Changing how we see people changes people…what does that mean?
“Changing how we see people changes people.” That statement from Robyn Gobbel felt like a brain teaser the first time I heard it.
This week I engaged in a Facebook discussion that reminded me of Robyn’s quote and illustrated its’ truth. The story starts with two kindergarten age boys who are struggling to meet the expectations of their classrooms. The boys are being treated by two different therapists, in two different states, and end up being seen through two very different lenses.
Every child has vast individual differences, so to say these boys are exactly the same would be a disservice. But, it is fair to say that they represent many kids that we see on our caseloads, as occupational therapists.
Both boys were having trouble staying in their seats, were rolling around on the floor at school, could not keep their hands to themselves, were being disruptive in class, and were not having a successful learning experience.
Both therapists had offered sensory strategies to help the boys to stay in their seats and meet the teacher’s expectations. Strategies included fidgets, weighted items (and other sources of deep pressure touch), movement breaks, and preferential seating.
The treating therapists were using sensory strategies, based on their knowledge of sensory processing, to facilitate participation in the school environment.
Sensory Integration (SI) theory, originated by A. Jean Ayers, informs many occupational therapists’ clinical reasoning. It is a specialty area of practice that takes intense study to fully grasp.
These days, on a more basic level than SI theory, many professionals are embracing the understanding that sensory strategies are helpful in supporting regulation and attention. Psychologists, health professionals, teachers, and parenting bloggers are all offering sensory strategies and sensory tools to support participation and self-regulation.
Many of these tools are helpful! Movement breaks, fidgets, things to chew on…those are all strategies that people use to support attention, even if they don’t know why they work. As adults we might bounce our legs, chew on pencils, fidget with pens, get a cold drink, eat sour candy, or get up to stretch when we are trying to focus.
Weighted blankets are a tool that started in OT practice and moved into the mainstream, because that sensory (deep pressure touch) input is calming to many people’s nervous system and helps them fall sleep or feel grounded.
Those sensory strategies are ways of using sensory input to help match the activation in our brain and body to the activation needed in the situation. But sensory strategies do not equate with providing sensory integration informed intervention that makes lasting changes in the brain.
For these boys, the tools were not enough. Offering the tools did not provide them with the regulation they needed to participate in the classroom. And still, the team of adults that worked with these children at school wanted the OT to figure out why the child was not able to meet the expectations of the situation and fix the problem.
So, these therapists reached out for help… and unfortunately the answer that some people gave was “You’ve tried sensory strategies and they didn’t work, so it is behavior”.
That’s the old “Sensory or Behavior” paradigm that plagues our profession.
OT’s are often asked “Is it sensory or is it behavior?”. On the surface that is a compassionate question. It allows leeway for the individual differences that come along with sensory challenges and encourages adults to assume a less judgmental stance on the behaviors they are seeing.
But underneath the question “Is it sensory or is it behavior?” is the assumption that if it is not “sensory” it is “just behavior”.
When we choose to lump together everything that is not “sensory” into the broad category of “behavior” we do the child a huge disservice.
It is not “just behavior”. Rather, it is likely a lagging skill or an inability to meet the expectation. For possibilities of what else could be contributing (beyond sensory integration challenges) see my previous blog.
While sensory strategies can be effective for some kids in some situations, they do not neccesarily make long term changes in the way that the brain is taking in, processing, and integrating sensory signals. Offering sensory tools and strategies in the classroom does not equate to providing sensory integration informed intervention. And having a situation where classroom tools have been tried without success does not mean that the child does not have sensory integrative processing issues.
In these particular cases, even though the strategies offered have not been effective, it is not accurate to say that “sensory” has been ruled out.
As a therapist that has trained in SI theory and intervention, I have known many kids with similar profiles. As a part of my SI education I have had the fortune to work with some amazing mentors who have helped me to learn to see movement patterns that indicate that the child may not have the breath and postural control that they need to have a secure foundation in their body. These boys quite possibility do not have the core strength and stability to sit in a chair and do their schoolwork.
It is beyond the scope of this blog to talk about how our vestibular and somatosensory discrimination are a common cause of this kind of postural and regulatory dysfunction, but that is the kind of information that highly trained OTs have studied to understand how to best support their clients.
I can remember, as a new therapist, not having the skill to see postural control and core activation issues. I once watched a before & after video of a child (pre and post intervention) and couldn’t see any difference in the way the child was moving post intervention; while experienced therapists sitting around me gasped at the changes they could see. It was uncomfortable to realize I couldn’t see what they saw.
It takes a lot of practice to develop the ability to see subtle postural control issues during normal activity. Specific clinical observations can be used to make those skills more visible.
One of the boys’ therapist realized that the child she was treating did not have the postural control that we would expect a child to have at that age. She couldn’t see that from just observing him sitting or moving in the classroom. She had him assume postures (supine flexion and prone extension) and noticed that he couldn’t do it without holding his breath, and even when holding his breath for stability he completed those movements with poor quality. She also noticed that the child’s skin was often clammy, and she attributed that to nervous system activation.
The other therapist was not able to assess the postural system and assumed the child was fine because he can walk and engage in gross motor activities. But without an assessment of postures and movement they were likely missing seeing breath holding, misalignment, and poor postural control, as well as underlying sensory discrimination skills.
The therapist who saw the postural control and nervous system issues said that she wasn’t sure how to support the child she was working with, but she knew he had potential, even though he would give up trying very soon after he started. She wondered how she could advocate for the child at an IEP meeting to get him the most appropriate accommodations and supports.
The other therapist believed that she had tried everything and because the things she tried didn’t work, the child was just choosing to behave that way. The recommendation was a behavior plan.
The difference in the way that these two children will be treated is immense.
The difference in the way children are seen has the potential to change who they are.
“Beware the temptation to blame behavior. This is usually shorthand for I don’t know what this is, but it is inconveniencing me. Take a breath and look deeper at the child, the context, the environment. A child’s sense of self is at stake.”
-Virginia Speilmann, PhD, OTR/L
In her quote above, Virginia alludes to the ability to 1) notice our own reactions 2) regulate ourselves and 3) deepen our clinical reasoning.
When we engage in reflective practice, we can notice how the depth of our knowledge influences the way that we see a child. Virginia Speilmann defines reflective practice as “a constant active process of learning and deepening behaviors so that they become baked into everything you do, everywhere you do it. Reflective practice occurs when we develop habits—through exercise and repetition—that make thinking and acting purposeful and holistic. By being intentional about reflective practice we can balance hard science with the soft human messiness of everyday life. It helps us to be person-centered and evidence-based, and to constantly grow in our practice and stay curious in our interactions.”
To change the way we see a person, we must have the ability to examine our own beliefs and knowledge and think critically about the biases we bring to the moment.
To do that takes self-compassion. None of us know everything and we all come with bias. We are limited by our experience and our own regulation that either supports or does not support questioning our own thoughts. When we criticize ourselves, rather than offering ourselves compassion, we hinder our ability to learn new things.
Self compassion is learned best through the experience of being offered compassion.
Psychotherapist Bonnie Badenoch says “Each of us is literally doing the best we can at any moment, given the state of our neurobiology and our level of support."
I believe that is true of the kids, the treating therapists, the team, and the people offering these therapists advice. They are all doing the best they can with what they know and the skills they have in that moment.
And I believe that we can always do better.
Sensory integration informed practice requires very specific knowledge of the sensory systems and the way that their signals are processed and integrated in the brain and body. But understanding sensory integration isn’t just about sensory. Occupational therapist Tracy Stackhouse has created a tool that helps us to visualize how the Sensory, Affective, and Motor (SAM) capacities must all be considered, and how they cannot be separated from regulatory capacity. For therapists looking to deepen their clinical reasoning, I suggest the SpIRiT tool, Tracy’s clinical reasoning framework.
Unfortunately, even with good tools and mentors, clinical reasoning around the topic of sensory integrative processing takes years to develop. But there is something we can do, even if we don’t yet have the ability to tease out the details of sensory integration processing that are contributing to dysfunction.
We can see the child as doing the best that they can.
You see, neither of these therapists are in a situation where they will be able to fully address these deficits. In many schools, what we can do as occupational therapists is more limited than it would be in an outpatient OT clinic. But the way the therapists sees the child will change his experience.
One therapist sees the child as doing the best that they can and that leads her to view him with compassion, to continue to seek accommodations that best meet his needs, and support him in all the ways that she can.
When a child is seen as doing the best they can, they can feel supported and connected to those around them. That literally changes the way that their body takes in sensory information. It provides felt safety and reduces the need for protective responses. It even changes their posture and their breath. It allows a child to see themselves and others in a positive light. And it empowers them to bring their best to the world.
When a child is seen as choosing to behave badly their experience is vastly different, and doing their best becomes impossible.
As adults who work with kids with challenging behaviors, we have likely all felt like it was “just behavior” sometimes. It is hard not to know how to help. We were doing the best we could. But as Maya Angelou said “When you know better do better”.
“Changing how we see people changes people.” -Robyn Gobbel
The ability to change the way we see people requires reflective practice and well developed clinical reasoning.
I believe it is imperative that we engage in both.
A child’s sense of self is at stake.