Waiting and Relating

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From Waiting toRelating: ParentsExperiences in theWaiting Room of anOccupational TherapyClinic

Ellen S. Cohn, ScD, OTR/L, FAOTA, is Clinical AssociateProfessor, Boston University, Sargent College of Health andRehabilitation Sciences, 635 Commonwealth Avenue, Boston,Massachusetts 02215; [email protected].

This article was accepted for publication March 9, 2000.

Ellen S. Cohn

Key Words: sensory integration socialenvironment support system

The American Journal of Occupational Therapy 167

Objective. The purpose of this study was to gain an under-standing of parents perceptions of outcomes of occupationaltherapy intervention using a sensory integration approach.

Method. Interviews with parents regarding their chil-drens participation in occupational therapy were analyzedusing grounded theory.

Results. The parents experiences of sitting in the wait-ing room while their children received occupational therapyemerged as a powerful outcome theme. Through their inter-actions with other parents, this particular group of parentsgave and received naturally occurring support for parentingchildren with sensory integrative dysfunction. Additionally,by virtue of repeated experiences of waiting, parents movedto positions of liminality, shared weekly rituals, engaged indownward social comparison, and reframed their views oftheir children.

Conclusion. Implications are proposed for expandingthe definition of family-centered intervention; attending tothe meaning of the cultural world of practice; and directingfuture research related to how a physical setting, such as awaiting room, might shape naturally occurring support andsocial interaction.

Cohn, E. S. (2001). From waiting to relating: Parents experiencesin the waiting room of an occupational therapy clinic.American Journalof Occupational Therapy, 55, 167174.

Karen is the mother of a 7-year-old girl who receivedoccupational therapy using sensory integrationapproaches at a private practice in a suburban

community. Responding to a question about her experi-ence of taking her daughter to the occupational therapyclinic, Karen said:

Wed sit in the waiting room and wed always be reading. Graduallyover the weeks, we just started talking. I really enjoyed talking with her[another parent], and it was like a little support group. She would share

with me some of the things she was concerned with, and I would sharemy concerns. So, it was nice to have someone, to have a little supportgroup, while we were there without having to go another night of the

week. She had similar concerns.

The analysis of waiting room phenomena came aboutduring a study designed to understand parents perspectivesof outcomes of occupational therapy using sensory integra-tion approaches for their school-aged children and theirfamilies. As I interviewed Karen and other parents tounderstand their perspectives, I started to hear a recurringpattern about the waiting room. Many of the parentsrepeatedly spoke about perceived benefits of sitting in thewaiting room and chatting with other parents. Some par-ents in the study even suggested that I contact other peo-

ple, now their friends, who they had met in theoccupational therapy waiting room. Peggy, a mother of a 6-


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year-old boy, said:

The waiting room was very helpful. It was a very helpful, quasi-spon-taneous support group, and even though my son was probably themildest of the group, it was a support group without having to make ithappen. It was just very nice moms all there for the same reason, talk-ing about various issues: advocacy issues, insurance issues, life-in-gen-eral issues. When you go week after week, you see the same people. It

was really helpful.

During the interviews, parents reflected on their expe-riences and repeatedly spoke of the unanticipated conse-quences of bringing their children to therapy; that is, theparents anticipated that the therapy itself would be themain change agent for their children. They did not antici-pate benefits for themselves as parents, and the benefits ofthe waiting room experience were an unexpected finding inthis research. Merton (1936), a sociologist, explained thatconsequences (expected or unexpected) result from inter-play between an action and the context of the action. Theanalysis here examines the context of the action: the wait-ing room and parents accounts of their transformative

experiences of waiting while their children received occu-pational therapy. Implications for occupational therapypractice and research are discussed.

By striving to understand parents perspectives, I rec-ognize the importance of family-centered care in providingservices to children with special health care needs andacknowledge the influence of families in childrens devel-opment. Family-centered care involves meeting family con-cerns, building on family strengths, respecting familydiversity and cultural backgrounds, sharing information,promoting partnerships and collaboration, and encourag-

ing social support (King, King, Rosenbaum, & Goffin,1999; Lawlor & Mattingly, 1998; Shelton, Jeppson, & Johnson, 1987; Shelton & Stepanek, 1994). Moreover,providing family-centered services requires practitioners tounderstand what the behaviors, events, persons, and insti-tutions mean to those who participate in them (Cohn &Cermak, 1998; Llewellyn, 1994). Therefore, the study wasdesigned to understand what childrens participation inoccupational therapy using sensory integration approachesmeant to parents.

Method

Participants

I interviewed 16 parents (14 families consisting of 12mothers and 2 husband-and-wife couples) of children whoreceived occupational therapy using a sensory integrationframe of reference at a private clinic in the northeasternUnited States. Participants were parents of children whohad documented conditions of some type of sensory inte-grative dysfunction as measured by the Sensory Integrationand Praxis Tests (Ayres, 1989). The children (410 years ofage) had participated in at least 32 1-hr therapy sessions

and had stopped therapy 1 month to 2 years before theinterview. All participating parents were white and in the

moderate to affluent socioeconomic status range. A major-ity of the participants had masters degrees, and except forone participant, all were college educated.

For the children whose parents participated in the inter-views, therapy had typically involved a 1-hr session one timeper week. Therapy consisted of the use of enhanced, con-trolled sensory stimulation in the context of a meaningful,self-directed activity in order to elicit an adaptive response

(Fisher & Bundy, 1991, p. 23). Selected activities incorpo-rated the use of suspended overhead equipment that provid-ed tactile, vestibular, and proprioceptive input to which thechild made adaptive responses. Therapists often invited par-ents into the therapy sessions to observe their children. Aminimum of 32 1-hr therapy sessions (approximately 8months) was the criterion selected to anticipate some type ofchange. This criterion is based on a review of nine sensoryintegration efficacy studies with children with learning dis-abilities (Ayres, 1972, 1978; Carte, Morrison, Sublett,Uemura, & Setrakian, 1984; Densem, Nuthall, Bushnell, &

Horn, 1989; Humphries, Wright, McDougall, & Vertes,1990; Humphries, Wright, Snider, & McDougall, 1992;Law, Polatajko, Schaffer, Miller, & Macnab, 1991; White,1979; Wilson & Kaplan, 1994). Twenty-four hours of inter-vention was the modal number of therapy sessions in thereviewed studies. Therefore, it is proposed that the childrenin the study reported here received enough therapy to antic-ipate some type of change.

A sample size of 16 was deemed adequate on the basisof two criteria. First, exploratory studies are recommendedto use at least eight participants to obtain an adequate

amount and range of information (McCracken, 1988).Second, the sample size is consistent with or even slightlylarger than that of other qualitative studies recently con-ducted in the occupational therapy field (Anderson, 1993;Case-Smith, 1997; Case-Smith & Nastro, 1993; Hinojosa,1990; Hinojosa & Anderson, 1991; Rudman, Cook, &Polatajko, 1997). Recruitment was stopped after the 16thparticipant because I reached a point at which findingsfrom newly collected and analyzed data became redundant(Strauss & Corbin, 1998).

Parents of children given a primary diagnosis ofautism, pervasive developmental disorder, or Fragile X syn-drome were not included in the study. Parents of children with these particular conditions may have different con-cerns about the socialemotional and behavioral manifes-tations of their childrens conditions than parents ofchildren without these conditions. The sample criteria arebased on the assumption that they represent a relativelyhomogeneous subgroup of children who receive occupa-tional therapy in private practice settings using a sensoryintegration framework.

Procedure

On the basis of chart review, 42 children met the inclusion

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criteria. Names of parents of 22 children to be invited aspotential participants were randomly selected from thetotal group of those eligible. A letter explaining the studypurpose and procedure and offering parents the opportu-nity to remove their names from the potential participantlist was sent to the selected families. Three families request-ed to have their names removed from the potential partic-ipant list, and eight families reported being too busy to

participate in an interview. Potential participants (those who did not request to be removed from the list) werecalled to clarify the purpose and procedure of the study andto determine interest in participating in the study. All par-ticipants signed Internal Review Board-approved informedconsent forms before the interviews began.

I conducted 1-hr to 2-hr semistructured interviews ineach familys home. Questions were adapted to respond tothe discussion in the context of each interview. I asked par-ticipants to describe a typical day with their child, whatabout their child led them to seek occupational therapy,

and what they had hoped to gain from therapy. I asked whether they saw changes in their child and, if so, todescribe an incident that illustrated the change; whetherchanges they had hoped for had not occurred; and howthey came to a decision to stop therapy. After each inter-view, I wrote reflective memos to record my immediatereactions to the interview. Each interview was audiotaped,transcribed, and checked by thorough review and compar-ison between the transcript and the original audiotape. Inaddition, I reviewed each childs clinical chart to documentreasons for referral and therapy goals. Throughout theresearch process, I wrote periodic analytical memos (Miles& Huberman, 1994) to record my evolving thoughts relat-ed to the research question and process. After the waitingroom phenomenon became apparent, I spent time observ-ing the waiting room.

Data Analysis

Hasselkus (1997) reminded us that as researchers, we arepositioned in relation to that which we are researching(p. 81) and our particular position becomes the lensthrough which we make interpretations. Examining this

lens is a starting point for all research and enables us to useour reflections productively for insight and analysis. In thespirit of reflexivity, I acknowledge the influences of my ownbackground as both a parent of school-aged children andan occupational therapist who has provided occupationaltherapy using a sensory integration approach. As a parent,I know firsthand the experiences of striving to nurture achilds growth and sense of competence. I share Llewellyns(1994) view that parenting is an intensely personal yetcommonly shared experience. Sharing my parenting expe-riences, both joys and dilemmas, with other parents pro-vides a powerful source of support and personal validationfor the challenges inherent in the occupation of parenting.

As an occupational therapist, I try to provide therapy thatultimately makes a meaningful difference for children inthe contexts in which they live, learn, and play. I carry anunderlying assumption that occupational therapy is effec-tive and can contribute to changes in children and theentire family system. However, I also believe and have doc-umented elsewhere (Cohn & Cermak, 1998) that we havenot empirically examined which outcomes of occupational

therapy are important to parents who bring their childrenfor intervention.

Using grounded theory procedures recommended byStrauss and Corbin (1998), I reviewed the transcripts toname and categorize the participants perceptions of valuedoutcomes. The category of the waiting room immediatelyemerged after the first interview. As other parents talkedabout their waiting room experiences, all instances of wait-ing room talk were compared and contrasted to detect sim-ilarities and differences across all the transcripts. The QSRNUD*IST 4.0 (1997) qualitative data analysis software

was used to manage and explore the data. To strengthencredibility and ensure that participants perspectives wereaccurately represented, I prepared written summaries ofeach interview and sent the summaries to participants forreview. I then contacted each participant by phone to dis-cuss the interview summaries and, on the basis of theirfeedback, made modifications to the summaries as needed.Finally, I analyzed the summaries along with the interviewdata. To honor confidentiality, pseudonyms are usedthroughout this article.

The Waiting Room ExperienceFor this particular group of parents, the waiting room wasan important component of their experiences of bringingtheir children to occupational therapy. Websters ThirdInternational Dictionary (1976) defines waitingas stayingin place in expectation of, deferring, holding back in expec-tation, delaying hope, or delaying hope of a favorablechange. Waiting is at the crossroads of the present and thefuture and certainty and uncertainty (Gasparini, 1995).These definitions ofwaitingcapture the essence of what theparticipants were doing while their children received occu-

pational therapy. The participants brought their children tooccupational therapy because they hoped for some change,and they held those hopes in abeyance while they sat withother parents. They waited in suspense, week after week,hoping for some change to unfold. The end result wasunknown, the future uncertain. Deb, the mother of a first-grade boy, described how she would sit in the waiting roomeach week and talk with other parents about her hopes: Isat in the waiting room hoping that there would be hopefor him. That he could learn to live with his condi-tion....We wanted him to be normal. We wanted him notto hurt himself or others. Another mother, Lynn, said: Ifelt like he [her son] was getting older, and I wanted him to



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be out in the world doing things that other kids do. Therewere a lot of us sitting there saying that.

Liminality

The participants children all have invisible conditions, thatis, their sensory integrative dysfunction is not readily visi-ble to the untrained eye. Yet, each participants presence inthe waiting room made his or her childs condition andneed for intervention obvious to the other parents. In addi-tion to being an assertion of hope, visits to the occupation-al therapy clinic each week activated feelings of liminalitydescribed by Murphy (1987) and Murphy, Scheer,Murphy, and Mack (1988) as a state of waiting. A distin-guished anthropologist who developed quadriplegia fromthe effects of a spinal tumor, Murphy views disability as aform of liminality. In Murphys view, liminality is closelyrelated to sociologist Victor Turners (1969) idea of rites ofpassage in which the purpose of the rituals of passage is toinvolve the community in the transformation of an indi-

vidual from one position in society to another. This trans-formation typically occurs in three phases: isolation orseparation, ritual emergence or transition, and reincorpora-tion into society. During the transition from isolation toemergence, the person is thought to be in a liminal state, asocial limbo in which he or she is left waiting. Turner(1964/1972) titled one of his essays Betwixt and Between,an apt description of the suspended position of a personseeking a change or transformation. By virtue of being inthe waiting room, parents move from a position of parent-ing a child with an invisible condition to the threshold of

waiting for some type of transformation.

A Weekly Ritual

Bell (1992) claimed that ritual activities are set aside fromthe flow of other daily activities and that the distinctionbetween rituals and day-to-day routines is based, in part,on the beliefs of the social group. I argue here, on the basisof what the participants told me, that the waiting experi-ence in and of itself provided parents with a weekly ritualin which they shared their experiences. This weekly waitingroom ritual helps parents to transform their experiences of

parenting their children with sensory integrative dysfunc-tion. The parents shifted from a position of isolation (par-enting children with invisible, yet challenging conditions)to a position of shared experience in which others under-stood their concerns. Two major characteristics of ritual arepredictability and sharing of experience. In fact, Durkheim(1915/1965) proposed that rituals provide a means for agroup to affirm itself through shared experience. Unlikewaiting rooms where there are different persons waiting ateach visit, the waiting room experience described here hadpredictability. The participants repeatedly saw the same

parents each week, which provided the opportunity to

develop relationships and share common concerns andfeelings.

Murphy (1987) observed that persons in a liminal stateoften put their differences aside and view others in thesame position in an egalitarian manner. This nonhierarchi-cal social position offers the potential for linking with otherparents and sharing revelations frankly. For the participantsin this study, the waiting room was found to have become

a contained setting that facilitated interaction, and theirexperiences were transformed into something other thanjust waiting. In the context of the waiting room, partici-pants found affiliation and a refuge from the world of oth-ers who could not understand their parenting experience.One mother, Nancy, talked about a parent she met in thewaiting room:

She had similar concerns. It was very nice to have someone to talk to.I think any parent dealing with SI [sensory integration] therapy mustexperience doubts [about their parenting]. The mothers that I talked toin the waiting room certainly did.

Naturally Occurring Support

Karen, the mother whose interview opens this article, toldme that over several weeks, parents gradually shifted fromreading to talking to each other. Typical waiting roombehavior usually involves reading or staring straight ahead.The chairs may be arranged in rows that minimize eye con-tact and the potential for interaction (Holmes-Garrett,1990; Rodgers, 1990). The waiting room I observed wasmore like a family room than a waiting area. Comfortablecouches facing a set of movable chairs sat in a sunny, wel-

coming room, with toys placed in an area behind thecouches for the children. Perhaps the furniture and itsarrangement coupled with the repetition of this particular waiting room experience invited parents to let go of theusual waiting room rituals of reading and avoiding interac-tions with others who are waiting. The social rules typicalof most waiting rooms were rewritten. Rather than being aplace where busy parents avoided each other, the waitingroom was transformed into a support network. The parentsshared a desire to understand their children; obtain infor-mation about their childrens conditions and available

resources; and receive support, hope, and affiliation. Forexample, one mother, Marie, said:

I heard about a tutor through someone in the waiting room....Thewaiting room was really fun....Because you are in a vacuum, you areworried about things. I had a doctor who I had a really bad experiencewith....I found out another mother was going to him. He was the pits.So you werent alone, and everybody else has concerns. Everybody therehad questions.

Marie and the other participants described importantinterpersonal, socially interactive, and supportive featuresof the waiting room experience. The perceived benefitsderived from these spontaneous social supports are consis-

tent with the benefits of social support described by other



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researchers. Caplan (1974) examined naturally occurringsocial supports and concluded that a mutual and reciprocalquality exists in the interactions with people who help eachother. The mutuality is emphasized by the fact that the sup-port is voluntary and spontaneous. Both the giver andreceiver of support are equally, though differently, benefit-ed by the contact. Often, people prefer to receive help fromothers who have personally experienced the same or similar

predicaments because the help appears more authentic.In a comprehensive examination of parent support

groups, Hauser-Cram, Warfield, and Krauss (1997) identi-fied two functions of such groups. One function is to act asa form of intervention for parents who have unusual par-enting challenges; another is to help parents be advocatesfor their children. Both functions assist parents in their par-enting occupation. The link between social support andwell-being is well documented for parents of children withdisabilities. Support, both informal and formal, has beenfound to enhance well-being and family functioning by

acting as a buffer to stress (Dunst & Trivette, 1990; King etal., 1999; Wallander et al., 1989). In related research,Quittner, Glueckauf, and Jackson (1990) suggested thatsocial support mediates the relationship between parentingstress and outcomes. In both the buffer model of socialsupport and the mediator model, social support is viewedas having a positive impact on family functioning. Further-more, parent-to-parent programs (Llewellyn, Griffin, &Sacco, 1992; Santelli, Turnbull, Lerner, & Marquis, 1993)provide parents with the valuable opportunity to give aswell as receive assistance, which has been found to enhanceself-efficacy and self-esteem (Kagan & Shelley, 1987; Zigler& Weiss, 1985). On the basis of their research, many ofthese authors recommended that centers of care providepractical assistance for information and networking oppor-tunities through such mechanisms as parent newsletters orparent support groups.

Downward Social Comparison

In listening to the words of the participants in this study,another waiting room phenomenon became apparent. Inaddition to the outward interactions resulting in social sup-

port, a quiet, internalized experience simultaneouslyoccurred that resulted from comparing one child withanother. Renowned social psychologist Leon Festinger(1954) identified the process of social comparison in whichpeople use others both for determining how well they havedone and for learning what they should do. In Festingersview, peoples attitudes and beliefs are based on particularreference points. Thus, one way in which we attempt tounderstand human experience or form beliefs is throughsocial comparison. Other people serve as a reference to helpus determine how we are supposed to behave and howgood we are at a particular type of behavior. By design, theparticipants children all had more subtle forms of sensory

integrative dysfunction than many of the other childrenreceiving occupational therapy at this particular clinic. Thesocial comparison process offered the participants a uniqueperspective that influenced their understanding of theirchildren. Deb described her observation this way:

It was a really good thing for me to see the children that were treatedat the clinic. It made me appreciate, help me remember how lucky we

were not to have a really stressful [son]. Some of these children, myheart goes out to their parents....It was very therapeutic for me to seethe other kids. Not all of them, but most of them at our time were inmuch worse shape than my son.

Many of the participants shared similar observations.Being better off than others in a similar situation, asdescribed previously, has been identified by social psychol-ogists as a downward social comparison. For example, stud-ies have shown that stress from health problems induces adesire to compare ones health with that of others(Mollerman, Pruyn, & van Knippenberg, 1986; Taylor,Buunk, & Aspinwall, 1990) and that downward socialcomparisons contribute to well-being and positive feelings

(Hakmiller, 1966; VanderZee & Buunk, 1995; Wills,1981). Numerous participants echoed these findings asthey spoke about observing parents with children who hadmore significant problems than theirs. This observationand downward social comparison process helped the par-ticipants reframe their perceptions of their children andhelped them accept their situation. For example, the moth-er of a 5-year-old boy said:

I always felt like he was borderline whether he needed to be therebecause I would talk to other people there or see other children comein and they clearly needed some kind of help. They had bigger issues.So I thought, Well, my situation isnt so bad. Theres nothing really

wrong with my son. He just needs help getting himself more cohesive.

Another mother, Johanna, framed her waiting room expe-rience in terms of sympathy. She explained:

I think I got a lot of sympathy for people whose kids who were in muchworse condition than my son. Just spending time in the waiting room was an amazing, eye-opening, and heart-wrenching experience....Ibegan to see my situation as a piece of cake compared to other people.

Reframing

The social comparisons that occurred in the waiting room

led many of the parents to reframe their assessment of theirchildren or situation. While reflecting on changes that mayhave occurred from bringing her son to occupational ther-apy, Johanna described how she reframed her expectationsfor him: You know, I think I am less hard on my son. Igave up on the homework [being perfect]. Who cares? Itdoesnt matter as long as an effort was made. It doesnt haveto be perfect. Niehues, Bundy, Mattingly, and Lawlor(1991) and Case-Smith (1997) identified reframing as aprocess of coming to see a person or situation in a new waybecause one has changed the framework, or lens, through which he or she views the situation. These researchersclaimed that reframing is a valuable service provided by



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occupational therapists working in schools. Case-Smithnoted that by educating teachers about the potential rela-tionship between sensory processing and behavior, occupa-tional therapists enabled teachers to view student behaviorsin a more positive way and gave them a basis for develop-ing effective teaching strategies. In the present study, ther-apists efforts to educate parents about sensory processingmay have helped the participants reframe their expectations

of their children. Perhaps unknown to the therapists, thecomparisons participants made in the waiting room alsohad a powerful influence on their construction of their ownchildrens behavior. Comparing their childrens behavior toothers less fortunate enabled the participants to see theirchildrens strengths. They reported a downward social com-parison and a positive reframing of their childrens behav-ior. What about the parents whose children have moresignificant conditions? How do these parents perceive theirwaiting room experience?

SummaryThe participants in this study took their children to thera-py with the expectation that somehow occupational thera-py would help their childrens future. It was surprising tofind that the experience of simply sitting in the waitingroom may have contributed to the process of expectedchange. Crossing the threshold into the waiting roommoved these parents from the isolation of parenting chil-dren with invisible conditions to the liminal state of wait-ing or readiness for change. Through their weeklyinteractions with one another, sharing stories, experiences,

parenting challenges, and resources, these parents gave andreceived naturally occurring support for parenting childrenwith sensory integrative dysfunction. Although family-cen-tered care encourages social support, this study shows usthat support not only may come from professionals, butalso can occur naturally in a waiting room environment. Inaddition to the natural support parents provided oneanother while in the waiting room, the parents were reas-sured by comparing their children with children who weremore severely involved. This comparison seemed to play animportant role in participants reframing their expectations

for their children and for themselves as parents.Implications for Practice and Research

At the theoretical level, this research echoes the importanceof expanding the definition of occupational therapybeyond direct intervention with children to include parentsas well. The findings raise our awareness that ritual interac-tions are complex and may have deeper meaning and con-sequences than we fully appreciate. Lawlor and Mattingly(1998) suggested that a redefinition of practice includesrecognition of how encounters with family members areinfluenced by the cultural world of practice. As therapists

and researchers, we need to pay attention to the entire con-

text surrounding the intervention process, not just theexplicit therapeutic encounter.

Findings from this research raise questions about whatconstitutes family-centered care. An outpatient clinic, byits very nature and no matter how family friendly the staffmay be, is not inherently family-centered. Thus, we mightask, How can we provide family-centered care in an out-patient setting? Some practitioners might argue that fam-

ily-centered care involves parents as active participants inthe therapy, collaborating with the therapist and child inthe therapy rooms rather than sitting in the waiting room.Although collaboration between professionals and parentsis important, we have seen in this sample that the socialsupport available in the waiting room might be anotherpowerful aspect of family-centered care. If the experience ofthese parents has implications for others, then attending tothe broader practice environment can be seen as part of afamily-centered approach. We need to understand howparents are making sense of the entire therapy experience,

not just interventions focused on children in isolation oftheir caregivers.

In this study, the waiting room experience emerged asa meaningful and symbolic feature of the entire therapy.Although occupational therapists have viewed occupationand adaptation as an interactive process between personsand environments (Barris, 1986; Barris, Kielhofner, Levine,& Neville, 1985; Frank, 1996; Spencer, 1998), we have notexplored how a physical setting, such as a waiting room,might shape naturally occurring activity and social interac-tion with the symbolic meanings attached to places.

Representing the field of humanistic geography, Rowles(1991) invited occupational therapists to consider the exis-tential meaning of environments to their clients.

Hoffman and Futterman (1971) noted that most pro-fessionals aim to eliminate waiting room time, especiallyfor busy parents. The insights from this research suggestthat occupational therapists should aim to create in theirwaiting rooms a milieu to foster sharing so that parents cantalk to one another. Practitioners in other fields have rec-ommended that waiting rooms provide comfortable seat-ing conducive to interaction; private space that is notshared with other professional practices; parenting infor-mation and education resources; a lending library; and bev-erages, such as water, tea, or coffee (Harman, 1997;Koepke, 1993). Providing an inviting environment inwhich parents can share with each other may be an impor-tant component of family-centered care.

Koroloff and Friesen (1991) noted that members ofself-help groups are likely to be white, middle income, andwell educated, as were the participants in the present study,and Hauser-Cram, Pierson, Walker, and Tivnan (1991)reported that parent support groups were not universallyappealing to all families. These findings remind us that the

participants in this study represent a very small homoge-



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neous group of parents of children who are likely to seekoccupational therapy services. Although the naturallyoccurring support groups were perceived as a positivebenefit of their childrens therapy, we must be careful toavoid assuming such a support group will be appealing toall our consumers or appropriate to all settings. Is it possi-ble that the similarity of the families receiving occupation-al therapy at this particular clinic made sharing in the

waiting room easier? Further investigation with a morediverse group of parents may help determine whether thesefindings have implications for other parents. The labelsupport group was not formally applied to groups of par-ents in the waiting room. Rather, the group supportoccurred naturally, not institutionally. Does the naturallyoccurring phenomena make a difference? Might it be use-ful to schedule like children at the same time to enhancethe possibility of parents developing naturally occurringsupport networks, or is the downward social comparisonresulting from observing a variety of children a crucial

change agent? Moreover, further investigation is necessaryto test whether the perception of support exchanged in thewaiting room and reframing are at all related to outcomesof perceived well-being and sustainability of family life.

Another possible implication of the research reportedhere is that the process of change resulting from occupa-tional therapy using a sensory integration approach occurs,to some degree, not only with the children, but also with theparents. By reframing their childrens behavior and receivingsupport, parents reconstruct their image of their childrenand themselves in their parenting occupation and change

their beliefs about their children. Some researchers have sug-gested that parental beliefs may directly affect children(Goodnow, 1988, Murphey, 1992). Research efforts need tofurther explicate whether parental beliefs are indeed con-nected to behaviors and child and family outcomes. If aconnection can be established, then optimal mechanismsfor facilitating reframing should be explored.

Finally, this research illustrates the importance of fam-ily-centered care. As we strive to provide meaningful inter-vention with children and their families, we must attend tothe broader context of the therapy experience and carefully

listen to how families are interpreting their experienceswith intervention.

AcknowledgmentsI gratefully acknowledge the support of the parents who participated inthis study. Much appreciated for their assistance are Teresa May-Benson,MS, OTR/L, and all the therapists at OTAWatertown, P.C., Watertown,Massachusetts. A special note of gratitude is extended to my dissertationadvisors, Linda Tickle-Degnen, PhD, OTR/L,Wendy Coster, PhD, OTR/L,FAOTA, Cathy Riessman, PhD, and Jane Koomar, PhD, OTR/L, FAOTA. Ithank Betty Crepeau, PhD, OTR, FAOTA, for memorable and stimulatingconversations about rituals.

This research was supported in part by a grant to Boston University,Sargent College of Health and Rehabilitation Sciences, from the

Department of Health and Human Services, Health Resources andServices Administration, Maternal and Child Health Bureau (MCJ-000-

901). Additional funding was obtained from the American OccupationalTherapy Foundation and the Anne Henderson Doctoral Scholarship.This article was written in partial fulfillment of the dissertation require-ments for the authors degree of Doctor of Science, Sargent College,Boston University.

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Waiting and Relating