Do Experts Always Know Best?
Personal Responsibility, Not Only Good Practice; But, Best Practice in Treatment for Children
WHAT QUALITY BEHAVIORAL & DEVELOPMENTAL TREATMENT FOR CHILDREN LOOKS LIKE?
How can you know if you are getting the treatment your child needs?
Is the most expensive treatment always the best treatment for your child?
Billions of dollars are spent every year on behavioral treatment for children with developmental and mental health needs. Are you getting your dollars worth?
As a young couple, my wife and I owned a Ford Escort. It was a good practical vehicle that served our family well for many years. One day it developed an electrical problem which caused a short in the system. We had it back into the dealer over and over again trying to fix the problem. Fuses were replaced and we were told that it could be this or that but the problem continued. Finally the underlying issue was located. We kept a spare set of keys in the ashtray which would, as the car moved, touch just the right pieces of metal and wires to short out part of our system. As soon as this was discovered, and we stopped leaving a spare set of keys in the ashtray, the problem was resolved. This doesn’t mean that treatment for children is always that quick and easy (though sometimes it can be, as I’ll discuss below). This does mean that it is extremely important for the right intervention to be provided for the individual child and family.
Fifty years ago, one of the ways depression was diagnosed was by how the therapist felt after spending an hour with the client. While there is some basis for this, because of extensive research, both diagnoses and treatment are now more advanced and prescriptive.
So how do you know what the best therapy options are for your child? The following is not all encompassing and may not fit your situation; however, it is based on comprehensive investigation and analysis, and may be used as a guide for evaluating treatment options.
The following are a few things you might consider and questions you might ask.
The intervention will be strength based (increasing the positive). While this does not mean that the intervention ignores deficits or problems, the primary focus will be strengths. Safety should always come first; however, the long term and clear emphasis will always be on strengths and increasing appropriate functional behavior and the overall health of your child?
Best Practice/Evidence Based Practice
As mentioned previously treatment has become and is becoming more and more prescriptive. Research is providing information about what works best for not only specific disorders; but in some cases even the individual nuances for the family and child. In many cases the research provides enough information to allow greater freedom of choice for individual families. There are often effective options from which you can choose.
There are two important questions which you can ask a potential service provider: a. is the recommended intervention/therapy developmentally appropriate? and b. is the recommended intervention based on research and Best Practice? After you have asked these two questions and if the answer is yes to both, ask the provider to show you the research and their qualification to provide this particular intervention.
The family is an integral partner in treatment and the parents are almost always experts on their own child. To the extent possible, the values and culture of the family should be honored and respected by the therapist. Individuals and families often have beliefs about how change takes place and what may be effective. The therapist is usually only involved with the child for a relatively short period of time; the extended family and support system are almost always with the child more than the therapist and will continue to be, and have a relationship with, the child long after the therapist is gone.
The therapist needs to understand the importance of the family, take it into account, and use the strengths and resources of the family to help the child. Do you as a family feel honored as an important partner in the collaboration to help your child? Is family centered coaching a significant component of the intervention provided by the therapist? Will the therapist support and train you and possibly other family members in things you can do differently to help the child? Even for children with special needs, with ongoing training and support, when you learn and do what needs to be done, you are often your child's best teacher.
Parent and other Caregiver involvement in therapy
When therapy is integrated into the family and child's typical routines, more really is better. Whenever possible you, your family, and sometimes even friends, should be an integral part of therapy. Will you be taught things you can do to support, expand, and make therapy more impactful and meaningful for your child? Will there be continual follow-up and additional training to see how well you are doing and what you might do differently to adjust for better results? Does the provider listen to you as a partner and expert on your child? Does therapy support and promote inclusion in typical healthy productive/enjoyable routines in which you and your family and your child's peers are involved, for example: 4-H, sports, scouting, school activities, church activities etc.? Are these activities in which you would like your child to be involved? (See Plan Quality: Functional Outcomes below.)
This approach can make treatment both very effective and relatively inexpensive.
Providing consultation, feedback, and support to you does not mean you are a bad parent or doing anything wrong. It may be that this child simply has special needs. It may be that you need some additional support in the home to help the child make the needed improvements.
Additional therapies are being provided for the child if needed.
For example: speech, physical therapy, occupational therapy, mental health, developmental, high risk nutrition assessment and counseling, or other types of specialized and legally licensed or certified therapies. Is there a global approach to your child’s needs? This does not mean that the other therapists have to be providing direct therapy. Sometimes this can be included through consultation and evaluation. This is not essential for every child but the need should be explored through the Functional Analysis of Behavior. For example if communication is a significant problem, you may either want a speech therapist directly involved or consulting/collaborating with your primary therapist.
Collaboration is more than simply the exchange of information. Is there communication and an integration or support of services being provided by other professionals? Does the therapist working with your child, collaborate with and integrate suggestions provided by other therapists, the child’s physician, and the school? Sometimes two therapists can even provide interventions which are at odds with each other. If there is more than one therapy, you want them to be supportive of each other.
Functional Behavioral Assessment
Was there a Functional Behavioral Assessment? (Also called a Functional Analysis of Behavior.) This must include looking at the child in respect to his or her environments, sleep, diet, medical condition, medication, communication, routines, setting events (events or interactions that impact the child either directly or through others within the child’s environment), etc. Was a functional analysis of behavior conducted? This is especially important for a child three years or older. Sometimes, a change or greater consistency in one or more of the above will bring about the change you are looking for in your child without providing direct treatment to your child. Sometimes putting a child on a healthy and consistent sleep and/or meal schedule, or taking care of a bladder infection (etc) is all that’s needed. Just like removing the keys from the ash tray.
Look at what’s going on around and within the child that may be causing or adding to the behavior or problem.
Plan quality: Measurable Behavioral Objectives
Quality and appropriate (including developmentally), Measurable Behavioral Objectives. Does your child's plan contain objectives that are so clear and concise that you know exactly what your child is to do and each time your child is to do it? Has it been written clear enough that you will understand when your child has achieved this objective?
Plan quality: Functional Outcomes
Quality and appropriate (including developmentally), Functional Outcomes. Are the outcomes and goals on your child's plan something that s/he will be able to use as a part of his or her normal routine? Is this a skill you would teach a typically developing child? If eventually, the child may be able to live on his or her own, is s/he learning something that s/he could possibly use prior to or at that time? Are the outcomes functional and meaningful to you and the child?
Service Providers often complain about the lack of interest and involvement from the parents, often, if not usually, this is at least partially the fault of the provider. If the outcomes or in other words, the primary goals are not meaningful in a way that will have a direct positive impact on the family and/or child, then you as a family will be less likely to actively participate in therapy. If you and at times other members of the family were not a real partner in developing the plan, then you and the family may be less likely to actively participate. In Becoming Solution-Focused in Brief Therapy, Walter and Peller, 1992 p.23, (quoting Bandler & Grinder 1979), the authors make a profound statement: “there were no resistive clients, only inflexible therapists.” The best therapists will partner with the parent/guardian to assure that the outcomes are both functional and meaningful for the family and the child.
Crucial Time Periods
There are especially crucial time periods for intervention; for example: early years, puberty, significant transitions, during changes and extra stress. This does not mean that intervention isn’t important for children at other times. It does mean that there are times when it is especially crucial, such as during the early years of life. So much is going on in the brain during the first three years of life. Whatever the issue is, don’t wait to see if the child will grow out of it. If you have concerns, seek for information and assessment from an early interventionist.
See resources in the US at: http://www.cdc.gov/ncbddd/child/development.htm
See resources in Canada at: http://www.socialunion.gc.ca/ecd_e.html
Medication is not needed for most children. If it is being prescribed, a children’s psychiatrist is recommended if at all possible. If there is medication is there close and ongoing communication between the therapist and the physician?
Does your child have a positive caring relationship with the therapist or do you believe that they will be able to develop one. (Knowing that the therapist personally cares about the individual is important for any therapy.) Do you have a good rapport with the therapist? Does therapy support positive relationships?
Oftentimes, strengthening positive relationships with family and friends for both you and your child, can improve the situation dramatically.
Order of intervention
When the issues are behavioral and/or social/emotional, there is an order to intervention. Safety and immediate health concerns always come first; however making adjustments to environment, schedules, and improving relationships when needed, come before direct treatment of the child. For further information please see: http://www.challengingbehavior.org/do/resources/documents/yc_article_7_2003.pdf and http://www.challengingbehavior.org/do/pyramid_model.htm
Once therapy has begun and usually within the first six months you will want to review progress. Is there evidence that the child is making significant progress with the existing interventions? (This may include maintenance for certain degenerative disorders or syndromes.) Can you easily recognize significant achievements made by your child which were written as specific goals and/or objectives on your child’s plan? Can the therapist show you data that is easily understood by you that relates directly to your child’s objectives? Ask your therapist about standardized assessments. Discuss changes in the results of these assessments over time?
In many situations intervention/therapy can and should be brief.
Find out if there is a governmental agency or a professional governing board that reviews this therapist/counselor or the agency that s/he works for. This information may be public and easily accessible. If the information is available find out what they have to say about the agency or individual therapist.
As mentioned previously, this is intended only as a guide and not a final determinant. These are elements that may be helpful and which you may want to consider in making your treatment decision.
The Final Word
Even when there is progress in a center and/or community setting, without family involvement, adjustment, and sometimes significant change, any improvement for the child is less likely to positively and more generally help the child through the normal challenges and events of life.
1) Some of this may be regulated and/or restricted depending on how the intervention is being paid for;
2) Most states and provinces require certification and/or licensing. Always ask for verification that any service provider you work with has the appropriate and required certification and/or licensure;
3) Assure the provider carries liability insurance.
add contextually mediated objectives
Quality Treatment for Children