Protocols are nice packages of processes that allow for a task to be completed or a problem to be addressed in a predictable organized fashion. They allow for for the process to be easily communicated, taught and used by a new person.
Protocols and the special needs needs child
Behavioral optometry recognizes the effect and importance of vision on the rest of the body. The effect of the visual intervention on the rest of the body increases the number variables that will effect the outcome of a protocol. Just as we as therapists must recognize the role of vision in the interventions we apply, the behavioral optometrist must also recognize the interaction of their intervention on the rest of the body.
A child with cerebral palsy develops a toe walking gait as a pathological solution to ambulating with increased trunk and lower extremity tone. The application of base down prism, a common solution for toe walking, would, in this instance, destabilize this patient’s gait and balance, most likely making him unable to walk. The visual input would be attempting to make his body do something it is unable to do. Is the base down prism helpful when when used during physical therapy sessions after a child has had other interventions for muscle tone? Maybe. This is the point at which an interdisciplinary team with a collective understanding of the entire person becomes most useful.
The larger point of the example is that the entire system is affected by the visual intervention but without an understanding of the entire system, the success of the protocol decreases.
Degrees of freedom
The variables within any biological human system are are complex and innumerable. The biological factors that influence the behaviors and abilities of children with special needs are even more difficult to list. Vestibular, proprioceptive, muscular tone, sensory interpretation, etc, all are acting upon every human at all times. As a child presents to a provider, the provider must understand these systems and take into account the affect a change to any one of the systems will have upon the others. This is the challenge of anyone working with special needs children.
But a child’s degrees of freedom reach beyond his biology. All children exist in a context that includes parents, siblings, socio-economic factors, and teachers that also have an effect upon their behavior and abilities. A failure to acknowledge and understand these factors will also make the outcomes of interventions difficult to predict. As therapists working with children, it is all of these things that make us continuously look for understanding of the entire context for each child allowing us to treat this child in the most efficient way.
Toolbox vs Protocols
A large part of a therapists education involves learning to assess the degrees of freedom of the systems that that fall under their disciplines scope. Occupational therapists learn about the developmental sequence, range of motion, coordination and strength assessment. We learn standardized assessment for sensory processing and function ability and many other things. Physical therapists look at posture and gait, muscle tone, and balance. Speech therapist learn about swallowing, articulation and language processing.
But speech therapists also recognize the importance of posture for breathing to produce sounds. OTs know that a child without sufficient hand strength cannot use a walker to help him walk. A physical therapist knows a too cold room will affect the behavior of their sensory sensitive patient. We are taught to have a holistic view of our patient to be successful.
Most therapists will talk about their “toolbox” rather than a protocol. Even interventions presented as a protocol, will quickly be modified and changed to accommodate a child’s needs and make the intervention more successful.
As the scope of behavioral optometry evolves, know that an understanding of the interaction of all systems, including the patient’s individual context, will render protocols less and less useful. The provider intervening must be able to apply tools from their toolbox freely and confidently to adjust for constantly changing demands of a specific patient and the individual needs of their special patient.