What Do You Do When NOTHING Is Working?

I’m writing this article to read later when I need to cheer myself on.  

As a pediatric SLP, there are times when I leave a session thinking, “I’ve tried EVERYTHING I know to do, and it’s not working.” There are times when I wake up in the middle of the night with one of my little friends on my mind, and I stare at the ceiling thinking, “Hmmmmm. What am I going to do about THAT kid?” There are certainly times when I call Kate to commiserate and say, “I’ve done x - y - and z, and NOTHING is working! UGH!!!!!”

Some days go along beautifully when every child you see has their best session ever. Most everyone on your caseload is clickin’ along. And then it happens. You eval a new kid who you just can’t get a good read on. Or a child who started out like gang-busters and said 15 words in his first session has suddenly hit a brick wall and not made a hint of progress in weeks. Or you walk out of a home when the only person talking was YOU! Mom sat there bewildered, and the kid ran circles around you, and it’s gone so horribly that you look around the room for the hidden camera and wait for someone to jump out and say that you’ve been punked since it couldn’t possibly go this badly without someone planning it!

There are some sessions, and occasionally even some children, who make you wonder what the heck you know about anything anyway.

What do you do when you’re the therapist, the person who’s supposed to know how to make things better? What do you do when you’re the mom who’s looking at the person who’s supposed to know how to make things better, and it’s not going the way either of you hoped?

Here’s my best advice - the same advice I give myself, or anyone else who asks me, on those days.  

1. Critically analyze everything you’re doing - during sessions (for therapists) and between sessions (for parents).

The key word here is “critically.” If you were called in for a consult on your own case, if you were supposed to “mentor” you, what would you recommend?  This “objective” analysis of your own actions, either during sessions for therapists and between sessions for parents, can shed lots of light on what’s going wrong.

Look at your overall approach.  Does it match the developmental age of your child?  I think this is the #1 reason early intervention and preschool therapists struggle.  You can’t take approaches designed for older children and expect them to work with young children - especially babies and toddlers!  When something is not working for a young child, try to back it down a developmental level or two and see what happens. 

For example, you want a child to imitate words and you’ve tried and tried to elicit a core set of words, but he’s silent, despite all your best tricks.  Reassess the situation.  Is he vocalizing at all?  When?  Simulate these circumstances in a session.   Instead of words, try sounds, or better yet, sound effects first.  You want a child to play interactively with you, but he’s still preferring cause and effect toys?  Meet him where he is.  Use his own preferences first, before you try to force a big cognitive jump he’s not quite ready to make.          

Look at external factors and circumstances.  Should you try a different time or day for the session?  Should you try a different environment?  Sometimes something as easy as playing in a smaller room with fewer distractions can make a huge difference.  Sometimes going outside can break the monotony of your same old routine.  If you’ve tried to play with the same things for weeks in a row and it’s not working, break out some new toys!  If you’ve tried books and puzzles and she hates it, get up and get moving!  If a child is clingy with mom in the room, try to have mom be “busy” within eye-sight and ear shot, but with a lap that’s not quite so accessible, or try to go when Dad or grandparents are the primary caregivers.  If a child is floundering in a not-so-great daycare situation, supportively suggest a change.   

Have you tried several different approaches, or are you stuck in a rut?  Are you using at least a few different methods and focusing on a few different things during each session and during play with your child?  Are you changing it at least a little from week to week rather than doing the same thing over and over day in and day out? 

For example, for parents, if one of your goals is identifying body parts and your only approach has been to ask your child, “Where’s your nose?” when he’s sitting on your lap, shake it up a little.  Honk Daddy’s nose.  Play with Elmo’s nose.  Look for a new doll in the store and find her nose.  If you’re a therapist and are working on body parts while you play Potato Heads, look around for other opportunities.  Get creative!    

On the other hand, for those of you who are like me (hyper with undiagnosed ADD), have you given your approaches enough time to work?  Are you looking for small, attainable changes, rather than long-term goals?  Earlier in my career I would jump ship just before I should, or make my expectations so lofty that no child with delays could reach them quickly enough for me!  Now I have learned to look for lots of different ways to target one specific goal, give a Mom and Dad several different ideas to work on the same core skill from week to week, am happy with more realistic gains, and then lastly, BREATHE, while I wait for my little friend (and his mommy and daddy) to catch up! 

2.  Check back in!  Make sure YOU’RE focused on what needs to be done.

Sometimes therapists who have worked for a while get on automatic pilot. Sometimes your crazy personal life can cause a temporary disconnect to last longer than the build up to your wedding, well after maternity leave is over, and beyond whatever “crisis” is going on in your everyday, non-professional, but real life.  You have to remind yourself to get back in the game.  Really think about your client that’s having a hard time.  Spend some time planning what you’re going to do.   

For a parent, you can have the best intentions to “do your homework” with your child, and then you realize that your next therapy session is TOMORROW and you’ve not done one thing you promised yourself you would try during last week’s session.  Commit.  Make yourself follow-through.

Check back in.  Connect.  Make sure you’re looking at what you’re supposed to be doing to make things better.  Don’t totally blame it all on the kid (”He’s so autistic.  He may not ever make progress”), or the therapist (”She’s so young!  Does she even know what she’s doing?”), or the parents (”If that mom really tried during the rest of the week, things would go a lot better for me while I’m here!) 

While all of those things may be true, it’s really easy to place blame squarely on someone else’s shoulders rather than your own.  Usually when things aren’t going well, everyone is at least a little responsible.  

3.  Read (AND DO) what the experts recommend.   

For therapists - Don’t get stale in your approaches.  If you aren’t reading and looking for new stuff to try between mandatory, annual continuing education requirements, you may not be staying fresh and current.  Can’t stand journals?  Look for easier-to-digest material on websites.  Don’t have time for a whole book?  Pick a new title and read only the chapters that apply to what you’re looking for.  You may surprise yourself by reading backwards for more info!  Not sure what ”experts” to look for?  Ask your other therapist friends what they’re reading or who they recommend.     

For parents - Ask your therapists who and what you should be reading.  If your therapist can’t recommend anything for you, ask them to get back to you.  (P.S. That’s a red flag!  Or she could be so shocked that she needs a week to scramble and find you something!) 

4.  Ask REAL people for help and new ideas. 

For therapists - If you have no friends who are therapists, make some!  Get out your clients’ IFSPs, or IEPs, or releases, or whatever documents professional contacts are listed on, and call them!  If the therapists aren’t your same discipline, even better!  Isolation does not breed professional growth!  Almost every therapist I know can’t resist a phone call or e-mail that starts with, “Can I pick your brain for a minute?  I have this kid who………”  If you’re fresh out of grad school in a brand new city, or feel totally alone in your new school district, find a mentor.  Latch onto someone who seems like she knows what she’s doing, and ask away!  Embarrassment over not knowing what to try next is completely overcomeable with practice!  The good advice you’ll get will outweigh any initial shyness you might have in asking for help. 

(One other side note for therapists - Cultivate the habit of regularly asking moms and dads what their child is doing for them AND for any other therapists he may have.  If you’re getting better reports that your sessions indicate, call the other therapist ASAP!  Ask what works!  Kate, my friend that I mentioned earlier and the developmental therapist/teacher of “Teach Me to Talk with Laura and Kate,” regularly has children perform better for her than the same child’s SLP, but SLPs rarely call her and ask for advice.  She says it’s because of the whole pride thing with SLPs who think, “How can a DI get more words than me, the SLP?” Sometimes they don’t even realize how much the child is under-performing in their sessions until a mom pipes up and tells them, or until they hear it in the 6 month IFSP?  Why?  Because they didn’t ask!)       

For parents - Befriend other parents who are going through similar struggles with their own children.  Don’t know any other parents of language-challenged kids?  Ask your child’s therapist.  Chances are, she can hook you up with someone, and that person can recommend a good resource for you.               

5.  Be ready to move on if, or when, you need to.

For parents, if your child needs a new or different approach and you’ve done everything you can to elicit a change with your current therapist with no luck, it may be time to look for someone else.  Give it your best try with your child’s current person because sometimes there is no one else, but if you can’t make it work, move on, and don’t look back. 

For therapists, this is even more difficult.  Sometimes your personality, or philosophy, or skill set, or even scheduling constraints, are not a good match for a child and his family.  Know when to throw in the towel.  Help a family help their child by knowing when to say when.  It’s a much more honorable thing to do than prematurely discharging a child claiming the goals are met when you know it’s really you who’s done, or keeping them on your caseload when your heart is not in it, or when you’re in over your head.  Although we’ve all had kids who were a challenge, who stretched us beyond our current abilities and made us become better therapists, sometimes, for whatever reason, it’s just not worth it.  Let the family go.  Apologize profusely, help them find someone else if you can, but help them move on for their child’s sake.   

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I hope these ideas help some of you!  I promise to read them to myself on days I need them, and we all have those!  Laura