Contributors
Leslie Altimier, DNP, RNC, NE-BC Fellow, Nursing Northeastern University Boston, Massachutsetts
Beth Ball, MS (Allied Medicine), BS (Occupational Therapy) Member, Occupational Therapy Section Ohio Occupational Therapy, Physical Therapy and Athletic Trainers Board Columbus, Ohio; Member, Occupational Therapy Advisory Board The Ohio State University Columbus, Ohio
Susan Bazyk, PhD, OTR/L, FAOTA Professor, Occupational Therapy School of Health Sciences Cleveland State University Cleveland, Ohio
Matthew E. Brock, PhD Department of Education Studies and Crane Center The Ohio State University Columbus, Ohio
Susan Cahill, PhD, OTR/L Assistant Professor Occupational Therapy Program Midwestern University Downers Grove, Illinois
Erik Carter, PhD Associate Professor Department of Special Education Vanderbilt University Nashville, Tennessee
Jane Case-Smith, EdD, OTR/L, FAOTA (deceased) Professor and Chair Division of Occupational Therapy School of Health and Rehabilitation Sciences The Ohio State University Columbus, Ohio
Jana Cason, DHS, OTR/L, FAOTA Associate Professor Auerbach School of Occupational Therapy Spalding University Louisville, Kentucky
Elizabeth Chapelle Occupational Therapy
Seattle Children’s Hospital Seattle, Washington
Dennis Cleary, BA, BS, MS, OTD, OTR/L Assistant Professor Division of Occupational Therapy The Ohio State University Columbus, Ohio
Patty C. Coker-Bolt, PhD, OTR/L, FAOTA Assistant Professor Department of Health Professions Medical University of South Carolina Charleston, South Carolina
Sharon Cosper, MHS, OTR/L Assistant Professor Department of Occupational Therapy College of Allied Health Sciences Georgia Regents University Augusta, Georgia
Laura Crooks, OTR, MHA Director, Rehabilitation Services Seattle Children’s Hospital Seattle, Washington
Melissa Demir, MSW, LICSW Department of Occupational Therapy Boston University Boston, Massachutsetts
Jenny Dorich, MBA, OTR/L, CHT Occupational Therapist II Program Lead, Hand Therapy Division of Occupational Therapy, Physical Therapy and Therapeutic Recreation Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio
Brian J. Dudgeon, PhD, OTR, FAOTA Professor and Chair, Department of Occupational Therapy School of Health Professions University of Alabama at Birmingham Birmingham, Alabama
M. Louise Dunn, ScD, OTR/L Associate Professor School of Occupational Therapy Brenau University Gainesville, Georgia
Charlotte E. Exner, PhD, OT/L, FAOTA Executive Director Hussman Center for Adults with Autism Towson University Towson, Maryland
Kaity Gain, PhD, MSc, OT Health and Rehabilitation Science Western University London, Ontario Canada
Rebecca E. Argabrite Grove, MS, OTR/L
Governance, Leadership Development & International Liaison Professional Affairs Division
American Occupational Therapy Association Bethesda, Maryland
Karen Harpster, PhD, OTR/L Director of Occupational Therapy Research
Occupational Therapy, Physical Therapy and Therapeutic Recreation Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio
Claudia List Hilton, OTR, Phd, MBA, SROT, FAOTA
Assistant Professor Occupational Therapy & Rehabilitation Sciences School of Health Professions University of Texas Medical Branch Galveston, Texas
Brooke Howard, MS, OTR/L Transition Coordinator Ivy Street School Brookline, Massachutsetts
Jan Hunter, MA, OTR Assistant Professor School of Health Professions University of Texas Medical Branch Galveston, Texas; Neonatal Clinical Specialist Clear Lake Regional Medical Center Webster, Texas
Lynn Jaffe, ScD, OTR/L, FAOTA Professor Emerita Department of Occupational Therapy College of Allied Health Sciences Georgia Regents University Augusta, Georgia
Susan H. Knox, PhD, OTR, FAOTA Director Emeritus Therapy in Action Tarzana, California
Kimberly Korth, MEd, OTR/L Occupational Therapist Feeding and Swallowing Coordinator Children’s Hospital Colorado Denver, Colorado
Jessica Kramer, PhD, OTR/L Assistant Professor
Department of Occupational Therapy & PhD Program in Rehabilitation Sciences Boston University Boston, Massachutsetts
Anjanette Lee, MS, CCC/SLP
Speech-Language Pathologist Infant Development Specialist Neonatal Intensive Care Unit Memorial Hermann Hospital Southwest Houston, Texas
Kendra Liljenquist, MS ScD Program in Rehabilitation Sciences Boston University Boston, Massachutsetts
Kathryn M. Loukas, OTD, MS, OTR/L, FAOTA Clinical Professor Occupational Therapy Department Westbrook College of Health Professions University of New England Portland, Maine
Amber Lowe, MOT, OTR/L Occupational Therapist Division of Occupational Therapy, Physical Therapy and Therapeutic Recreation
Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio
Zoe Mailloux, OTD, OTR/L, FAOTA
Adjunct Associate Professor
Department of Occupational Therapy
Jefferson School of Health Professions
Thomas Jefferson University Philadelphia, Pennsylvania
Angela Mandich, PhD, MSc, OT School of Occupational Therapy Western University London, Ontario Canada
Heather Miller-Kuhaneck, PhD, OTR/L, FAOTA
Assistant Professor Occupational Therapy Sacred Heart University Fairfield, Connecticut
Christine Teeters Myers, PhD, OTR/L
Associate Professor and Coordinator, OTD Program Department of Occupational Science and Occupational Therapy Eastern Kentucky University Richmond, Kentucky
Erin Naber, PT, DPT
Senior Physical Therapist Fairmount Rehabilitation Programs Kennedy Krieger Institute Baltimore, Maryland
Patricia S. Nagaishi, PhD, OTR/L
Occupational Therapy Specialist Preschool Assessment Team Pasadena Unified School District
Special Education-Birth to 5 and Clinic Services
President, Occupational Therapy Association of California Pasadena, California
Jane Clifford O’Brien, PhD, MS EdL, OTR/L, FAOTA
Associate Professor
Occupational Therapy Program Director
Occupational Therapy Department
Westbrook College of Health Professions University of New England Portland, Maine
L. Diane Parham, PhD, OTR/L, FAOTA Professor Occupational Therapy Graduate Program School of Medicine University of New Mexico Albuquerque, New Mexico
Andrew Persch, PhD, OTR/L Assistant Professor Division of Occupational Therapy The Ohio State University Columbus, Ohio
Teressa Garcia Reidy, MS, OTR/L Senior Occupational Therapist Fairmount Rehabilitation Programs Kennedy Krieger Institute Baltimore, Maryland
Lauren Rendell, OTR/L Occupational Therapist Spalding Rehabilitation Hospital Aurora, Colorado
Pamela K. Richardson, PhD, OTR/L, FAOTA Acting Associate Dean College of Applied Sciences and Arts San Jose State University San Jose, California
Zachary Rosetti, PhD Assistant Professor of Special Education Boston University Boston, Massachutsetts
Colleen M. Schneck, ScD, OTR/L, FAOTA Professor and Chair Department of Occupational Therapy Eastern Kentucky University Richmond, Kentucky
Judith W. Schoonover, MEd, OTR/L, ATP, FAOTA Occupational Therapist/Assistive Technology Professional Loudoun County Public Schools Ashburn, Virginia
Patti Sharp, OTD, MS, OTR/L Occupational Therapist II Department of Occupational, Physical Therapy and Therapeutic Recreation Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio
Jayne Shepherd, MS, OTR/L, FAOTA Assistant Chair, Associate Professor Director of Fieldwork Department of Occupational Therapy Virginia Commonwealth University Richmond, Virginia
Karen Spencer, PhD, OTR (retired) Associate Professor Department of Occupational Therapy Colorado State University Fort Collins, Colorado
Kari J. Tanta, PhD, OTR/L, FAOTA
Program Coordinator Children’s Therapy Department UW Medicine—Valley Medical Center Renton, Washington; Clinical Assistant Professor Division of Occupational Therapy University of Washington Seattle, Washington; Adjunct Faculty Department of Occupational Therapy University of Puget Sound Tacoma, Washington
Carrie Thelen, MSOT, OTR/L Occupational Therapist II Division of Occupational Therapy, Physical Therapy and Therapeutic Recreation Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio
Kerryellen Vroman, PhD, OTR/L Associate Professor and Department Chair Occupational Therapy College of Health and Human Services University of New Hampshire Durham, New Hampshire
Beth Warnken, MOT, OTR/L, ATP Occupational Therapist II Division of Occupational Therapy, Physical Therapy and Therapeutic Recreation Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio
Renee Watling, PhD, OTR/L, FAOTA
Clinical Assistant Professor Division of Occupational Therapy Department of Rehabilitation Medicine University of Washington Seattle, Washington; Autism Services Lead Children’s Therapy Center Dynamic Partners Kent, Washington
Jessie Wilson, PhD, OT Reg. (Ont.) Discipline of Occupational Therapy School of Public Health, Tropical Medicine & Rehabilitation Services
James Cook University, Douglas Campus Townsville, Queensland Australia
Christine Wright-Ott, OTR/L, MPA Occupational Therapy Consultant The Bridge School Hillsborough, California
Acknowledgments
We would like to thank all the children who are featured in the video clips and case studies:
Adam
Ana
Annabelle
Camerias
Christian
Christina
Eily
Ema
Emily
Emily Faith
Isabel
Jessica Jillian
Katelyn
Luke
Matt
Micah
Nathan
Nathaniel
Nicholas
Paige
A special thank you to the parents who so openly shared their stories with us:
Charlie and Emily Adams
Robert and Carrie Beyer
Freda Michelle Bowen
Nancy Bowen
Kelly Brandewe
Ernesty Burton
Ruby Burton
Lori Chirakus
Joy Cline
Sondra Diop
Lisa M. Grant
Ivonne Hernandez
Shawn Holden
Luann Hoover
Sandra Jordan
Joanna L. McCoy
Maureen P. McGlove
Jill McQuaid
Stephanie L. Mills
David J. Petras
Theresa A. Philbrick
We are very appreciative of the siblings and buddies who agreed to help us out:
Aidan
Lori Megan
Robert Todd and Keith
Tommy, Owen, and Colin
We thank all the therapists and physicians who allowed us to videotape their sessions and provided us with such wonderful examples:
Chrissy Alex
Sandy Antoszewski
Mary Elizabeth F. Bracy
Amanda Cousiko
Emily de los Reyes
Katie Finnegan
Karen Harpster
Terri Heaphy
Katherine Inamura
A special thanks to Matt Meindl, Melissa Hussey, David Stwarka Jennifer Cohn, Stephanie Cohn, and all the authors who submitted videotapes. Thank you to Emily Krams, Alicen Johnson, Britanny Peters, Katherine Paulaski, Kate Loukas, Scott McNeil, Jan Froehlich, MaryBeth Patnaude, Molly O’Brien, Keely Heidtman, Greg Lapointe, Caitlin Cassis, Judith Cohn, Jazmin Photography, and Michelle Lapelle. A special thanks to Mariana D’Amico, Peter Goldberg, and Carrie Beyer for all their expertise with videotaping. Jolynn Gower, Penny Rudolph, Tracey Schriefer, and Katie Gutierrez were instrumental in developing and completing this text and were
Lisa A. King
Dara Krynicki
Marianne Mayhan
Taylor Moody
Peggy
Samuel
Sydney Teagan
Tiandra
William
Zane
Ann Ramsey
Teresa Reynolds-Armstrong
Tuesday A. Ryanhart
Julana Schutt
P. Allen Shroyer
Douglas Warburton
Julie Potts
Ann Ramsey
Suellen Sharp
Carrie Taylor
a pleasure with whom to work. Jane O’Brien would like to thank her family—Mike, Scott, Alison, and Molly—for their continual support. She would also like to thank her colleagues and students at the University of New England, all the authors, and Jane Case-Smith.
Jane Case-Smith thanks her family—Greg, David, and Stephen—for their support and patience. She also thanks her colleagues in the Division of Occupational Therapy, The Ohio State University, for their support. We both thank all the authors for their willingness to share their expertise and their labor and time in producing excellent chapters.
SECTION I Foundational Knowledge for Occupational Therapy for Children
1 An Overview of Occupational Therapy for Children, 1
Jane Case-Smith
Essential Concepts in Occupational Therapy for Children and Adolescents, 1
Individualized Therapy Services, 1
Inclusive and Integrated Services, 4
Cultural Competence That Embraces Diversity, 6
Evidence-Based Practice and Scientific Reasoning, 8
Comprehensive Evaluation, 9
Ecologic Assessment, 10
Analyzing Performance, 12
Occupational Therapy Intervention Process, 12
Interventions to Enhance Performance, 13
Activity Adaptation and Environmental Modifications, 18
Interventions Using Assistive Technology, 18
Environmental Modification, 20
Consultation, Coaching, and Education Roles, 20
Consultation and Coaching, 21
Education Roles, 21
2 Foundations and Practice Models for Occupational Therapy with Children, 27
Jane Case-Smith
Overarching Conceptual Models, 28
Occupation and Participation, 28
Ecologic Theories, 30
Occupational Therapy Practice Framework and World Health Organization International Classification of Functioning, Disability, and Health, 32
Child-Centered and Family-Centered Service, 33
Strength-Based Approaches, 34
Conceptual Practice Models Specific to Performance Areas, 36
Cognitive Performance, 36
Social Participation, 40
Sensorimotor Performance, 44
Biomechanical Approaches, 51
Neurodevelopmental Therapy, 51
Task and Environment Adaptation, 54
Coaching and Consultation Models, 56
3 Development of Childhood Occupations, 65
Jane Case-Smith
Developmental Theories and Concepts, 65
Cognitive Development, 65
Motor Development, 67
Stages of Motor Learning, 70
Social-Emotional Development, 71
Self-Identity and Self-Determination Development, 74
Development of Occupations, 76
Ecologic Models and Contexts for Development, 77
Children’s Occupations, Performance Skills, and Contexts, 79
Infants: Birth to 2 Years, 79
Early Childhood: Ages 2 to 5 Years, 87
Middle Childhood: Ages 6 to 10 Years, 94
4 Adolescent Development: Transitioning from Child to Adult, 102
Kerryellen Vroman Adolescence, 102
Adolescent Development, 102
Physical Development and Maturation, 105
Physical Activities and Growth: Teenagers with Disabilities, 105 Puberty, 106
Psychosocial Development of Puberty and Physical Maturation, 107
Cognitive Development, 108
Psychosocial Development, 109
Search for Identity: Identity Formation, 109
Self-Identity and Well-Being, 112
Sexual Orientation: Gender Identity, 112
Self-Concept and Self-Esteem, 112
Adolescence and Mental Health, 113
Areas of Occupation: Performance Skills and Patterns, 115
Work: Paid Employment and Volunteer Activities, 115
Instrumental Activities of Daily Living, 116
Leisure and Play, 117
Social Participation, 117
Evolution of Adolescent-Parent Relationships, 120 Environments of Adolescence, 121
Occupational Therapy to Facilitate Adolescent Development, 121
5 Working with Families, 129
Lynn Jaffe, Sharon Cosper Reasons to Study Families, 129
The Family: A Group of Occupational Beings, 130
System Perspective of Family Occupations, 131
Family Subsystems, 133 Parents, 133
Siblings, 133
Extended Family, 134
Family Life Cycle, 134
Early Childhood, 135
School Age, 136
Adolescence, 137
Family Resources and the Child with Special Needs, 137
Financial Resources, 137
Human Resources, 138
Time Resources, 139
Emotional Energy Resources, 139
Sources of Diversity in Families, 140
Ethnic Background, 140
Family Structure, 141
Socioeconomic Status, 141
Parenting Style and Practices, 142
An Ecologic Perspective, 142
Supporting Participation in Family Life, 142
Development of Independence in Self-Care and Health
Maintenance Routines, 142
Participation in Recreational and Leisure Activities, 143
Socialization and Participation in Social Activities, 144
Fostering Readiness for Community Living, 145
Family Adaptation, Resilience, and Accommodation, 145
Partnering with Families, 146
Establishing a Partnership, 147
Providing Helpful Information, 147
Providing Flexible, Accessible, and Responsive Services, 147
Respecting Family Roles in Decision Making, 149
Communication Strategies, 149
Home Programs: Blending Therapy into Routines, 149
Working with Families Facing Multiple Challenges, 149
Families in Chronic Poverty, 149
Parents with Special Needs, 151
SECTION II Occupational Therapy Evaluation in Pediatrics
6 Use of Standardized Tests in Pediatric Practice, 163
Pamela K. Richardson
Influences on Standardized Testing in Pediatric Occupational Therapy, 164
Purposes of Standardized Tests, 167
Determination of Medical or Educational Diagnoses, 167
Documentation of Developmental, Functional, and Participation Status, 167
Planning Intervention Programs, 168
Measuring Program Outcomes, 168
Measurement Instruments for Research Studies, 168 Characteristics, 168
Types of Standardized Tests, 168
Technical Aspects, 174
Descriptive Statistics, 174
Standard Scores, 175
Reliability, 176
Validity, 179
Becoming a Competent Test User, 181
Choosing the Appropriate Test, 181
Learning the Test, 182
Checking Inter-rater Reliability, 182
Selecting and Preparing the Optimal Testing Environment, 184
Administering Test Items, 184
Interpreting the Test, 184
Evaluating the Clinical Usefulness of the Test, 185
Ethical Considerations in Testing, 185 Examiner Competency, 185
Client Privacy, 185
Communication of Test Results, 186 Cultural Considerations When Testing, 186
Advantages and Disadvantages of Standardized Testing, 186 Advantages, 187 Disadvantages, 187
SECTION III Occupational Therapy Intervention: Performance Areas
7 Application of Motor Control/Motor Learning to Practice, 193
Jane O’Brien
Motor Control: Overview and Definition, 194 Dynamic Systems Theory, 195 Person, 195 Task, 200
Environmental Contexts, 200
Motor Performance Results from an Interaction Between Adaptable and Flexible Systems, 200
Dysfunction Occurs When Movement Lacks Sufficient Adaptability to Accommodate Task Demands and Environmental Constraints, 201
Therapists Modify and Adapt the Requirements and Affordances of Tasks to Help Children Succeed, 201 Practice Models That Use Dynamic Systems Theory, 202
Translating Dynamic Systems Theory Principles to Occupational Therapy, 202 Whole Learning, 202 Variability, 205 Problem Solving, 206 Meaning, 206 Development of Motor Control, 207 Motor Learning, 209 Transfer of Learning, 209 Sequencing and Adapting Tasks, 209 Practice Levels and Types, 211 Error-Based Learning, 212 Feedback, 212 Application of Motor Control/Learning Theory in Occupational Therapy Practice, 213
8 Hand Function Evaluation and Intervention, 220
Jane Case-Smith, Charlotte E. Exner Components of Hand Skills, 220 Factors That Contribute to the Development of Hand Function, 220 Social and Cultural Factors, 221 Somatosensory Functions, 221 Visual Perception and Cognition, 222
Musculoskeletal Integrity, 222 Development of Hand Skills, 223 Reach and Carry, 223 Grasp Patterns, 224
In-Hand Manipulation Skills, 225 Voluntary Release, 227 Bimanual Skills, 227 Ball-Throwing Skills, 228 Tool Use, 229 Hand Preference, 230
Relationship of Hand Skills to Children’s Occupations, 230 Play, 230
Activities of Daily Living, 231
School Functions, 231
Evaluation of Hand Skills in Children, 231
Intervention Models, Principles, and Strategies, 232
Biomechanical and Neurodevelopmental Approaches, 232
Occupation-Based Approaches, 240
Adaptation Models, 249
9 Sensory Integration, 258
L. Diane Parham, Zoe Mailloux
Introduction to Sensory Integration Theory, 259
Neurobiologically Based Concepts, 259
Sensory Integrative Development and Childhood Occupations, 261
When Problems in Sensory Integration Occur, 265 Types of Sensory Integration Problems, 266
Sensory Modulation Problems, 267
Sensory Discrimination and Perception Problems, 270
Vestibular-Bilateral Problems, 271
Praxis Problems, 272
Sensory-Seeking Behavior, 273 Impact on Participation, 274
Assessment of Sensory Integrative Functions, 275 Interviews and Questionnaires, 275
Direct Observations, 276
Standardized Testing, 277
Interpreting Data and Making Recommendations, 278
Interventions for Children with Sensory Integrative Problems, 279
Ayres Sensory Integration Intervention, 279
Sensory Stimulation Protocols, 289
Sensory-Based Strategies, 290
Individual Training in Specific Skills, 290
Group Interventions, 290 Consultation on Modification of Activities, Routines, and Environments, 291
10 Cognitive Interventions for Children, 304
Angela Mandich, Jessie Wilson, Kaity Gain
Theoretical Foundations of Cognitive Approaches, 304
Scaffolding, 306
Discovery Learning, 306
Metacognition, 306
Instrumental Enrichment, 306
Rationale for Using Cognitive Approaches, 306
Motivation, 306
Generalization and Transfer, 307
Lifelong Development, 307 Cognitive Interventions, 307
Cognitive Orientation to Daily Occupational Performance, 307
Primary Objectives of CO-OP, 308
Who Benefits from CO-OP?, 308
Key Features of the CO-OP Approach, 309 Evaluations Used in CO-OP, 314 Evidence for Using Cognitive Approaches, 314
11 Interventions to Promote Social Participation for Children with Mental Health and Behavioral Disorders, 321
Claudia List Hilton
International Classification of Functioning, Disability, and Health, Occupational Therapy Practice
Framework, and Social Participation, 321 Importance of Social Skills and Social Participation, 321
Occupational Therapy Goals for Social Participation and Social Skills, 322
Social Participation Impairments in Specific Childhood Conditions, 322
Autism Spectrum Disorders, 322
Fetal Alcohol Spectrum Disorder, 323
Attention-Deficit/Hyperactivity Disorder, 323
Anxiety Disorders, 323
Learning Disabilities, 323
Mood Disorders, 323
Theoretical Basis of Social Deficits, 324
Occupational Therapy Evaluation of Social Participation, 324
Assessment of Social Participation in Children, 325
Goal Attainment Scaling, 325
Theoretical Models and Approaches for Social Skills Interventions, 325
Peer-Mediated Intervention, 325
Sensory Integration Intervention, 328
Self-Determination, 328
Social Cognitive, 329
Behavioral Interventions, 329 Interventions for Social Skills, 329
Social Interventions, 329 Description and Evidence for Specific Interventions in Social Skills Groups, 338
12 Social Participation for Youth Ages 12 to 21, 346
Jessica Kramer, Kendra Liljenquist, Matthew E. Brock, Zachary Rosetti, Brooke Howard, Melissa Demir, Erik W. Carter
What is Social Participation?, 346
Identity Development and Social Participation, 346
Participation and International Classification of Functioning, Disability, and Health, 347
Role of the Environment and Culture on Social Participation, 347
Environment and the International Classification of Functioning, Disability, and Health, 348
Social Participation in Adolescence and Young Adulthood, 349
Interpersonal Relationships, 349
Education and Postsecondary Training, 351
Work and Prevocational Experiences, 351
Community Life, Religion, and Citizenship, 353 Recreation and Leisure, 356
Evaluating Social Participation, 357
Youth Self-Reports of Social Participation, 357
Parent Assessments of Social Participation, 358 Interventions to Facilitate Social Participation, 359 Skill-Focused Interventions, 359
Environment-Focused Interventions, 363
Peer Support Interventions, 363
13 Interventions and Strategies for Challenging Behaviors, 374
Renee Watling
Strategies for Managing Difficult Behavior, 374 Behavior Happens, 374
Behavior Always has a Purpose, 374 Being Prepared for Problem Behavior, 376 Behavior Management Approaches, 377 Preventing Challenging Behavior, 377 Supporting Positive Behavior, 379
General Strategies, 380
Specific Strategies, 381
General Support Strategies, 384
Intervening When Children are Known to Have Challenging Behaviors, 384
Positive Behavioral Support, 384
Functional Behavioral Analysis, 385
14 Feeding Intervention, 389
Kimberly Korth, Lauren Rendell
Feeding: Definition and Overview, 389 Incidence of Feeding Disorders, 389
Common Medical Diagnoses Associated with Feeding Disorders, 390
Feeding Development and Sequence of Mealtime Participation, 390
Anatomy and Development of Oral Structures, 390
Pharyngeal Structures and Function, 391
Phases of Swallowing, 391
Stages and Ages of Feeding Development, 392
Mealtime: An Overview, 393
Contextual Influences on Mealtime: Cultural, Social, Environmental, and Personal, 394
Comprehensive Evaluation of Feeding and Swallowing Skills, 396
Initial Interview and Chart Review, 396
Structured Observation, 397
Additional Diagnostic Evaluations, 397
Intervention: General Considerations, 398
Safety and Health, 400 Intervention Strategies, 400 Environmental Adaptations, 400 Positioning Adaptations, 400
Adaptive Equipment, 402
Interventions to Improve Self-Feeding, 402
Modifications to Food Consistencies, 403
Modifications to Liquids, 403
Interventions for Dysphagia, 404
Interventions for Sensory Processing Disorders, 405
Behavioral Interventions, 406
Interventions for Food Refusal or Selectivity, 407
Delayed Transition to Textured Foods, 407
Delayed Transition from Bottle to Cup, 408
Neuromuscular Interventions for Oral Motor Impairments, 409
Transition from Nonoral Feeding to Oral Feeding, 410
Cleft Lip and Palate, 411
Other Structural Anomalies, 411
15 Activities of Daily Living and Sleep and Rest, 416
Jayne Shepherd
Importance of Developing ADL Occupations, 416 Factors Affecting Performance, 417
Child Factors and Performance Skills, 417
Performance Environments and Contexts, 418 Evaluation of Activities of Daily Living, 420
Evaluation Methods, 421
Team Evaluations, 422
Measurement of Outcomes, 422
Intervention Strategies and Approaches, 423
Promoting or Creating Supports, 423
Establishing, Restoring, and Maintaining Performance, 423
Adapting the Task or Environment, 426
Prevention and Education, 431
Specific Intervention Techniques for Selected ADL Tasks, 433
Toilet Hygiene and Bowel and Bladder Management, 433
Dressing, 438
Bathing or Showering, 443
Personal Hygiene and Grooming, 445
Sexual Activity, 445
Care of Personal Devices, 447
Sleep and Rest, 448
Evaluation of Sleep and Sleep Needs at Different Ages, 450
Sleep Issues for Children with Disabilities, 450
Occupational Therapy Interventions for Sleep Disorders, 451
16 Instrumental Activities of Daily Living, Driving, and Community Participation, 461
M. Louise Dunn, Kathryn M. Loukas
Occupational Development of Instrumental Activities of Daily Living and Community Participation, 462
Late Adolescence (16 to 18 Years), 462
Early Adolescence (12 to 15 Years), 464
Middle Childhood (6 to 11 Years), 465
Preschool (3 to 5 Years), 465
Personal and Contextual Influences on Instrumental Activities of Daily Living and Community Participation, 466
Personal Influences, 466
Contextual Influences, 467
Evaluation of Instrumental Activities of Daily Living and Community Participation, 468
Measurement of Outcomes, 468
Transition Planning, 470
Theoretical Models and Intervention Approaches, 471
Family- and Client-Centered Models of Practice, 471
Ecological Models, 475
17 Play, 483
Kari J. Tanta, Susan H. Knox
Play Theories, 483
Form, 484
Function, 486
Meaning, 486
Context, 486
Play in Occupational Therapy, 487
Play Assessment, 488
Developmental Competencies, 488
Play, Playfulness, and Play Style, 488
Interpreting Play Assessments, 489
Constraints to Play, 489
Effects of Disability on Play Behavior, 489
Play in Intervention, 491
Playfulness in Occupational Therapy, 492
Play Spaces and Adaptations, 492
Parent Education and Training, 493
Societal Concerns, 493
18 Prewriting and Handwriting Skills, 498
Colleen M. Schneck, Jane Case-Smith
The Writing Process, 499
Preliteracy Writing Development of Young Children, 499
Writing Development of School-Aged Children, 499
Handwriting Readiness, 500
Problems in Handwriting and Visual Motor Integration, 500
Pencil Grip Progression, 501
Handwriting Evaluation, 501
Occupational Profile, 501
Analysis of Occupational Performance, 503
Measuring Handwriting Performance, 503
Domains of Handwriting, 503
Legibility, 504
Writing Speed, 504
Ergonomic Factors, 504
Handwriting Assessments, 505
Interplay of Factors Restricting Handwriting Performance, 505
Educator’s Perspective, 506
Handwriting Instruction Methods and Curricula, 506
Manuscript and Cursive Styles, 513
Handwriting Intervention, 513
Models of Practice to Guide Collaborative Service Delivery, 513
Acquisitional and Motor Learning Approaches, 514
Sensorimotor Interventions, 515
Biomechanical Approaches, 516
Cognitive Interventions, 518
Psychosocial Approaches, 519
Service Delivery, 519
19 Influencing Participation Through Assistive Technology and Universal Access, 525
Judith W. Schoonover, Rebecca E. Argabrite Grove Introduction, 525
Influencing Children’s Growth and Development with Assistive Technology, 526
Definition and Legal Aspects of Assistive Technology, 526
Models for Assistive Technology Assessment and Decision Making, 527
Human Activity Assistive Technology, 527
Student Environment Task Tool, 527
Matching Person and Technology, 528
Child- and Family-Centered Approach, 528
Technology Abandonment, 528
Learned Helplessness and Self-Determination, 529
Setting the Stage for Assistive Technology Service
Provision, 529
Practice Settings, 529
Occupational Therapy Process and Assistive Technology in the Schools, 530
The Interprofessional Team, 530
Assistive Technology Evaluation and Intervention: A Dynamic Process, 531 Evaluation, 532
Decision Making, 533
Device Procurement, 534
Funding, 534
Implementation of Assistive Technology Services, 535
Measuring Progress and Outcomes, 536
Universal Design and Access, 536 Access, 536
Universal Design, 537
Positioning and Ergonomics, 537
Participation: Supporting Life Skills with Assistive Technology, 538
Switch Use to Operate Toys and Appliances, 538
Switch Use with Computers, 539
Alternative and Augmentative Communication, 540 Computers, 545
Electronic Aids for Daily Living, 548
Changing the Landscape in Education: Planning for Every Student in the Twenty-First Century, 549
Universal Design for Learning, 549
Instructional Technology, 550
Assistive Technology for Literacy Skills, 550
Reading Skills, 551
Assistive Technology for Writing, 552
Assistive Technology for Math, 553
Assistive Technology as a “Cognitive Prosthetic”, 553
Assistive Technology and Transition, 554
Evidence-Based Practice and Assistive Technology, 554
20 Mobility, 560
Christine Wright-Ott
Developmental Theory of Mobility, 560
Impaired Mobility, 562
Self-Initiated Mobility, 562
Augmentative Mobility, 564
Assessment and Intervention, 564
Classification of Mobility Skills, 564
Mobility Assessments, 564
Mobility Evaluation Teams, 565
Mobility Devices, 566
Alternative Mobility Devices, 566
Wheeled Mobility Systems, 570
Manual Wheelchairs, 571
Power Wheelchairs, 572
Selection of Wheelchair Features, 577
Powered Mobility Evaluation and Intervention, 579
Selecting the Control Device, 579
Assessing Driving Performance, 582
Power Mobility Training, 582
Seating and Positioning, 583
Understanding the Biomechanics of Seating, 583
Seating Guidelines, 583
Seating Evaluation, 585
Mobility Devices and Diagnoses, 586
Transportation of Mobility Systems, 587
Factors That Influence the Successful Use of Mobility Devices, 587
SECTION IV Areas of Pediatric Occupational Therapy Services
21 Neonatal Intensive Care Unit, 595
Jan Hunter, Anjanette Lee, Leslie Altimier
Overview of the NICU and Developmental Care, 595
Nursery Classification and Regionalization of Care, 596
Developmental Specialists Emerge as Integral Members of the NICU Team, 596
Becoming a Developmental Specialist, 597
Developing a Medical Foundation, 597
Abbreviations and Terminology, 597
Classifications for Age, 597
Classifications by Birth Weight, 600
Medical Conditions and Equipment, 600
Models of Care in the NICU, 600
Universe of Developmental Care Model, 600
Neonatal Integrative Developmental Care Model, 600
NICU Environment and Caregiving, 602
Evidence-Based Practice and Potentially Better Practices to Support Neurodevelopment in the NICU, 602
“Mismatch” of an Immature Infant in the High-Tech Environment, 602
Physical Environment, 604
Sensory Environment, 604
Potential Impact of the NICU Environment on Brain Development in the Preterm Infant, 609
Safeguarding Sleep, 610
Minimizing Pain, 611
NICU Caregiving, 612
Infant Neurobehavioral and Neuromotor Development, 614
Evaluation of the Infant, 614
Infant Neurobehavioral Development, 615
Neuromotor Development and Interventions, 618
Feeding, 622
A Word about Breastfeeding, 622
Oral Feeding, 622
Partnering with Families in the NICU, 626
Skin-to-Skin Care: Kangaroo Mother Care, 628
Establishing Your Niche in the NICU Team, 629
Building a Successful NICU Practice, 629
Reflective Practice, 630
22 Early Intervention, 636
Christine Teeters Myers, Jane Case-Smith, Jana Cason
Definition of Early Intervention Programs, 636
Legislation Related to Early Intervention, 636
Importance and Outcomes of Early Intervention, 636
Occupational Therapy Services in Early Intervention Systems, 637
Best Practices in Early Intervention, 638
Partnering with Families, 638
Partnering with Professionals, 639
Evaluation and Intervention Planning, 640
Working in Natural Environments, 644
Occupational Therapy Early Intervention Practices, 646
Occupational Therapy in Natural Environments, 646
Occupational Therapy Interventions, 651
23 School-Based Occupational Therapy, 664
Susan Bazyk, Susan Cahill
Federal Legislation and State-Led Initiatives Influencing School-Based Practice, 664
Individuals with Disabilities Education Act, 665
Free and Appropriate Public Education, 666
Section 504 of the Rehabilitation Act and Americans with Disabilities Act, 667
Elementary and Secondary Education Act and No Child Left Behind, 667
Common Core Standards: A State-Led Initiative, 668
Occupational Therapy Services for Children and Youth in Schools, 668
Occupational Therapy Domain in School-Based Practice, 668
Shifts in Occupational Therapy Service Provision, 668
Occupational Therapy Process in General Education, 669
Occupational Therapy Process in Special Education, 670
Data-Based Decision Making and Special Education, 680
Occupational Therapy Services and Special Education, 682
Target of Services: Who Occupational Therapists Serve, 683
Range of Service Delivery Options: What Occupational Therapists Provide, 684
Integrated Service Delivery: Where Services Should be Provided, 685
School Mental Health: Emerging Roles for Occupational Therapy, 690
School Mental Health Movement, 690
Multitiered Public Health Model of School Mental Health, 692
Role of Occupational Therapy, 692
24 Hospital and Pediatric Rehabilitation Services, 704
Brian J. Dudgeon, Laura Crooks, Elizabeth Chappelle
Characteristics of Children’s Hospitals, 705
Region (Location) Served, 705
Missions of Children’s Hospitals, 705
Research on Systems and Care Outcomes, 706
Family and Child-Centered Care, 706
Accrediting and Regulatory Agencies, 706
Reimbursement for Services, 707
Occupational Therapy Services in a Children’s Hospital, 707
Functions of Occupational Therapists, 707
Documentation of Occupational Therapy Services, 712
Scope of Occupational Therapy Services, 712
Organization of Hospital-Based Services, 713
Hospital-Based Therapy Teams, 713
Acute Care Units, 715
Intensive Care Unit Services, 715
General Acute Care Unit, 715
Specialty Units, 715
Oncology and Bone Marrow Transplantation Units, 715
Rehabilitation Services, 718
Transition from Rehabilitation to the Community, 720
Outpatient Services, 722
25 Transition to Adulthood, 727
Dennis Cleary, Andrew Persch, Karen Spencer
Occupational Therapy Contributions to Transition, 728
Intersection of Policy and Scientific Evidence, 728
Transition to Adulthood in America, 731
Transition Outcomes, 736
Best Practices in Occupational Therapy, 738
Early, Paid Work Experience, 738
Student Involvement in Transition Planning, 739
26 Intervention for Children Who Are Blind or Who Have Visual Impairment, 747
Kathryn M. Loukas, Patricia S. Nagaishi Terminology, 747
Visual Impairment, 751
Developmental Considerations and the Impact of Visual Impairment, 751
Parent-Infant Attachment, 752
Sleep and Rest, 752
Exploration and Play, 752
Learning, Education, and Academic Performance, 753
Use of Information from Other Sensory Systems, 754
Sensory Modulation, 754
Activities of Daily Living and Instrumental Activities of Daily Living, 755
Social Participation and Communication, 755
Occupational Therapy Evaluation, 756
Occupational Therapy Intervention, 756
Develop Self-Care Skills, 758
Enhance Sensory Processing, Sensory Modulation, and Sensory Integration, 758
Enhance Participation in Play or Productivity Through Postural Control and Movement in Space, 758
Develop Occupation-Based Mobility Through Body Awareness and Spatial Orientation, 759
Develop School-Based Tactile-Proprioceptive Perceptual Skills, 760
Improve Manipulation and Fine Motor Skills, 760
Maximize Use of Functional Vision, 760
Encourage Social Participation, 760
Strengthen Cognitive Skills and Concept Development, 760
Maximize Auditory Perceptual Abilities, 761
Supporting the Transition to Adulthood, 761
Specialized Professionals, Services, and Equipment for Children with Visual Impairment, 761
27 Autism Spectrum Disorder, 766
Heather Miller-Kuhaneck
Introduction to Autism Spectrum Disorder, 766
History of the Diagnosis, 766
Recent Diagnostic Changes, 766
Prevalence, 767
Occupational Performance in Autism Spectrum Disorder, 767
Social Participation, 767
Play, 768
Sleep, 768
Activities of Daily Living, 768 Education, 768
Performance Patterns, 769
Performance Skills and Client Factors, 769
Family Impact, 769
The Role of Occupational Therapy in Autism Spectrum Disorder, 770 Evaluation, 770
Family-Centered Practice, 772
Interventions, 773
Specific Intervention Approaches, 773
Specific Interventions for Areas of Occupation, 778
Additional Intervention Concerns, 783
28 Neuromotor: Cerebral Palsy, 793
Patty C. Coker-Bolt, Teressa Garcia, Erin Naber Introduction, 793
Prevalence and Etiology of Cerebral Palsy, 793
Practice Models to Guide Interventions for Children with Cerebral Palsy, 794
Sensorimotor Function in Children with Cerebral Palsy, 794
Associated Problems and Functional Implications, 796
Assessment, 798
Occupational Therapy Interventions, 799
Adaptive Equipment Training, 800
Casting, Orthotics, and Splinting, 801
Constraint-Induced Movement Therapy, 802
Physical Agent Modalities, 805
Therapeutic Taping and Strapping, 805
Positioning, Handling, and Neurodevelopmental Treatment, 805
Community Recreation, 806
Complementary and Alternative Medicine, 806
Robotics and Commercially Available Gaming Systems, 806
Medical Based Interventions, 808
29 Pediatric Hand Therapy, 812
Jenny Dorich, Karen Harpster Assessment, 812
Initial Screening and Assessment, 813
Clinical Assessment, 814
Standardized Assessment Tools, 817
Unstructured Clinical Observations, 818
Intervention Principles and Strategies, 819
Pain Management, 819
Splinting, 821
Casting, 823
Kinesiology Tape, 823
Child and Family Education: Activity Modification, Joint Protection, and Energy Conservation, 824
Wound Care, 824
Scar Management, 825
Edema Control, 825
Desensitization and Sensory Re-education, 826
Range of Motion Exercises, 826
Strengthening, 827
Reducing Muscle Tone, 827
Fine Motor Skills and Bimanual Coordination, 827
Mirror Therapy, 827
Interventions for Specific Conditions, 827
Congenital Differences of the Upper Extremity, 827
Upper Extremity Impairments Caused by an Underlying Disorder, 828
Upper Extremity Injury, 831
30 Trauma-Induced Conditions, 839
Amber Lowe, Patti Sharp, Carrie Thelen, Beth Warnken
Introduction, 839
Spinal Cord Injury, 839
Traumatic Brain Injury, 840
Burn Injury, 840
Therapeutic Relationships, 843
Grief Management, 843
Caregiver Education, 844
Multidisciplinary Team, 844
Post-Trauma Occupational Therapy Interventions, 844
Post-Trauma Continuum of Care, 844
Intensive Care Unit, 846
Children with Spinal Cord Injury in the Intensive Care Unit, 846
Children with Traumatic Brain Injury in the Intensive Care Unit, 846
Children with Burn Injury in the Intensive Care Unit, 847
Acute Care, 847
Children with Spinal Cord Injury in Acute Care, 847
Children with Traumatic Brain Injury in Acute Care, 848
Children with Burn Injury in Acute Care, 848
Inpatient Rehabilitation, 849
Children with Spinal Cord Injury in Inpatient Rehabilitation, 852
Children with Traumatic Brain Injury in Inpatient Rehabilitation, 852
Children with Burn Injury in Inpatient Rehabilitation, 853
Outpatient Rehabilitation and Community Reintegration, 853
Children with Spinal Cord Injury in Outpatient Rehabilitation and Community Reintegration, 855
Children with Traumatic Brain Injury in Outpatient Rehabilitation and Community Reintegration, 855
Children with Burn Injury in Outpatient Rehabilitation and Community Reintegration, 856
Conclusion, 856
TABLE 1-1 Principles of Client-Centered Intervention
Area of Intervention Principles
Assessment
Team interaction
Intervention
Child or adolescent and family concerns and interests are assessed in a welcoming and open interview.
Child or adolescent and family priorities and concerns guide assessment of the child.
Child or adolescent and family are valued members of the intervention team.
Communication among team members is child- and family-friendly.
Relationships among team members are valued and nourished.
Child or adolescent with caregivers guide intervention.
Families choose level of participation they wish to have.
Family and child or adolescent interests are considered in developing intervention strategies. When appropriate, intervention directly involves other family members (e.g., siblings, grandparents). Life span approach As child transitions to preadolescence and adolescence, he or she becomes the primary decision maker for intervention goals and activities.
BOX 1-1 Themes That Characterize
Occupational Therapy Practice with Children and Adolescents
Individualized therapy services
• Client-centered services
• Strength-based approaches
• Family-centered services
Inclusive and integrated services
• Natural environments
• Integrated services
Cultural competence
Evidence-based practice and scientific reasoning
As illustrated throughout the book, client-centered evaluation involves first identifying concerns and priorities of the child and family. Initially and throughout therapy services, occupational therapists prioritize and make specific efforts to learn about the child and family’s interests, goals, daily routines, and preferred activities. What is important to the child and caregivers frames the goals and activities of the intervention. Fit of occupational therapy recommendations to family goals and interests is revisited throughout the intervention period to ensure that services are meeting the priorities of the child or adolescent and family.
Child-Centered Practices
As described by Law, Baptiste, and Mills,73 client-centered occupational therapy is an approach to service that embraces a philosophy of respect for and partnership with people receiving services. Tickle-Degnen128 further explains that practitioners form a therapeutic alliance with their clients in which they build rapport and collaborate to develop common goals and shared responsibility for achieving those goals. According to Parham et al.,96 a primary feature of sensory integration intervention is “fostering therapeutic alliance.” They describe this alliance as one in which the occupational therapist “respects the child’s emotions, conveys positive regard toward the child, seems to connect with the child and creates a climate of trust and emotional safety”96 (see Chapter 9). This relationship with the child is a priority for the occupational therapist and is believed to be instrumental to achieving positive intervention outcomes.
Philosophically, theoretically, and practically, clientcenteredness is ubiquitous to occupational therapy interventions This concept means that occupational therapists provide choices, allow the child or youth to make activity choices, and broadly consider the child’s culture and context when designing interventions. In child-centered practice, practitioners use activities that are meaningful to and preferred by the child, knowing that they engage the child’s efforts. Children are motivated to take on skill challenges that the occupational therapist embeds in preferred activities. It is also implied that the occupational therapist selects activities that are developmentally appropriate, suitable to the child’s environment, and aligned with the child’s expressed or understood goals. Occupational therapists invite children and youth to participate actively in the evaluation process and goal setting using developmentally appropriate methods.87 Measures have been developed to assess the child’s perspective on his or her ability to participate in desired occupations. For example, when using the Canadian Occupational Performance Measure (COPM), the family and child rate the importance of self-identified performance problems. By administering the COPM as part of the initial evaluation, the occupational therapist can prioritize the child’s goals and begin a collaborative relationship with the family. The Perceived Efficacy and Goal Setting System (PEGS) is another example of a measure that uses the child as the primary informant.88 These assessments are explained further in Chapters 11, 15, and 23. The information gathered from measuring children’s thoughts and feelings about their participation in childhood roles can complement results obtained from functional assessments. In addition, occupational therapists may consider gathering information about the child’s life satisfaction. Often the best strategy for gathering information about the child’s or adolescent’s interests and perspectives is to ask open-ended questions about his or her play preferences, favorite activities, best friends, special talents, and greatest concerns.
The occupational therapist monitors the fit of intervention activities to the child’s daily routines by asking parents and teachers. The occupational therapist seeks ways to adapt recommendations to match the child’s evolving interests and routines and to ensure that therapy is directed to current priorities of the child and family. Continually assessing which therapeutic activities are most appropriate given the child’s developmental levels, current performance, and interests, the practitioner
CASE STUDY 1-1 A Strength-Based Approach with a Child Who Has High Functioning Autism
Victor is a 10-year-old boy with high functioning autism. He has extraordinary visual perceptual skills and visual memory; he also has significant delays in social skills. In particular, he has difficulty knowing how to interact with his peers on the playground or in unstructured social activities. The therapist, Amy, suggests that he video record his peers when they are playing together or talking on the playground. Using these videos, Victor has examples of appropriate social interactions. He and Amy analyze the videos together, discussing how the children initiate and respond to social interaction; he practices some of the interactions with Amy. Amy encourages him to watch the examples of positive social interactions a number of times.
Using the videos, Victor makes and labels photographs of different examples of social interactions. With Amy’s help,
& Smiley.10
selects activities that are most useful for obtaining the child and family’s goals.128
Strength-Based Approaches
Using holistic approaches, occupational therapists begin intervention by considering the strengths of a child or youth. With a full understanding of the child’s strengths and interests, practitioners develop a plan to increase participation by building on those strengths. By identifying the positive aspects of a child’s behavior and areas of greatest competence as well as performance limitations, the occupational therapist can access these strengths to overcome the challenges to participation. The strength-based model contrasts with the traditional medical model, in which the focus of intervention is on identifying the health or performance problem and resolving that problem. As explained in many chapters of this book, focusing on a child’s performance problem does not always lead to optimal participation and improved quality of life. Because occupational therapists are concerned with a child’s full participation in life activities, focusing solely on impairment narrows the vision of what the child can become and do.
Children and youth with disabilities often have unique strengths that are overlooked by professionals, but if these strengths are identified and encouraged, they can lead to increased participation. For example, a youth with high functioning autism may have excellent visual memory or analytic abilities. For this youth, cognitive approaches that engage the youth in problem solving and in determining how to structure social activities can help him overcome social skill limitations. For a child with spastic quadriparesis cerebral palsy who has a joyous sense of humor, encouraging his sense of humor in a social group can help to build peer supports and friendships that increase his participation in school activities.
As explained in numerous chapters, strength-based approaches can lead to increased self-efficacy and selfdetermination. When an occupational therapist acknowledges a child’s strengths and competence, the child becomes more self-efficacious and motivated, and he or she may be more willing to take on performance challenges. A child with positive
Victor organizes the photographs into stories that he uses to learn how to engage with others socially. Amy also helps him organize the photographs into a social story; she creates a visual step-by-step procedure for initiating a social interaction.
The other children were interested in his videos and stories; they read the stories and praised Victor’s skills in video recording and photography. His interest in and talents for photography resulted in a sequence of naturally occurring social interactions that allowed Victor to practice the social skills. By using a strength-based approach, he not only had used his talents to learn new skills, but also his peers recognized and appreciated his talent, establishing enhanced contexts for social participation.
self-efficacy is more likely to make repeated and sustained efforts to achieve his or her goals, despite lack of immediate success.7 Case Study 1-1 illustrates use of a strength-based approach with a child who has high functioning autism spectrum disorder. Chapter 12 explains how an occupational therapist’s emphasis on strength-based approaches can facilitate increased self-determination and skills in self-advocacy in youth with disabilities. Identifying an adolescent’s strengths can be particularly potent in interventions to promote social participation and friendship networks because it helps peers and family members recognize and acknowledge the adolescent’s talents and interest and establish these as the basis for social interaction. Kramer and colleagues (Chapter 12) describe a community service program, EPIC Service Warriors, in which youth with disabilities serve others by cleaning up parks and making food at homeless shelters. This program expands the social networks of youth with disabilities, demonstrates a model of community inclusion, and changes the way these adolescents think about themselves. Envisioning roles for youth and adults with disabilities to serve others can enhance self-efficacy and change society’s view of potential roles for people with disabilities.
A strength-based approach when offering parent supports and education is equally important. By identifying positive characteristics in the child, occupational therapists can help relieve parents’ stress and can improve parents’ engagement.49,121 Steiner121 found that when occupational therapists acknowledged the strengths of parents of children with autism (versus noting their deficits), parents demonstrated more positive affect and physical affection toward their child. When occupational therapists made positive statements about a child, parents repeated their statements and, less expected, demonstrated more playful behaviors and physical affection.121
Family-Centered Practices
In a family-centered approach, the occupational therapist is invested in establishing a relationship with the family characterized by open communication, shared decision making, and parental empowerment.12 An equal partnership with the family
Adapted from Bianco, Carothers,
is desired, where each partner values the knowledge and opinions of the other.53,130 Trust building between professionals and family members is a first step in building a relationship. Demonstrating mutual respect, being positive, and maintaining a nonjudgmental position with a family appear to be important to establishing trust (see Chapter 5). Trust building can be particularly challenging with certain families—for example, families whose race, ethnicity, culture, or socioeconomic status may differ from that of the occupational therapist. These families may hold strong beliefs about child rearing, health care, and disabilities that are substantially different from those of the occupational therapist. However, establishing a relationship of mutual respect is essential to the therapeutic process.
Jaffe and Cosper (Chapter 5) explain that occupational therapists cultivate positive relationships with families when they establish open and honest communication and encourage participation of parents in their child’s program to the extent that they desire. When asked to give advice to occupational therapists, parents stated that they appreciated (1) specific, objective information; (2) flexibility in service delivery; (3) sensitivity and responsiveness to their concerns83; (4) positive, optimistic attitudes24; and (5) technical expertise and skills.12
In a qualitative study in which 29 families were interviewed about their experiences in parenting a child with disabilities and working with the intervention systems, four themes emerged.42 (1) Parents need professionals to recognize that parenting a child with a disability is a “24/7” job with continual and often intensive responsibilities. (2) Both internal (coping and resilience) and external (e.g., extended family) resources are needed to raise a child with a disability; these should be bolstered and encouraged. (3) Parents ask that professionals respect them as the experts on their child. (4) Parents also ask that professionals accept their family’s values. Although this study’s qualitative findings do not constitute rigorous evidence of intervention effects, the findings concur with other descriptive studies of family-centered intervention. When combined, these studies suggest that respecting parents’ knowledge of their child, acknowledging their resilience, accepting their values, and facilitating the building of a network of social resources are important components of family-centered intervention.40
In Chapter 22, on early intervention services, Myers, CaseSmith, and Cason explain methods for partnering with families. Recommended activities most likely to be implemented by and most helpful to the family are activities that are directly relevant to the family’s lifestyle and routines. When interventions make a family’s daily routine easier or more comfortable, the intervention can have an immediate positive effect and is more likely to be sustained and generalized to other routines and environments.
In a meta-analysis of family-centered practice in early intervention service, two types of family-centered services were identified: (1) services that fostered positive professional-family relationships and (2) services that enabled the family’s participation in intervention activities.40 In relationship building practices, occupational therapists actively listen, show compassion and respect, and believe in the family’s capabilities. Occupational therapists enable and promote the family’s participation by individualizing their services, demonstrating flexibility in meeting family needs, and being responsive to family concerns. Dunst, Trivette, and Hamby41 found that the provision of family-centered services was highly related to the family’s
self-efficacy beliefs, parents’ satisfaction with the program, parenting behaviors, and child behavior and functioning.
Inclusive and Integrated Services
Practitioners of occupational therapy are strong advocates for inclusion of all persons with disabilities. They embrace the vision that children and youth with disabilities fully participate in the community and take on roles to facilitate full participation. Inclusion of people with disabilities into communities involves transforming attitudes and assumptions, through education but primarily through demonstration that children and youth with disabilities can fully participate. To support inclusion of children and youth with disabilities in environments with children without disabilities, practitioners may recommend modifications to increase physical access, accommodations to increase social participation, or strategies to improve the child’s ability to meet the performance and behavioral expectations. For example, occupational therapists often have roles in evaluating physical access in schools or jobs and recommending assistive technology or task modification. Occupational therapists have been leaders in promoting inclusion throughout their history,54,65 providing services that enable full inclusion of persons with mental, physical, and cognitive disabilities.
In current practice, legal mandates necessitate that services to children with disabilities be provided in environments with children who do not have disabilities. The Individuals with Disabilities Education Act requires that services to infants and toddlers be provided in “natural environments” and that services to preschool and school-aged children be provided in the “least restrictive environment.” The infant’s natural environment is most often his or her home, but it may include any place that the family defines as the child’s natural environment. This requirement shifts when the child reaches school age, not in its intent but with recognition that community schools and regular education classrooms are the most natural and least restrictive environments for services to children with disabilities. Inclusion in natural environments or regular education classrooms succeeds only when specific supports and accommodations are provided to children with disabilities. Occupational therapists are often important team members in making inclusion successful for children with disabilities. (This concept is discussed further in Chapters 22 and 23.)
Early Intervention Services in the Child’s Natural Environment
The Division of Early Childhood of the Council for Exceptional Children supports the philosophy of inclusion in natural environments with the following statement: “Inclusion, as a value, supports the right of all children, regardless of their diverse abilities, to participate actively in natural settings within their communities. A natural setting is one in which the child would spend time if he or she had not had a disability.”36
As explained by Myers, Case-Smith, and Cason (Chapter 22), the philosophy of inclusion extends beyond physical inclusion to mean social and emotional inclusion of the child and family.26,131 The implications for occupational therapists are that they provide opportunities for expanded and enriched natural learning with typically developing peers. A natural environment can be any setting that is part of the everyday routine of the
FIGURE 1-1 When occupational therapy is provided in the child’s home, the practitioners and child have easy access to practice of self-care activities.
child and family where incidental learning experiences occur.42 Intervention and consultation services can occur in a childcare center, at a grandmother’s house, or in another place that is part of a family’s routine. Social, play, and self-care learning opportunities in these environments are plentiful. Figure 1-1 shows an example of a child’s natural environment in which the occupational therapist could intervene.
When occupational therapy occurs in a natural environment such as the home, the intervention activities are embedded in naturally occurring interactions and situations. In incidental learning opportunities, the occupational therapist challenges the child to try a different approach or to practice an emerging skill during typical activities. The occupational therapist follows the young child’s lead and uses natural consequences (e.g., a smile or frown, a pat or tickle) to motivate learning (Figure 1-2).
Research has shown that intervention strategies that occur in real-life settings produce greater developmental change than those that take place in more contrived, clinic-based settings.18,42 In addition, generalization of skills and behaviors occurs more readily when the intervention setting is the same as the child’s natural environments.58,59
Early intervention therapy services in natural environments require the occupational therapist to be creative, flexible, and spontaneous.41 The occupational therapist must accept and use the toys, objects, and environmental spaces in the family’s home as those are most important and culturally relevant to the child’s development (Figure 1-3). The occupational therapist must think through many alternative ways to reach the established goals and adapt those strategies to whichever situation is presented.52 Recognizing and accepting the family’s uniqueness in cultural and child-rearing practices enables the occupational therapist to facilitate the child’s participation in his or her natural environments.
Integrated Service Delivery Models
In school-based services, inclusion refers to integration of the child with disabilities into the regular classroom with support to accomplish the regular curriculum. Box 1-2 lists the desired outcomes of inclusive school environments. In schools with well-designed inclusion, every student’s competence in
FIGURE 1-2 A and B, Therapist and child rapport is demonstrated by sharing pleasure and clowning around.
BOX 1-2 Desired Inclusion Outcomes
• Children with disabilities are full participants in school, preschool, and childcare center activities.
• Children with disabilities have friends and relationships with their peers.
• Children with disabilities learn and achieve within the general educational curriculum to the best of their abilities.
• All children learn to appreciate individual differences in people.
• All children learn tolerance and respect for others.
• Children with disabilities participate to the fullest extent possible in their communities.
diversity and tolerance for differences increases. To promote the child’s participation across school environments, occupational therapy practitioners integrate their services into multiple environments (e.g., within the classroom, on the playground, in the cafeteria, on and off the school bus). The occupational therapist’s presence in the classroom benefits the instructional staff members, who observe the occupational therapy intervention. As explained by Bazyk and Cahill (Chapter 23), integrated therapy ensures that the occupational therapist’s focus has high relevance to the performance expected within the classroom. It also increases the likelihood that adaptations and therapeutic techniques will be carried over into classroom activities,8,117,137
FIGURE 1-3 The occupational therapist uses the child’s own toys in the home to challenge and practice his or her emerging skills with the high probability that the child will continue to practice these skills.
and it allows the occupational therapist to link his or her goals and activities to the curriculum and the classroom priorities.
Children with disabilities benefit when therapy is provided as both direct and consultative services. Occupational therapists provide these services in the context of an interprofessional team, where communication about the child’s strengths and limitations, expected performance, and contextual barriers and resources enables a cohesive plan and the likelihood of positive outcomes. Because children constantly change and the environment is dynamic, frequent team communication and planning are needed. With opportunities to interact directly with the child and experience the classroom environment, the occupational therapist can best support the child’s participation and guide the support of other adults.
In a fluid service delivery model, therapy services increase when naturally occurring events create a need—for example, when the child obtains a new adapted device, when the child has surgery or casting, or when a new baby brother creates added stress for a family. Similarly, therapy services should be reduced when the child has learned new skills that primarily need to be repeated and practiced in his or her daily routine or the child has reached a plateau on therapy-related goals.
Models for school-based service delivery that offer the possibility for greater flexibility21 include block scheduling99 and co-teaching.22 These models of flexible scheduling allow occupational therapists to move fluidly between direct and consultative services. In block scheduling, occupational therapists spend 2 to 3 hours in the early childhood classroom working with the children with special needs one on one and in small groups, while supporting the teaching staff (see Chapter 22). Block
Children
scheduling allows occupational therapists to learn about the classroom, develop relationships with the teachers, and understand the curriculum so that they can design interventions that are easily integrated into the classroom. By being present in the classroom for an entire morning or afternoon, the occupational therapist can find natural learning opportunities to work on a specific child’s goals. Using the child’s self-selected play activity, the occupational therapist employs strategies that are meaningful to the child, fit into the child’s preferred activities, and are likely to be practiced.119 During the blocked time, the occupational therapist can run small groups, coach the teacher and assistants,21,109 evaluate the child’s performance, and monitor the child’s participation in classroom activities.
Another integrated model of service delivery is coteaching.31,37 This model emphasizes preventive approaches in that children at risk for disabilities as well as children in individualized education programs receive occupational therapy services. In this model, the occupational therapist and teacher plan and implement the sessions together. Collaborative planning allows interdisciplinary perspectives on student issues and behaviors; enables the occupational therapist to align interventions closely with the curriculum; and ensures that interventions can be feasibly implemented in the classroom, with consideration given to the teacher’s goals and curricular expectations. Co-teaching models have been successfully implemented for handwriting programs, in which occupational therapists take on teaching roles while providing individualized supports and interventions for students who have handwriting difficulties.23 Benefits of co-teaching are that occupational therapy services are embedded into the classroom instruction; students at risk receive more intensive instruction with individualized supports; and students with individualized education programs receive integrated services that support performance throughout their school day.
Cultural Competence That Embraces Diversity
To achieve full inclusion, all team members and systems must demonstrate cultural competence.29 With increasing diversity within all communities, respecting and honoring the culture of the child and family are important to enable full inclusion and facilitate full participation. Cross-cultural competence can be defined as “the ability to think, feel, and act in ways that acknowledge, respect, and build upon ethnic, [socio]cultural, and linguistic diversity.”79 Cultural competence in health care refers to behaviors and attitudes that enable an individual to function effectively with culturally diverse families.29 Crosscultural competence is salient to occupational therapists who work with children and youth given that:
1. Cultural diversity of the United States continues to increase.
2. A child’s occupations, including social participation, are embedded in the cultural practices of his or her family and community.
Cultural Diversity in the United States
The diversity and heterogeneity of American families continue to increase each year. The latest census numbers132 show that the fastest growing populations in the United States are multiracial Americans, Asians, and Hispanics and that non-Hispanic white Americans will become a minority group within the next 3 decades. The United States has become a multicultural
nation, and today’s children will become adults in this environment that is rich with cultural and racial diversity. In 2011, the United States was home to 74 million children. Of these, 53% were white, 14% were African American, 4.5% were Asian, and 23.5% were Hispanic.3
Diversity of ethnicity and race can be viewed as a risk or as a resource to child development.45 Low birthrate, preterm delivery, and infant mortality are higher in African American families, suggesting that these families frequently need early childhood intervention programs. Race can also be a resource; for example, African American families are well supported by their communities and focused on their children (Figure 1-4). Studies also show that African Americans are child-centered and highly invested in child development.55 Parents often perceive discipline and politeness as positive attributes and instill these in their children.134 Children are taught to be obedient and respectful of adults. In addition, many African American families emphasize the importance of spirituality and religion.126 Occupational therapists who work with African American families find many positive attributes in their family interactions and parenting styles. Families from other cultures, such as Hispanic families, have similar beliefs and child-rearing practices.102
Poverty has a pervasive effect on children’s developmental and health outcomes.28 Despite overall prosperity in the United States, a significant number of children and families live in poverty. Although children younger than 18 years old represent only 23% of the U.S. population, they account for 34% of all people in poverty. Among all children, 45% live in low-income families, and approximately 20% live in poor families.62 In 2014, the Children’s Defense Fund reported that 1 in every 5 children, or 16.1 million, was poor and that 40% of these lived in extreme poverty. These children are disproportionately black, American Indian, and Hispanic. Often these children live in families with a single parent. Families in poverty often have great need for, yet limited access to, health care and educational services.
Many families who are served by early intervention and special education systems are of low socioeconomic status. When families lack resources (e.g., transportation, food, shelter), their priorities and concerns orient to these basic needs. Responsive occupational therapists provide resources to assist with these basic needs, making appropriate referrals to
community agencies. They also demonstrate understanding of the family’s priorities as these relate to the child’s occupational performance goals and the family’s participation in the community. Chapter 5 describes helpful practices for families with limited resources.
Influence of Cultural Practices on a Child’s Development of Occupations
To support and improve a child’s participation in the home, school, and community, occupational therapists need to understand the multitude of ways that cultural practices influence a child’s occupations. Table 1-2 lists questions to elicit information about the cultural practices and values that may influence a child’s development of occupations. For certain cultures, performance goals of interdependence may be more appropriate than goals for independence, particularly at certain ages. Cultural groups vary in their perception of giving and receiving help, communication styles, and child-rearing beliefs. The literature is replete with examples of the influence of culture on children’s occupations.27,34,45,61,108
Cultural values in families often influence their routines, daily activities, and expectations for child participation in family routines. For example, Middle Eastern families often do not emphasize early independence in self-care; skills such as selffeeding may not be a family priority until ages well beyond the normative expectations.115 Interventions to promote selffeeding during early childhood may not be a priority for Middle Eastern families. In Hispanic cultures, holding and cuddling are highly valued, even in older children.138 Mothers hold and carry their preschool children. Recommending a wheelchair for a young child may be unacceptable to families who value close physical contact and holding.
In some cultures (e.g., Polynesian), parents delegate childcare responsibilities to older siblings. In established families, siblings care for the infants. Young children in Polynesian cultures tend to rely on their older siblings rather than their parents for structure, assistance, and support. Being responsible for a younger sibling helps the older sibling mature quickly by learning responsibility and problem solving.108 Primary care by an older sibling is challenging when the younger child has a disability and needs additional or prolonged assistance.
Because the focus of occupational therapy is to enhance a child’s ability to participate in his or her natural environment and everyday routines, the occupational therapist must appreciate, value, and understand those environments and routines. Recommendations that run counter to a family’s cultural values are not likely to be implemented by family members and may be detrimental to the professional-family relationship. By asking open-ended questions, occupational therapists can elicit information about the family’s routines, rituals, and traditions to provide an understanding of the cultural context.
A culturally competent occupational therapist demonstrates an interest in understanding the family’s culture, an acceptance of diversity, and a willingness to participate in traditions or cultural patterns of the family. In home-based services, cultural competence may mean removing shoes at the home’s entryway, accepting foods when offered, scheduling therapy sessions around holidays, and accommodating language differences. In center-based services, cultural sensitivity remains important, although a family’s cultural values may be more difficult to ascertain outside the home.
FIGURE 1-4 A father bonds with his just-born son. (Photo © istock.com.)
