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Transcript for Episode 12: Writing Strengths-Based Goals and Evaluations with Dr. Scott Tomchek and Dr. Evan Dean

Interview between Speaker 1 (Meg) and Speaker 2 (Scott) and Speaker 3 (Evan)

[Introductory music]

Welcome to the Two Sides of the Spectrum Podcast. A place where we explore research, amplify autistic voices, and change the way we think about autism in life, and in occupational therapy practice. I’m Meg Proctor from learnplaythrive.com. 

 

Meg: Before we get started, a quick note on language. On this podcast, you’ll hear me and many of my guests use identity-affirming language. That means we say, ‘autistic person,’ rather than, ‘person with autism’. What we’re hearing from the majority of autistic adults is that autism is a part of their identity that they don’t need to be separated from. Autism is not a disease, it’s a different way of thinking and learning. Join me in embracing the word ‘autistic’ to help reduce the stigma.

 

Welcome to Episode 12. In this episode, you'll hear my interview with Dr. Evan Dean and Dr. Scott Tomchek. Dr. Evan Dean, PhD, OTR/L, is an Assistant Research Professor at the University of Kansas and Associate Director at the Kansas University Center on Developmental Disabilities. His research focuses on promoting community participation for people with intellectual and developmental disabilities through enhancing self-determination, supported decision-making, and career design. Before beginning his research, Evan worked as an OT in a community-based organization where he supported adults with intellectual disabilities to live and work in inclusive settings. 

We also have Dr. Scott Tomchek, PhD, OTR/L, FAOTA who's also an OT, a Professor of Pediatrics (Term), and Assistant Director of the Weisskopf Child Evaluation Center at the University of Louisville. He has over 25 years of pediatric clinical practice and leadership experience in various settings with an emphasis on early intervention and autism. Scott co-authored the AOTA practice guidelines on autism along with Dr Kristie Patten, who you heard on Episode 4 of the podcast. Scott also oversees a statewide training and mentorship program for Kentucky’s Early intervention System providers, to help them deliver services via coaching with fidelity. Strengths-based and family-centered care are central to all of the programs that Scott touches. 

This episode is so practical and answers many of your burning questions about how to do strengths-based evaluations and write strengths-based goals. So, listen to this episode and, if you didn't already, go back and listen to Episode 4 with Dr Kristie Patten on strengths-based interventions. 

 

And then I need a favor. After you’ve listened to both episodes, e-mail me with any and all remaining questions you have about how to use a strengths-based approach in your work. Next month I have Matt Braun, who is a speech language pathologist specializing in strengths-based approaches. He's coming on to answer all of your lingering questions. His interview is on October 30th, so you have until then to send me your questions. You can email them to me at meg@learnplaythrive.com or leave a comment on Facebook or Instagram. Okay, here’s the episode.

 

Hi, Scott and Evan! Welcome to the podcast.
 

Scott:     Hello!
 

Evan:     Hi, good morning. 

 

Meg:     So, in Episode 4, Dr. Kristie Patten talked about what it looks like to use a strengths-based approach in our work with kids on the spectrum. And one of the questions I've gotten since then is, "How can we write strengths-based evaluations and goals?" So, let's start there. What can you tell us about writing evaluations from a strengths-based perspective?
 

Evan:     Well, thanks Meg, and I'll kind of start off by saying my clinical work and my research is really focused on supporting autistic adults and adults with intellectual disability to enhance their community participation. And in this work, one of the things I've really been struck by is how little opportunity people have to really exercise their self-determination and make decisions for themselves, decide where they want to work, things like that. And one of the things that I've noticed in this is that a lot of family members and caregivers often have pretty low expectations for their — I don't want to call them their child, but, you know, the person that they support, their adult. 

 

    And I think one of the things that is leading to this, I mean all families would want the best for their child. I think one of the things where we as professionals have gone wrong is that we're very good at documenting everything that's wrong with the person, and then that's what families read and they begin to internalize that to the point where then they kind of see their child as some of their deficits. And I think what that does is contributes to these low expectations that people have for people. 

 

    So, I think writing from a strengths-based perspective is critical throughout the person's lifespan, to really say, "Hey, we need to set high expectations we need to think about this person as a, 'It's going to be an adult, that's going to work,' you know, that we want to have the same kind of interest and everything else that we do for all of our other kids."

 

Meg:     I want to tie that in to what Ido Kadar, who is a non-speaking autistic person, said in Episode 9, which was about being labeled 'low-functioning', that that diminished hope for him. If no one had any expectations for him and everyone was focused on what he couldn't do, how could he have hope for himself. So I imagine what you're saying about our evaluations being so deficits-based is impactful not just for the parents but also for our clients themselves.
 

Scott:     Absolutely. You know, the words we use are so powerful. On the opposite end of the spectrum, I work primarily in early intervention with younger children at a diagnostic center. And so, the evaluation reports that we do oftentimes have really focused on those deficits, and we'll talk about some specific examples of kind of the words we use. 

 

    But when I'm working with providers or I'm working with students, you know, I asked them to take a look at their reports and pull out a highlighter — pull out a yellow one and a green one — and go through the report. Just highlight all the words that are deficits-based, all the things that are wrong with the individual, or that are not what we would expect them to do, or we want them to do, and highlight all those strengths or positives in green. And let's take a look at what the colors are of our reports, and as Evan alluded to, typically, there's a lot more yellow in those reports than there is green. We were trained to really focus on, and to illustrate those deficits. 

 

Meg:     I love that. I think that's a great challenge for our listeners, to take their most recent evaluation and just see what it looks like. Because often we have this token section that's like 'Client's strengths', and we write a few interests and strengths, and then we call that done, and we move on with our actually deficits-based evaluation. And you're saying, "Look at the whole thing and see what kind of language we're using."
 

Scott:     Right. The purpose of that evaluation really is to document what the strengths are, and those differences or challenges better — you know, that are the priority of that individual or the significant other. But where typically we focus on — things that are the deficits and not the strengths. And so that little activity really allows us to highlight those areas. And instead, what I would challenge, from a strengths-based perspective, therapists to do is to really focus on being descriptive. Free of judgment, free of diagnostic labels, and without really the need to counterbalance a strength. 

 

    I think that oftentimes when I look at reports or read reports, I read things that are strengths — "Johnny did a nice job," or, "Johnny looked at," HOWEVER, "He did not," or, "But he didn't," "Though was unable to." And so, we tend to counterbalance a strength with three or four deficits because that's oftentimes how we were trained. Or we make things diagnostic and we say, "Johnny's play was repetitive or restricted". Instead of describing things like, "Johnny really enjoyed playing with cars and he got really excited when he saw the wheel spin." So, that descriptive piece without judgment is really, from my perspective, a key factor in writing a strengths-based document, or documenting the strengths-based evaluation.

 

Meg:     So then how do you talk about the skills that are emerging? Do you describe them as 'the emerging skills' or 'the next skills that he's working on', as opposed to describing them as 'things he can't do and milestones he hasn't met'?
 

Scott:     I think our scores oftentimes — so when we're administering a norm-referenced assessment, the descriptors on that norm-referenced assessment typically are not deficits, they're descriptions of what the individual is doing, and this is across the lifespan. And we oftentimes make them deficits-based. So, the score itself in an evaluation kind of documents what that challenge is, or what that difference is. 

 

    We can talk to families about —or other caregivers — about what the next steps are that we anticipate. We can talk about skills that we observed, describe them on the observations, or if it's a play-based assessment and we are working on, say sequencing, or we're working on some other activity and play color sorting. You know, "He'll sort for two colors. When we attempted three colors, he was unable to sort four of the five." So that quantitative factor, the factualness of it, is being descriptive without judgment. Without just leaving it as, "He is unable to."

 

Meg:     I see, because a lot of therapists would say, "Demonstrated delay in color sorting," or, "Unable to complete age appropriate color sorting activities.

 

Evan:     And not, "Was unable to," yeah, "Was unable to sort three colors," and just leave it at that.
 

Meg:     Okay, so, "Here's what he did when presented with this skill, here is what he did." Scott when you say score, were you talking about on standardized evaluations?
 

Scott:     Yes.
 

Meg:    Okay, so you're saying that on the standardized evaluations, we tend to score what they can do and then it's our interpretation that frames it as a deficit. 

 

Scott:     Right. Or we go on in our reports to say things like, "He demonstrated the ability to do X, Y, and Z," and then we list those next 18 skills on that norm-referenced assessment that the individual didn't demonstrate. 
 

Meg:     Gotcha. Okay.

 

Scott:     And so that's how we get out of that balance, or we kind of counter-balance or over-balance the strengths by really focusing on all of these things that we think third-party payers need to see to justify the need for intervention. 
 

Evan:     And when Scott said providing some great examples, I wanted to provide an example from an older student perspective also. And thinking about, you know — I've seen OT's and teachers write things around independence also. We may write a goal that, you know, "This child is not independent in their math work, math homework or something," instead of writing, "When using a peer support, when another student is sitting close to them and explaining the problem, they can answer the question." So, we kind of get away from this idea of independence, but really think about under what conditions is the person successful, and describe those so then we can better understand how to support this person to be successful.

 

Meg:     This is so helpful. So, what I'm hearing you all say is that we can describe the skills, the child has without the 'but' — "They do this, but they can't do that." Describe them. "Here's what they can do," when presented with something else, "Here's what we gave them. Here is how they responded." Not that they didn't do it, but that they left the table or that they — like you said, sorted three out of four colors, acted out one pretend play action and then left the table, whatever it might be that they did. 

 

    And then Evan, you're saying if we dug deeper and figured out what kind of supports the child needed to be successful, we can also describe those. That the child is able to work the cash register at his job site, I guess an adolescent in this case, given X-Y-Z supports. Awesome. 

 

    So, I know that one question that everybody has is, "But that doesn't sound billable. Don't we have to document deficits for insurance, and don't we have to describe what the child should be able to do and can't do to justify our services?"

 

Scott:     Coding and reimbursement for Occupational Therapy evaluation services really is based on complexity, complexity of that evaluation. Complexity is the key theme. How complex and how detailed is your occupational profile. What areas of occupation did you address. Was it low complexity, did you address only one, did you address more than one to get it to, you know, moderate or high. So it's really that level of complexity that is the key defining factor, as well as your clinical decision making. 

 

    Instead, we make the deficits and listing all the deficits the main event, when in fact it's that clinical decision making that we have to do, and the number of occupations that we're addressing during that evaluation as the main event. And so, that detailed occupational history, how we're gathering our information, what strengths the individual has, how we can use those strengths and preferences for our intervention, really contributes to the complexity of how we should be documenting what occupations are meaningful for that individual, which ones are not a preferred occupation, but you know we all have to engage in some personal hygiene activities. That's kind of a societal norm. And so, how we document that complexity is really the key for reimbursement purposes. It's not the number of deficits that we're documenting.
 

Evan:     And I would argue from, you know, from an IDA standpoint too in schools. You know, OT's are really there to support the student and the learning environment. And so we definitely need to consider the areas of support that the student needs, but we can do that through lots of different ways by thinking about what the student is successful in doing, and how do we do more of that to make the person successful, instead of just, "I need to address this specific skill, because the child can't do it and other kids this grade can."

 

Meg:     Thank you for bringing in that IEP perspective, too, because I know that's another thing that people believe, is that they need to really be deficits-based in the IEP. So, my question is, is this really just a myth that in the United States for billing insurance for Occupational Therapy, if we don't, document deficits and write a deficits-based evaluation, our claims are going to be denied. I'm starting to feel like this just hasn't really been tested. It's something we all tell ourselves and something we all believe, but it's really not founded on the actual criteria for getting our claims paid.

 

Scott:     I would argue that I have colleagues who write from a strengths-based perspective, Evan has colleagues who write from a strengths-based perspective, and we are getting reimbursed for services. Again, I think your scores that you will document in an evaluation — and I don't think anyone is saying we don't describe or we don't include challenges that individuals have. I don't think we're saying, or I know that we're not saying that we don't include developmental differences or challenges to performance or participation. It's how we describe them, how we document, is that that's the key element. 

 

    And I think what's also the main event, I think we make deficit scores and ratings on a score significantly delayed. You know, those criteria that are part of those norm-referenced tests as the main event. We put them first in our reports instead of at the end as illustrating factors. Just that very piece of what we describe first versus last, I think makes a report more strengths-based. And that may be a real easy progression for someone to make. Instead of having those norm-referenced scores, we first move them to the end of the report so that they're more illustrative of your descriptors of the individual, rather than maybe the main event.

 

Meg:     I've had years of billing insurance for my work without using standardized evaluations because I found that they didn't inform my understanding of the child, or my development of goals that were appropriate for that child's values in their life and their family. And I would just write my evaluations based on informal assessments with the child, with the actual activities that they needed to do, and parent interview. And as far as I know, I never had an insurance denial for not including standardized assessments.

 

Evan:     Well, I think one of the key things there, too, is that most standardized assessments are designed to find the deficits in a person. And I think we create our treatment plans based on the information that we have and the information that we assess. So, by using those standardized deficits-based assessments, that's going to lead us to a more deficits-based approach in our practice.
 

Meg:     Absolutely. That is such a good point. I want to shift from here to goals because one of the things we're doing in our evaluation is developing our goals which guide our treatment. So, what does a strengths-based goal look like?
 

Evan:     So, one of the things I'd say is that first we need to start with thinking about the process of setting the goal. I think when we write our goals in partnership with the person or the family, and then we focus really on enhancing the strengths of the person instead of addressing the deficits. Supporting the deficits instead of addressing them, and really seek to understand the person's interests, and design the goal with that in mind, more as a central piece to the goal rather than some kind of reinforcer at the end of the goal. 

 

    And I think the other piece of that process I'd say is that really, I think we need to focus more on adapting the context and thinking about how to support rather than fix. So, I think when we use that process, we come up with goals that are really meaningful to the person. And they can still be measurable, but are also motivating to the person.
 

Scott:     That's a great introduction, Evan. We talked earlier this week and I oftentimes use those exact same words. That our goals have to be measurable, they have to be meaningful to the client, and at the same time we have to include the motivations of the individuals. So, I think one of the things that Dr. Patten really highlighted on her podcast was that the preferences, the strengths, these interests, really are a conduit to making the progress. They're really a key element of our intervention and goals, so I like to include them in goals as well. I think we can learn a lot, Meg, from how we write our evaluation and how we write our goals. And I know that sometimes it is also a — we really have to balance talking about our friends who are in ABA world, who are behavior analysts, but I think we can we can learn a lot from how we how we scale our goals, how we write observable behavioral objectives for our goals. 

 

    And if providers are going to worry about reimbursement mechanisms, and they're going to worry about getting reimbursed for their services, these are the kind of things that third-party payers really want to see. They want to see progress. And so if we start our goals with that observable measurable context with the number of environmental supports, or the number of prompts, or the variety of strategies we're going to use those, those factors that are clearly descriptive, they're clearly measurable, they're clearly observable, they're not deficits-based. Again, we're being descriptive of what we're detailing, those are the kinds of things from a goal perspective that are readily applicable. And so I think it does really start with writing our evals.

 

Meg:     I see. So, one of the ways we can make our goals measurable is actually talking about what sorts of supports we're going to put in to help the client be successful. And it also sounds like a way that these types of strengths-based schools are going to actually go over well with insurance, is because they're going to be motivating, they're going to be meaningful for our clients, and so we are going to be more likely to see progress because we're writing starting from the place of their strengths and their emerging skills.
 

Scott:     Absolutely. I could not agree more with that. And I think that we have, again, we've been trained to do it differently. And Evan, you can talk about about schools a little bit more in depth if you'd like, but I think that we've often written IEP goals, and then we have like two other sections, three other sections below on that IEP, and one of them, you know, 'Specially designed instruction' is down, and so we don't include the supports, the strategies up front. 

 

    And I think that if we recognize what the strengths are, what the preferences are, as a key fundamental component of an individual being self-determined in those goals, I think that that's key. 

 

Evan:     Yeah, and I'd go one other step further, too, to think about. Like, really, what is the intent of the goal that we're setting, and to really think about that participation down the line. So, you know, one of the examples I go back to, and I know OT's talk a lot about this, is handwriting. Like, do we need to set a handwriting goal? That may be, you know, a goal when other kids in their classroom are also working on handwriting. But after that point, let's focus on how can we support the person to effectively communicate or express their ideas, which can be done. That opens up a whole bunch of ways outside of handwriting for the person to be successful.
 

Meg:     That is really interesting. So, at the point that everybody's working on handwriting, if they need extra supports to work on handwriting, we might write that goal. But beyond that it becomes a deficits-based goal. If we're sitting down with a middle schooler to work on handwriting, as opposed to writing a broader goal about what are these child's goals — they want to be able to communicate, they want to be able to self-advocate. So, what tools can we use to help them do that. It might be writing and it might be something else.
 

Evan:     Yeah, it could be voice-to-text, you know, I think there's a lot of technologies now where a person could be successful expressing themselves without handwriting. If handwriting was really that important, I would still need an OT to be addressing my handwriting. My handwriting is terrible. I swear it's terrible. [Laughs]
 

Meg:     Me too. I can't actually cut a straight line either. [Laughs] Not within a quarter inch.
 

Evan:     [Laughs] Yeah, we think that's really important for kids with disabilities to do and we write all kinds of goals to do that. 

 

Scott:     I'm just gonna say, can I ask — you know, I think we have also here clinically in our intervention programs, really tried to live that spirit, Evan. And so I think we typically have goals for bettering not handwriting goals, but they are more communication goals. So in our adolescent, some of our adolescent-based intervention programs, we really want individuals to be able to communicate things like past medical history. That's important when they become adults and have to go to the doctor, to be able to communicate. And so, address, primary care doctor, past medical history. The approach that we take, if 'handwriting' — in air quotes, because you can't see me — if 'handwriting' is important, is the focus primarily from a participation, life skill, independence perspective, and not that we properly form an S in cursive?

 

[Intermission begins] 

If you're enjoying this podcast, you'll love my free 50-minute training, ‘Autism-specific strategies that transform OT practice.’ In this training, I dive into the places where many OT's are getting autism wrong, why it matters way more than we realize, and four concrete strategies you can start using right away. We even talk in-depth about what we know now about autism learning styles, because when we can shift our perspective and truly consider how autistic kids think and learn, we can start generating more meaningful and effective interventions to help our clients find more joy, independence, connection, and acceptance in their lives. Visit learnplaythrive.com/masterclass to start learning right away. 

[Intermission ends]

 

Meg:     What other examples so you all have of strengths-based goals that you can share with us?

 

Evan:     So, one other thing that I was thinking of, and this kind of gets into these ideas of supports too, because there's literature to show that when autistic adults, adults with intellectual disability, go on to secondary education or post-secondary education to college or, you know, vo-tech school, that they don't always seek out the accommodations that they need. And I think part of the reason for that is that in school and how those supports are just provided, the student is well-supported to get what they need. But we never really teach them to think about, "Okay, what supports do I need to be successful?" So, I think setting goals around identifying three supports that they're going to need to successfully accomplish whatever their interest-based tasks that they're working on is, is a goal that really focuses on self-knowledge that could really be impactful for the students post-school. 

 

Meg:     I love this, because often therapists think about goal mastery as fading out the supports. So, right now they do this with these three types of supports and over time, I want them to do it without any supports. And I always use the example of, I learn by taking notes, and I hope no one ever writes a goal for me that I have to take a college class without taking notes, because it would be frustrating, and I would fail, and I wouldn't like learning, and your goal for me is that I'm going to learn lots of other things while taking notes. So, I love that you're saying that we're going to help our clients recognize what accommodations help them, and learn how to ask for those, and self-advocate so that they can be successful in new activities, in new places, in new ways.

 

Evan:     And your example is great, and it highlights that, like, we talk about independence for people with disabilities a lot, and none of us are really independent. We all use different types of supports to get done what we need to do. And so, I think really focusing on identifying the supports that are needed instead of being independent is critical. 

 

Scott:     One other, I think, one other comment I would make is a core value in strengths-based approaches are that we can collaborate with families, clients, partner with them to locate resources that will help them achieve whatever outcomes they desire. And so, when you ask for examples of strengths-based goals, Meg, I think, starting with the 'Who'  — who is this goal meaningful for — is from my standpoint oftentimes the key elements of the goal. Is this a goal or strategy that we have set as a provider, as a therapist, because it's either the next skill on a checklist we've used, or the next step we think it should be in the process, the next step we want to get the individual to. Or, is it important to them? 

 

    And so the strengths-based goal really starts with what's meaningful to them, and I think what also sets us apart as occupational therapists is this real understanding that the occupation of a mealtime routine, the occupation of getting dressed, the occupation of playing with a toy, is unique and individual for that person.

 

    It's not generic, it's not a norm-referenced item, it's not a standardized item. And so I think as occupational therapists, our ability to do task analysis and take a look and observe; we have strengths in all of these areas that really make it possible for us to write strengths-based goals that are — that have the level of description. I think that's where therapists or students oftentimes say they struggle. It's, "How do I make this measurable? How do I make this measurable?" And if we start with being really, really descriptive in our evaluation, it makes it really easy to write goals that just play on that. 

 

Meg:     This really leads us to self-determination. Evan, I know that's one of the things that you've written about a lot in your research. How does self-determination tie in to what we've been talking about?

 

Evan:     Meg, that's a great question. So, a couple of things. One, when we're talking about self-determination, we're talking about people making things happen in their life, or causing things to happen in their life. So, it's about using your actions and your supports toward moving you towards your goals. And so that's why I think OT's can play a critical role, especially when we talk about that process for setting strengths-based goals and really including the person in that. By including the person in that we're actually creating opportunity for the person to exercise their self-determination, and to set their goals, and also to demonstrate that we're really taking their goals seriously. Because we all need practice in setting goals. 

 

    We only practice in setting goals that are not necessarily good goals, too. Like, we all learn from doing things the wrong way. But, you know, if we over-support people in being sure that everything is done right, then they miss the opportunity to learn from that. 

 

Meg:     That's really taking it a step farther. So, you're saying that self-determination, or involving our clients in the process of setting their goals is important, not just for a process to be empowering, and strengths-based, and relevant to that child's life, but also to teach them the life skill of setting goals.

 

Evan:     Exactly, yeah. Setting goals, making decisions, you know, solving problems. A lot of the interventions that — the intervention that we use a lot, I should say, is really a three phase process where we support the person to set a goal, and not just by saying, "Okay, what do you want to work on? What's your goal?" But to go through an actual four step problem solving sequence to think about, "What do you want to learn?" or, "What career job do you want?", "What are some barriers that might get in the way of that?", "What do you know about it now?" You know, all that leading down to, "Okay, you know what's one thing you can do to move yourself closer to your goal right now." 

 

    Moving into phase two where we're actually putting an action plan in place and working to achieve that. And then the other key piece is reflecting on that. So, thinking about, "Okay, did my goal get me to where I wanted to go?", "Dude, my action plan I put in place worked to actually achieve that goal." But so we don't do that with a person by saying, "No, don't do that. If you do that, this is going to happen, this is going to happen," but say, "Okay, let's give that a try. It doesn't have to be right every time."

 

Meg:     We are teaching our adolescent and young adult clients to be their own strengths-based occupational therapist.
 

Evan:     Yes, that's a great way to put it.

 

Meg:     I love it. What does this look like with younger children and children who might not have as many ways to communicate their own goals with us?
 

Scott:     I think we have to really rely on caregiver history and our, again, skill of observation. So, what are preferences, what are interests, how does the younger child spend their time, what do they spend their time doing? And we can really use those as our mechanism and insight into what their interests are, what their preferences are, so that we can either pull together the common elements or common themes of those observations to highlight what must be the key element, or the activity, or the preference. And describe that and use that in our goals, rather than trying to squelch it. 

 

    Sometimes I'll use echolalia as an example. I work on interdisciplinary teams. Very, very little of what I do is just specific to OT. I am working with physicians, psychologists, occupational therapists, social workers, behavior analysts, working with a variety of team members. And so they oftentimes impart knowledge on me, and one of the things I learned is that echolalia as a skill, again, was something that was extinguished or attempted to extinguish really early when it presented. What we know now is that echolalia has a lot of different functions. It can be a mechanism to request, a mechanism to answer, a mechanism to add to, or to make conversation. 

 

    And so by recognizing that it has a function and not extinguishing really helps us use those skills to some degree. We may shape it down the road to build and expand, but oftentimes the things that we observe in play, or we observe, you know, our first notion is to extinguish. Like I used earlier, "That play is repetitive, we're going to get rid of that." Well, instead of learning, instead, let's learn from that. What about that play activity is so motivating, is so enjoyable, is so pleasurable that that makes them passionate to engage in that activity? How can we then use that in our interventions?
 

Meg:     These are really big shifts, because in general, what therapists are doing now — most of us are neurotypical, or at least non-autistic. And we're coming into our sessions with our own perspective, without any strong ability to take the perspective of our autistic clients. We are looking through our non-autistic developmental lens at what the child is and is not doing, what they should be doing. We are writing goals to remediate their deficits, and we're moving pretty quickly. 

 

    We're coming in — not everyone, there's obviously a huge range in how people practice —but the general trend is to come in as the expert, establish some expert goals that are really founded in this belief that we should be making autistic kids look more like their non-autistic peers. And then we are doing these remediation-based interventions. And what you guys are saying is, we should slow down. We should spend a lot more time learning from and about the child and being curious about the child. Why do they like this, what did they get out of this, what are they telling me, and start there. 

 

    Look at what the child can do, describe what the child can do, and then explore those areas of opportunity where with supports, they are going to learn the next thing that they're ready to learn. And then beyond that saying, "Well, what's actually important to them? What matters to that child, what matters to that adolescent or young adults, what's important to their family, and what supports do they need to get there?" And then even one step further, Evan, and how do we help them figure out how to replicate that process themselves in a lifelong manner. 

 

    So, these are really big shifts, and I think they're really important for all of us to hear. And I want to tie a bow around it with this one last question — of everything we've talked about today, if there was just one thing you'd like for OT's to start doing, or to do differently, what would that one thing be?

 

Scott:     So, I think for me, the key is the lens. What lens, are we looking through? Are we looking through that expert, of the provider whose gonna drive the evaluation and intervention; or, are we going to use the lens and try to get into the lens of the individual client we're working with, whether it's a young child, whether it's that adolescent, or whether it's that young adult. What is our lens? And that lens, if we use a strengths-based approach, is going to be of that individual. 

 

    We're going to remain descriptive. We're gonna continue to collaborate and partner to get them where they would like to go, rather than we feel like they need to go, or we want them to go in this journey. 
 

Evan:     That's a great point. I think the other thing that I'd say too is, I think it's really important that — and I try to teach my students a lot too — that strengths-based for practice takes a lot of reflection. That we always need to be thinking about — because it's easy to say, "Well, yeah, I do strengths-based practice because I wrote that they're happy in the goal or, you know, something that we've talked about. Like, I considered their interest.

 

    But I really think that when we're setting goals we really need to think about who really wants this outcome. Is it really the person or is this something that I think would be really good for the person, because those are two very different things. And if I answer that it's the person, how do I really know that it's the person that wants this outcome? 

 

    So, the other thing I'd say, because I agree with what you're saying Meg, that this is a really big shift. And this was a big shift for me too, even when I thought I was practicing from a strengths-based perspective. A couple of things that I had to do to really shift my framework is whenever I was saying, "This person can't," what I really needed to say was, "I haven't figured out how to support the person in doing this." 
 

    That makes the emphasis more on my learning and my collaborating with other people to really try to figure out how to support the person in doing it. I remember I had a great mentor who when I was trying to do something said, "How do you know that the person is understanding what you're asking?" Because we know that I'm sitting there telling the person verbally what to do, and the person was was not really processing the verbal — wasn't really understanding what I was saying. But I just assumed that they could. 

 

Meg:     These are such great points and one of the themes is really that we're taking the whole burden of changing and learning differently off of the child. And we are sharing that, and we're saying it's on us to learn about the child and figure out how to support them, not just on them to do all of the work, and try and learn in the ways their peers learn, and do the goals we've set for them just because we set them.
 

Scott:     I think also what's really important, Meg, and I think Evan alluded to it with maybe the first question, or early on — its parent vision, caregiver vision of their child. So, our words and how we describe things are so powerful. And I refer back a lot of times to an early study where there were two conditions of early intervention providers, and one condition was the providers use strengths-based language, and in this second condition, they use deficits-based language. 

 

    And what that study found was that the parents who were exposed to strengths-based language had stronger parent-child interactions. They had a more positive affect towards their child. They were better able to support their child. They had less stress. They were better able to cope. And so if we're going to set up a relationship and a partnership with a family, and a strength based approach in early intervention, early, early on for an individual with a disability, it starts early. And if we do it right early we can build, build, build, and then it will follow throughout that life course. 

 

Meg:     Thank you for that. This is so important. Making the shift. One feels better to us, feels more aligned with our values and what we want to be doing as OT's. It feels better to our kids. It helps them see that they're important, that they're respected, that they are listened to, that they have autonomy and self-determination from a very young age. And it shapes how our families build their relationships with their child, and how they reflect on their child's diagnosis, and their child's strengths, and the journey that they're on together. Thank you so much for all those insights. Tell us, what are you both working on now, and where can we find you online?

 

Evan:     I've got a couple projects going. Some of my work is related to — well, all of its related to self-determination as we talked about. But I have a couple of projects related to supported decision making. So, again, you know, in the adult world we think about supported decision making as an alternative to guardianship. How can we support a person to make their decisions rather than taking away their rights to make a decision and having somebody else make them for them? There we're really partnering with families and self-advocates to really understand how people that are using supported decision making, how they're using it, and how can we support others to use supportive decision making also, and plan for the supports. 

 

    Then we recently also got a project related to the intervention I was telling you about, which we call the Self-determined Career Design Model, which is a companion model to the Self-determined Learning Model of Instruction which is an evidence-based practice and transition. So, our project now which is really appropriate for COVID times is we're implementing that via telehealth with adults with intellectual disability around the state, so that'll be fun.

 

Meg:     Absolutely. What about you, Scott?
 

Scott:     I continue to work here at the University of Louisville in a developmental behavioral pediatrics program and facilitate some of the clinical operations there and of our separate center for autistic individuals. But the bulk of my time right now is really continuing to expand upon this, that many of the concepts we talked about today — so, Kentucky's state systemic improvement plan for our early intervention program is targeting improving implementation of evidence-based practices for our EI providers, and coaching is the primary focus. And so, I'm heading up that program to train. Initially it was pilot sites. We've seen some really great success in our pilot sites and so, Kentucky's sustainability plan has communicated that we're rolling statewide. And so pretty much all early intervention providers in Kentucky will be participating in the coaching and early intervention training and mentorship program that we're facilitating. And strengths-based practice, collaborating with families, partnering with families, it's such a natural fit. And so that's where I'm spending the bulk of my time, continuing to use these concepts and training early intervention providers across Kentucky.

 

Meg:     Thank you both so much for the work you're doing to move forward the journey of OT into a more strengths-based model. I'll link to any of your resources that are currently available in the show notes, and thank you so much for your time today.

 

Scott:     Thank you. It's been great. Great to be here. Evan and I both were mentored by Winnie Dunn, who many who listen to this podcast will know. You know, one of the Top 100 Most Influential OT's, I think, most recently was named at the Centennial Conference last year. 

 

Meg:     And a future guest of the podcast, I'll add.

 

Scott:    Woo-hoo!

 

Evan:     Awesome stuff.

 

Scott:     So, we've talked about this transition to strengths-based practice and strengths-based documentation as a wave, and we've, you know, had a little bit of a ripple; we're starting to see a little bit of a wave, and our goal as colleagues and teams is to create that whitecap. And so we can continue to see the strengths-based perspective roll across occupational therapy. We think it's the right thing for the families we work with, the clients we work with, and society, frankly.
 

Meg:     Awesome, I love that metaphor. Let's go surfing on this giant swell of strengths-based practice that we're creating here together.

 

Scott:     Love it.

 

Meg:     Thank you. 

 

Evan:     It's awesome. Thanks, Meg.

 

[Ending music]

Thanks for listening to the Two Sides of the Spectrum podcast. If you enjoyed this episode, share it on social media, and head to iTunes to give it a five-star rating and review. And if you thought the audio on this episode sounded better than the last ones, it's because it was professionally edited and mixed by Christian Parry at christianparry.com. I'll link to his website in the show notes, in case you need a sound editor for your podcast too. Join us next time, where we'll keep diving deep into autism.

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