Foundations for Occupational Therapy Practice with Children

Development

Perspectives on development and occupation have changed over the past century with changes in our knowledge about children, the factors affecting their development, and their basic need for engagement in purposeful tasks and activities. Developmental theories focus on explaining the processes by which infants mature and gain skills to become fully functioning adults. At the core of developmental theories is an explanation of the relationship between human biologic capacity and maturation and the influence of the environment on the behavior and performance of the individual. In fact, developmental theories tend to be distinguished from each other by the relative weight given to these two factors, nature or nurture, or by the emphasis on a particular aspect of human biologic function or environment. The theories of Gesell emphasized the genetic and biologic determinants of development; however, more recent theories (e.g., Piagetian theories) focus on interaction of biologic and environmental determinants of behavior.⁷⁰ In current times, developmental theorists generally agree that human development is both the process and the product of biologic maturation and environmental experiences.

Development may be defined as the sequential changes in function that occur with maturation of the individual or species. These sequential changes should be differentiated from the concept of growth, which refers to maturational changes that are physically measurable. In the past, different dimensions of development have been emphasized. For example, longitudinal development focuses on the stages of development, whereas hierarchical development focuses on the prerequisite skills needed for higher-level skills. Evolving views and theories of development place less emphasis on the stages and components of development and more on the person as a whole and his or her development in relation to environment, roles, and occupations.⁸⁴ The emerging theories of person–environment relations and complex systems have influenced these changes. Developmental theories are further explained later in the chapter.

Participation in Occupations

Throughout the 1920s and into the 1930s, the focus of occupational therapy was the development of the idea of occupation as a cure for disease and disability. The occupations best suited to cure specific medical problems were identified. Dunton led an effort to analyze occupations systematically.⁶⁰ Occupational therapists used the principles of graded, purposeful activity and a balance of work, rest, and play as the basis for treatment methods.^122,172

In the 1940s, changes in the medical arena (e.g., the discovery of antibiotics and the advancement of specific medical and surgical techniques) had a tremendous influence on the way in which occupational therapists used occupation in treatment. The development of specific techniques increased, and more focus was placed on programs addressing activities of daily living. Occupational therapy treatment focused on the prescription of activities with specific aims.⁸⁷ For example, the flexion-extension-pronation-supination (FEPS) loom was developed to ensure that targeted ranges of movement were achieved. As a result of these changes, treatment became “medicalized.” In other words, the focus of occupational therapy became a series of technical activities rather than purposeful occupation. The influence of the medical model on the profession dominated for three decades and remains a predominant influence today.

As the 1960s ended, occupational therapists were increasingly uncomfortable with the technical focus of their profession. There was a call for more emphasis on the development of theory and a renewed interest in the roots of the profession: occupation.²⁰³ During this time, Reilly described a theory of occupational behavior in which the individual strives to develop skills and competencies directed toward mastery and achievement.^153,156 Work and play were viewed as the contexts in which these skills and competencies developed. Fidler and Fidler focused on the importance of purposeful activity, or doing, in the development of self and the prevention of dysfunction.⁶⁵ Kielhofner and Burke, building on Reilly’s work, described a model of human occupation that incorporated a systems theoretical view of the nature of occupation.⁹¹ This model expanded the understanding of life roles and the powerful influence they have on daily life and health.

In the past 20 years, a specific academic discipline called occupational science became a basis of occupational therapy.²⁰⁴ Study of the human as an occupational being is essential to an understanding of the complexity of engagement in occupation and the relationship between occupation and human health. As noted by Parham, “A full understanding of occupation requires the integration of knowledge from many disciplines, such as philosophy, biology, psychology, sociology, and anthropology” (p. 25).¹⁴² Wilcock emphasized occupation as purposeful activity and explained that humans need to use time in a purposeful way in order to develop and flourish.¹⁹⁵

As the study of occupation has developed, occupational therapy scholars have proposed definitions of occupation. Clark and colleagues defined occupations as “chunks of daily activity that can be named in the lexicon of the culture” (p. 301).³⁶ Christiansen, Clark, Kielhofner, and Rogers defined occupation as the “ordinary and familiar things that people do every day” (p. 1015).³⁴ The definition adopted by the Canadian Association of Occupational Therapists (CAOT) states that “occupation refers to a group of activities and tasks of everyday life, named, organized, and given value and meaning by individuals and a culture” (p. 34).³⁰

Each definition refers to daily activities or “chunks” of activity. Because occupation references daily activity, it is often thought of as simple; that is, the basic activities that people perform each day to look after themselves, to be productive, and to enjoy life. The definition of occupation becomes more complex with the inclusion of its meaning or purpose. The meaning of an occupation for an individual or the value of an occupation determined by a culture begins to show the many layers of occupation and the central relationship of occupation to the human experience.

Participation in occupations meets a basic human need.³⁰ Dunton expressed his belief that occupation is as necessary to life as food and drink.⁶⁰ Occupation also is an important determinant of health. Health can be strongly influenced by a person’s engagement in meaningful occupations, and conversely, the absence of meaningful occupation can have dire health consequences.¹⁹⁶ Occupation serves as a means of organizing time, space, and materials. Patterns, habits, and roles evolve through the organization of occupation.⁹⁰ Occupations change over the lifespan (as do patterns of time use), representing occupational development.

Play is a key area of occupational focus in practice with children. Chapter 18 describes occupational therapy perspectives on play. Most of the focus in the occupational therapy literature has been on play as a means and an end: as a therapeutic medium (a means to developmental change) and as an indication of developmental level (an outcome of intervention).¹⁴² Therefore, play elicits more than enjoyment; it is also a catalyst to the development of motor or cognitive skills. In their survey of pediatric occupational therapists, Couch, Deitz, and Kanny found that pediatric occupational therapists most often use play in therapy as a medium for developing both the skills underlying function (e.g., understanding cause-and-effect relationships, exploring an object by manipulating it) and an understanding of the rules that guide behavior (e.g., taking turns).⁴² Occupational therapists often observe children’s play and play with them to determine their level of performance and to analyze their performance (Figure 2-1).¹⁰⁴ Less often, but probably more importantly, therapists view play as a priority outcome of interest, the end rather than the means. Parham suggested that therapists must understand that “play is a legitimate end in itself because it is a critical element of the human experience” (p. 24).¹⁴² Play is therefore a quality-of-life issue that promotes health and well-being.

In a similar way, occupation has a dual role in the profession, as both the focus of intervention and the medium through which occupational therapists often intervene. For example, a child may be struggling at school to successfully fulfill his role as a student because he has Asperger’s syndrome. The student struggles with his academic occupations because he is anxious and overaroused. His social participation is limited because he has limited ability to read the social cues of his peers. The occupational therapist evaluates the school activities in which this child is expected to participate and determines the personal and environmental factors that are influencing the child’s performance. These occupations become the focus of intervention; for example, the occupational therapist helps the teacher make accommodations to the classroom environment to decrease the student’s overarousal and improve his concentration in class. The occupational therapist also helps the student interpret social cues and gestures. The therapist models and instructs the student in appropriate social responses and creates opportunities for him to interact with peers with therapist support. Scaffolding the child’s participation in social activities with peers at school is likely to develop skills that generalize to other opportunities for social participation. This brief example illustrates intervention principles that enable children’s participation in everyday occupations (Box 2-1).⁹⁶

The goal of an occupation-based model of practice is the child’s achievement of optimal occupational performance. What do professionals know about the occupational performance of children with special needs? According to the National Health Interview Survey of 1992 to 1994, 6.5% of children in the United States with disabilities are limited to some degree in their participation in daily activities.¹³⁵ The study investigators reported that children with physical disabilities are “two to three times more likely to be unable to perform their usual activities than children with other conditions (e.g., asthma)” (p. 612).¹³⁵ Children with special needs also have lower rates of participation in ordinary daily activities.¹⁷³ Researchers have documented that children with disabilities are more restricted in active recreation and community socialization activities.¹⁶ Specifically, Bedell and Dumas found that children with acquired brain injury were most restricted in participating in structured community events, managing daily routines, and socializing with peers and they were least restricted in physical mobility.¹⁷

Australian studies¹¹³ and Canadian studies¹⁰¹ have found an inverse relationship in children with disabilities between amount of physical activity and age, with a significant decline in active leisure participation from childhood to adolescence. Although healthy children are less physically active as adolescents, they continue to participate in a wide range of leisure activities. In contrast, adolescents with disabilities engage in fewer leisure and social activities, and their activities tend to be more often home-based than community-based.¹⁶⁸ See Chapter 4 for a discussion of adolescent participation.

In their systematic review of studies of leisure activities in children and youth with physical disabilities, Shikako-Thomas et al. found that children with disabilities participate more in informal activities (e.g., those activities that require little or no planning and are often self-initiated [reading, playing with toys]) than in formal activities (e.g., those with a formally designated coach or instructor [music or art lessons, organized sports]).¹⁶⁸

Both intrinsic (personal) and environmental (family and community) factors influence the diversity of activities and the intensity of participation. The intrinsic factors include motor function,¹⁴⁰ personality, social skills, age, and gender. Girls tend to participate more in arts and social activities, and boys participate more in group activities involving physical activity and sports.^61,168 Family support can have a positive or negative effect. Children’s activities may be restricted by family time constraints, financial burden, and lack of supportive mechanisms (e.g., babysitting).¹⁰¹ Participation for children with disabilities is positively influenced by high levels of family cohesion, high incomes, strong family coping skills, and low levels of stress.^101,168 Community barriers to children’s participation include barriers to physical access, lack of programming, and negative attitudes. Clearly, encouraging participation in the typical activities of childhood needs to be the major focus of pediatric occupational therapy.

Environment

Human ecology is the study of human beings and their relationships with their environments. Environments are the contexts and situations that occur outside individuals and elicit responses from them, including personal, social, institutional, and physical factors. Environmental factors can facilitate or limit engagement in occupation. A concept prevalent in the human development literature and more recently in health care is person–environment congruence, or environmental fit, which is described as the congruence between individuals and their environments.¹⁷⁶

Over the past two decades, occupational therapists have stressed the importance of the interaction between individual and environment. Specific models of practice have been developed with a focus on environment.^57,99 Systems theory, emphasizing the interdependent relationship between individual and environment, forms the basis for concepts that define occupational therapy and models of practice. Primary models of practice address the environment in terms of its cultural, social, institutional, and physical dimensions and the transactional relationship between people and the environments in which they live, work, and play.^158,204

Psychologists who created theories and models about the relationship between humans and their environments that have influenced occupational therapy include Bronfenbrenner,²⁵ E. Gibson,⁷¹ and J. Gibson.⁷² Bronfenbrenner, with a background in developmental psychology, studied how the child’s social and cultural environments influenced development.²⁵ He believed that an interdependent relationship exists between a person and his or her social and cultural environments. Different levels of social support and social interactions surround the individual, including informal (e.g., family and friends) and formal (e.g., occupational therapists and teachers). Levels of the environment are defined by their proximity to the individual; that is, family is most important, then friends and extended family, and then the community and society. Children interact with and are influenced by all levels of the social environment. Changes at any level of the environment influence a person’s behavior. Throughout his or her life, a person constantly adapts to and influences changes in his or her social environments.

According to Bronfenbrenner’s theories of social development, occupational therapists are part of a person’s social environment.²⁵ These theories help the therapist understand lifespan changes in clients in the context of their social settings. The interdependence between a person and the social environment helps therapists to expand intervention strategies to include families and communities.

Ecologic psychologists E. Gibson and J. Gibson considered the interdependence of a person with his or her environment to be an explanation of perceptual development. E. Gibson understood that manipulative play had a key role in the infant’s cognitive development.⁷¹ She believed that the child’s intrinsically motivated exploratory actions lead to perceptual, motor, and cognitive development through the concept of affordance. An affordance is a quality of an object or an environment that allows an individual to perform an action. Action and perception are tightly linked: the child’s first actions are to gather new information about the environment and those actions form the basis for perceptual development (the child’s understanding of the environment). “As new action systems mature, new affordances open up and new experiments on the world can be undertaken” (p. 7).⁷¹ As explained by E. Gibson:

Successful adaptation to the environment occurs when a person matches his or her activities to the affordances of the environment or when the person modifies the environment to ensure successful completion of an activity.

The Gibsons’ theories emphasize the importance of understanding a child’s development in the context of daily surroundings and activities. Occupational therapists are encouraged to provide activities (based on their understanding of the activity’s inherent affordances) that allow a child to explore and learn about the environment, enabling achievement of the child’s goals. Figure 2-2 demonstrates an infant’s motivation to explore.

Risk and Resilience

Several theories and research programs have been developed to explain the ways the environment influences the developmental outcomes of children and adolescents. Most of this work focuses on the participation of children and youth in everyday activities and on factors that either place children and adolescents at risk for poor outcomes or help them achieve optimal outcomes. For example, psychologist Emmy Werner studied the people of Kauai for more than 40 years. Her research indicated that participation in extracurricular activities plays an important role in the lives of resilient adolescents, especially when they participate in cooperative activities.¹⁹²

Resilience can be defined as the characteristic of an individual who achieves a positive outcome in the context of risk, or factors known to be associated with negative outcomes. Research on risk and resilience has attempted to explain why some children have better outcomes than others who were raised in similar circumstances. The study of resilience has implications for increasing understanding of child development and for developing new interventions to improve outcomes for children at risk. When the concept of resilience was first studied, it was believed to be a stable personality characteristic, such as temperament or IQ. If resilience were an internal, stable characteristic, it would explain why one child did better than another in a particular environment. Currently, researchers understand resilience to be a dynamic process that is refined over time through ongoing transactions between a child and the environment.¹¹⁰

What are the risk factors for children who receive occupational therapy? Often the disability is not a primary risk; however, it can add to cumulative risk when the family has socioeconomic disadvantage, negative parental relationships, parental mental illness or physical illness, and lack of extended family support. Emerging evidence indicates that it is the total number of risk factors to which a child is exposed and the resources available to promote resilience for that child that ultimately are predictive of the child’s vulnerability to future adverse events and developmental outcomes.^62,163

Protective factors are defined as characteristics of the child, family, and wider environment that reduce the negative effect of adversity on the child.¹²⁰ These protective factors may be specific to the risk factor; for example, having warm and loving parents is a protective factor in early childhood, but may not serve as a protective factor when the child become an adolescent and is more influenced by peers and the teen culture. Researchers such as Rutter¹⁶² and Garmezy⁶⁸ have identified general protective factors related to the child, the family milieu, and the social environment. Understanding these general protective factors may be helpful in designing interventions for at-risk children. Child protective factors include strong self-esteem and positive communication skills.^68,192,193 Other child attributes that are associated with positive outcomes include intelligence, emotion regulation, temperament, coping strategies, and attention.¹⁸⁴ Children who can effectively process information and problem-solve can use these abilities in adverse situations. Children who can regulate their emotions can monitor and modify the intensity and duration of their emotional reactions, enabling them to better function at school and in social relationships. An easygoing temperament is also a protective factor because it may evoke more positive attention from adults. Coping skills are also important because children with strong coping skills can moderate the impact of a difficult situation.

Essential resources that lead to resilience in the child are family resources such as love, nurturance, and a sense of safety and security. These must be accompanied by material resources such as nutrition and shelter.¹⁸⁴ Attributes of the family that influence positive outcomes include family cohesion and harmony.⁶⁸ Researchers have shown that a high-quality relationship with at least one parent, characterized by high levels of warmth and openness and low levels of conflict, is associated with positive outcomes across level of risk and stages of development.¹⁰⁹

Protective factors in the community also contribute to the child’s development. Neighborhood quality, youth community organizations, quality of school programs and after-school activities can all influence a child’s ability to cope with risk factors and overcome adversity.¹⁸⁴ Attributes of the social environment that promote resilience include extended social support and availability of external resources.⁶⁸ Environmental factors, such as family-centered service delivery, acceptance of community attitudes, supportive home environments, and mentoring relationships with adults, have been shown to have a positive influence on child development.^157,189,193

Family-Centered Service

During the past 20 years, families of children with disabilities have increased their role in determining and implementing services for their children. Families have been leaders in promoting family-centered service, a philosophy of service provision that emphasizes the central role of families in making decisions about the care their children receive. Challenged by the changes in the health services field and an increased demand by consumers for involvement in the services they receive, health care providers have made great strides in implementing family-centered service.

The term family-centered service arose from early intervention programs. Three important concepts define family-centered service: (1) parents know their children best and want the best for their children; (2) families are different and unique; and (3) optimal child functioning occurs in a supportive family and community context. Chapter 5 explains the rationale for and application of family-centered practice.

In family-centered service the family’s right to make autonomous decisions is honored. The relationship between the family and professionals is a partnership in which the family defines the priorities for intervention and, with the service providers, helps direct the intervention process.⁵⁹ In working with families, service providers emphasize education to enable parents to make informed choices about the therapeutic needs of their child. Comprehensive education about services and community resources can help families understand the disability, acquire tools to manage behavior, and develop strategies for obtaining community resources. In family-centered practice intervention is based on the family’s visions and values; service providers recognize their own values and do not impose them on the family. The family’s roles and interests, the environments in which the family members live, and the family’s culture make up the context for service provision. Individualization of both the assessment and intervention processes is essential to family centeredness. Intervention is viewed as a dynamic process in which clients and parents work together as partners to define the therapeutic needs of the child with a disability. Services are designed to fit the needs of the family, rather than to force the family to fit the needs of the service providers or the intervention policies already in place. DeGrace explains that occupational therapy intervention needs to fit into a family daily routine because how a family participates in daily routines “defines who that family is and plays a key role in determining its health” (p. 348).⁵⁰ Because each family is unique, practitioners need to ask about and learn how each family defines their routines, habits, and values, and to adapt their services to this family-constructed definition.

Research has demonstrated that parents feel more positive about their roles when service providers solicit and value parental participation. Increasing evidence in the literature indicates that interdisciplinary, family-centered service for children with disabilities leads to increased family satisfaction and may lead to greater functional improvement in children with disabilities.^114,161 Parents are less likely to act on behalf of their child when practitioners are unresponsive to the family’s needs, are paternalistic, or fail to recognize and accept family decisions.⁵⁸

Family-centered practice is characterized by appreciation and valuing of the family’s concerns and priorities, family support, and family education. Therapists who practice family-centered care seek information about how the disability impacts family occupations and what occupations are important to the family.⁵¹ Other examples of family-centered practice include helping families find social supports and network with other families¹⁹ and supporting families in gathering needed resources.⁷⁷

The findings of a recent survey completed by 494 parents and 324 service providers from children’s rehabilitation centers indicate that parental satisfaction with service is primarily determined by the family-centered culture of the organization and by parental perceptions of family-centered service.¹⁰⁰ Families’ satisfaction with services also decreases feelings of distress and depression and improves feeling of wellbeing.⁹² Occupational therapists who work with children enhance the effectiveness of their services when they practice from a family-centered perspective.

World Health Organization International Classification of Functioning, Disability, and Health

The World Health Organization (WHO) International Classification system, which is used in the broad rehabilitation and disability arena, influenced the structure of the Occupational Therapy Practice Framework² and has been used to guide the structure of occupational therapy evaluation. The International Classification of Impairments, Disabilities, and Handicaps (ICIDH) was first developed and published in 1980.²⁰¹ The revised classification system is titled the International Classification of Functioning, Disability, and Health (ICF).²⁰² The ICF views human functioning at three levels: the body (structure and function), the person (activities), and society (participation). It also includes the domain of environmental factors, which can have a significant influence on a person’s functioning and health. The ICF model of functioning, disability, and health depicts the dynamic interaction between a person and his or her environment at all levels of functioning. A recent extension of the ICF, the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) has been developed to address the unique concerns of developing children.¹⁰⁷ Recently developed measures align with the ICF and enable practitioners to assess children at multiple levels. The School Function Assessment is an example of scale that rates function at two levels, activities and participation.⁴¹ The American Occupational Therapy Association (AOTA) has acknowledged the strong connection between its practice framework and the ICF by establishing the domain of the profession as “supporting health and participation in life through engagement in occupation” (pp. 626-627).²

Piaget and Cognitive Development

Jean Piaget was concerned with the developmental adaptation of the individual in response to ongoing environmental experiences.¹⁴⁵ He defined adaptation as the child’s ability to adjust to change to fit into his or her environment, and he examined adaptation through the child’s relationships with human and nonhuman objects and through time and space. Piaget¹⁴⁴ introduced the idea that children are intrinsically motivated to learn from their surroundings and that they act on, rather than simply react to, their environment.⁹⁵ Piaget used the terms cognitive structures, or schema, to describe the way in which children represent objects, events, and relationships in their minds. Piaget viewed every interaction as an opportunity either to assimilate new knowledge into existing structures or to adapt existing structures to accommodate new information. Accommodation is new learning, and it is believed to be the way that the cognitive progress is made. Piaget’s developmental stages have been the focus of research and critique; however, his descriptions of the gradual accumulation of knowledge in specific content areas remain valid concepts in child development.

Piaget believed the child organizes his experiences into mental schemes (concepts) through mental operations. Operations may be defined as the cognitive methods used by the child to organize his or her schemes and experiences to direct his or her actions. The totality of operational schemes available to the child at any given time constitutes the adapted intelligence, or cognitive competence, of the child.

Piaget believed that an invariant, hierarchical development of cognition proceeded from the simple to the complex, from the concrete to the abstract, and from personal to worldly concerns. He specified four maturational levels or periods of cognitive function: sensorimotor, preoperational, concrete operational, and formal operational.^37,67 He believed that this sequence of development leads to the cognitive maturity of adulthood. The culmination of these levels is a person with values, goals, and plans and an understanding of his or her purpose in society. In current times, most child researchers agree that the child is an active learner, but do not view development in discrete stages.

An understanding of Piaget’s theory is important to occupational therapists who plan programs for children. Regardless of the therapeutic approach used in treatment, the therapist interacts with a thinking child who is continually learning from his environment. It is essential that the selection and structure of an activity be in accordance with the operational skills and concepts of the child.

The primary focus of Piaget’s concept is an explanation of cognitive learning, but Schmidt developed the idea further in the area of motor learning.¹⁶⁷ He proposed that motor schemas are formed as combinations of (1) the initial conditions of the movement, (2) the specific parameters used to create it, (3) the knowledge of the results in the environment, and (4) the sensory consequences of the movement. Through repeated experiences, the child abstracts relationships among these four features and is considered to have learned a new movement.

Vygotsky and the Zone of Proximal Development

Vygotsky viewed human development as historically situated and culturally determined.¹⁹⁴ The child develops by internalizing the social interactions that he experiences. Vygotsky was primarily interested in speech and language development; however, his concepts have important applications to child development across domains. Like his predecessors (e.g., Gesell and Piaget) Vygotsky understood that genetics has unequivocal influence on psychological development. However, he recognized that psychological function could only be explained by considering the role of social interaction. Social interaction has a fundamental influence on the child’s development of high mental functions. Vygotsky explained that a child’s cognitive processing first requires the assistance of another being within a social interaction before the child can mentally process on his own. Therefore, cognitive processing is a social process before it is an internal process and a child’s development and learning are critically dependent on social interaction. Vygotsky defined a “zone of proximal development” to explain how learning occurs through social interaction. The zone of proximal development is “the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance or collaboration with more capable peers” (p. 86).¹⁸⁸ What a child can achieve and learn with the assistance of another is the zone of proximal development and defines the area in which adults can work with the child to promote his development and independence in a particular skill.

When an adult and a child experience an activity together, they interpret the objects and events differently. Adults use language to help the child redefine the situation so that adult and child have a shared definition. When a learning opportunity is created that provides an optimal balance between the child’s existing skills and the challenge of the task, the adult can model language and behavior that will help the child progress. Vygotsky’s emphasis on the interactions among a child’s learning, his environment, the type of instruction provided, and his culture was a precursor to many of the dynamic systems models that influence learning theory today.

Vygotsky’s concepts about social learning within the zone of proximal development led to a therapeutic principle called scaffolding. Scaffolding is the process by which therapists or adults support or guide a child’s actions to improve his or her competence. Appropriate guidance is the just right amount of support that enables the child to perform at a higher level. When using scaffolding to facilitate the child’s learning, the adult gradually decreases the amount of support provided such that the child performs more independently. Through this process, actions that are externally supported become internalized. Wertsch makes the point that the child’s help-seeking in an activity can be as important to his learning as receiving that assistance.¹⁹⁴ By asking questions and help-seeking, the child becomes more self-directed in his learning; he also develops an understanding about his own learning and how to direct social interactions that can lead to his learning. When the occupational therapist understands a child’s zone of proximal development and perceives methods for scaffolding his learning, she or he can design an optimal activity to promote the child’s learning. Case Study 2-1 presents an example of applying Vygotsky’s theories.

Maslow and the Hierarchy of Basic Needs

Abraham Maslow is generally considered the father of humanistic psychology in the United States.⁷⁶ He outlined a hierarchy of basic human needs that is believed to follow a longitudinal sequence.^118,119 An individual’s most basic needs, those at the base of this hierarchy, are physiologic needs, such as food, water, rest, air, and warmth, that are necessary to basic survival. The next level is characterized by the need for safety, broadly defined as the need for both physical and physiologic security. The need for love and belonging promotes the individual’s search for affection, emotional support, and group affiliation. The need for a sense of self-esteem, which is defined as the ability to regard the self as competent and of value to society, is evidenced as an individual grows. The need for self-actualization, which represents the highest level, is attained through achievement of personal goals.

Maslow proposed that each of these needs serves as a motivator to achieve a higher level of human potential. Throughout development, individuals must satisfy their most basic needs before they are motivated by or interested in other life goals. Foundational biologic and egocentric needs must be satisfied before an individual has social interests and can fully participate in social relationships. With important social relationships established, an individual becomes interested in the broader community and has a broader sense of commitment and responsibility to others within the community. If the lower level needs are not met, the individual is not able to direct his or her energies toward higher levels. For example, a child who comes to school hungry finds it difficult to concentrate on the classroom learning activities. Recognition of a child’s needs and the hierarchy of development of these basic needs helps the occupational therapist understand behaviors that indicate that basic needs are not met and identify needs that should become the focus of goals and interventions.

Behavioral Theories

The past 60 years have witnessed tremendous progress in the field of learning theories. Early learning theorists, such as Thorndike, emphasized the association between a behavior and the resulting reward or punishment as a simple explanation of behavioral change. Skinner described perhaps the best known learning theory from this era. He believed that the environment shapes all human behaviors and that behaviors may be randomly emitted in response to an environmental stimulus.¹⁷⁰ In other words, a person tries a behavior that worked in a previous situation, or an involuntary, reflexive response is elicited by an environmental stimulus. The behavior is then reinforced by the environmental consequences that follow. This sequence—stimulus situation, behavioral response, and environmental consequence—constitutes a contingency of behavior, the mechanism by which the environment shapes behavior.

Skinner stated that through natural occurrences in the environment, a child’s adaptive behaviors are reinforced, and behaviors that are not adaptive are ignored or punished.¹⁷¹ The Skinnerian concept that became fundamental to interventions for children is instrumental or operant learning or the use of reinforcement to modify behavior. Behavior is strengthened and maintained when it results in positive reinforcement (rather than punishment). If reinforcement is absent (i.e., not given) and therefore is negative, positive behaviors may be extinguished.

Skinner believed that all behavior is a result of the environmental control of the individual, culture, and species. He specified that humans, species, and culture are all part of the environment; therefore, they control as much as they are controlled. Problems arise when an environment changes and becomes inconsistent with prior contingency patterns. For example, children use one set of behaviors with their families and another set with friends. Behaviors that are reinforced by friends may bring complaints from or may be ignored by parents. Critics of this theory cite its failure to explain personality traits (e.g., motivation) and cognitive abilities (e.g., imagination and creativity) and its tendency to generalize across age and gender spectrums with no recognition of developmental differences. Chapter 14 provides further explanation of behavioral interventions.

Extensive research has confirmed that when particular behaviors result in specific, consistent consequences, these behaviors can be modified.⁴⁰ Therapists using a behavioral approach can help a child achieve a higher level of performance through a process called shaping. Shaping involves breaking down a complex behavior into components and reinforcing each behavior individually and systematically until it approximates the desired behavior (Box 2-2).

In recent years, learning and behavioral theories used with young children have evolved into approaches that can be applied broadly across settings. Applied behavioral interventions primarily use operant conditioning in highly controlled environments in which a therapist or teacher gives the child an instruction and then rewards the child for an appropriate response (reinforcement). Applied behavioral interventions are successful in developing skill; however, skills learned in an isolated setting, as in discrete trial training, do not always generalize into new or higher level behaviors across all settings. Educators have developed behavioral approaches that also use Skinner’s framework of instrumental (operant) learning and can be implemented in the child’s natural environment to teach children adaptive behaviors that generalize across environments.⁹⁴ Educators in early childhood programs have advocated for naturalistic teaching procedures that can be implemented in minimally structured sessions, in a variety of locations and contexts, with a variety of stimuli. Although educators who used naturalistic teaching procedures hold the same developmental goals for children as those who use classical behavioral theory, their procedures are much less structured, incorporate peers, and use naturalistic conditions and reinforcers.⁴³ Two types of these naturalistic learning procedures, incidental teaching and pivotal response training, are frequently used with young children in early childhood programs.

In incidental teaching, a play environment is created to stimulate the young child’s interest and curiosity. It is important that toys used be developmentally appropriate, with both novel and familiar toys. The goal is for the child to select an activity and spontaneously begin to play. The therapist builds on the child’s play selection by expanding the play scenario so that it becomes more challenging or creates a problem for the child to solve. The therapist may cue the child to perform a different action and reward the child for attempting more challenging actions. These teaching sessions take a different approach than do behavioral interventions, which use discrete trial training in which the child is given specific directives and rewarded for a specific response. Table 2-1 compares incidental teaching and discrete trial training.

Pivotal response training is also a naturalistic teaching and learning approach used with young children.⁹³ The goal of pivotal response training is to teach children a set of pivotal behaviors believed to be central to learning. The desired outcomes of pivotal response training include increasing (1) the child’s motivation to learn, (2) attention to learning tasks, (3) persistence in tasks, (4) initiation of interactions, and (5) positive affect.¹¹⁵ Procedures that are used in pivotal behavioral training are similar to those used in incidental teaching with emphasis on methods to promote generalization of learning. When applying pivotal response training, the therapist gives the child a choice in play materials, uses natural reinforcers, intersperses mastered tasks with learned tasks, and reinforces attempts at new learning (Figure 2-3).⁴³ These theories are further explained in Chapter 23 on early intervention programs.

Social Cognitive Theories

In general, social cognitive theory explains learning that occurs in a social context. The initial acquisition of highly complex and abstract behaviors was difficult for learning theorists to explain until the advent of the social cognitive theory proposed by Bandura.¹¹ Bandura¹¹ and Piaget¹⁴⁴ introduced the idea that children can learn by observing the behavior of others. This learning may not be immediately observed in behavior but becomes part of the child’s general understanding of the world. In contrast with the behavioralists, who believe that all learning produces behavioral change, social cognitive theorists believe that learning can occur without observable behavioral changes. A child can learn by observing the behavior of others, such as subtle nonverbal gestures that are used in conversation. These are observed and stored in memory and may not be demonstrated by the child until a much later time, when the child may exhibit similar gestures but with his or her own unique style.

In social cognitive theory, people determine their own learning by seeking certain experiences and focusing on their own goals. Therefore, children do not simply learn random elements from the environment, but they direct their own learning and are goal oriented in what they learn. Social cognitive theorists also believe that children learn indirectly by observing how their peers’ behaviors are rewarded or punished. Direct reinforcement is not always needed when learning new behaviors.¹³⁸

Social cognitive learning is often indirect, as when the child learns by observing the consequences of behaviors of those around him or her. Learning that occurs when observing the behaviors of others also depends on the child’s goals, interests, and relationship to those observed. Children’s learning increases when they are given an incentive to learning (i.e., an anticipated valued outcome or reward). Learning is also promoted when the child establishes his or her own goals, is given opportunities to work on those goals, and evaluates whether the goal was accomplished. When children set their own goals, they direct their behavior in a specific way, they are more likely to persist in the behavior to achieve the goal, and they are often more satisfied with the outcome.

In this theory, children learn social skills through group experiences. When children have delayed social skills, they can gain an understanding of social gestures and peer interaction by becoming involved in a group where these behaviors are modeled and rewarded. Bandura believed that critical factors in the child influence the learning process, including the child’s perception of his or her competencies (i.e., self-efficacy). The ways in which a strong sense of efficacy can enhance personal accomplishment are described next.

The Influence of Motivation and Self-Efficacy on Learning

A number of factors in the child are believed to influence learning, such as cognition, motivation, attitude, and self-perception. The relationship between learning and other affective components is complex. It is widely accepted that children’s motivation to perform occupations is influenced by their perceptions of their efficacy, regardless of whether these perceptions are correct.¹¹ If children experience success in learning situations, it is assumed that they increase their perceived competence and internal control, gain support from significant others, and show pleasure at mastering the task. The assumption is made that children are more likely to seek out optimal challenges if they have experienced success.¹³ The corollary of this theory is that children who experience repeated failure begin to avoid challenges and are less likely to seek out new learning situations.⁷⁹

Motivation to learn and to achieve is developed through (1) casual attributions, (2) outcome expectancy, and (3) personal goals. When children feel self-efficacious, they attribute any failure to lack of effort. When children feel inefficacious, they attribute their failure to low ability. The efficacious child remains motivated to try harder and to improve performance; the inefficacious child believes that there is no point in trying harder because he or she is destined to fail. A child self-motivates by setting a personal goal higher than his or her current skill levels. Then the child mobilizes the energy to achieve that goal. With success the child sets a higher goal and become motivated to achieve a higher-level task.

Self-efficacy beliefs contribute to motivation in several ways. They determine the goals people set for themselves, how much effort they expend, how long they persevere in the face of difficulties, and how they respond to failure.¹¹ All of these decisions contribute to success in a particular goal and contribute to learning. Perceived self-efficacy also contributes to a child’s coping ability, which is discussed later in this chapter.

Therapists need to be aware of the importance of providing successful learning opportunities and optimal challenge situations. It is also important to note, however, that when children are young, they may not have the metacognitive awareness required to compare their own performance accurately against that of others. This lack of awareness may actually have an adaptive purpose in childhood. The fact that young children do not evaluate their own performance increases the likelihood that they will put energy and effort into practicing skills in a wide variety of environments with little concern about their actual competency.²¹ As children develop, however, their expectation of competence becomes more specific to the type of task and is influenced by their prior experiences with that task, their observations of typically developing peers performing it, and the evaluative feedback provided by credible adults.¹²

Dynamic Systems Theory

Emerging theoretical ideas from systems theory influence today’s thinking in many areas of development in children, and these ideas are beginning to lead to creation of alternative models of practice for therapy intervention. In contrast with a hierarchical model of neural organization, systems theory (also called dynamic systems theory) proposes a flexible model of neural organization in which the functions of control and coordination are distributed among many elements of the system rather than vested in a single hierarchical level.¹⁸⁶ Work that led to the development of dynamic systems theory includes research by Bernstein,²⁰ who used concepts from physics related to movement and applied these ideas to motor development. Bernstein proposed that the central nervous system (CNS) controls groups of muscles (not individual muscles) and that these groups can change motor behavior on their own without CNS control. He believed that motor control could emerge spontaneously from relationships among kinematics (muscles) and biomechanics (joints and bones) that naturally limit the degrees of freedom of movement. Therefore the motor system is self-organizing.¹⁶⁹

Systems theory has its roots in geometric concepts, and at the most basic level, a dynamic system is simply something that changes over time. Dynamic systems theorists emphasize that learning does not occur just in the brain and that the body and environment are all constantly changing and simultaneously influencing each other.¹⁸⁵ In this theoretical approach, instead of viewing behavior (e.g., motor skills) as predetermined in the CNS, systems theory views motor behavior as emerging from the dynamic cooperation of the many subsystems in a task-specific context. It implies that all factors contributing to the motor behavior are important and exert an influence on the outcome by either facilitating performance or constraining it.

In this approach, the therapist looks for periods of stability in learning and watches for signs that a child is ready to shift to a qualitatively different type of behavior. Identification of the system variables that drive the transition from one level to another facilitates learning.²⁷ These variables can be related to the child, the task, or the environment. Thelen suggested that variables such as physical growth and biomechanics may be more important for motor learning in infancy, whereas factors such as experience, practice, and motivation may be more influential in the learning of motor activities in an older child.¹⁸⁰

Dynamic systems theory is an ecologic approach that assumes that a child’s functional performance depends on the interactions of the child’s inherent and emerging skills, the characteristics of the desired task or activity, and the environment in which the activity is performed. Self-organization is optimal in a functional task that has a goal and outcome. Most functional tasks (e.g., eating and drinking) elicit a predictable pattern of movement; therefore, the task itself can organize the movements attempted. These features suggest that dynamic systems theory aligns well with occupational therapy.

Research in dynamic systems theory has focused on explaining the ways new skills are learned.^{64,133,181,182} The learning of new movements or ways of completing an activity requires that previously stable movements be broken down or become unstable. New movements and skills emerge when a critical change occurs in any of the components that contribute to motor behavior. These periods of change are called transitions. Motor change in young children is envisioned as a series of events during which destabilization and stabilization of movement take place before the transitional phase movement becomes stable and functional.¹⁴⁷

The period of instability that occurs in a transitional phase is seen as the optimal time to effect changes in movement behavior. Three characteristic situations mark the transitional stage:

In children with impairments such as cerebral palsy, constraints hinder the emergence of motor functions. Such constraints are limitations imposed on motor behaviors by the child’s physical, social, cognitive, and neurologic characteristics. The constraint that traditionally has received most attention is the integrity of the CNS; less frequently, other biomechanical constraints are considered, such as biomechanical forces, muscle strength, or a disproportionate trunk-to-limb ratio. Environmental constraints include physical, social, and cultural factors not related to a specific task. One example of a physical constraint is a suboptimal surface for the child’s activity (e.g., a slippery or inclined surface); a social constraint could be a parent’s lack of reinforcement of the acquisition of motor behaviors. Task constraints are restrictions on motor behavior imposed by the nature of the task. Established motor behaviors may be altered by specific task requirements. For example, when faced with the task of crawling on rough terrain, infants may alter motor behavior by straightening the knees and “bear walking.” When a child reaches for a ball, the ball’s size influences the shape of the child’s hand and the approach taken (e.g., one hand versus two). The unique features of these tasks have shaped the child’s motor behavior. See Table 2-2 for a list of dynamic systems theory principles. Dynamic systems theory has many similarities to the emerging occupational therapy theories that focus on person, environment, and occupation relationships. This theory is further explained in Chapters 3 and 9.

A Systems Approach

Occupational therapists approach intervention with a child by first gaining an understanding of the environmental, family, and child factors that influence the performance of specific activities. From the literature that discusses the application of systems theory or dynamic systems theory to occupational therapy intervention, the following principles emerge:

Models of practice for therapy assessment and intervention, based on dynamic systems theory, are beginning to emerge, although challenges to implementation remain.^31,46 Common among these models is the focus on successful achievement of functional goals rather than on the development of typical patterns of movement.^26,47,169 Ketelaar et al.,⁸⁹ in a study of 55 children receiving either functional therapy based on dynamic systems theory or therapy aimed at developing “typical” movement patterns, found that children in the functional therapy group demonstrated significantly more functional skills (mobility and self-care) as measured by the Pediatric Evaluation of Disability Inventory.⁸⁹

Cognitive Approaches

Cognitive approaches are “top down” or occupation-based approaches because the emphasis in therapy is on assisting the child to identify, develop, and use cognitive strategies to perform daily occupations effectively. These models build on Bandura’s research¹¹ supporting the importance of self-efficacy and establishing goals to motivate individual achievement.

In cognitive approaches, the occupational therapist designs interventions to increase a child’s repertoire of cognitive strategies and improve the child’s ability to select, monitor, and evaluate his or her use of these strategies during the performance of a task. The inherent assumption is that improved performance results from the dynamic interaction of the child’s skills with the parameters of the task in the context in which it needs to be performed. Therefore, the child discovers, applies, and evaluates cognitive strategies during task performance in his or her typical environments.¹³¹

The cognitive model of practice requires that the therapist identify and use a global problem-solving strategy, which provides a consistent framework within which the child discovers specific strategies applicable to tasks that he or she either needs or wants to perform. This global strategy is based on the five-stage problem-solving structure first outlined by Luria.¹⁰⁸ Using occupational therapy terminology, these steps include (1) task analysis, (2) anticipation of the child’s difficulties, (3) exploration and selection of task-specific strategies, (4) application of a strategy to the task, and (5) evaluation of the strategy’s effectiveness.¹³⁰ The child is guided to develop his or her own cognitive strategies based on the problems encountered during tasks. The task-specific strategies a child discovers are unique to him or her.

Using cognitive skills to assess his performance, identifying successful and unsuccessful actions, the child learns to become more efficient in functional activities. The occupational therapist supports the child’s goals and self-evaluation. The therapist can also cue, prompt, or model the task, aligning these supports to the child’s goals. The atmosphere in the therapy session is one of acceptance and support for taking risks. Although the child guides the selection of activities, the therapist is always aware of the generalization and task-specific strategies that the child needs to learn and creates opportunities for the child to discover these.^131,150

Because the selection of tasks is critical to the approach, a client-centered tool must be used that allows the child to identify goals for intervention. An appropriate goal-setting instrument for use with children older than 9 years of age is the Canadian Occupational Performance Measure (COPM)⁹⁷; for children 5 to 9 years of age, the Perceived Efficacy and Goal Setting (PEGS) system can be used.¹³² The cognitive approach is probably not a suitable model of practice for children under 5 years of age because of its emphasis on the development of metacognitive skill and knowledge.

One of the key features of a cognitive model of practice is the way in which the therapist helps the child explore strategies, make decisions, apply strategies, and evaluate their use. The therapist does not give instructions. Rather, he or she uses questions to help children (1) discover the relevant aspects of the task, (2) examine how they are currently performing the task, (3) identify where they are getting “stuck,” (4) creatively think about alternative solutions, and (5) try out these solutions and evaluate them in a supportive environment. Once a strategy is found to be helpful, the therapist uses questions to help the child “bridge” or generalize the strategy, eliciting from the child other times and situations in which that strategy may apply.¹⁵⁰

In recent years a particular cognitive approach, the cognitive orientation to daily occupational performance (CO-OP),¹⁴⁹ has been researched systematically to determine whether it is an effective model to use with children with developmental coordination disorder. Evidence is accumulating that CO-OP is effective at enabling skill acquisition and that it also results in generalization and transfer of learned skills.¹⁵⁰ A randomized clinical trial comparing CO-OP with an equivalent number of sessions of direct skill training found that, although children in both groups improved and achieved motor goals, the gains in the CO-OP group were greater; long-term maintenance both of the motor goals and of the cognitive strategies was significantly stronger in the CO-OP group, which led parents to report greater satisfaction with this treatment approach.¹²⁷ Studies on CO-OP have shown its effectiveness with children with developmental coordination disorder,^127,179 cerebral palsy or acquired brain injury, and Asperger’s syndrome.^159,160

Through research such as this, a variety of cognitive strategies have been identified that seem to be helpful to many different children experiencing occupational performance difficulties. Videotape analysis has been used to systematically identify and describe some of these strategies.¹¹⁶ It appears that children need to be able to state and apply a global executive strategy, such as “Goal, Plan, Do, Check,”¹²³ to guide their problem solving. In addition, specific strategies seem to be useful for improving their performance, including verbal self-guidance (child talks himself or herself through the motor sequence); feeling the movement (drawing attention to an aspect of the sensation of movement as it is performed); motor mnemonic (labeling a body position or motor sequence); body position (verbalizing or directing attention to the body position or body parts relative to the task); and task specification (discussing specific parts of the task or actions to change the task).¹¹⁶

In summary, occupational therapists who use a cognitive model of practice (1) focus on the occupations a child wishes to perform rather than on foundational skill building; (2) use a general problem-solving framework that guides the child to discover, select, apply, and evaluate the use of specific cognitive strategies; (3) use process questions to increase the child’s awareness of the use of strategy during the performance of daily tasks; and (4) plan for transfer and generalization of the strategies that the child has learned.^130,150

Adaptation and Compensation Interventions

Occupational performance is successful when the demands of the task, the skills of the child, and the features of the environment are congruent. When the skills of the person do not meet the demands of the task in the environment, occupational performance becomes less successful. Most of the models of practice in occupational therapy, particularly with children who are still developing, focus on increasing the child’s skills. The adaptation model of practice involves adapting the demands of the task or modifying the environment so that they are congruent with the child’s ability level. Adaptations may involve modifying the occupation so that it is easier to perform, using assistive technology devices, or changing the physical or social environment.⁴⁴ Often when children have significant impairments, task modification is needed to maximize the child’s participation. For example, a child with cerebral palsy may require an adapted spoon and cup to eat dinner with his family. A child with autism may require a picture exchange card system to communicate his need to use the bathroom.

When skills are insufficient to enable performance, task adaptation is used to modify the demands of a task to bring it to the competence level of the child. Task demands are analyzed and functional limitations are identified, and difficulties then are creatively circumvented. An example in school-based practice would be adapting the writing surface by using a slant board so that the child’s written work is more easily visualized and the child’s hand and arm posture are supported in a posture that promotes writing skill. A child with a learning disability may be able to complete a page of arithmetic problems when the font is enlarged and the paper has a color tint.

Often adaptive equipment or assistive technology (AT) is used to modify or adapt the task. Campbell, Milbourne, and Wilcox view assistive technology as a bridge or mediator between the skills that a child can currently perform and the requirements of the task.²⁹ Assistive technology may be as simple as adaptive brushes or crayons that allow a preschool child to participate in art activities. A wide variety of assistive technology devices can enable children with significant motor impairments to better access their environment. For example, AT devices can help position the child to perform an activity (e.g., a prone stander) or provide postural support (e.g., wheelchair straps). “High-tech” technology is also available to provide a method for written communication (e.g., a laptop computer) or augmentative communication (e.g., a device for synthesized speech). Chapters 16, 20, and 21 describe assistive technology devices that use this approach to increase children’s participation in their natural environments.

With children, the compensatory approach often complements other approaches that focus on skill building. Methods for adapting tasks are selected not only so that the child succeeds at a particular task, but also to promote skills in similar tasks and in other environments. For example, a boy with poor drawing skills can create a picture using peel-off stickers of animals. Although this adaptation allows the boy to create a picture more easily than drawing with markers, peeling off and placing the stickers provide practice of fine motor skills—specifically, bilateral coordination, isolated finger movements, spatial relations, and use of force. Practice in these skills may generalize to other art activities, and the easy success the child achieves when using colorful animal stickers may encourage him to attempt other art activities.

Psychosocial Approaches

Occupational therapists use a variety of psychosocial approaches when working with children and adolescents experiencing problems in occupational performance because of social, emotional, or behavioral issues or difficulties with relationships. Several of these approaches, such as a cognitive approach or the compensatory and environmental approach, are discussed elsewhere in this chapter. These approaches are grounded in theories that focus on the development of self, on family and peer relationships, and on the aspects of the social and cultural environment that influence each of these. Although the number of occupational therapists who work with children with chronic mental health issues is relatively small, all occupational therapists who work in pediatrics use the concepts of psychologic and social development implicitly, because developing the ability to maintain relationships with peers and significant others is an essential part of the occupational performance of childhood and adolescence.

Chapter 13 describes the models of practice that focus on social behavior and the development of self. Personal attributes, such as temperament, self-esteem and self-efficacy, problem-solving ability, and social skills, are considered important determinants of healthy functioning. Environmental influences on behavior and social development suggest the need to consider the expectations and social elements of the home, school, and community environments and to recognize the importance of friends in a young person’s life. For the occupational therapist, the critical consideration is the impact of the person’s attributes and environmental influences on ability to participate in daily occupations.

Given the complex nature of behavior and social relationships, occupational therapists often draw on a number of intervention approaches in this model of practice. The therapist’s knowledge of normal behavior, vulnerabilities associated with particular disabilities, attachment, coping skills, and compatibility of temperaments may guide intervention with a parent–child dyad. Cognitive behavioral strategies may be used by occupational therapists to help young people who are depressed or socially withdrawn develop strategies that encourage participation in social situations (see Chapter 13).

Coping Model

The coping model addresses psychosocial function, uses cognitive behavioral strategies, and is congruent with the PEO model.^199,205 Therapists who use this model emphasize the use of coping resources that enable the child to meet challenges posed by the environment. The goal is to improve the child’s ability to cope with stress in personal, social, and other occupational performance areas. When children are successful in coping with their own personal needs and the demands of the environment, they feel good about themselves and their place in the world. Coping strategies are learned, and children build on previous successful experiences in coping with environmental expectations.²⁰⁵

All children experience stress when faced with physical, cognitive, and emotional challenges. When these challenges are successfully met by the child’s inner resources and caregiving supports, the result is a sense of motivation, learning, and mastery. Stress can evoke negative feelings when the child’s resources are poorly matched to the environment’s demands. Both internal and external resources assist in the process of coping. Internal coping resources include coping style, beliefs and values, physical and affective states, and developmental skills. External coping resources include human supports and materials and environmental supports.

Social Skills Training

Interventions that develop positive coping strategies in children and adolescents with psychosocial dysfunctions can be essential for promoting the ability to participate in social interactions and relationships. Occupational therapists working with older children and adolescents with mental health problems often use social skills groups to promote coping effectiveness and occupational performance. A group milieu allows young people to master developing skills in a safe and supportive environment. Social skills training groups have shown positive effect with adolescents with autism.⁸⁰ Monthly group meetings focused on social skill development resulted in adolescents improving in maintaining and initiating conversation. Broderick, Caswell, Gregory, Marzolini and Wilson evaluated the effect of a social skill group of adolescents with autism spectrum disorder and found that they improved in self esteem and confidence.²⁴ See Table 2-3 for examples of venues for social skills training.

Social networks have been shown to help a person establish positive attitudes and role behavior, maintain and improve self-esteem, and develop moral and social values.^35,78 Other studies have identified the interactive, protective factors in child, family, and social environment that enable a child to be resilient to the effects of disability. Bedell, Cohn, and Dumas described a “Building Friendship Approach” in which collaborative student-centered school teams (student, school personnel, family, and friends) identify strategies for improving the social opportunities of the student with brain injury.¹⁶ The team helps the student generate his or her own solutions and set goals to improve his or her social opportunities. This approach appears to be effective but the outcomes need to be monitored to ensure that they are maintained.

Research on psychosocial approaches is difficult to review because of its scope and because of the variety of types of practice and their implementation across different disciplines. Evidence in the literature supporting the use of specific approaches is minimal. Studies on the effectiveness of social skills training have been conducted with school-age children with brain injury,⁷⁴ depression,^66,152 schizophrenia,⁸⁰ and autism.^24,83 Although many of these studies have methodologic limitations, the results seem to offer support for social skills interventions in improving self-esteem, positive affect, problem-solving, and social behaviors.

Motor Learning and Skill Acquisition

Motor learning as a model of practice focuses on helping the child achieve goal-directed functional actions. It may initially appear to be a skill-building approach, because the focus is on the acquisition of skills involved in movement and balance. However, motor learning is actually an occupation-based approach, because it is directed toward the search for a motor solution that emerges from an interaction of the child with the task and the environment.

When a child is learning a new functional task, a general movement structure is brought into place that takes into consideration the relationship involving the child’s movement capabilities, the environmental conditions, and the action goal. When the task is performed repeatedly, these correspondences become more refined, and the goal is achieved more successfully. Specific processes, such as muscle contraction patterns, stabilization and positioning of joints, and response to gravity and other forces, are only crudely organized at first. However, with continued practice, these become more organized and finely tuned.⁶⁹ These patterns are called movement synergies, or coordinative structures, and they represent the child’s preferred strategy for solving a task in the most energy-efficient way.¹⁸⁰

Children with motor programming and motor control deficits often have difficulty establishing the timing and sequencing of functional synergies. Task and activity demands may vary, and each of these dimensions is relevant to the way in which tasks are learned. These characteristics of a task determine what motor learning strategies are used to improve performance.

Different types of feedback contribute to the motor learning process. Feedback is intrinsic when it is produced by the child’s sensory systems and is inherent in a task. An example of intrinsic feedback is information available to the child through vision, proprioception, sensation, or kinesthesia. Extrinsic feedback is provided to the child by an external source, such as the therapist, or by observing the results of one’s actions.^136,169Knowledge of results is a type of extrinsic feedback in which the therapist provides information to the child about the relationship between the actions and the goal, but only after the fact. For example, a child who is throwing a basketball toward the hoop may be told that the ball is not going high enough and therefore is missing the hoop. Knowledge of performance is a type of extrinsic feedback that emphasizes the pattern of movement and its relationship to achievement of the task. In the same example, the child may be told that he is not extending his arms far enough before releasing the ball. In both cases, the therapist’s feedback focuses on the outcome of the action, not on the child’s effort. These terms are further explained in Chapter 9.

Research on the scheduling, frequency, and amount of feedback that best promote learning has been published.^102,178 Studies have shown that immediate extrinsic feedback may prevent the learner from paying attention to the intrinsic sources of feedback that are always available, such as vision and proprioception. This lack of attention to intrinsic feedback may make the learner dependent on information from the person providing instruction.¹⁶⁷

Very little research has focused on the effect of different types of feedback on task performance with children experiencing occupational performance difficulties. However, research investigating motor learning principles with children with movement difficulties has suggested that these children may not solve movement problems in a typical way. The research suggests that extrinsic sources of feedback that focus a child’s attention on specific aspects of the task and on important sensory cues may be important.¹⁰³

Another important concept in motor learning is the influence of different types of practice on learning and performance. There is no question that practice of a task is beneficial to learning. The difficulty confronting most therapists is the dilemma of whether to practice the whole task or only parts or components of the task. Study results indicate that the benefits of practicing either the whole task or parts of the task depend on the inherent goals of the task.¹⁶⁹ If coordination or timing of the parts is important to the task, whole-task practice is more effective for learning. Examples of these continuous types of tasks are walking, swinging at a ball, and bicycling. If a task contains distinct parts that can be performed in a serial manner, these can be practiced as parts of the task. A child learning to don his jacket can be taught how to zip it as a first step. Most occupations involving movement are actually a combination of continuous and discrete tasks (Figure 2-7). Consequently, doing the whole task must follow learning its parts. In learning to ride a tricycle, for example, the child can focus on learning to pedal separately from steering, but he or she must then combine them.

Another important consideration in planning practice sessions is the use of random versus blocked practice. During random practice, the environmental conditions vary slightly each time; blocked practice involves drilling the task over and over in the same way. In most cases, random practice produces better learning, because the variable practice allows the child to solve a slightly different movement “problem” every time.¹⁰²

Some of the key techniques that therapists use in this model of practice are giving verbal instructions and demonstrating movement strategies. Verbal instructions focus on the relationship between the child and the objects in the environment and emphasize key movement features directly related to achievement of the functional goal.⁶⁹ Physical or manual guidance can be helpful during the initial teaching of a movement because it may clarify the goal, guide selective attention, and help the child organize and plan the movement (Figure 2-8). Researchers stress that guidance or facilitation of movement should be removed as soon as possible, arguing that the therapist rapidly becomes part of the environment, which alters the performance context and the intrinsic feedback available to the child.⁶⁹

Motor learning researchers^137,178,200 recognize that learning takes place only when there is evidence of a relatively permanent change in the child’s ability to respond to a movement problem or to achieve a movement goal. The learning of a new motor skill needs to be evaluated through tests of retention and transfer, not just immediate changes in performance.¹¹² Therefore, therapists who use a motor learning model of practice must create opportunities for the child to demonstrate their learning during a subsequent therapy session (retention), on a closely related task (transfer), or in a different setting (generalization). Table 2-4 summarizes motor learning concepts, with examples of application in occupational therapy intervention.

Occupational therapists use theories about motor learning to promote development in areas of function that involve learning complex skills and behaviors. Self-care and handwriting are examples of areas of occupational performance to which occupational therapists have applied a motor learning approach. Handwriting is an area of occupational performance in which a motor learning or acquisitional approach has been advocated (see Chapter 19). Although few studies of the effectiveness of this approach to handwriting have been published, many remedial or practice-based handwriting programs are commercially available. A few published studies have demonstrated that the use of acquisitional principles by therapists and educators in a positive, interesting, and dynamic learning environment promotes the development of handwriting.^15,129 Some handwriting studies provide therapists and educators with strategies for remediation that use some of the concepts previously listed.^18,52 Further research is needed to determine the effectiveness of this approach with different populations of children across a broad range of skills and areas of occupational performance.

To summarize, a therapist using a motor learning model of practice:

Neurodevelopmental Theory

Historically, the primary concept underpinning a neurodevelopmental therapy (NDT) approach to practice was that normal postural reactions are necessary for normal movement and that these postural reactions are for the most part automatic.²³ Although this intervention approach continues to focus on problems in postural control and motor coordination, as seen in cerebral palsy, the principles underlying the treatment approach have expanded to include motor learning and dynamic systems theories. In addition, NDT principles have shifted to recognize the importance of the environment and to place more emphasis on activities that are clearly functional and meaningful to the child.⁸²

When using this approach to evaluate a child, the therapist analyzes the child’s movements to identify missing or atypical muscular-skeletal elements that create functional limitations. These missing elements become one focus of intervention and are used to select the developmental level of therapeutic activities. Therapeutic handling is integral to the NDT approach and is used to facilitate postural control and movement synergies and to inhibit or constrain motor patterns that, if practiced, would lead to secondary deformities and dysfunction.⁸² A therapist applying NDT strategies focuses on changing movement patterns to achieve the most energy-efficient performance for the individual in the context of age-appropriate tasks.

As the therapist manually guides and handles the child in the context of an activity, these elements are always combined with the child’s active participation. With the therapist’s guidance, the child practices sequences of movements in slightly different ways to reinforce learning of the task. This practice is important for making a movement strategy functional and automatic. Therapists emphasize quality of movement (e.g., accuracy, quickness, adaptability, and fluency). Although therapeutic handling remains an integral part of NDT, practitioners use many treatment methods, “manipulating the individual task or the environment in order to positively influence function” (p. 63).⁸²

Acknowledging that NDT principles have changed over the years to incorporate theories of motor learning and dynamic systems theory, clinical evaluation studies of the neurodevelopmental therapy approach (many of which were completed more than 10 years ago) have raised questions about its efficacy. Comparison studies of this approach for children with cerebral palsy have been conducted over the past 30 years. In these studies, the NDT approach has been compared with functional therapy,^166,174 with infant stimulation,¹⁴¹ with Vojta therapy,⁴⁸ and with differing intensities of therapy.^98,121 The results of these trials have been mixed, with two demonstrating no difference,^99,174 two supporting NDT,^121,166 and two supporting alternate treatments.^48,141 The more rigorous randomized clinical trials have generally produced results that do not support the efficacy of the neurodevelopmental approach.¹⁴⁶

A recent systematic review of NDT concluded that “the preponderance of results….do not confer any advantage to NDT over alternatives to which it was compared” (p. 789).²⁸ The only consistent effect of NDT that was statistically significant was an immediate effect on range of motion. In contrast with NDT methods, the motor-based interventions that produce meaningful improvements in functional outcomes for children with disabilities incorporate three essential elements: (1) intensive task repetition, (2) progressive challenges to the learner with increasing difficulty, and (3) the presence of motivators and rewards.^137,165 Despite lack of evidence on efficacy,¹⁶⁵ NDT remains a widely used approach with children who have cerebral palsy and CNS dysfunction affecting motor performance. Because the conceptual basis of NDT has evolved over the past decade, a first step in additional research on its efficacy would be to operationalize the new concepts into treatment protocols that can be measured and replicated for research purposes.

Sensory Integration

The theory of sensory integration, together with the treatment approach derived from that theory, grew from the work of Jean Ayres.^3–5 Ayres developed her theory in an effort to explain behaviors observed in children with learning difficulties based on neural functioning. Specifically, she hypothesized that some children with learning difficulties experience problems in “organizing sensory information for use.”⁴ She named this neural process sensory integration.

Much of Ayres’ work, and that of her colleagues, was devoted to the development of evaluation tools that could clearly identify individuals with sensory integrative problems. The Sensory Integration and Praxis Tests (SIPT) are the result of this work.⁸ Included in this area of identification and evaluation are a number of studies aimed at describing different subtypes of sensory integrative problems (see Chapter 11 for a summary). Based on current confirmatory studies, these identified subtypes that can be identified by the SIPT include (1) visual and tactile perception with praxis, (2) vestibular and proprioceptive processing with bilateral functions, (3) attention and tactile defensiveness, and (4) visual and tactile discrimination.¹³⁴

In recent years, scholars in sensory integration have further described sensory integration processes⁵⁵ and categorized sensory integration disorders.¹²⁵ Miller and colleagues proposed three patterns of sensory processing disorder, described in Table 2-5.

Although there is some overlap in these disorders, each suggests a specific type of intervention. Dunn’s work identifying children with a sensory modulation disorder has shown that they have patterns of poor registration of sensation, are hypersensitive to stimuli, avoid certain sensations, or seek particular inputs.⁵³ These sensory processing patterns may be present in children with a variety of developmental disorders, and they are often described in children with pervasive developmental disorders or autism.^{14,88,183,191} Dunn and colleagues have developed evaluation tools for identifying sensory processing problems in children and adults.^54,56,63 A number of authors have proposed intervention programs to address sensory modulation disorders.^128,164,198 Although there is significant intuitive appeal for sensory modulation disorders as explanatory models for children’s observed behaviors, more research is required to validate these theories and to investigate appropriate interventions.

Ayres also developed interventions that she believed would help to resolve sensory integration problems. She proposed an intervention approach based on assumptions drawn from neuromaturation theory and systems theory.^4,7 Neuromaturation concepts, such as hierarchical organization of cortical and subcortical areas, developmental sequence of learning and skill acquisition, and neural plasticity, are essential to an understanding of the mechanisms of sensory integration. Systems theory also underlies sensory integration because the focus is on the child seeking sensory input and using adaptive behavior as an organizer of the input. Figure 2-9 shows a child’s choice of activity. Based on these assumptions, a sensory integration approach seeks to provide the child with enhanced opportunities for controlled sensory input, with a particular emphasis on vestibular, proprioceptive, and tactile input, in the context of meaningful activity. In intervention the therapist facilitates an adaptive response, which requires the child to integrate the sensory information (Figure 2-10). Sensory integration is hypothesized to improve through this process.

Ayres^5,9,10 and Miller¹²⁶ have conducted research aimed at evaluating the process of sensory integration and determining the efficacy of sensory integration intervention (see Chapter 11). In a recent study, a group of scholars examined the research literature on sensory integration to develop a fidelity measure for sensory integration intervention.¹⁴³ This study involved a comprehensive review of the research literature and produced a definition of the core elements of sensory integration intervention that will be useful to future trials (see Table 2-6).

Early work by Ayres^5,6 and others^9,139 had reported positive changes resulting from sensory integration intervention in such outcomes as motor, academic, and language performance. Studies in the late 1980s and the 1990s evaluated the efficacy of sensory integration intervention using more rigorous methods, including randomized controlled trials. Using meta-analysis techniques, Vargas and Camilli found that early efficacy studies of sensory integration produced large positive effects, but studies conducted after 1982 did not yield significant positive effects.¹⁸⁷ The more recent studies of sensory integration intervention have demonstrated effects equal to those of alternative treatments in the participants’ psychoeducational and motor performance areas, with no improvement noted in sensory perceptual areas.¹⁸⁷

Recent studies using rigorous methods have shown positive effects of sensory integration interventions. In a randomized trial comparing sensory integration intervention to an activity protocol or no treatment, Miller, Coll, and Schoen assigned 24 children with sensory modulation disorders to one of three groups.¹²⁶ The children in the sensory integration group and the activity group received intervention twice a week for 10 weeks, and the control group children were placed on a wait list for intervention. Those in the sensory integration intervention group made significant gains on goal attainment scaling and in attention, cognition, and social performance as measured by the Leiter International Performance Scale. Other measures of child behavior, sensory processing, and electrodermal reactivity improved in the sensory integration group but did not differ when the sensory integration group was compared with the activity and control groups. Miller et al. suggested that a larger sample was needed to detect significant differences in these measures.¹²⁶

Although sensory integration research typically has demonstrated only small positive effects, sensory integration intervention is widely practiced by occupational therapists and is a powerful force in clinical reasoning in the field of pediatrics. In a survey of occupational therapists working with children with autism, fully 99% of the therapists reported using sensory integration techniques with their clients.¹⁹⁰ More recent research has also included parents’ perceptions of change in their children and in themselves as a result of occupational therapy that used sensory integration intervention.^38,39 Parents reported positive changes in their children’s social participation, perceived competence, and self-regulation. The parents valued the new understanding of the child’s behavior and used this perspective to support and advocate for the child more effectively. Ayres’ work has had a significant impact on occupational therapy practice with children, and its controversial nature has led to an increased sophistication and rigor in the scholarly work accomplished in the field of occupational therapy.

Developmental Approaches

During the 1960s and 1970s, occupational therapists working with children had a strong developmental perspective. These theories attempted to explain the functioning and growth of children and adolescents from an occupational therapy perspective. Perhaps the best-known occupational therapy theorist of this time was Lela Llorens. She identified a developmental frame of reference that focused on the physical, social, and psychologic aspects of life tasks and relationships.^105,106 Llorens viewed the role of the occupational therapist to be one of facilitating development and assisting in the mastery of life tasks and the ability to cope with life expectations. Chapter 3 explains developmental theories used in occupational therapy.

The section on developmental theories presented earlier in this chapter provides a broad basis for occupational therapy evaluation and intervention. Specifically, the theories of Piaget¹⁴⁵ form a foundation for the spatiotemporal adaptation model of practice.⁷³ Piaget explained that the adaptation process has four components: assimilation, accommodation, association, and differentiation. Assimilation is the reception of sensory stimuli from internal and external environments. Accommodation is the motor response to these stimuli. Association is the organized process of relating current sensory information with the current motor response and then relating this relationship to past responses. Differentiation is the process of identifying the specific elements in a child’s situation that are useful and relevant to another situation to refine the responsive pattern. Based on prior experience, the child develops a sense of what is useful and what is not useful to motor activity in the current situation. In this view of development, the child is continually modifying older, more primitive behaviors for effective motor responses, rather than continually acquiring new skills. The spatiotemporal adaptation model of practice⁷³ views development as a spiraling process, moving from simple to complex. Adaptation is a continuous process of interaction involving the individual, time, and space. This model became central to occupational therapists’ view of child development and fostered the development of intervention models.

Recent theories and models of development in the occupational therapy literature incorporate new concepts of PEO relationships, dynamic systems theories, and lifespan changes. Instead of focusing on different components of functioning, such as motor, social, or cognitive development, occupational therapy theorists are addressing the development of occupation across the lifespan.^49,84,86

Two emerging occupational perspectives on development remain in the conceptual and exploratory stages of theory development and require further research and validation. In one of these proposals, Humphry suggests a dynamic system perspective in a model of developmental processes.^84,85 A child’s occupational development is based on complex, reciprocal, and nonlinear relationships involving the child’s innate characteristics and environmental factors. Humphry proposes that children learn through three broad mechanisms. First, communities invest in children by developing programs, places, and opportunities for social engagement that enable them to participate in community life. Examples of community investment in child development include (1) child care centers that allow children with disabilities to attend their programming, (2) play spaces that use universal design allowing all children to use them, and (3) educational programs that encourage the participation of families with young children. Communities that are invested in child development support human resources, child-care centers, educational programs, and spaces that encourage healthy development and learning in children of all abilities. A second mechanism of child development are interpersonal influences (i.e., the social opportunities for children to interact with others). Children learn by observing others perform activity, through play with other children and adults, and through adults teaching and modeling for them. These social mechanisms are the catalyst for much of a child’s learning. Humphry noted that vicarious learning through observation of others can be as important as direct teaching.⁸⁵ Children also learn through shared occupations such as circle time or group activities in preschool. Occupational therapists need to recognize the complexity of children’s learning across domains when children participate in groups.

Although vicarious learning in social situations is important to development, a third mechanism, doing, is equally important. When engaging in a novel activity, the child reorganizes learned skills, adapts skills on the basis of trial and error, and tries new actions to accomplish the activity. Fully engaging in an activity is an important catalyst to learning. To completely engage, the child must find the activity to be meaningful, fun, and challenging. These concepts about development of performance imply that children learn in social contexts and that engagement in activity results in learning. A variety of adult roles are implied by these concepts, including designing group activities, creating learning environments, modeling, encouraging, supporting, and guiding.

Occupational therapy approaches have logically evolved from theories and concepts of psychology, education, neuroscience, and other fields. These practice models guide interventions that consider the child, his or occupations, the environment, and the interactions of these elements. Practitioners recognize that theories are overlapping and complementary. To meet the individual needs of the children they serve, they use theoretical concepts specific to certain problems but also in combination. Occupational therapists seek evidence regarding each practice model’s effectiveness in making decisions about which model to implement.