Goal setting – a must for your therapy toolbox – Dr Annemarie Lombard*

Posted: 20 May, 2016

By: Annemarie Lombard

Section: Wellness

Goal setting

I hated goals! After finishing my 4 years of studies at Stellenbosch University in 1988, I had goals coming through every pore of my body. I just had enough of goals morning, noon and night and I vouched – never again! And I didn’t. I started clinical work with enthusiasm, but not a single goal was written. I told myself that I was using them and that they were “in my head” but none ever surfaced on paper. Ignorance is bliss, I guess…

Then I had the privilege to work at Therapy West in California, USA with Erna Blance between 1999 and 2000. Being surrounded by about 20 therapists who used a pure sensory integration approach aligned with Ayres’s principles opened up a whole new world to me. I learned so much, so quickly, but there was a catch…

There were two non-negotiables at Therapy West:

1. You had to write daily notes on your therapy sessions; and
2. Every child had to have a goal sheet.

This was checked on a weekly basis and if outstanding, you were not paid! I did not have a choice, dusted off my rusted goal writing knowledge (which was hidden very deep in my cortical bank) and took up the challenge.  It was difficult as I had many cases with no evaluation results, no history in the file and I solely had to rely on my observation skills, reason for referral and the family.  I think that was a blessing in disguise as I was forced to write goals that were functional and meaningful for the child and family.  An example:  A mother would report: “My child has real difficulty eating and cannot tolerate any textures”.

This then became a feeding goal to expand the food choices for the child. I also worked with a large group of children on the autism spectrum and goals helped me to establish and track every small increment of change.
This is critical when working with such a diagnostic group as their shifts are mostly small and un-noticeable. Without a tracking system, progress is not clear and you can feel useless as a therapist. I learned to establish, track and identify the small successes they achieved and each small gain became a celebration. The reality is that if that was not clearly documented in my goal sheet, it would have been missed.

With goals my therapy also became a lot more evidence based!  Children’s problems were identified, the family shared their concerns and needs, and it was converted into a document clearly stipulating what the goals of therapy were going to be.  It changed my life, my therapy and my reputation – all for the better!

What are goals?

Goals are clearly defined objectives of therapy. Following assessment and collaboration with parents, teachers and other professionals, the therapist determines and documents suggested outcomes according to the problem areas of the child. Goals are always written in the positive and what the child will obtain from occupational therapy. It assists the therapist to stay on track with treatment, know when to adapt, when to advance, and when to discharge. It becomes a dynamic working document that forms part of the therapeutic programme for daily reference.

A goal sheet should ideally accompany an assessment report or follow soon thereafter.

How do you write goals?

Thanks to university, we do have some solid academic background on the process of goal writing. Goals should obviously be SMART:

Specific
Measurable
Appropriate
Realistic
Time frame

I however want to add another component – F for functional! In my experience this is where we are more likely to get it wrong. We become wrapped up in assessment results, terminology, development stages and grading processes, to name a few. Our focus must always be to increase daily function for the children or clients we work with.

In order to make the F-SMART goal writing practical; we will do the following:

1. Explain what the goal component means and use examples
2. Underline this component in the same goal throughout

Functional (Why)

Why are you doing this? Day to day functional gain should always be our primary objective. Therefore ensure that your goals are functional. Use the development component as the base for knowing what to address but your outcome should always be daily function.

An example:  If you work on prone extension, that is your developmental component but sitting posture will be the functional outcome you want to address when writing your goal.  You will target therapy components (i.e. prone extension, supine flexion, balance, tactile defensiveness, etc.) but the outcomes should be functional gain (sitting, climbing, sport, dressing, grooming, feeding, etc.).

• Improving prone extension and supine flexion will result in improved sitting posture, climbing skills, sport participation, etc.
• Improving tactile defensiveness will result in improved dressing, grooming and feeding skills, etc.

Functional outcomes are particularly useful to turn our OT-jargon into understandable language for parents, teachers and other professionals.

Specific (What)

What exactly are you trying to achieve?  Therefore goals need to be specific to the child’s function, age, environment, needs and problems.  Be clear on what you want to obtain and do not use vague, indistinct, jargon-type language.

A vague example would be: “..improve sitting posture…”
A specific example would be: “..maintain an upright sitting posture at a desk without falling out of the chair …” The goal below stipulates specifically what Sarah needs to achieve.

Measurale (How)

How will you know whether you’ve achieved the goal or not?

If it can’t be measured it cannot be achieved. Detailed measurements are important and established through discussions with the parents and teachers. Since the outcomes should always be functional, it is imperative for a therapist to know how, when, where and how much dysfunction impacts on the child’s daily behaviours and learning. The measurements for the goal below was obtained as the mother reported the child to have 4-5 outbursts during music ring which created difficulty not only for her, but also the teacher and her peers. It impacted her classroom participation, attention and social skills.

Appropriate (Who)

Who is this child?

Goals must fit in with the child’s age, background, socio-economic situation, school and home environment. An appropriate goal for a 7-year old child would be sitting posture at a desk, but the same goal would be inappropriate for a 2-year old. Eating with a knife and fork will be inappropriate for Muslim children, as they eat with their hands, but appropriate for other cultures.

I wrote many inappropriate goals for autistic children when I started out. I did not understand the extent of their difficulties and the general rate of progress. It is important to know and understand as much as possible of the child you will be working with. Not just their assessment results and/or diagnosis, but the specifics about their daily lives, context, family, school, social, ADL’s.

This goal is appropriate for Sarah as she is a 6-year old little girl with significant sensory processing issues and on the autism spectrum disorder. She attends her local pre-primary and really battles with social integration at school with lots of behavioural difficulties. She does music ring daily at the end of their day so it is important and appropriate that this be considered for functional gains.

Realistic (Where)

Where is this child in his/her life span, context and world?

Goals must fit within the wider intellectual and skills base of the child as well as the diagnosis. An unrealistic goal would be drawing and colouring for a 3-year old classic autistic child. Make sure you match your goal with the child’s bigger picture and expectation. This becomes the key when discussing goals with parents as you will clearly determine whether parents have realistic or unrealistic expectations. Ask parents what they want to achieve through therapy. If they say “to create another Ernie Els (when the child has dyspraxia) or read (when the child is 4), you know you are in trouble…

This is the best place, time and opportunity to ensure expectations are discussed an unpacked with parents. Your and their commitment to the therapy process should be very clearly outlined and discussed. If at all possible, make sure you include both parents with this discussion. This is an opportunity to make the parents part of the therapy process and empower them with new insight and knowledge too. We also get confronted with the fact that our goals and objectives for the child might not be relevant or important for the parents. Playing sport and being part of a team could be a lot more important to the child and parents than manipulating a pencil correctly. We have to listen to them, honour their needs but help them to make sure it is realistic.

This goal was established with the parents as music ring participation was identified as an area of concern.  Sarah is 6-years old and a 30 minute music ring is realistic.  A full day at school without any behavioural outbursts would have been unrealistic; being able to eat all types of food all the time, would also be unrealistic.  This is where you need to understand the age, extent and context of the child you are working with.

Time frame (When)

When puts the important time frame on your goals and provide a period in which to measure goal attainment.

If there is no time frame you cannot evaluate whether the goal was successfully reached. Time frames apply to every single goal that you write as well as your goals in total. Each goal should have a time frame in it (where relevant) so that you can re-evaluate every goal for achievement. Your set of goals for the child should also have a time frame.

The child’s diagnosis and problems, personal preference and parents’ needs will dictate the time frame you decide for your goals. I used to write goals in time batches of 3-6 months of therapy. You can also write short-term (1-3 months) and long-term (6-12 months) goals. This will however fluctuate based on the child you are working with, the parents, the diagnosis and your personal preferences.

I believe the quicker we can show results (1-3 months) the better. So ensure that you set goals in small increments for the short-term time, building up to more long-term goals. Also be mindful that some diagnosis will need longer time frames (e.g. dyspraxic and autistic children).

The above 30-minute time frame is specific to this goal.  The group of goals set for Sarah was over the first 6-month period.  These goals were then reviewed and amended for the next 6 months of therapy.

Why should you write goals?

The benefits of goal writing are enormous.  For those who haven’t done goals before, it is often a new, uncertain and scary step but absolutely worthwhile doing.  I’ve experienced every single one of the benefits listed below in clinical practice.  It not only helped me stay on track, but also made the parent-child-therapist relationship a lot more solid.   Parents knew what I was doing, why I was doing it, and were 100% supportive of the therapy process.

• Outcomes based intervention:
Goals ensure that you stay outcomes based and functional. Making a tangible and measurable difference, where it matters, and when it matters in the lives of children is what occupational therapy is all about.

• Guide your treatment:
Whether you work with an easy or difficult case, having a focused and clear guideline is important. Your goal sheet should become your blueprint and daily reference when in clinical practice. It keeps you focussed and on track, always knowing what to do next.

• Give parents excellent insight on what you are trying to achieve:
Parents battle when their children have problems and are not coping in school, home, life and social settings. When they end up in your practice they are somewhere on a journey of having to make peace with the fact that their children aren’t perfect and that work is needed. Our assessments and reports highlight these issues and the parent “fall to pieces” a little bit more. We then suggest an intervention process asking for commitment and money and the parent “fall to pieces” another little bit more. Then we provide them with a written document of goals and objectives written in the positive and we give parents hope! Goals turn the faults we’ve identified into opportunities. We really owe that to our clients.

• Simple, functional terminology that makes sense:
Your “goal language” should be functional, real and not “OT jargon”. Words such as bilateral integration, praxis, prone extension, muscle tone, auditory defensiveness, etc. do not have much meaning to parents and/or teachers. And while we spend time explaining them, they should not be included in your goal sheet. Your goal sheet is the one primary opportunity to show the parents (and all those other important people reading your report) how we translate developmental components into everyday life actions. Sensory defensiveness may result in poor class participation and attention issues – focus on the class participation and attention. Bilateral integration may be the underlying reason to reversals and poor tying of shoelaces – focus on the reversals and laces. Make it real, make it functional.

• Make re-evaluation during therapy easier and more effective:
With a goal sheet following your initial assessment report, tracking, grading and discharge are easy. You can literally cut and paste your goals into your discharge report and elaborate on the functional gains made. Over the years I’ve also had a few obstinate parents (usually dads) interrupting therapy wanting to know what we do and what he is paying for. Being able to immediately access a specified document and reporting on progress and goals have converted many difficult parents over the years into supporters.

• Accountability:
We should be accountable to our clients and the people we serve. We have an ethical responsibility and our daily conduct should be to honour the amazing profession we have. Writing goals and making it visible to our clients is a commitment and a show-off to what we can offer.

Tips to make your goal writing easy, simple and meaningful

• Just do it – don’t be scared. Goals are not set in stone! You can change them, re-write them, and/or discard them. This becomes necessary after you’ve worked with the child for a bit to realise that your goal setting might need updating. A child may also have reached one goal but something else occurred through the process that needs inclusion. Goal writing is a dynamic process and should be reviewed and updated regularly during therapy.
• Goals should be written after the child has been tested, parent feedback given and collaboration with teacher and other involved professionals occurred. You need to discuss goals and expectations with the parents during your feedback session. A therapist can never determine the goals for a child independently. In my experience parents and teachers can be quite vague about goals but prompt them and ask the right questions. Use the reason for referral, what are the parents battling with most, what is the teacher battling with most, what would they like to see improving? Ask the “what” question and you will get to the functional dilemmas the family and school experience. Focus your goals there. Obviously if unrealistic expectations (from the parents or teachers) are present use this explorative session as an opportunity to rectify this. Nothing wrong with saying: “Your child has problems with sensory processing problems, we cannot shift reading age but we can make it easier for the child to sit during reading at school with fewer distractions”.
• A good and solid assessment is necessary. Combine that with history and collaboration from other professionals and/or teachers involved to ensure correct identification of problems, thus ensuring appropriate goals. Know your development stages and grading processes to position your goals as realistically as possible.
• Attach your goal sheet (try to stick with one page) at the end of your report and mark it: “Suggested Occupational Therapy goals”. This way you allow yourself the freedom to adapt or change them. Goals are always written in the positive and what gains the child is likely to have. After a predominantly negative report (remember we highlight what was wrong during an assessment); the goals will give parents hope and guidance! You will love the feedback and support!
• Keep it simple, keep it functional. No jargon or OT terms, leave that for your report.
• Make sure your goals follow your assessment report format, if you first documented gross motor development; then ensure gross motor development is covered first under your goals.
• I preferred to start with sensory modulation as it forms the basis of your therapy and obtaining arousal, focus and behaviour.
• You can divide your goals into short-term and long-term goals, but guard against goals getting too long and complicated.
• Cut and paste a copy for your own use and divide each goal into functional components for further guidance and grading during treatment. Functional components are the steps you will follow to reach your goals. Create a format which you can access and use every day. It should not be a document lying somewhere in a file. Have it readily available with every session.
• Check your goals regularly and revise them when necessary. You might also have to add new goals or discard some of them.
• Base your discharge report on your goals. You will be amazed at how much easier it makes your re-assessment and reporting process.
• Decide on discharge when you’ve reached your goals and feel no other goals are relevant or appropriate. Verify your recommendation with the parents and teacher before formally discharging the child.
• The goal writing process can be regarded as a fairly personal process and try to work out a format that works for you. As long as you maintain the F-SMART goal guidelines.
• Just do it! Please!

*About the author

Founder and CEO of Sensory Intelligence® Consulting, Dr Annemarie Lombard holds a PhD in Occupational Therapy, backed by nearly three decades clinical and training experience. She is the thought leader behind Sensory Intelligence® and author of the book, Sensory Intelligence, why it matters more than IQ and EQ.

Annemarie worked in clinical practice using sensory integration for children for 15 years, in South Africa and the USA. During 2003, she shifted her focus to incorporate a mental health and wellness approach in adults, which she now applies to teach Sensory Intelligence® solutions to health practitioners, therapists, organisations, corporate teams, parents and teachers. She has a passion for the wider application of sensory processing and improving the quality of life for adults and children.

Sensory Intelligence® is the registered trademark of Annemarie Lombard. She lives in Cape Town, South Africa with her husband and two sons.

*This article is dedicated to Ruth Watson, my PhD supervisor, mentor and friend. She was an absolute angel in my life and the reason I managed to complete the doctoral journey.  Her love and wisdom surpassed everything and everyone I encountered in the OT world. She passed away last year; her last words to me were to write more. This is for you Ruth, I love you and miss you.