Increments
Progress can be made in increments over time. Change can be realized after many bits accumulate. Absolutely cliché, one-step-at-a-time finishes the race. Sometimes it’s tough to believe in the results when the effect at each increment is invisible. I’ve spent loads of time trying to convince parents of young children with motor delays to stand their child daily. Placing a child in a stander requires a lot of effort, but the incremental or daily effort leads to the child taking those first steps. Without those incremental daily efforts, sometimes as long as years, the potential for those first steps can be lost. In the same way that brushing teeth provides an incremental but necessarily repeated effort, failing to clean teeth over time results in cavities.
Striving for incremental behaviors has been a consistent theme in my life as a therapist. Early in my career I realized that treatment two times per week would not reduce or prevent joint contractures in a child with cerebral palsy. Twenty to thirty years ago, the term Home Program was the high moral ground for therapists and parents. Therapists excelled if they could write the perfect Home Program – determined by whether the parent actually implemented the Home Program. Parents who did not follow the Home Program were the bane of therapists whose patients did not demonstrate gains in therapy. Therapists who gave Home Programs were the bane of parents in the throes-of-cure-or-care. How in the world can she expect me to do range-of-motion exercises 3x/day?! Isn’t that her job?! Both the parents and the therapists believed in therapy; both were expecting something close to cure; both bought-into the 2x/week dosage; and both blamed each other if the child did not progress. They were in a Catch-22.
Sometimes the smallest change in behavior can make the biggest difference in a child’s development. Early in my career I figured-out that identifying those small changes in any particular family situation with any particular child with any particular diagnosis was important to providing effective therapy. Teaching an attentive mother to change the way she held her baby – something she did many times a day – was effective for helping the baby to develop head and body control; far more effective than minutes of handling on a ball twice-a-week for months at a time. What was most effective about the 2x/week therapy sessions was the relationship that developed between the mother and the therapist. By gaining the trust of the mother during repeated therapy sessions over time, she was more receptive to suggestions from the therapist to change how she cared for her child.
The classic problem-solving required by a therapist is to create treatment and recommendations with the best potential for change, including recognizing a family situation where a Home Program will not be implemented. I would likely not recommend a standing program for a child that lives poverty with a mother who is a fourth-generation teen-parent. I have to make a judgment as to when to introduce such a complex activity into the life of a family that struggles to feed itself daily. Equipment recommendations are another potential foible by therapists who make the decision based on the child’s condition as opposed to whether the equipment will actually be used by the family. In the case of a standing program, an indicator that the family is not ready for a $1000 piece of equipment might be that they do not don the child’s orthoses daily.
Home Programs should fit easily into the lifestyle of the family in order to be effective. Repetition is the third critical aspect for achieving effective incremental behavior. Like endless rain into a paper cup is the perfect analogy for effective incremental therapeutic behavior, and it is the clever name of one of my favorite blogs. Susannah provides word-increments causing me to repeatedly LOL. And Terri recently reminded me how important laughter is when helping people understand the needs of special children. Humor is not at the top of my personal toolbox, so I rely on the innate talent of others and the solid nature of my opinions. I digress.
Incremental behaviors repeated can become habit. The advantage of habits over the Home Program is that they are performed with less thinking, with less planning, with less energy – like brushing teeth. An occupational therapist uses the term sensory diet for children who are diagnosed with a sensory processing disorder. By thinking of sensory experiences as food – individually chosen and daily sustenance, they become habit and much easier for the parents to implement in their daily lives. Parents should not expect to keep the same habits for all the years of childhood. The perfect analogy continues to apply in that once the cup overflows, it’s time to get a new cup. Once the child develops head and body control, it’s time for the therapist to suggest another incremental behavior to support the next targeted milestone.
Housekeeping: Read the blogs of other parents of children with diagnoses - linked in my right-side column. I read all of the blogs listed. These bloggers are as diverse a group as you could imagine. They share the same joys and struggles you do.

