From Therapy Room to Real Life: Are We Measuring What Matters?

There's a familiar moment in paediatric occupational therapy. A child demonstrates a skill successfully in a session.

- We practise it.

- We grade it.

- We document progress.

- Perhaps they even achieve the goal.

Then the parent says: "But they still can't do it at home." Or the teacher reports: "We're not seeing that at school." We often describe this as a difficulty with skill generalisation.

But I wonder whether that explanation sometimes stops our clinical reasoning too soon. Perhaps the question isn't simply: "Why hasn't the child generalised the skill?" Perhaps we also need to ask: "What changes when the occupation moves from therapy into real life?"

Demonstrated capacity is not always available capacity

A child may demonstrate excellent problem-solving during a structured therapy activity. But now place that same child in a noisy playground where they have to interpret social cues, tolerate unpredictability, manage sensory information, inhibit an immediate response and negotiate with peers.

The underlying skill may still exist. The conditions under which the child needs to access it have changed dramatically.

Similarly, handwriting at a quiet therapy table is not occupationally equivalent to handwriting in a classroom while simultaneously:

- listening to instructions

- remembering what to write

- ignoring conversations nearby

- organising ideas

- monitoring time

- finding equipment

- keeping up with peers

The motor skill hasn't necessarily changed.

The occupational demand has.

State matters

Executive function research gives us an important lens here.

Zelazo and Carlson's work differentiating "hot" and "cool" executive function reminds us that cognitive skills don't operate independently of emotional and motivational context.

The availability of executive functions can change when situations become emotionally significant or demanding.

This fits with what clinicians observe every day.

A child can tell us exactly what they should do when they're frustrated while sitting comfortably beside us. That does not mean the same cognitive resources will be equally available during an emotionally charged interaction with a peer.

Within The Regulation Hourglass™, this is why I make an important distinction:

Having a skill doesn't guarantee access to that skill in every state.

Context isn't background information

Occupational therapists are well placed to recognise this because occupation never occurs in isolation.

Performance emerges through the interaction between the person, the occupation and the environment.

Yet therapy can inadvertently simplify that interaction.

We control the sensory environment.

We grade the task.

We provide individual attention.

We repeat instructions.

We allow additional processing time.

We scaffold frustration.

We anticipate problems.

Then we ask why the child's performance looks different when those supports aren't present.

Perhaps sometimes the more useful question is:

What did our therapy environment make possible?

And:

What would need to change for that capacity to become accessible within the child's everyday occupation?

Generalisation, or intervention design?

This can create an uncomfortable clinical reasoning dilemma.

If a child can only perform a skill under the highly supported conditions we create in therapy, should our next intervention focus primarily on more practice?Or do we need to investigate the environment in which the occupation actually occurs? Perhaps intervention needs to involve:

- modifying the task

- altering environmental demands

- supporting the adults around the child

- changing timing

- providing visual or structural support

- reducing competing demands

- deliberately scaffolding participation within the authentic context

This doesn't mean individual therapy is ineffective or unnecessary. There are many situations where direct individual intervention is appropriate. The challenge is ensuring that successful performance within therapy doesn't become our endpoint.

Before we teach again

When a child can't demonstrate a previously learned skill, clinicians can easily assume the skill requires further consolidation. Sometimes it does. But sometimes we're looking at a capacity mismatch rather than a knowledge deficit.

That distinction matters.

If the child's available capacity is insufficient for the current occupational demand, repeatedly teaching the skill may add cognitive load without addressing the actual barrier to participation. This is where Timing is therapy becomes clinical reasoning rather than simply a phrase.

Before teaching, we can ask:

- Is the child available for learning?

- Is this actually a skill deficit?

- What demands are competing for their available capacity?

- What support would make participation possible here?

- Can that support be gradually reduced as capacity develops?

Download our free resource: 5 Signs You are Teaching Too Soon ↙️ 

https://www.theregulationhourglass.com.au/5-signs-you-are-trying-to-teach-too-soon

From transfer to participation

Perhaps we need to think beyond whether a child has "generalised" a therapy skill. Instead, we can examine whether intervention has changed the child's participation within the occupations and contexts that matter.

- Can they join?

- Can they remain involved?

- Can they recover when something becomes difficult?

- Can they access more of their existing skills?

- Do they require less support than previously?

- Has something meaningful changed in their everyday life?

Those questions shift our focus from: "Can the child demonstrate the skill?"

towards: "Can the child access the skill when and where they need it?"

And that may be a much more meaningful measure of occupational therapy outcomes.

Reflective supervision questions

1. Which children on your caseload demonstrate significantly different capacity in therapy compared with home, school or community environments?

2. What supports are naturally built into your therapy environment that may not exist elsewhere?

3. When a skill isn't transferring, how do you distinguish between a skill deficit and a capacity mismatch?

4. Are you measuring acquisition of a skill, generalisation of a skill, or change in occupational participation?

5. What might change if you spent less time asking, "How do I get this skill to transfer?" and more time asking, "What makes this skill accessible here?"

REMEMBER:

Capacity before behaviour and Capacity Changes Everything.

The Regulation Hourglass™

Chat soon :)

Beryl