With the outbreak of COVID-19 causing us to nestle up at home more than usual, OT month has been an unusual one this year. For many of us, it has meant adjusting the ways we think about treatment, from getting a crash course in teletherapy to navigating how to show empathy to older adults in the hospital while wearing face masks to helping children with autism learn that initiating with peers using expected proxemics now actually means standing much farther away than we normally say!
In pediatric settings, we may not always spend as much of our treatment time with parents as we do when they are facilitating sessions on the home front via telehealth. For both outpatient and school-based occupational therapists, this provides some excellent opportunities for increased parent education and involvement. As families experience unprecedented changes at home with many parents suddenly becoming teachers for the first time and children not getting to play at the park or see friends in person, we as clinicians are applying our expertise in emotional regulation and sensory processing to helping our families navigate new scenarios in many aspects of daily living.
Working largely with children with autism in an outpatient setting at the International Center for Autism and Neurodevelopment, I regularly incorporate Michelle Garcia Winner's Social Thinking Curriculum into my treatments to help children develop increased self-awareness. Social Behavior Mapping is a great tool to help children with low theory of mind begin to connect the dots of how their behavior impacts the feelings of people around them and, in turn, affects what they get to do and how they feel. Mapping behavior is relevant, easy to apply to telehealth sessions, and helps families gain insight into their child's thinking, especially with a new Autism Spectrum Disorder diagnosis.
Whether we behave in ways people expect or not has a large impact on how they feel and react. Expected behaviors tend to help other people feel calm, happy, comfortable, confident, safe, able to work, proud, connected, relieved, or appreciated. Producing unexpected behaviors can lead other people to feel nervous, uncertain, uncomfortable, scared, angry, confused, annoyed, disappointed, anxious, stressed out, unfocused, or impatient
Not only children with atypical neurology behave in unexpected ways. Sometimes I share with my clients about how expected and unexpected behaviors lead me to feel when I am driving on the freeway. Drivers on the freeway expect each other to follow certain rules to keep everyone safe when we are moving at the speed of cheetahs rather than at the speed of humans. In the United States, that means keeping right except to pass, following the posted speed limit, driving multiple car lengths behind the car ahead, and using a turn signal before changing lanes. When a driver gets so close behind me that I cannot see their license plate in my rearview mirror, their behavior is not what I expect. I feel nervous and frustrated because I am not sure what they will do next. Will they pass me on the right when there is not enough room or continue to drive very close behind me? What if there is debris in the road, and I have to brake suddenly? Will they run into my car? When I do not know if I will be safer staying where I am or trying to move over, the consequence for that driver is that they may not get to drive as fast as they want to or pass me when they were planning, and they probably feel even more frustrated and impatient than they already appear to.
Sharing this example helps my clients when I begin introducing this curriculum to a child and their family. It is important to help the child understand, not only that this applies both to children and adults, but also that whether a behavior is expected or unexpected is contingent upon the environment – social, temporal, or physical.
Oftentimes, children with autism have a hard time considering what would be in someone else's thought bubble if we were in a comic strip or graphic novel. Helping children develop this insight is one of our goals when we begin training them to use Social Behavior Mapping. Now, my thought bubble almost never includes Minecraft. After becoming a pediatric occupational therapist, this fact is more pertinent than I ever expected. As you may realize, Minecraft is frequently in my clients' thought bubbles and those of their friends. This gives me the opportunity to help my clients understand how the social environment determines whether a 20 minute conversation about the game is expected or unexpected. Let's use our behavior map to see how this works.
The behavior map has four steps: The expected or unexpected behavior you produce, how those behaviors make others feel, consequences you experience, and how you feel about yourself after those consequences.
With your best friend:
- Initiating a long conversation about Minecraft is expected
- Your friend feels happy, excited, and connected
- No one interrupts your story
- You feel satisfied and happy
With your parent or therapist:
- A long conversation about Minecraft is unexpected
- Your parent/therapist feels bored, restless, impatient, or frustrated
- Your story gets cut short or people ask about your interests less often
- You feel frustrated, disappointed, and rejected
Let's look at how this applies to the temporal environment:
Playing outside on a warm day:
- Asking to play in the backyard without a coat is expected
- Your parent feels calm and safe
- You get to play outside as long as you want to
- You feel happy and excited
Playing outside on a cold day:
- Refusing to put on a coat and shoes is unexpected
- Your parent feels worried and frustrated
- You do not get to go outside to play
- You feel angry, resentful, and disappointed
Here is an example of how this might apply to the physical environment:
At home during a pandemic:
- Going to school in your pajamas might be expected
- Your parent feels relaxed and calm
- You get to sleep in later and be comfortable during class
- You feel happy and calm
At your regular school:?
- Going to school in your pajamas is unexpected
- Your parent feels annoyed, frustrated, and disappointed
- You are late for school and your parent restricts your screen time
- You feel frazzled, angry, and disappointed
Our field was born in the aftermath of the First World War, helping people physically and emotionally rehabilitate and adapt to the world in the wake of an unprecedented disaster. As we find ourselves in the midst of another unprecedented change in our environment, just like the people we serve, we are learning to reflect and adapt. What is and is not expected are changing every day as we shift from a primarily in person model to an online one that requires more creativity and adaptability.
Though many things are changing, some things remain the same. Occupational therapists have always used our creativity to serve people navigating changing expectations, and our understanding of person, environment, and occupation continues to inform our practice. We will continue to apply our skill set and tools to promoting occupational performance for people who, children or adults, typically or atypically developing, need our expertise and support.