Appendix B. Narrative Description of OPC Sessions and Goal Achievement of Each Participant
1. Case 1 (a boy with autism and developmental delay, aged 5.25 years)
Both parents of Case 1 were coached for six sessions. During the first session, the parents considered that concentrating on completing homework within 30 min after school, while remaining emotionally stable, was the most important goal for their child. They reported many concerns regarding the child’s emotional stability, and the impact of his engagement in academic tasks. The OPC coach directed the parents’ focus to the days on which the child could complete the homework timely. During the solution-focused talk, the mother noted that the child might be more obedient if he was told about what to do one day before. The father also mentioned that the use of iPad/television as a reward after homework completion worked sometimes. The OPC coach instructed the parents to notice the timing and details around using those strategies in their daily routine, to which the parents agreed.
The second session was postponed for one week, due to school suspension as a result of the social unrest happening at the time. In the session, the parents reported an improvement in the child’s performance in completing homework, but they were unable to continue implementing the strategies during the school suspension period. The parents also had concerns about the child’s slow pace in writing Chinese words with complex strokes, and the over-use of iPad/television as the reward. The parents were encouraged to explore other strategies to write the complex words efficiently (e.g., breaking down the words or completing the same word in a row), and alternative rewards (e.g., allowing playtime with his brother) that could support the child’s performance.
In the third session, the parents reported further improvement in the child’s performance. They also identified the best timing for the child to engage in Chinese homework (e.g., good quality sleep the night before). Subsequently, a new goal emerged from the parents’ concern regarding the child’s emotion and disruptive behavior during piano lessons. After eliciting the parents’ knowledge, the mother decided to use a similar strategy, in other words, to let the child know what the piano teacher would teach in the next lesson. The mother would also practice with the child, letting him familiarize himself with the learning topics.
The fourth session was held two weeks later, as the mother had work commitments. In the session, the parents reported that the child became more cooperative and, in fact, the mother had not told him about the teaching content of the next lesson in advance. Instead, she had modified the strategy and asked the piano teacher to tell the child directly about what she would teach him at the beginning of the piano lesson. This modified strategy did enhance the child’s emotion and cooperation successfully.
During the remaining sessions (fourth, fifth, and sixth), the parents shifted their focus to another goal, which was that the child could complete homework during Christmas and Chinese New Year holidays. However, they struggled to identify successful strategies every time, because their holiday schedules were varied. The OPC coach shared several ideas (e.g., sorting out types of homework based on difficulty, offering breaks for lengthy homework), and invited the parents’ comments on the ideas. The parents decided to let the child complete difficult homework when he was emotionally stable, and shift to easy/interesting homework when he was tired. The plan was modified twice over the fifth and sixth sessions, when the child felt distressed and unsettled. For example, in the sixth session, the mother reported that the child suddenly stopped doing the homework after being asked to correct a wrong stroke sequence of a Chinese word. The OPC coach led the parents to think about what they observed at that moment, and how they could maintain the child’s motivation for homework completion. Additional strategies were further generated from the parents’ reflection; those were, to allow the child to make mistakes, but guide him to find and correct mistakes after the completion through game-playing approaches. These strategies were used depending on the child’s emotional status.
In the fifth session, the father reported an incident that had impacted on the child’s emotional state. The child had bit his brother’s arm when the brother did not want to share the new toy with him. The OPC coach facilitated the parents’ reflection on their understanding of their child’s behavior, and identification of possible strategies to prevent or deal with the behavior in the future (e.g., educating the child and reaching an agreement before playing with new toys, or using a timer to take turns to play). Similarly, in the sixth session, the mother reported an occasion where the child had suddenly started to cry and refused to eat lunch at home. Through the OPC coach’s guidance, the parents concluded that this incident might have been caused by the differences in the child’s routine, as they usually had lunch outside on the weekends. The mother further reported that she made use of the timer and gave the child time to calm himself down. Surprisingly, these strategies worked. The parents planned to continue using these strategies to help the child calm down when needed, as well as teach him to count down and take deep breaths as a self-soothing strategy.
In summary, three out of the seven goals were addressed in the six sessions (see
Table 2). One goal was particularly related to the child’s community participation. Unfortunately, the remaining OPC sessions were terminated because of the outbreak of COVID-19, and the post-intervention measures were completed immediately. The parents also completed the follow-up measures two months after post-intervention.
2. Case 2 (a boy with autism, aged 4.00 years)
The mother of Case 2 was coached for one session only. During the session, it emerged that the mother’s priority was that her son followed her instructions during the morning routine, and left for school on time. The mother used a problem-oriented narrative to describe her son’s stubborn tendency, in other words, her son would cry and require time to calm down if things did not go the way he wanted. This would delay the arrival time at school in the morning. The OPC coach guided the mother to think about what happened in a good morning, and explore possible strategies. The mother reported that she used candy/seaweed as the reward to motivate her son, or used pictures to explain things along the road, which sometimes worked. Furthermore, if the iPad or iPhone were used as the reward, the child would comply. However, the mother hesitated to reward her son with the iPad/iPhone, as she was afraid that people would think that she was not a good mother. The OPC coach elicited her to reflect on the reasons behind this fear. The mother proposed to give her son the opportunity to watch the iPad or iPhone for ten minutes whenever they arrived at school on time (rather than along the way to school) as the reward. Unfortunately, the second session was postponed for one week because of the social unrest and, later, the child was ill and required hospitalization, resulting in the mother’s decision to withdraw from the research. Thus, no post-intervention or follow-up measures were completed.
3. Case 3 (a boy with autism and developmental delay, aged 5.50 years)
The mother of Case 3 was coached for the whole eight sessions. In the first session, the mother reported that the most important thing for her son was to have a regular morning routine, in order to get ready for school without any conflict. The OPC coach guided the mother to think about what she would like to happen in her son’s morning routine, and to explore strategies that might work. For example, her son was a visual learner, so the mother, as a casual architect, decided to use her skills to make a series of visual cards that could be shown to her son, letting him know what he needed to do in the morning. She also planned to use verbal prompts and reward, to encourage her son to complete the morning routine. The mother agreed to try the plan one morning in the following week. She would generate the visual cards, one day before executing the plan, and set the alarm in order to get up earlier.
In the second session, however, the mother reported that she only made some of the visual cards. Her son understood the steps of the cards, but was slow and felt unmotivated to complete the morning routine. He required a lot of verbal prompts from the mother, and ended up upset and crying. The OPC coach supported the mother and they worked together to explore alternative strategies (e.g., encouragement-oriented prompting, aiding in completing difficult steps, or using sensory play as the reward). However, the following week was affected by the social unrest, postponing the third session for one week.
During the third session, the mother reported that the plan had not been successfully implemented, as the school had re-opened for two days and their morning was very rushed. She also disclosed that she was tired from the previous night because she had spent time sorting her son’s toys and tidying up the home, and had gone to sleep late. This impacted on her energy level and she did not feel up to try the entire plan. Later she recognized the organization of her timetable as being important, in order for her to have sufficient energy. The mother identified that setting an alarm to go to bed by 12 a.m. could be a workable strategy, and she also planned to use a timer and visual cards to prompt her son to tidy up his toys after free play in the afternoon.
In the fourth session, the mother reported that she was unable to manage her time and went to bed by 12 a.m. Her sleep was also disrupted a few times by her second son at night. The original morning routine plan was missed out completely, and became less important for her. Instead she wanted to manage her time in order to organize the home (i.e., tidying up all her son’s toys and sorting them into lockers). Strategies were identified, through the OPC coach’s guiding questions, and included involving her son and husband in putting the toys away. At the same time, she put forward the idea of involving her husband in part of her son’s morning routine (i.e., taking charge in playing warm-up games or jumping on the trampoline with her son).
In the fifth session, the mother reported that she had had an unexpectedly busy week at work, and did only a little sorting and planning. Through guided reflection, the mother expressed that she had a perfectionist tendency, which made her want to sort out everything at once and, if not, she would feel that she could not do anything next. The OPC coach worked with her to narrow down the goal, and develop a step-by-step plan that began with two categories of toy sorting. Furthermore, the mother reported that her son had enjoyed playing matching games and trampoline with her husband in the morning, and she would continue with the plan. Meanwhile, her son had received a therapeutic listening program, requiring him to wear a special headphone for 30 min in the morning. The child seemed more calm and willing to follow instructions in the morning, according to the mother’s observation.
In the sixth session, the mother had managed to complete almost all of the domestic chores the night before. She planned to continue packing her son’s toys into the lockers, by narrowing the task down and labeling the items. When asked what the most important thing for her at that moment was, the mother returned to the previously unfinished goal regarding her son’s morning routine, and revealed that she wanted it to be extended to his after-school routine at home. The OPC coach guided her to think about what she wanted, and she created five-step morning and after-school routines for her son. The mother would use the visual cards to let her son know the steps and try out the routine plans for two days in the coming week. However, in the seventh session, the mother explained that the routine plans had not been implemented due to the busy holiday preparation. She had only been able to organize the house, but she felt comfortable with her time schedule and routine, and ready to implement the activities in the after-school routine with her son. In addition, while he still wore diapers at home, she had noticed that her son had started telling her when he needed the toilet. So, she created another goal for her child, which involved him going to the toilet every 45 min, without wearing diapers at home or when he expressed the need. Through collaborative performance analysis, she devised a reward system, to be trialed for half a day in the coming week, and an electronic alarm would be used as a reminder for her son to go to toilet regularly.
In the last session, the mother reported that she had modified the types of reward (originally collecting five points to get a chocolate croissant at the end) from small and instant ones (i.e., candy) to big and delayed ones (i.e., going to a theme park). The child was able to express the need to go to the toilet on two occasions. However, the mother did not use the system consistently, owing to the sickness of the child over the previous week. The OPC coach guided the mother to apply the successful reward system to other daily routines. The mother thought about behavior at the dinner table and homework compliance, and planned to extend the reward system to these areas.
In summary, two of the six goals were addressed in the eight sessions (see
Table 2). None of the two goals were related to the child’s community participation. Since the number of sessions had reached the maximum, the OPC intervention was concluded. The mother completed the post-intervention and follow-up measures.
4. Case 4 (a girl with developmental delay, aged 5.25 years)
The mother of Case 4 was coached for one session only. During the initial stage of the session, the mother specified that she wanted her daughter to be more motivated to engage in academic-learning activities, for 30 min at home, during weekday evenings. The OPC coach used collaborative performance analysis to guide the mother to think about a preferred future and, through solution-focused conversation, to identify strategies that could support her daughter’s performance. Some strategies that were identified as being useful sometimes included having enough sleep the night before, incorporating motor activities that did not require sitting, using snacks as the reward after completion, or reducing the time of the activities. When the OPC coach moved it forward to action identification, the mother’s mobile phone had no battery charge, and the session ended abruptly. After the participant’s phone was recharged, she sent a text-message to the OPC coach, enquiring why she had been asked to identify solutions by herself, rather than receiving advice from the coach. As she preferred an expert-directed approach, she decided to withdraw from the study. No post-intervention or follow-up measures were completed.
5. Case 5 (a boy with developmental delay and dyslexia, aged 5.33 years)
The mother of Case 5 was coached for six sessions. In the first session, the mother identified the two most important things for her son. One was to complete the morning routine without bargaining behaviors, and the other was to complete the bed-time routine by 9 p.m. and go to bed by 9:30 p.m. For the morning routine, the mother was encouraged to identify a strategy that could motivate her three children (including the target child) to follow the rules. Strategies included processes around breakfast preparation, for example, asking the children what foods they would like to eat, preparing the necessary materials, and making breakfast in the morning. For the bed-time routine, the mother identified that watching television until bedtime could be a good motivator, provided that the children had showered, eaten, and completed their homework on time. The mother agreed to implement the two plans in the following week.
In the second session, the mother reported that the strategy for the morning routine had worked very well with her children, and they were now able to complete it smoothly. However, for the bed-time routine, watching television as a reward had only been successful on specific days, in other words, when the child did not receive intervention training and was back home at 5 p.m. When the child had to attend intervention after school he arrived home around 7 p.m., and by then was tired and just wanted to have free play. Furthermore, the child’s father usually came back home around that time, and had dinner together with the children. Before/after dinner, the children played with their father, or watched television, which delayed the bed-time routine. Through the mother’s reflection and knowledge elicited by the OPC coach, she put forward two strategies to be trialed in the coming week. One was to prepare different foods for her children (children’s favorite meals) and husband (ordinary meals), to incentivize the children to eat quicker. The other was to involve her husband in the bed-time routine by reading books to the children (instead of watching television) after dinner.
In the third session, the mother seemed frustrated as her son was still going to bed around 10 p.m. on the days when he had the intervention. The strategy of separate meals for her children and husband had been successful, but her husband did not feel comfortable reading books to the children. The mother reflected that it was understandable as her husband was not good at reading books and was also tired after work. The mother decided to create a schedule, and educate the children about the evening routine by using a whiteboard. In addition, the children were allowed to watch television if they completed the evening routine on time. The mother also relaxed the bedtime from 9:30 p.m. to 10 p.m., on those days the child came back late, to allow room for a buffer. In addition, during story time, the mother wanted to encourage her son to read more books and express his ideas, to reinforce his learning from school. She discovered who to approach at the school, in order to find out the school themes in advance, and where she could borrow similar books. She also planned to facilitate a story sharing time among her children during the weekends.
In the fourth session, the mother reported that her children did not get the meaning of the evening routine written on the whiteboard. Therefore, she had decided to put up pictures to assist their understanding of what they needed to follow in the evening routine for the next week’s plan. The mother was able to obtain the school theme from the teacher and incorporated it into the bedtime reading. Meanwhile, the mother reported that she had recently taken her child to the playground near the school, or to the clubhouse after school. Her son was able to invite his classmates or other kids to play together, by sharing snacks with them. Since this was one of the mother’s goals identified in the goal setting session, the OPC coach encouraged her to continue the initiative. For the remaining time, the mother expressed a need for her son to complete Chinese homework with a proper sitting posture at home. The OPC coach guided her to review her son’s current sitting posture and elicited her knowledge about the ideal one. Soon, the mother realized that the height of the chair was relatively lower than the table, so that her son had to lean his body toward the table, and sometimes the hand he used for writing was not placed on the table. The mother showed willingness to address this issue.
In the fifth session, the mother reported that she had managed to get her children to go to bed around 9:30 p.m. by following the previously discussed strategies on the days her son had the intervention. The child started to express his ideas, and interacted with his little sister during the story-time. The mother also went to the library to borrow books with similar themes to the ones being learned at school, to reinforce learning. Additionally, it was unexpected by the OPC coach that the mother asked her husband to share her workload and help with the child’s homework. Since her husband appeared to accept this duty, the mother would continue it. The mother also reported that the chair, after the height adjustment, improved the child’s sitting posture and performance in writing Chinese. She also adjusted the height of the chairs for her other two children. For the remaining time, the mother raised a concern about her son’s poor performance in using scissors to cut lines/shapes accurately for homework. Several strategies were generated to enhance his performance, for example, to widen the lines by using color markers to easily trace lines while cutting, and to place direction signs in each turn to remind her son to turn the paper while cutting. The mother planned to apply these strategies while sharing a fun project with the child, such as making a Chinese New Year card.
In the sixth session, the mother reported that the child was able to accurately cut the straight lines that were highlighted in red using the marker, and to turn the paper using the non-dominant hand while cutting. However, he needed constant reminders to place his elbow on the table and maintain good sitting posture. He also did not enjoy making the card and stopped it after cutting six pieces. After the OPC coach-guided reflection, the mother realized that the paper for making the cards seemed too thick for the child to cut. Thus, she planned to organize a Chinese lantern making activity in the coming weeks, as this was usually a homework task for the Lantern Festival. The mother would prepare different sets of materials for the child and his older sister, divide the task into smaller portions, and complete some portions daily. Highlighting with color markers and reminders for the posture were continued, and the mother also thought that cutting straight (not curve) lines was most suitable for her son’s ability at that moment.
Unfortunately, the remaining OPC sessions were terminated because of the same reason (i.e., the impact of COVID-19) mentioned previously for Case 1. In summary, four of the eight goals were addressed in the six sessions (see
Table 2). One goal that was dealt with was related to the child’s community participation. The mother completed the post-intervention measures immediately and the follow-up measures two months later.
6. Case 6 (a boy with autism and developmental delay, aged 5.25 years)
The father of Case 6 was coached for three sessions. In the first session, he considered his son’s completion of homework within one hour to be the most important goal to achieve. The father reported that the child was constantly asking for assistance or refusing to do the homework, especially when the subject was Chinese. After prompting for the father’s reflection, he reasoned that his son might not know how to write Chinese words, particularly within the grids. Since the child’s Chinese homework was supervised by his wife, the father agreed to invite his wife to join the next OPC session. In addition, the father identified several strategies that he planned to try out for enhancing his son’s compliance with homework completion. These included watching television as the reward, and physical demonstration of how to write simple Chinese words (within 4 strokes).
Both mother and father attended the second session. The father reported that his son had shown some improvement, after he had been instructed on how to break down the Chinese for writing, and was also more willing to complete the homework that contained less complicated Chinese words on his own. However, the mother reported that the child was still unable to write Chinese words with complicated structures, even though she had taught him the stroke sequence twice. Through the OPC coach’s guidance, the mother reflected that she, at times would get very angry if the stroke sequence made by the child was wrong, and would require 5–10 min to calm herself down. In the meantime, the child would be offered a break to watch television before continuing the homework. The parents identified the inconsistency in their parenting styles, especially regarding the use of television as a reward, in other words, at the end (father’s style), or as a break in-between (mother’s style). The break was important for the mother, as it helped her to calm down, however she agreed to use it as little as possible. The OPC coach shared his view about breaking down complicated Chinese words into small parts, given that the child was able to write simple Chinese words. The mother considered it as a possible strategy, and agreed to try it out. Regarding the reward for homework completion, after being prompted for an alternative, the father suggested taking his son out to the playground.
In the third session, the mother was not available. The father reported that the plan for taking the child to the playground as the reward had worked only for school days but not for holidays. He reasoned that there was not much homework over Chinese New Year holidays, and his son wanted to watch television as the reward. He would continue the playground plan after the holiday period. He also did not know whether breaking down Chinese words supported the child’s performance. This plan would be reviewed when his wife attended the session later. For the remaining time, the father prioritized that he wanted his son to play with other children with no fighting, and demonstrate appropriate behaviors when visiting friends or engaging in the community. He noticed that the child behaved differently (i.e., more uncooperative) when he was present, compared to when his wife was present (more obedient). Through guided reflection, the father mentioned that he usually acted as a friend of his son, which could explain the difference in behavior. He felt it was necessary for him to change this, and to show his son that he would not be manipulated easily. The father proposed a punishment system, which involved reducing the time spent watching television if the child had a fight with other children, as well as removing his son from the conflict situation immediately to allow him to calm down. Afterward, he would listen to his son and educate him about appropriate behavior when playing with other children.
Owing to the impact of COVID-19 starting in March 2020, the father agreed to stop the OPC intervention earlier. In summary, two out of the five goals were addressed in the three sessions (see
Table 2). One of the goals that was addressed referred to the child’s community participation. The father completed the post-intervention measures immediately and the follow-up measures two months later.