Tuesday, November 07, 2006

Clinical problem solving in occupational therapy and the need to eliminate special case thinking

Lots and lots of questions these days and I am doing my best to answer them...

What I would like to try here is to throw my problem solving methodology to the winds and perhaps if someone finds this useful there will be fewer questions in the world. Is that likely?

There is a difference between a primary problem and a secondary behavioral attribute but people constantly confuse the two. So when someone says, "My child won't pay attention," or "One kid on my caseload won't eat any solid foods" they will often look for a direct and concrete answer to their 'problem' and completely misunderstand what the 'problem' really is. Let's take one example and walk through it.

First of all, if you have a clinical/presenting problem, place it in a circle at the top of the page and then make 5 circles underneath it. Five is a random number, but these circles will represent the POSSIBLE causes of the problem in the circle above:

PROBLEM


REASON 1____REASON 2____REASON 3____REASON 4___REASON 5

Then start filling in the details. This is your opportunity to be creative. Let your mind fly over all the potential reasons.

Let's talk about why a child won't sit during circle time. Here are 5 possible reasons off the top of my head:

1. He is only three years old and has no experience with this context and the behavioral expectations.
2. He has an organic neurological problem like a TBI, MR, lead poisoning, etc.
3. He has to go to bathroom, or any number of common sense possibilities.
4. He has no concept of behavioral boundaries; his parents let him run roughshod all over the house with no consequences.
5. The lesson plan is not adequately engaging or developmentally appropriate.

I am absolutely certain that there are many other possible reasons here but this will do for now. The trap that clinicians (and those that rely on them) fall into is to start swinging at the behaviors but not really knowing what the problem is. Everyone wants a simple answer, and here are some examples of simple answers:

1. Implement a brushing program - the child obviously has some regulatory problems. Use lots of deep pressure, heavy work prior to sitting, and a weighted blanket or 'lap buddy' or weighted vest while sitting at circle time. Incorporate movement into circle time to accomodate for the child's obvious sensory seeking behaviors.

2. Implement a behavioral program. Use a token system that reinforces desired behavior and chart progress accordingly.

3. Refer to the physician, asking to evaluate for ADHD. This child clearly needs medication.

4. Enroll the parents in a parenting program. They need to learn how to set limits because this child is simply out of control.

Any of these answers may be inherently inappropriate for the given situation. What happens is that clinicians and intervention teams get into ruts and start swinging their sensory bats at this pitch, or their behavioral bats at this pitch - excuse the baseball analogy. Sometimes they will hit a home run, but sometimes they will strike out. You can't automatically use the same 'bat' to try to hit a pitch - you need to choose your intervention to meet the actual need.

A dose of R. Buckminster Fuller fits here:

"I am enthusiastic over humanity’s extraordinary and sometimes very timely ingenuities. If you are in a shipwreck and all the boats are gone, a piano top buoyant enough to keep you afloat that comes along makes a fortuitous life preserver. But this is not to say that the best way to design a life preserver is in the form of a piano top. I think that we are clinging to a great many piano tops in accepting yesterday’s fortuitous contrivings as constituting the only means for solving a given problem. Our brains deal exclusively with special-case experiences. Only our minds are able to discover the generalized principles operating without exception in each and every special-experience case which if detected and mastered will give knowledgeable advantage in all instances."

So my strong recommendation is that next time you believe that you are presented with a problem, make sure that you really have a problem and not a secondary behavioral attribute that is associated with the problem. Root out the cause of the behavior and your treatment plan will be so much more likely to be effective.

Finally, if you find yourself stuck in a rut and swinging the same kind of bat at every problem you perceive - please spend a couple hours with Bucky Fuller. I promise that you will be cured of special case thinking.

References:

Fuller, R.B. (1968). Operating Manual for Spaceship Earth, Carbondale: Southern Illinois University Press.

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