This is something that was talked about a lot in my training and even more so in my internship. In my internship, I worked with many students who were very limited in their responses to their environment due to communication, physical, and other deficits. Many children that this applies to have multiple disabilities, may not be able to communicate currently, and may “look” like they function at the level of a 2-6 month old. However, we were always taught that we assume the client is at the functioning level of their chronological age, unless we have significant evidence to prove otherwise. 

For instance, talking to a teenage client with a TBI like they are a child can severely hamper your clients self-esteem, motivation, competence, and the therapeutic relationship. Something I think that is not talked about enough is the emotional support for clients who are severely limited in their ability to engage with the environment. As their therapist, it is your responsibility to take this into account, even if you are only working on physical, communication, or cognitive skills. These clients still have an internal world that is rich with emotions and experiences.

Some questions to ask yourself:

  • How you are talking to this person? What is your tone?
  • What is the age appropriateness of the songs you choosing for interventions?
  • How much autonomy are you giving them within the session?
  • Are you “chatting” with them like you would a peer of the same age?
  • Am I seeing consistent affective responses to certain elements within the session? What can I do to support/decrease those responses?
  • What can I change about what I am doing? What haven’t I tried yet?
  • Also, if in doubt, seek supervision!!!

Although these clients may present at a much lower level of functioning, oftentimes assessments are unable to determine cognitive levels due to the limitations in assessment instruments. We want to be sure we are supporting the client as much as possible and this requires us to assume competence at its highest level.

What are your thoughts?


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