Thursday, April 19, 2012
Finding a Balance Between Remediation and Compensation
When a person wants to learn daily living skills, but has difficulty, there are two approaches that can be taken: remediation and compensation.
Remediation involves addressing the underlying deficits that lead to difficulties with daily living skills. For example, a person may have difficulty learning new skills due to poor concentration. A remediation approach would mean that the person would engage in tasks to improve concentration.
Compensation involves adapting around a skill deficit to still find a way that the task can be accomplished. It usually involves making changes to the way the task is done or to the environment it is done in. For example, if a person does not feel like she can leave her apartment due to anxiety, a way of compensating would be to help her learn to order groceries online or by phone.
I believe both approaches can be helpful in the right circumstances. However, what are the right circumstances? Also, are we consciously thinking about which approach we are using?
I have been making a few observations about how these approaches are used differently for children and adults, and I am not sure we always choose the most appropriate approach.
Working in adult mental health, "skills teaching" is probably the most common way of addressing deficits in performance of daily living skills. This is primarily done with a remediation approach.
The assumption is that the person is unable to perform the skills because he has never learned them. My question is, how many people actually reach adulthood and have never had the opportunity to learn daily living skills? My guess is not very many.
If the person has had the usual opportunities to learn daily living skills, and has not, there must be a reason he has not learned them. The reason is often cognitive deficits, but can also be things like physical deficits or having different goals.
It therefore seems that to teach the skills in a regular way is not likely to be particularly helpful. Yet that is the approach being taken in many settings.
Another way that remediation is done is through programs designed to increase a person's abilities in different areas. I think this was the rationale for the older-style arts and crafts kind of occupational therapy (e.g. working on concentration).
There are some new studies being done that have some promising results using computers for cognitive remediation programs. It will be interesting to see where this leads.
It seems to me that with adult mental health, a compensatory approach is often not given the recognition it deserves. I am not recommending giving up skills teaching. What I am suggesting is that skills teaching be done in alternate ways that adapt around deficits.
I am also suggesting that if a person is really having difficulty learning a new skill, it is OK to find other ways of doing the skill that still allows the person independence.
For example, if impulsiveness interferes with budgeting, learning to pay bills and get groceries immediately after receiving money is a valid approach, as is choosing to not have a bank card or credit card. Not everyone will be able to make their money last to the next cheque, no matter how much skills teaching you do.
The other side of the coin is what is happening with children. When I look at the school my daughter goes to, they are experts in compensating. If a child cannot handle transitions well, she gets a visual schedule, and lots of warning about transitions. If a child has a need for movement, he is given a wobble board or ball to sit on. There are a multitude of classroom adaptations.
This compensatory approach is also evident in interventions given for the home setting. Parents are often encouraged to set up routines, schedules, and checklists. They are encouraged to use a behaviour modification approach, which addresses the behaviour, but not the underlying causes of the behaviour.
I think this compensatory approach is necessary in a setting where there are many other kids to think of, and individualized attention cannot be given. However, I wonder about it. If our children are allowed to stay in their rigid worlds, and in fact the school and home interventions help to make it even more rigid, how are they going to learn to be more flexible? Given their brain plasticity, shouldn't we be looking at more remediation?
In the sessions I went to by the RDI-trained OT, she explained that her approach was to address the underlying relationship difficulties that led to many of the problems. This is a remediation approach, and it made me realize what had been missing with other approaches. However, I really do not know the evidence on RDI, so I am not promoting it specifically.
If you read my blog regularly, you are probably tired of me going on and on about just right challenges. If you want to find out more, click here to read my post on just right challenges. I really think that they are the key to finding a balance between remediation and compensation.
If just right challenges are being provided, remediation is happening. The very nature of a just right challenge is that it causes you to stretch and learn. However, if a situation is going to be too much of a challenge (more than just right), it is time to use a compensatory approach in order to make it just right.
I think just right challenges can be used when using a compensatory approach as well. For example, if a person has difficulty using a stove safely, you might recommend cooking only with the microwave. A just right challenge can be found with learning to cook with the microwave, and being able to be independent with cooking.
Both remediation and compensation are important. I think we need to provide as many opportunities for remediation as possible, but also recognize that compensation can be a viable alternative.