Critical or Not?


Critical or Not?

Last week I wrote about the need to prioritizing treatment needs from the perspective of knowing what needs to be treated, placing treatment in an appropriate context in the life of a family, and using an approach that treats foundational issues as priorities. There is one more thing I would like to address in this arena, and that is how to determine treatment priorities from a developmental perspective. To place this discussion in context I’d like you to consider the following:

Joe gets in a bad car accident and ends up with a variety of major and minor injuries. He has a brain bleed, a collapsed lung, broken ribs, a leg broken in 2 places, and a sprained wrist. When he arrives at the hospital the doctors immediately call in specialists to address the most critical issues – the brain bleed and breathing problems. He is in surgery for hours, but survives and begins the process of healing in his brain and lung. Once he is stable and out of surgery the orthopedic surgeon comes onto the scene and puts pins in his leg so the bones can heal properly. He then begins the process of healing his leg bones in a cast. The doctor doing rounds comes in the next day and decides that the course of treatment for the broken ribs and sprained wrist is rest and allowing the body to heal those things over time.

This progression of treatment makes sense. Joe’s doctors prioritized the needs of their patient according to what was most life threatening and then worked there way to other issues from there, each time making a decision about what was the next most pressing issue to treat. It wouldn’t make sense to any of us if upon entry to the hospital the doctors had put a cast on Joe’s leg first; or wrapped an ace bandage on his wrist; or wrapped his head in bandages to stop the bleeding without doing surgery. No! When it comes to a situation like this is seems very obvious what to treat first, second, etc. down the line.

When it comes to treating children on the spectrum, however, we have historically gotten our priorities backwards – treating things first that are best left to later, and very often not treating the main problem(s) at all. Consider the child who presents with the core deficits of autism (which means problems in experience-sharing communication, dynamic analysis, episodic memory, self-awareness, and flexible thinking), speech articulation problems, academic delays, and self-stimulatory behaviors. Very often it’s the more obvious and tangible things that get treated first. The child might be placed in speech therapy for the articulation problems, tutoring or discrete trial training to learn academic skills, and sensory therapy or behavioral therapy to address the stimming behaviors. The problem with this treatment approach is that it is the equivalent of treating Joe’s sprained wrist first when he has a brain bleed and a collapsed lung! It’s not that those things aren’t important to address – it’s that they are not the MOST important things to address first.

If we were to prioritize treatment for a person with autism in a way that makes sense we would treat the foundational developmental issues that contribute to the core deficits of autism first. Obviously if there were significant behaviors, feeding problems, etc. that were at a critical level we would work on those first or at the same time as starting work on developmental foundations. This process would entail beginning to establish the developmental foundations for interpersonal engagement and relating between parents and child. Once those foundations of development were begun we would reassess the remaining needs to determine what still required treatment. In many cases there are issues that fall by the wayside when we begin to treat the most pressing developmental foundations first. What also often happens is that as adults we re-prioritize what is critical in terms of treatment, and issues that seemed critical before become not so critical as children begin to progress developmentally. By looking at the problems that are still present once developmental foundations begin to come together we can determine what to treat next. It doesn’t make any sense to treat speech articulation problems when a child has no developmental foundations for using their speech to engage in real communication! It doesn’t make any sense to teach a child to read words or do math facts when they don’t have the developmental foundations to think about what they are doing and apply it in their lives! We have to think about what makes sense and understand the process of child development enough to know that teaching things out of context doesn’t make sense. We have to look beyond trying to fix a tangible problem that we can easily see or assess (Johnny doesn’t say any words. Susie flaps her hands. Tommy doesn’t know his alphabet. Lily doesn’t know how to play with other kids.) and look at whether the child has developmental foundations to make working on those things meaningful. If not then we must start with developing those foundations. To do anything else just doesn’t make sense!

Where are you in the process of sorting out what is important and not important for you and your child to work on? What are critical priorities and what aren’t? Are you spending a lot of time, energy, and money wrapping sprained ankles instead of treating the major problems? I hope some of you feel great having read this post, knowing that you are treating the critical areas now and leaving less critical problems until later!

Until next week,

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