Therapy is often recommended to children and their parents in order to address various issues that come up during development. Writing that referral is incredibly easy, but setting a child up for therapeutic success is much more difficult. This is how I consider which therapies to implement and when to time those referrals.
What is the Issue?
Before we start any therapy, we need to consider why we’re embarking on this particular journey. It usually starts with a perceived deficit that needs to be corrected. But the framing of therapy needs is critical because it impacts the perspective with which we view the child. And children strongly understand how we perceive them.
I recommend moving away from the deficit view and into the model of filling gaps. The gaps we’re filling are based on the human hierarchy of needs.
Therapies should be offered in a specific, prioritized order, meeting needs from the bottom of the pyramid to the top. So, for example, a child’s chronic constipation needs to be addressed with medical therapies before we begin to address feelings of personal safety related to sensory needs. Sensory needs are a priority over relationships because without personal safety those relationships can’t be secure.
Moving forward and as we climb higher in the hierarchy of needs, it’s essential that future therapies not disrupt already established mechanisms of meeting needs without replacing them with equally effective means. There is no friendship or intimate relationship in the world that is worth disrupting feelings of security and safety. It’s imperative that we keep the past in mind as we move forward through the therapy process.
Does the Therapy Match the Issue?
This question can be pretty straightforward. But there are little twists and turns that sometimes come up. Learning to walk is a goal for physical therapy. Writing is occupational therapy. Anxiety is an issue for a psychological therapy modality.
But there are some gaps that need deeper consideration. Selective or situational mutism is a great example. This is a failure of speech under anxious or stressful conditions. So it’s speech therapy right? And that’s a no. It’s not a speech problem. It’s an anxiety problem and it needs treatment that addresses anxiety. Perhaps speech therapy could assist in providing communication augmentation with an AAC device for stressful moments. But speech therapy isn’t appropriate as the primary therapy for this condition.
Connecting the child with the right therapy modality is the only way to fill the gaps and set a child up for success.
What is the Goal?
Therapy has to have goals. Otherwise, it becomes an endless chore cycling over and over, rather like the laundry when you have kids. So the first question you should ask is “What are we trying to achieve?” When setting therapy goals, the goals need to meet one of three criteria. The goal must make the child either a) physically healthier -or- b) psychologically healthier -or- c) happier.
Let’s run a few scenarios to test this out.
Your child is unable to brush their teeth. Is learning to brush teeth independently a reasonable goal?
Tooth decay is linked to heart disease and early death. So yes, this goal will make your child physically healthier.
Your child is unable to express needs and wants. Is a communication goal, whether via spoken words, sign language, or AAC, a reasonable goal?
Children who can’t communicate are incredibly frustrated. And communication is key to developing and maintaining autonomy and agency. So yes, this goal will help your child’s mental health and probably make them happier too. Plus, since communicating with physicians is necessary during illness and routine well care, it will make them physically healthier too.
Your child doesn’t understand how to take turns during play. This doesn’t seem to bother your child, and they are perfectly happy to play alone. They are only interested in playing with other children on their own terms. Is turn-taking a reasonable goal?
Turn-taking is obviously not going to contribute to their physical health. But other children may not want to play with your child if they can’t take turns. So that would seem to impact their future mental health and happiness, which is usually the justification for goals like this one. But there’s a flaw in this reasoning.
This child doesn’t seem to mind playing alone. And not taking turns is an expression of their autonomy and an early manifestation of agency and authenticity. In fact, not taking turns is a boundary that this child seems happy to set and maintain. When someone disrupts our boundaries, it does not make us happier or mentally healthier. It has quite the opposite effect. This is a situation in which the child’s preferences are an important consideration. This is not an acceptable goal, because it’s based on the notion that we need to please our friends to be happy.
Setting appropriate therapeutic goals is the only way that therapy can be guaranteed to help and not harm a child.
Therapy can be a huge benefit to a child, but only if it’s considered in a child-centered framework that addresses hierarchical needs, matches to the correct modality, and sets goals that help, not harm, the child.