Are we doing children a disservice when we keep them on our therapy caseload for years?

Updated: Jul 21, 2020

Pediatric occupational therapy clients commonly receive therapy services for at least a year. For many, that time period extends to multiple years.

Blunt question: Is it okay for a child to be on therapy services for years?


Is there a one-size-fits-all answer? Absolutely not. But this is definitely a question we should examine. How long should a child be on therapy services?

A better question is probably, “How do we know when a child is ready for discharge?”

I could screen or evaluate 98 children and find “dysfunction” with each and every one of them—biomechanically or behaviorally.

That means I cannot rely on my own expertise in identifying dysfunction to decide on the appropriate time for discharge. If this were my only tool, I would keep all of my clients on caseload indefinitely.

The only way we answer the question of when to discharge is by prioritizing the involvement of the parents in an ongoing conversation about their child’s plan of care, progress toward goals, and pending discharge.

Remember our purpose!: to help our clients maximize their participation and independence in occupation.

Occupation as defined by we, the therapists? No. Occupation as defined by the child and his caregiver.

Mom gets to decide whether it’s important for her child to complete all of his dressing tasks at this time. Dad gets to decide whether it’s important that his child participate in family meals at the dinner table. Grandma gets to decide if she wants her child to have the motor planning skills needed to follow a family recipe.

Occupational therapists are absolutely responsible for education and recommendation on the implications of participation and independence in particular occupations. But we never ever ever get to prioritize certain occupations for our clients. Those priorities should always be set by our client or their caregiver.

So, my next question is, do the caregivers of your pediatric clients have any idea what goals are included in their child’s plan of care? Could they read a copy of the plan of care you authored and nod in agreement, thinking, “Oh, yeah, we talked about these things when we first started treatment.” Do you check in on a regular (4-6 week) basis about the progress toward the stated goals?

If the answer is “no,” you need to immediately check in with the parents involved in your plans of care and collaborate.

Give a thorough description of your purpose and goal as an occupational therapist. Be sure that the family understands why they are bringing their child to you weekly.

Ask the question, “What do you want to look differently for your child in 3-6 months?”

Boom. Their answer to that question serves as the new goals in your plan of care.

Easy as that. Seriously.

Let’s say the parent in our scenario responds to that question with, “I really want him to just get dressed within the hour we have before school in the morning. I have to remind him 75 times. I want him to be able to take a shower by himself. He is getting too old to have his mom help him. And I want him to be able to fix something simple to eat on Saturdays when I am having to do some work from home.”

Your long term goals should be written directly from their statement, and might look something like this:

1. Peter will complete his morning dressing routine in no more than 30 minutes increasing to independent with no verbal cuing to stay on task by 6 months.

2. Peter will complete all bathing tasks increasing to modified independent, using environmental modifications (ie visual routine) as needed by 6 months.

3. Peter will prepare 3 different snack/lunch items (ie sandwich, oatmeal, trailmix) increasing to independent by 3 months.

Follow this pattern and you will no longer find yourself staring at a blank documenting screen thinking, “What in the world does this child need to accomplish over the next year?” The parent will be able to read your plan of care and know the exact reasons they bring their child to you weekly.

I personally prefer to use my short term goals to address specific performance skills deficits which limit the participation/independence in the long term goals.

Peter is taking over an hour and requiring many verbal cuing to complete the dressing task because he has difficulty putting his shoes and socks on

1. Peter will complete all lower body dressing tasks including donning shoes and socks increasing to independent by 3 months.

Peter has difficulty sequencing the steps of bathing and requires his mother’s assistance to move to the next task during his showers.

2. Peter will sequence a 3-step task increasing to independent with no more than minimal verbal cuing to improve independence in bathing by 1 months.

Peter is a picky-eater and has a vary narrow list of foods which he will eat. My hope in implementing this goal is to give Peter an option and increase his interest in learning to prepare some foods independently.

3. Peter and his mom will make a list of 8 different snack/lunch items he enjoys by 2 weeks in order to prepare for training in meal-prep task.

Back to our original question, “How do we know when do discharge our client from therapy services?”

At the end of your chosen time period—3-6 months , 9 months, a year—perform another patient/caregiver interview, just like you did at the time of the evaluation. Check-in with your long-term goals. Review the progress made by specifically asking the parent if they feel occupational therapy has helped and if so, how? Ask about any changes in needs or expectations. And again, ask the question, “What do you want to look differently for your child in 3 to 6 months.”

You will know when to discharge when you and the family can collaborate and decide together that

· The goals and expectations of the family have been met

· The goals and expectations of the family have not been met, but they are now at a place that they can comfortably use a detailed home program without your ongoing expertise

· Deficits in performance skills are ongoing and not much progress has been made with the interventions set forth by occupational therapy—the OT can make appropriate referrals or recommendations for the next step in care at this time

The age-old therapy saying is that we want to ‘work ourselves out of a job.’ How true this is! When we do a good job, our hope is that the clients and families we have the pleasure of helping no longer feel like they need us.

I try to keep the perspective of my clients and their families at the forefront of my mind. Coming to therapy once or twice weekly is time consuming and at times, exhausting. We have a responsibility to ensure they get the value they need for their money and their time, and then release them to live with confidence and the tools needed to fully participate in their desired occupations.

When in doubt, collaborate with the parents. You need them onboard to make any kind of progress.

You’re doing a great job, my fellow OT. What a privilege it is to get to help people live today. Live better tomorrow. And inspire others to do the same.

Your (fellow) OT,

Ashley

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