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Yes, But How Do we KNOW?
"We must look at learning as the product of educational self-organization."
-Sugata Mitra
I have been an occupational therapist (OT) for 20 years and worked with children for over half that time. When I transferred from adults to pediatrics, I had no idea what I was doing. I had briefly learned about sensory integration treatment in OT school. I knew that it was a specialty of OT practice and a framework for understanding children's behavior and difficulties at a neurological level. Children who need sensory integration treatment have trouble with daily activities because they process bodily sensations abnormally. I wanted to do my best for the children I would be treating, so I read books and attended workshops about sensory problems in children. Clinically, I experimented with suggestions for addressing sensory problems from those books and workshops; such as sensory exposure using water-based toys, bins full of rice or shaving foam on mirrors.
To the parents with whom I worked, I parroted the same suggestions for increasing sleep or dealing with problems behaviors; warm baths, consistent bedtime routines, using weighted vests or blankets. I modeled techniques for increasing eye contact with my children with autism; physical modeling and hand-over-hand guidance, engaged play, and discreet trials (an attempt to elicit a desired response in exchange for something the child likes). All those methods worked for some children. a little bit. But no book or workshop truly explained why children with autism, ADHD, learning difficulties, or sensory processing problems were different. No source I encountered explained why I might choose one method over another or what to do when nothing seemed to work.
Most importantly to me, nothing I tried in my first year of working with children provided the rapid results I wanted to see. I wanted results so evident that I would know for certain that what I was doing was helping children adapt to their world. Because if I wasn't helping a child make concrete, functional changes in their abilities, then I was wasting families' precious time.
Everything I tried felt as if I was putting out little fires, but not addressing the big blaze. A child would have a definitive deficit that affected their family, such as, "Timmy won't sit for more than three minutes, so we can never have a family meal together." I would offer suggestions specific to mealtimes for the family to try, given what I thought might be making it difficult for Timmy to sit still. I felt as if I was offering solutions to individual problems a child had, like so many "band-aids" to place over the outside, without understanding the problems each child was facing on the inside. I didn't really understand how to help children interact with their world more functionally, from within themselves.
A large part of my frustration was knowing that I had no more knowledge about how to help a child than their parents or teachers. Parents are the experts on their children. Why were they bringing their children to me? What could I possibly suggest or add that they had not researched on the internet, considered or tried on their own?
By way of example, a parent might ask, "Can you help my child learn to tie their shoes?" When a child ties their own shoes, they have a sense of accomplishment, are more independent, and free up precious moments of time from a harried parent. I desperately wanted a child to be able to tie their shoes. However, other than repeating the tying procedure ad nauseum (for both of myself and the child), I had no idea how to teach a child to tie their shoes, or more accurately, to get a child to learn to tie their shoes. What I needed to know was how to help a child to teach themselves how to tie their shoes. This is how all children learn new skills; they observe, possibly with an explanation from a more experienced person, then they are let loose on the field to build the skills from the ground up.
Children can't teach themselves to tie their shoes if they lack the requisite skills of attention, visual control, finger isolation, fine motor control, reach and grasp, ability to sequence, an understanding of perspective (to translate the viewing of how I tie my shoe to how theirs might look), and finally, the ability to critique their own work to evaluate success and learn from failure. Say what? How am I going to help a child with ALL THAT!? That was an extremely tall order when I only had an hour or two each week with any given child. Even as a professional with a good understanding of human development, I still felt lost and ineffective. Parents were bringing their children to me for help, and I felt like I couldn't offer them anything unique, effective and of true value in their lives.
I was reaching the point of feeling that transferring to pediatrics was a mistake, when I took a continuing education course on auditory therapy. It was my introduction into how important the auditory (listening and looking) system and vestibular (balance and movement) system are in everything we do as functional human beings. During the course, I was jotting notes furiously as light bulbs were popping in my head, connecting the theory on which auditory therapy is based to the individual children I was trying to help. These theories explained so many of the behaviors I didn't understand and felt unable to help my children with.
However, understanding what might be wrong in a child's wiring and being able to help them straighten out the wires are two very different things. Was this therapy effective in treating what might be the actual problem for a given child? By the time I returned to the clinic, I was dubious that one particular intervention could accomplish everything that auditory therapy seemed to promise; better motor control, fewer disruptive behaviors, greater comprehension and flexibility of ideas-the list went on and on. I'm a natural skeptic, and until I've reproduced results myself, I never quite believe what's promised.
Clinton Anderson, a noted horse trainer, says, "Your frustration begins when your knowledge ends." After the auditory-therapy course, I continued to work with a wonderful boy with autism who was whip-smart, funny, and loving. My frustration with treating him was definitely growing, because I had reached the end of my knowledge regarding how to help him communicate, tolerate noises around him and behave more functionally. He was a perfect test subject with whom to try something new and hopefully expand my knowledge.
At only five-years-old, Brandon had been in occupational, speech and physical therapy for years. When he was diagnosed with autism, his mother Susan immediately sought out all the therapies recommended by Brandon's doctor. She followed all of the recommendations of those therapists, as much as a mother with another son and a household to think about possibly could. While Brandon did not speak, he had found ways to communicate his intelligence, sense of humor, and needs by laughing, sometimes drawing intricate pictures of what he wanted. He was an extraordinary boy with a devoted, but completely no-nonsense mother. Despite years of treatment, he remained unable to speak and he was often frustrated by his inability to communicate. He had strong emotional tantrum reactions, particularly to sounds and crowds, limiting his ability to participate in school and at home. In the six months I had been working with him, we had made almost no progress.
I knew I had reached the limit of my abilities to help Brandon. We lived in an area with very limited options for therapy and there was no one with more experience to refer Brandon's mother. Ethically, I couldn't continue to see Brandon when progress seemed unlikely, but I had no alternative to offer. It felt like a dead-end. It was with anxiety and sadness that I confessed to his mother that I wouldn't be able to continue seeing Brandon because we had reached what the therapy world refers to as a "plateau." I knew that, at least for the immediate future, this version of Brandon was as functional as I knew how to help him be. The best hope I could offer was the possibility that, after some time to mature, he might be ready to learn additional skills or new routines.
However, at the workshop I'd just attended I had purchased some of the requisite equipment to administer auditory therapy. While I knew Brandon tended to be overly sensitive to sounds, I had no idea what this therapy might do for him. "Susan," I said, "I have these headphones and a couple of CDs that I just learned how to use. While I won't see Brandon clinically anymore, I could prescribe a listening program. If you're willing to learn to help him listen through the headphones at home on a schedule, you and I can touch base when he's here for other therapy appointments, you can tell me how it's going. If you want to continue with it, we can adapt the program as he needs it." Being game to try anything that might help her son, she agreed and took the equipment home that day.
The following week, she and Brandon arrived for a speech therapy appointment. Susan took Brandon's hand and almost ran up to me in the hallway. "Robin! Robin! You have GOT to hear this!" Then she leaned down toward her son and said, "The sheep in the field...
