  Because each session was focused on smaller goals.  Whenever we achieved these smaller goals, I readjusted the goals for the next session.  Reaching these smaller goals helped me to assess if therapy was working.

How do you know if therapy is working for your child?  Ask your therapist for more details about the short term goals.  Walking may be the long term goal, but what stepping stones will be achieved first?  What methods is the therapist using to achieve these goals and how can you supplement at home?

Actually providing therapy at home will help you see, or actually feel the progress.  You'll feel how your child needs less and less help.

The parent above was asking me about her son who was suffering from difficult bowel movements.  He would only have one bowel movement every 14 days and it would cause him pain for two hours.  He had suffered botulism as a 4 month old and spent a month in NICU.  I showed her a few Masgutova techniques and a few therapeutic massage techniques as well. 

 The next day she reported that her son immediately started to pass gas after the first session.  Within 24 hours, he had a "stealth bowel movement".  For the first time, he had a painless and uneventful poop session.  I suggested she continue treatment for 4 weeks.

For two weeks she followed the suggested regimen with several resulting "stealth poops".  However, illness delayed treatment one week.  He immediately stopped pooping.  She continued therapy again and eventually saw permanent results.  She was convinced that these techniques had worked for her son.

How about my son?  Yes.  Therapy has definitely helped my son.  I can tell that his movements are not as smooth on the days we miss therapy.  In fact, when he was 4 months old, we took a 2 week therapy break.  I wanted to enjoy being together without thinking about strokes, therapy, or the future.  We had a great time, but his development definitely slowed down.

After the 2 week break, we started a more relaxed version of therapy, by fitting it in throughout the day.  I also don't stress out if we miss specific techniques for a day or two.  We do what we can and enjoy being together. 


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