Applied Behavior Analysis, Autism, and Occupational Therapy: A Search for Understanding.

Occupational therapists strive to be mindful, competent practitioners and continuously look for ways to improve practice. Applied behavior analysis (ABA) has strong evidence of effectiveness in helping people with autism achieve goals, yet it does not seem to be implemented in occupational therapy practice. To better understand whether ABA could be an evidence-based option to expand occupational therapy practice, the authors conducted an iterative, multiphase investigation of relevant literature. Findings suggest that occupational therapists apply developmental and sensory approaches to autism treatment. The occupational therapy literature does not reflect any use of ABA despite its strong evidence base. Occupational therapists may currently avoid using ABA principles because of a perception that ABA is not client centered. ABA principles and occupational therapy are compatible, and the two could work synergistically.

Enabling children with Developmental Coordination Disorder to self-regulate through the use of Dynamic Performance Analysis: evidence from the CO-OP approach.

Anecdotal evidence suggests that Dynamic Performance Analysis (DPA) is learned by children with Developmental Coordination Disorder (DCD) during Cognitive Orientation to Occupational Performance (CO-OP) intervention. DPA is a tool used by therapists during the CO-OP approach to identify performance breakdowns and strategies for skill acquisition. This suggests that the self-regulation difficulties experienced by these children are amenable to intervention. The purpose of this proof of principle study was to determine: if school-aged children with DCD carry out DPAs, if DPA use was positively affected by intervention, and whether CO-OP had a larger effect on DPA use. Previously recorded videos of 13 children with DCD undergoing CO-OP, contemporary treatment or task-specific training were analyzed for evidence of DPA use. It was found that children in all three groups used simple DPAs before intervention; those receiving CO-OP intervention dramatically increased the number and quality of DPAs and could spontaneously apply it to the performance of another child. These findings indicate that, despite issues of self-regulation, children with DCD do self-monitor performance. More importantly, this ability can improve with CO-OP intervention as it guides the discovery of self-identified performance solutions, thereby enabling skill acquisition, generalization and transfer.

Rites of passage: understanding participation of children with developmental coordination disorder.

Children with developmental coordination disorder (DCD) experience difficulty participating in the typical activities of childhood and are known to have a more sedentary pattern of activities than their peers. Little research has been done to investigate the impact of these deficits on the lives of children with DCD and the importance of their participation in the typical activities of childhood. This qualitative study explored the impact of the disorder and the importance of participation for children with DCD from the perspective of the parent. Twelve in-depth interviews were conducted with parents of children with DCD who attended a university clinic specializing in using the Cognitive Orientation to daily Occupational Performance (CO-OP) approach, a cognitive-based intervention. Findings revealed that incompetence in everyday activities had serious negative effects for the children. Conversely, intervention that was focused on enablement at the activity and participation level had a significant positive impact on the children's quality of life. Emerging themes highlighted the notion that performance competency played an important role in being accepted by peers and being able "to be part of the group". As well, parents reported that successful participation built confidence in their children and allowed them to try other new activities. The World Health Organization's International Classification of Functioning, Disability, and Health provides a unique framework for analyzing and understanding the impact of the physical disability on the lives of families with children with DCD. Results illustrate how intervention that focuses on enabling children to choose their own functional goals in the area of physical activity has important implications for enabling participation and building the social networks of children with DCD.

The evolution of our occupational perspective: the journey from diversion through therapeutic use to enablement.

Occupational Therapy, in the broad sense of the term, has become the most serious problem before the statesmen of every nation in the world at the present time. All over the civilized globe, the widespread disease of unemployment (lack of occupation) is monopolizing the attention of national parliaments and world conferences. Everywhere the effort is being made to remedy human dissatisfaction and mental unrest by providing daily tasks so that minds may be occupied, bodies may be healthy, and the means of sustenance may be found (Howland, 1993, p. 4).

A pilot trial of a cognitive treatment for children with developmental coordination disorder.

This pilot study compared a new treatment approach, the Cognitive Orientation to daily Occupational Performance (CO-OP) to the Contemporary Treatment Approach (CTA) to treating children with Developmental Coordination Disorder (DCD). CO-OP emphasises problem-solving strategies and guided discovery of child and task specific strategies. CTA encompasses a variety of approaches, such as neuromuscular, multi-sensory, and biomechanical, focusing on motor aspects of skill acquisition. Twenty children with a mean age of 9.05 years (S.D. = 1.23) participated in the study. All children had normal intelligence, scored below the 15th percentile on a standardised test of motor ability, and demonstrated motor difficulties significant enough to warrant referral for treatment. Pre- and post-measures included the Canadian Occupational Performance Measure (COPM), the Vineland Adaptive Behavior Scales (VABS), the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP), the Developmental Test of Visual-Motor Integration-Revised (VMI), the motor items of the Self-Perception Profile for Children (SPPC), and the Performance Quality Rating Scale (PQRS). In both groups, treatment goals were child-chosen. Both treatments lead to improved COPM self-ratings of performance and satisfaction; however, improvements in the CO-OP group were greater than those in the CTA group. These results were paralleled by PQRS scores, and the Motor scores on the VABS, but not on the BOTMP measures. This outcome still needs replication as no control group was involved and because of the occurrence of pre-treatment differences between the CO-OP and CTA groups on relevant measures. Follow-up data indicated that children who received CO-OP tended to experience greater long-term maintenance of their motor goals and acquired strategies; follow-up parent-report rated CO-OP treatment as more useful than CTA treatment. Self-report, observer report, standardised assessment, and follow-up all demonstrated the effectiveness of the CO-OP approach, supporting the use of CO-OP and suggesting further investigation of this new cognitive intervention.

The search for subtypes of DCD: is cluster analysis the answer?

Studies using cluster analysis as a method to identify distinct subtypes of developmental coordination disorder (DCD) have been inconclusive leading some authors to conclude that the method of cluster analysis should be abandoned while others call for the validation of previously defined subtypes. The objective of the current study was to examine the use of cluster analysis as a method of searching for subtypes of DCD to gain a better understanding of how different samples and different measures influence the interpretation of results. The paper provides a detailed review of three commonly cited cluster analytical studies and then explores the possible reasons for the discrepant results by replicating the approach with a different clinical sample. The results highlight the impact of different measures on cluster structure and the importance of adoption of a common standard to facilitate interpretation across studies.

Cognitive orientation to daily occupational performance (CO-OP): part III--the protocol in brief.

Parts I and II of this series introduced the Cognitive Orientation to daily Occupational Performance (CO-OP), a new approach to intervention that is based on the premise that cognition plays an important role in the acquisition of occupational skills and the development of occupational competency. Developed for use with children who have occupational performance deficits, CO-OP is an individualized, client-centred approach focused on strategy-based skill acquisition. This third paper in this series presents a brief description of the actual CO-OP protocol including its objectives, prerequisites and key features.

Cognitive strategies and motor performance in children with developmental coordination disorder.

Recently, researchers in occupational therapy have investigated the use of a cognitive or "top down" approach to improving the occupational performance of children with developmental coordination disorder. A cognitive approach is multifaceted in nature and one essential component of such an approach is the use of cognitive strategies. Although strategy use has a long history within the education and psychology literature, little discussion within the pediatric therapy literature has occurred. This paper reports the results of an in-depth videotape analysis of therapists using cognitive strategies during occupational therapy intervention. Eight domain specific strategies were identified and elucidated. This research will be beneficial to therapists who wish to incorporate a cognitive approach into their clinical practice.

Treatment of children with Developmental Coordination Disorder: what is the evidence?

Children with Developmental Coordination Disorder (DCD) experience significant difficulty performing everyday tasks and management of these children is a great source of debate. Because little is understood about the etiology of the disorder, treatment design has been driven by competing theories of motor development and motor skill acquisition. Traditional approaches to treatment have been based on neuromaturational, hierarchical theories and, consequently, therapies have focused on remeditating underlying deficits with the expectation of subsequent improvement in motor performance. Contemporary approaches, drawn from human movement science, propose that treatment methods be based on the assumption that skill acquisition emerges from the interaction of the child, the task and the environment. This paper provides a review of the treatment literature over the past 15 years, highlighting the fact that little evidence exists to suggest any one approach is better than another. Given current demands for evidence-based practice, and evolving concepts in skill acquisition, a movement toward interventions that are based on functional outcomes is recommended.

Cognitive orientation to daily occupational performance (CO-OP): part I--theoretical foundations.

This paper is the first in a series of three papers that present the systematic development and evaluation of Cognitive Orientation to daily Occupational Performance (CO-OP). CO-OP is a cognitively based, child-centred intervention that enables children to achieve their functional goals. In Part I, the breadth of literature that provides the theoretical underpinnings for the approach is reviewed. Parts II and III provide a description of the approach and present the evidence to support its use with children with developmental coordination disorder.

Cognitive orientation to daily occupational performance (CO-OP): part II--the evidence.

CO-OP is a child-centred, cognitive based intervention, focused on enabling children to achieve their functional goals. It has been developed over the last nine years through a series of systematic studies that have specified the treatment protocol and evaluated its effect. Initially CO-OP was explored in two series of single case experimental studies. Subsequently, an informal follow-up study and a detailed analysis of the video-taped sessions of the approach were completed. Based on information from these studies, the approach was refined, key features elucidated and the protocol was specified. Next, a pilot randomized clinical trial was completed. The trial was conducted to determine how best to approach a full scale randomized clinical trial on the effectiveness of CO-OP, relative to the current therapeutic approach. Finally, a retrospective chart audit was carried out to examine the cumulative evidence on the effectiveness of CO-OP in improving the performance of children with DCD. This paper presents a detailed summary of these five studies and discusses the implications of the findings.

Clinical description of children with developmental coordination disorder.

Occupational therapists working within School Health Support Services are receiving increasing numbers of referrals, relative to past rates, for children who are experiencing motor problems and may have developmental coordination disorder. Based upon clinical experience, therapists indicate that these children are typically referred in the early school years and that most have handwriting difficulties; to date, however, there has been little empirical evidence to support these observations. In this paper, descriptive information is presented for 556 children who may be presumed to have developmental coordination disorder and who had been referred to school-based health services in two centres. Typical reasons for referral, co-morbidity information, and assessment practices are presented. Findings confirmed the presence of many occupational performance issues in this population, including handwriting difficulties, and challenge therapists to broaden the current scope of school health assessment and intervention practices.

Dynamic performance analysis: a framework for understanding occupational performance.

Occupational therapy is now consistently described as a profession concerned with enabling occupation. A crucial step in enabling occupation is understanding the occupational performance of our clients. Dynamic Performance Analysis (DPA) is a new approach to occupational analysis that focuses on the client's actual performance. DPA, acknowledging that optimal performance is the product of the interaction of person, environment, and occupation, and thus highly individualistic, places the client and his or her occupation, in interaction with the environment, at the center of the analysis process. Embedded in a top-down framework, DPA is a dynamic, iterative process, carried out as the client performs the occupation. The purpose of DPA is to identify where performance breaks down and test out solutions. In this article, the rationale, origins, and basic assumptions of DPA are discussed, and a detailed description of the DPA process together with two clinical examples is presented.

Chronic pain in the elderly: occupational adaptation as a means of coping with osteoarthritis of the hip and/or knee.

OBJECTIVE: To determine whether elderly individuals with chronic pain as a result of osteoarthritis of the hip and/or knee would report adaptations to their activities, or occupational adaptations, as a coping response to pain and, if so, to describe these adaptations and their relation to chronic pain, functional difficulty, depression, social support, and life satisfaction. DESIGN: Thirty elderly individuals completed rating scales and a structured questionnaire designed to measure occupational adaptation and the importance of activity. SETTING: Participants were community-dwelling elderly individuals and were interviewed in their homes or in a research office setting. PATIENTS: Consecutive orthopedic surgeon, family physician, or Arthritis Society patients, whose names were provided with the patient's consent, to the researcher. RESULTS: Individuals reported two approaches to occupational adaptation: they changed how they performed personal activities of daily living that they rated as most important and they stopped performing a number of avocational activities that they rated as less important. Statistically significant correlations were found among occupational adaptation, pain, depression, and difficulty with functioning. These variables were inversely related to life satisfaction. CONCLUSIONS: This sample of elderly individuals with chronic pain described occupational adaptations, or adaptations to "doing," as a means of coping with their chronic pain. There appeared to be a relation among pain, functional difficulty, depression, social support, and occupational adaptation. Additional research to increase the understanding of occupational adaptation as a means of coping with chronic pain is warranted.

Motor problems in children with developmental coordination disorder: review of the literature.

Occupational therapists frequently work with children with developmental coordination disorder (DCD) in hopes of enhancing their occupational performance. There is debate among researchers and health care professionals about whether the motor coordination problems experienced by children with DCD have a physiological basis or whether they are the result of a developmental delay. Even among researchers who agree that these difficulties are of physiological origin, there is a lack of consensus as to whether these motor problems are multisensory or unisensory. This article focuses on the physiological explanation, presents a review of the literature on the possible physiological origins of motor coordination problems in children with DCD, and shows that the current literature on the physiological basis of DCD requires more empirical evidence to substantiate either multisensory or unisensory theories of motor dysfunction in children with DCD. The debate over the nature of motor problems in children with DCD has two implications for occupational therapists: that there is no one way to treat these children and that the cause of the difficulty varies from child to child.

A clinical trial of the process-oriented treatment approach for children with developmental co-ordination disorder.

The process-oriented treatment (POR chi) approach is a time-limited programme aimed at increasing the kinaesthetic performance of children with mild motor problems in order to improve their motor performance. The approach was compared with a traditional or general motor approach and with no treatment in a randomized clinical trial of 75 children with developmental co-ordination disorder. The children were assessed before and after treatment and after a six-week follow-up period. The results were mixed. The study provides evidence of the severity of so-called 'mild' motor problems of children referred to occupational therapy. The data suggest that these children do not improve spontaneously, and that their motor problems are very resistant to treatment. The data also suggest that an appropriate treatment strategy might be one that involves direct, repetitive training of a specific skill.

Use of the Bruininks-Oseretsky test of motor proficiency in occupational therapy.

OBJECTIVE: In addition to the need for good measurement tools in occupational therapy, there is a need for the tools to be used knowledgeably. The purpose of this article is to investigate the usefulness of the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) for both descriptive (diagnostic) and evaluative (change over time) purposes. METHOD: The typical profile of subtest scores for children with mild motor problems revealed that certain subtests of the BOTMP may be better indicators of motor problems for these children than others. An analysis also was performed to compare the use of raw (point) scores with standard (age-adjusted) scores in evaluating change. RESULTS: Four subtests that provide a greater degree of discrimination between children with and without motor problems were identified. Raw (points) scores were found to provide a more valid measure of change over time than standard (age-related) scores. CONCLUSION: We recommend that, for clinical use, the BOTMP subtest standard scores be used for diagnostic purposes and that the raw scores be used for evaluative purposes.

Measuring perceived self-efficacy in occupational therapy.

OBJECTIVES: Occupational therapists sometimes observe an alarming discrepancy between the occupational performance skills developed in the clinical setting and the degree to which the client willingly puts these skills to use outside the clinical environment. The literature strongly suggests that perceived self-efficacy partially explains this discrepancy; however, an understanding of perceived self-efficacy has not yet been integrated into the practice of occupational therapy. Both a lack of awareness of the construct and a lack of ability to assess perceived self-efficacy within the occupational performance domain are responsible for this lack of integration into practice. This article presents the development, reliability, and validity testing of a measure of perceived self-efficacy developed particularly for use by occupational therapists, the Self-Efficacy Gauge. METHOD: Reliability and validity testing was performed through use of a mailed survey (n = 126). Test-retest reliability, internal consistency, and alternate form reliability were examined. In addition, the subjects' scores on the Gauge were compared to actual performance and a hopelessness scale. RESULTS: The Self-Efficacy Gauge has a reasonable degree of reliability when used on a clinical sample whose perceived self-efficacy for occupational performance activities is unlikely to change. The results also provide preliminary support for the validity of the instrument. CONCLUSION: It is recognized that without a gold standard for comparison, validity testing will be an ongoing need.

Dreams, dilemmas, and decisions for occupational therapy practice in a new millennium: a Canadian perspective.

This article presents the hope that, in the 21st century and the millennium it ushers in, the world will eliminate the concept of handicap by creating an environment where persons with different abilities can live with dignity. In this world, the focus of occupational therapy will shift from reducing impairment through purposeful activity to preventing handicap through enablement. Basic assumptions about occupational therapy and its values are provided, including that the ultimate goal of practice is the enablement of occupational competence.

Reexamination of sensory integration treatment: a combination of two efficacy studies.

Little empirical support exists for the application of sensory integration treatment (SIT) to assist children with learning problems. Treatment efficacy studies are expensive and difficult to carry out, and they have necessarily employed small samples that are inevitably heterogeneous. We have reanalyzed the efficacy of SIT by combining the data from one study involving 29 children in Alberta and a second study involving 67 children in Ontario. The results from each individual study, and now the results from the combined study, lead one to the conclusion that the therapeutic effect of SIT on children with learning deficits is not greater than other, more traditional methods of intervention.