Introduction to Learning and Vision Therapy: Clinically Speaking Part III

Building A Strategy For Success

Introduction

Behavioural concerns require long-term attention and ultimately must not rely exclusively upon third-party providers for long-term success. Management of behavioural problems requires that systems be implemented to assist in developing routines in the child’s life that will lead to and reinforce positive outcomes. A child cannot be expected to develop these routines on their own, and success can only occur if parents are implicated in developing and maintaining good habits in the home and at school. In difficult cases, such as with autism, it is still reasonable to try to train parents to work with children at home and rely less on contract therapists, even if to accelerate therapy. Of course, with autism, contracted therapy provides respite for parents, which is often as important as the child’s therapy.

This section provides notes on preparing for therapy. It is written to assist therapists in teaching parents to delivery meaningful and regimented therapy at home, though the principles apply equally well to any therapist working with children with school-related learning and behavioural problems.

State of Mind

The therapist/parent much approach therapy with a clear mind and be prepared to be fully present for the child. It is better to start a session a little later and clear immediate concerns from one’s mind than to proceed in therapy and waste most of it due to lack of focus.

Impulses to answer phones, email, text, or to speak unnecessarily must be suppressed. Commentary and interaction must be focused on the task at hand, providing more support at first, and then paring this down as the child begins to master the activity and automaticity arises. Unnecessary comments should be reserved for the pre- and post-session times. If the child choses to discuss something unrelated to therapy, this can be put off until a break, or the end of the session. The therapist should resist making comments unrelated to the task while the child is practicing.

Perspective: Interested Objectivity

It is easy for a contracted therapist to step back emotionally from a child who they see perhaps only infrequently. Parents and guardians do not have this luxury and are fully invested in all aspects of their children’s lives.  Because of this, they are burdened with a variety of filters that impair their objective view of the child sitting in front of them.

A parent is inextricably interested in their child’s health and wellbeing, and will also have a great personal interest in the child’s growth and development. Parents are concerned not only with the struggling child today, but where these struggles will lead. This investment combines with burdens of guilt, remorse, frustration, and isolation to make it next to impossible for a parent to sit down to coach their children with any sort of objectivity. It is important, however, to train parents to learn to put their concerns aside and to focus on the activity in the immediate moment, as opposed to concerning themselves with causes or future outcomes. Generally, when they approach therapy in this way, parents find it much easier to use time effectively. The child will also notice a change in the parent’s tone and will relax knowing that, during therapy, there is a reduced threat of judgment.

Parents must also be encouraged to unburden themselves of any feelings of guilt or regret surrounding the current state of their child’s behavior. Even if there was a precipitating event that could be linked to a child’s poor behaviour or performance, wallowing in negative self-talk and self-pity can only detract from the immediate goal. Worry and regret never solved any problem, and in this case, they prevent the parent from moving the child forward.

Scheduling

Principles Parts IX and X provide more detail regarding program planning from the therapist’s perspective. It is equally important to assist parents in defining scheduling and rules at home that promote regular uninterrupted therapy sessions at home.

The therapist will provide a list of activities, with alternates, to the parent at various points in the therapeutic program. The programming should be flexible enough as to allow substitutions for a variety of reasons, including difficult scheduling. Home-based programming should happen most days of the week, and begin with shorter sessions. Parents can be told that 20-30 minutes is sufficient at the start, but they need to build upon this until sessions are around 60 minutes in duration. These are minimums, and parents are encouraged to expand on this to the extent that the child is willing and not developing anxiety or dislike for therapy. It is helpful to remind parents that the program is only 3 months in duration and so it is incumbent upon them to do as much as possible each week.

Notes on Tone and Stress

Build activities and instructions that facilitate home-based therapies. Focus more on motivating parents than on reliance on clinic-based work. Teach parents to see their children in the right light, and help them to learn techniques to help in achieving desired outcomes. Teach them to step back and look at things more objectively. This can be done by having the parent change clothes, wear a special hat, or have a special room dedicated to the task of therapy. When the hat is on, or when in the designated room, the parent becomes therapist and new rules apply. Role play also allows the parent to let go of some of the parental burden they carry, which is pleasant in its own right, but clinically this is important as it allows the parent to focus more on the task at hand.

Presence of mind is key. It is not that the activity gets done that is important so much as the attention paid to the task, and the quality of the work completed.

There is no ‘winning’ in therapy and it should be approached competitively except that the child should learn to challenge herself. Success is only gauged by a comparison of current to previous performance. Negative results, such as slower times or fewer items succeeded, should be discussed frankly and matter-of-factly, but not in a serious tone.  Consider the difference between the following two statements spoken to a child who is unable to beat her previous score on an activity:

  • “Your score last time was better. Let’s try again.” or “Why do you think your score was better last time?”, and after some reflection, “Do you think you would like to try again? What will you try differently this time?”
  • “You did better last time. It’s important that you do better (if you want to read / so the doctor can see we were working / some other reason), so I need you to try again and try harder.”
  • The first answer provides a context for self-assessment and correction, and this leads to an intrinsic motive to succeed while maintaining the child’s self-worth and self-esteem. This approach does not shirk from pointing out negative findings, it just doesn’t apply moral judgment to them. The provision of concrete feedback allows little room for guessing, allowing the child to observe, conceive, correct, and retry behaviour until a solution is found. These successes build upon one another to reinforce the extension of motor and cognitive constructs (schema).

It is likewise important to offer praise, but in moderation. Effusive compliments should be avoided, with a preference towards kind acknowledgment of success. Again, the emphasis should be on showing the child they can motivate themselves and not have to rely on others to know if they did something correctly – they must develop their own sense of what constitutes an acceptable effort. It is appropriate to emphasize successes and strengths at the beginning and end of therapy sessions, but a constant need of praise is an indication therapy has gone awry and is now more about the relationship between child and therapist than on moving skills forward. Therapy should be fun and engaging, but the emphasis is on trying, not having a day at the beach, or at a theme park. The child should be held in a state of readiness, prepared to perform, maybe even feel somewhat stressed. The stress should be constant and helpful, Hans Selye’s notion of eustress, as opposed to excessive stress that can lead to problems with performance and anxiety.

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