What’s Wrong With This Picture?

Image courtesy of Pixabay.com

Spoiler alert – the larger picture in this text, not the photo above…

I’ve recently begun working with a culturally and linguistically diverse adoptive family. Mom is an immigrant. Dad is Latino. And, the adoptive child is Caucasian. The family is middle-class. Both parents are bilingual (in different languages) and have college degrees.

A little background. The parents decided to adopt the little boy I work with after years of not being able to have a biological child. They knew when they adopted the baby that he’d been exposed to a lot of drugs during fetal development. He came home at the age of 3 weeks after detoxing in the NICU immediately after birth. The parents formally adopted him after fostering him for about 2 years.

Because he was involved in the foster-to-adopt program and prenatally exposed to a variety of drugs, he was eligible for early intervention (EI). In the state we live in, EI programs are parent education programs. The parents reported they did not learn much from EI about how to interact with or help their son. As he was turning 3, the family sought outside, private speech-language and occupational therapy because he still wasn’t talking beyond the 1-2 word level, didn’t really play with toys, and had a lot of fine motor issues and sensory needs.

The child was seen for in-home speech-language and occupational therapy services for 6 months before the mother decided to search for another provider for both services. Both in-home therapists insisted the child should be evaluated for autism. At least one of the therapists told the parents they should medicate a preschooler because he was not able to attend and/or sit at the table for more than 5- to 10-minutes at most. Complex behavioral supports, including token economies, were provided but weren’t implemented consistently. The parents reported that the child began screaming upon the therapists’ arrival and cried during the entire sessions. Per mom’s report, the SLP tried to make the child sit at the table and work on speech sound development and coloring objects on worksheets to work on following directions. Mom reported her son never used more than 1-2 words at a time with the SLP.

Can you catch all of the mistakes that were made along the way with this family?

Let’s start with the most obvious: Graduate school educated clinicians told the parents to medicate a preschooler who had been exposed to multiple substances prenatally with stimulants. First and foremost, no respectable doctor would put a 3-4 year old on those drugs. Secondly, it is not the SLP’s or OT’s place to tell parents to medicate a child secondary to behavior. That is a discussion to be had between the parents and the pediatrician, or better yet between the parents and the neurologist. It is the SLP’s or OT’s place to suggest strategies to manage challenging behavior and demonstrate ways to do that. An attempt was made in this case, by giving the parents complex token economies. But, because there was no parent education (per mom, it was assumed the parents would just know how to use those systems), they failed.

Let’s go back to the family’s concerns coming out of EI: the child wasn’t talking beyond the 1-3 word level, he didn’t really play, couldn’t attend to one activity for more than 5-10 minutes at a time, and had fine motor/sensory issues. Yet, per parental report, the SLP chose to work on flash cards for speech sound development and coloring to follow directions. That means the SLP was asking the child to do two of things that were hardest for him – sit and sit at the table and use his fine motor skills. And, there was no indication from the family that they didn’t understand him – only that they were concerned because he wasn’t talking as much as he should. I can second guess the SLP’s goal selection because I am working with this child. At the single word level, his overall speech intelligibility is about 75% in a known context. Just because sitting at the table and doing flashcards and worksheets is easier for the SLP doesn’t mean it’s appropriate for the child. And, it backfired in this case, as it often does when there’s a mismatch between the client’s/family’s needs and the SLP’s wants. One of the family’s primary complaints was that the child wasn’t able to play by himself. So, why didn’t the SLP choose to work on play skills? That’s well within our scope of practice.

Now that we’ve identified the problems, how do we go about changing what’s wrong with this picture? What are your thoughts and suggestions?

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