Module 1: Best Practice and Treatment Planning in Occupational Therapy with Children and Youth

What is “best practice” in occupational therapy with children?

***universal design

• Child and Family-centered

• Comprehensive evaluation

  • Occupation centered (i.e., how does the child engage in occupation? e.g., play, school, education, dressing, feeding, etc.)

• Effective Intervention (evidence based)

  • Enhance child’s performance

  • Provide the “just right challenge”

  • Adapt activities and/or modify the environment

  • Consult, educate and advocate

• Support Inclusion

  • Within the child’s natural environment

• Follow Professional Practice Standards (NBCOT)

Domain 1: Client-Centered Care

Maximize occupational performance for individuals and populations while embracing diversity in roles, habits, routines, values, beliefs, expressed needs, and preferences through engaging in a process of ongoing client collaboration

Domain 2: Interprofessional Teams

Cooperate, collaborate, communicate, and integrate care in teams to ensure that services are reliable and effective

Domain 3: Evidence-based practice

Integrate the best available research with clinical expertise and client values for optimum care

Domain 4: Quality Improvement

Design and implement processes and interventions to continually measure and refine quality of care for improved client and program outcomes

Domain 5: Informatics

Use data and information technology to manage and communicate client information to improve the delivery of occupational therapy services

• need to know how to score manually —> and then, move onto electronic

• also need to know how to electronically document things

Domain 6: Professional Responsibility

Elevate occupational therapy practice through communicating the value of occupational therapy services, advancing clinical competence, and adhering to professional and ethical codes of conduct

Interventions enhancing cognitive development

• ***evidence-based OT interventions to support development in children birth-5 years

• Therapist-led interventions with premature infants

  • Clinic and home-based interventions

  • pdf: A therapist-led intervention using NIDCAP to address cognitive development for preterm infants

  • pdf: A combined therapist-led, clinic-based EI program and home-based activity program for preterm infants

  • pdf: Therapist-led home-based EIs for preterm infants to train parents to implement play and developmental activities with their child

• Therapist-led interventions with preschoolers

  • pdf: Therapist-led interventions for preschoolers with ADHD that emphasize attention, inhibition, eye–hand coordination, visual focusing, balance, sensory awareness, and listening skills to enhance executive function

  • pdf: Therapist-led interventions for preschoolers with ADHD that include pivotal response treatment and positive behavior strategies

  • pdf: Therapist-led fantastical play (vs. imaginative play) to improve executive function for at-risk preschoolers

  • Parent education and interactions

    • pdf: Educating parents of at-risk preschoolers to play with their children regularly to improve cognitive development

    • pdf: Therapist-led, clinic-based EI programs that focus on parent–child dyads

    • pdf: KC education for parents of preterm infants

  • Touch interventions

    • i.e., something in the sensory realm (e.g., desensitization of the skin, proprioceptive input)

    • pdf: Therapist-led individual or group interventions focused on developmental and sensory activities for preschoolers with developmental delays

• Interventions implemented by a preschool team

  • Early literacy programs

    • pdf: Use of curricula, such as Read It Again and REDI, in a preschool setting to improve reading skills for children at risk for learning delays

    • pdf: Use of the REDI program with preschoolers to improve learning and attention and increase print, letter, and letter-sound knowledge

    • pdf: The Kids in Transition to School program to improve literacy skills for children at risk for developmental delay

    • pdf: 45 weeks of the Early Reading Program for preschoolers with Down syndrome to improve literacy skills

  • Reading books

    • pdf: Mothers reading books to their child, particularly shared reading (e.g., parent–child interaction that may include pointing and naming pictures or comments about the topic or picture) and dialogic reading (e.g., encouraging active participation from the child during book reading and adjusting reading style to fit the child’s language skills), to improve attention, working memory, and literacy skills for at-risk preschool children

  • Other interventions

    • pdf: Specific daily activities focused on working memory and cognitive flexibility to improve cognitive development of at-risk children in a preschool setting

Interventions supporting mental health and positive behavior

• ***evidence-based OT interventions to support development in children birth-5 years

• Touch-based interventions

  • Kangaroo care and skin-to-skin (i.e., putting the baby on the bare chest of mom or dad)

    • pdf: Parental use of KC to enhance maternal–infant attachment (minimum of 3 30-minute sessions) and reduce maternal depression (minimum of 10 hr total) and anxiety (singing a lullaby during 60 min of KC)

  • Massage

    • pdf: Use of massage to improve infants’ self-regulation

    • pdf: Infant massage to reduce parental stress levels

• Parent-child interaction therapy

  • to create bonding and communication

  • pdf: Parent training to improve parenting behavior with consistent meetings over a 12-month period to improve parent–child dyadic behavior and parental responsiveness

  • pdf: Manualized PCIT to decrease the child’s externalized and challenging behaviors

  • pdf: 4 months of Qigong massage for preschoolers with autism to improve behavior

• Instruction-based interventions

  • Parent training: parenting behavior, child behavior, parental mental health, child mental health, and infant sleep

    • pdf: A parenting program (7.5–11 hr) to improve mothers’ sensitivity to infant cues

    • pdf: An 11-wk parenting behavior training to improve parental response to children’s externalizing and internalizing behaviors

    • pdf: A 10-wk Incredible Parent Training program to increase the use of positive parenting strategies and consistent use of discipline

    • pdf: Self-help books with weekly phone consultations to improve preschool children’s internalizing and externalizing behaviors

    • pdf: A home-based PLAY Project intervention for parents to decrease depression levels

    • pdf: Parent training to improve infant sleep latency

• Group-based parent training

  • pdf: The Incredible Years and Mother–Infant Transaction programs to decrease child aggression and increase compliance and socialization

  • pdf: 14 wk of group parenting classes for parents of preschool students to reduce callous–unemotional behaviors

• Preschool teacher training

  • pdf: A 2-year LEAP training and coaching model for teachers to improve social behavior and reduce problem behaviors among preschool children with ASD

  • pdf: A 15-wk teacher training to reduce conflict between teacher and children, improve child conduct, and decrease hyperactive and inattentive child behavior

Interventions supporting motor development

• ***evidence-based OT interventions to support development in children birth-5 years

• EI for children 0-3

  • Premature infants

    • pdf: EI services for premature infants to improve short-term motor development

    • pdf: NIDCAP to improve motor function of preterm infants with severe intrauterine growth restriction at 2 wk corrected age

  • Parent-implemented home-based interventions

    • e.g., education/training of the parents

    • pdf: The home-based IBAIP, a preventive neurobehavioral intervention that supports infant–family interactions and infants’ self-regulatory competence, to improve motor function

    • pdf: A parent-implemented EI program for infants resuscitated at birth to improve motor development

  • Combined clinic and home-based interventions

    • used if home treatments are not enough (e.g., need clinic equipment/technology)

    • pdf: A combination of clinic and home-based programming to improve fine and large motor performance (compared with clinic alone)

  • Massage

    • pdf: Parent-provided Qigong massage to improve large motor skills in children with CP or Down syndrome

  • Caretoy

    • pdf: The CareToy, a smart infant gym, to improve motor skills of preterm infants

  • Other interventions

    • pdf: A low-cost virtual reality game to improve one-leg balance and grip strength for children ages 3–5

    • pdf: Fine motor OT interventions to improve fine motor skills for kindergarten students in general education

    • pdf: The Mighty Moves program, which focuses on stability, locomotor, and manipulation skills, for 4 days/wk over 18 wk to improve motor skills in preschoolers

Interventions Supporting Activities of Daily Living, Rest, and Sleep

• ***evidence-based OT interventions to support development in children birth-5 years

Feeding and Eating

• Repeated exposure

  • pdf: Repeated-exposure feeding interventions paired with reinforcements to reduce food refusals and increase vegetable intake among preschoolers

• Nonnutritive suck

  • give pacifer, chewy toy, etc., to work on their oral motor skills

  • pdf: Use of a recording of the mother singing lullabies paired with nonnutritive suck on a pacifier for 15 min/day for 5 days to increase oral feeding rate and feedings per day

• Parent training

  • pdf: 8 hr of parent training in using feeding behavioral strategies with their children diagnosed with ASD to reduce parental stress

  • pdf: Home visits 2× during pregnancy and 5 follow-up visits at 1, 3, 5, 9, and 12 mo to increase breastfeeding and decrease food rewards for behavior

• Tube feeding weaning

Toileting

• Caregiver education

  • pdf: Use of a wetting alarm with children ages 18–30 mo to improve toilet training

• Multidisciplinary approach in CP

Rest and Sleep

• Parent training for infants and young children

  • pdf: 3 parent training sessions regarding causes of and responses to infant cries to decrease infant crying and increase infant sleeping

  • pdf: Internet-delivered parent training related to infant sleep to improve sleep latency, reduce difficulty falling asleep, reduce the number and duration of night wakings, and increase maternal confidence

  • pdf: Provision of ≥3 hr of parent training related to improving the child’s sleep, such as gradual extinguishing of response to their infant’s cries at bedtime or decreasing the child’s sleep window time to improve sleep latency

  • pdf: 8 wk of parent training for parents of children with ASD to improve sleep

• Touch-based interventions

  • pdf: 1 wk of mothers providing 15–20 min of massage 2×/day with 1 session before sleeping to decrease crying and colic severity and increase sleep duration

• Positioning devices

  • pdf: Use of a conformational positioner (which conforms around the infant in an individualized way) in the NICU to decrease time in awake alert, active awake, and crying states and improve sleep efficiency

Interventions for Preschool Children Ages 3–5 Years

• Video games

  • can be used if motivating for the child

  • but still not the best intervention traditionally; still probably better for the child to use basic toys in which the child must engage w/ their imagination, cause and effect perception, etc.

• Programs emphasizing motor skills

• Movement

• Sensory-based interventions

Activity- and Occupation-Based Interventions to Improve Activities of Daily Living, Instrumental Activities of Daily Living, Play and Leisure, and Rest and Sleep

• ***evidence-based OT interventions for children 5-12 years

• Activities of Daily Living (ADL’s)

  • Functional physical activity

    • pdf: For children with idiopathic arthritis, participating in a program focused on musculoskeletal strategies coupled with functional activities to improve their occupational engagement (dressing, grooming, eating, hygiene), pain management, and quality of life

    • pdf: Functional activities program with caregiver training and home practice to improve occupational engagement (dressing, grooming, eating, hygiene) for children with idiopathic arthritis

    • pdf: For children with CP, an active lifestyle and sports participation intervention that includes logging daily physical activity and engagement in daily life activities to increase physical activity

    • pdf: Hippotherapy for children with CP to improve their functional mobility skills

  • Task-oriented training

    • e.g., need to work on dressing? practice donning the shirt over and over

  • Cognitive-based interventions

  • Technology-based interventions

    • pdf: Wii Fit balance-based video game training to improve self-care participation of children and youth with mild CP

    • pdf: Video modeling to teach functional living skills to youth with ID, ASD, and high-functioning autism

    • pdf: Pedometers and support of creative strategies to increase physical activity for 8th graders

• Instrumental Activities of Daily Living (IADL’s)

  • Health Maintenance and Management

  • Physical Activity and Fitness

    • pdf: Interventions such as Playworks and Ready for Recess to increase participation in physical activity provided in a school setting for students in Grades 3–5

    • pdf: Weekly center-based and weekly home-based physical fitness activities, with counseling focused on increasing daily physical activity and scores on a physical activity self-report measure for children with CP

    • pdf: A 24-month school-based intervention for adolescents to promote physical activity using student physical activity plans, fitness activities and lessons, provision of equipment, and promotion of community activities and parent engagement

    • pdf: A web-based obesity prevention program, provided either in class or as homework, to improve participation in physical activity for adolescents

  • Diet and Nutrition

    • pdf: A skills-based interactive curriculum for teenagers to improve dietary and nutrition knowledge and activities using role-play and homework or web-based, self-directed learning with support from a coach and a peer

    • pdf: A 6-wk family-centered program (Kids Nutrition and Fitness) for children ages 8–12 yr from low-income schools to improve dietary behavior

  • Health Routines and Wellness

    • pdf: Engagement in self-care activities and routines to improve participation in and performance of functional life skills of children with disabilities (CP, ASD, idiopathic arthritis)

    • pdf: Collaborative goal setting, instruction, and feedback (e.g., CO–OP™) to improve self-care participation, performance, and satisfaction of children with DCD

  • Safety, Driving, and Communication Management

• Play and Leisure

  • pdf: A therapist-led intervention in a specialized school setting using the Learn to Play station to decrease the number of play deficits of children with ID

  • Cognitive-behavioral Interventions

  • Computer and Technology Interventions

  • Structured and Guided Play Participation

    • pdf: Active coaching, modeling, and guided play on the school playground for children with ASD to increase active game engagement

• Rest and Sleep

  • pdf: Guided imagery interventions to improve sleep for youth undergoing surgery for idiopathic scoliosis

  • pdf: A brief behavioral sleep coaching program for parents of children with ADHD and behavioral sleep disorders to improve healthy sleep routines and sleep hygiene practices, habits and routines, quality of sleep, and daily functioning in children and their caregivers

Activity- and Occupation-Based Interventions to Improve Mental Health, Positive Behavior, and Social Participation

• ***evidence-based OT interventions for children 5-12 years

• Occupations and Life Skills Training

  • pdf: Manualized psychosocial Child Life and Attention Skills program to support social participation and increase organizational skills, self-efficacy, and psychosocial functioning

• Outdoor Groups and Camps

  • pdf: Outdoor groups and camps (2 days–10 weeks) that include activities such as rock climbing, backpacking, canoeing, ropes challenge courses, and camping to improve depression, anxiety, and self-esteem

• Play

  • pdf: Play interventions that provide opportunities to play with other children and parent-facilitated homework assignments and activities on a weekly or biweekly basis (from 6 to 16 weeks) to help children with ASD and ADHD increase their levels of play and playfulness

• Sports Activities

  • pdf: Group sports activities, such as basketball, jump rope, tennis, darts, and modified boxing, to support improved social participation, including attention, perseverance, cooperation, and conflict resolution, for children and youth with ADHD and ASD

• Video and Computer Games

  • pdf: Computer and video games (e.g., Wii, virtual reality, role-play, Zoo U, Plan-It-Commander) to support mental health, positive behavior, and social skills training among young boys with ADHD and ASD in the school setting

  • pdf: A virtual reality intervention game to decrease depression among children receiving cancer treatment in a hospital setting

• Yoga

  • pdf: Yoga (e.g., Yoga Ed, Get Ready to Learn), in a group format, for 12 weeks to improve the behavior of children and youth

• Meditation

• Animal Assisted Interventions (i.e., emotional support animals)

  • pdf: Animal-assisted activities and occupations to improve children’s and youths’ behavior

• Creative Arts

  • pdf: Blogging about social problems to improve how youth feel about themselves and their satisfaction with their interactions with peers

Activity- and Occupation-Based Interventions to Improve Learning, Academic Achievement, and Successful Participation in School

• ***evidence-based OT interventions for children 5-12 years

• Educational Participation

  • Stability balls

    • sit the child on a therapy ball, so that they can get some movement while still attending to class

  • Weighted vests

  • Yoga

    • pdf: Manualized yoga-based socioemotional wellness program (Transformative Life Skills) for 6th and 9th graders (12 15–60 min sessions) to decrease unexcused absences and increase school engagement

• Social Participation

  • Peer mediation

    • pdf: A peer-mediated social participation intervention (6-wk session) for children with ASD to improve social skills in the classroom

    • pdf: Peer-mediated cross-age and direct reading tutoring (≥16 hr) to improve attitude toward recreational reading

  • Manualized programs

    • pdf: A family literacy event to increase the number of books read

    • pdf: Manualized social participation interventions (Remaking Recess or Program for the Education and Enrichment of Relational Skills) over 14–16 sessions to increase peer engagement, social awareness, communication, and motivation for children with ASD

• Animal-assisted activities

• Physical Activity

  • Activity- and Interaction-Based Programs

    • pdf: PLAYgrounds (encouragement of playground use, monthly themes, and environmental strategies) to increase physical activity at school

  • Context modifications

    • pdf: Standard chairs instead of stability balls for 2nd graders in the classroom to improve cooperation with classroom rules and amount of time on task while working independently and with peers

    • pdf: Contextual modifications (painting of playground surfaces, provision of small and large equipment, school policy changes) to increase physical activity among school-age children

  • Video games

• Literacy participation

  • Embedded and Supplemental Creative Literacy Activities

    • pdf: Embedded creative discussions and rotating literacy activities in small groups to increase positive attitudes toward reading and improve self-concept as a reader

  • Parent coaching

  • Peer tutoring

• Handwriting

  • Visual Perception, Kinesthesis (the sense that provides awareness of the position, movement, and actions of one's own body and limbs), and Motor Skills

  • Sensorimotor vs Therapeutic Practice approaches

    • pdf: Therapeutic practice (vs. sensorimotor approaches), such as paper-and-pencil activities and self-evaluation techniques, and performance feedback to improve legibility of children with handwriting difficulties

  • Combined Sensorimotor and Therapeutic Practice Approaches

    • pdf: A multisensory approach to a cognitively oriented therapeutic practice method for children in 1st and 2nd grade to improve legibility

    • pdf: Combining sensorimotor and therapeutic practice using a manualized program (e.g., Write Start, Handwriting Without Tears, Size Matters) with usual classroom activities to improve handwriting legibility

Interventions for Children With or At Risk for CP, Ages 0–5 Years

• EI programs

• Constraint-Induced Movement Therapy and Bimanual Intensive Therapy

  • constrain the unaffected side

  • pdf: CIMT and BIT for 3–6 hr/day in the clinic, home, or a group setting to improve motor skills in children ages 0–5 yr with unilateral CP

• Child- and Context- Focused Interventions

  • pdf: Child-initiated movement, task-specific training, and environmental modifications to improve motor skills of children with CP

• Hippotherapy

  • pdf: Hippotherapy for 30 min 2×/wk for 8 wk to improve motor skills of children with CP

  • pdf: Hippotherapy for children with CP to improve their functional mobility skills

• Other Interventions

  • pdf: Parent-provided Qigong massage to improve large motor skills in children with CP or Down syndrome

  • pdf: GAME program for children with CP to improve motor function

  • pdf: Engagement in self-care activities and routines to improve participation in and performance of functional life skills of children with disabilities (CP, ASD, idiopathic arthritis)

  • pdf: For children with CP, an active lifestyle and sports participation intervention that includes logging daily physical activity and engagement in daily life activities to increase physical activity

  • pdf: Weekly center-based and weekly home-based physical fitness activities, with counseling focused on increasing daily physical activity and scores on a physical activity self-report measure for children with CP

  • pdf: Wii Fit balance-based video game training to improve self-care participation of children and youth with mild CP

Current Views of Best Practice in Early Intervention and School-Based Settings (Handley-More et al., 2013)

5 Best Practices

• 1. Providing contextual services (may need to teach the skill in isolation —> but then, must gradually change the environment so the child is learning to do it in their contextual situations)

  • Occupational therapy within the child’s:

    • Natural environment

    • Daily activities

    • Daily routines

  • Best practice for promoting early learning

• 2. Participation-based evaluation, goals, and services

  • begin

    • Begin the evaluation process with a participation-based reason for referral

    —> utilize

    • Utilize participation-based evaluations

    —> —> write

    • Write goals that address participation in natural environments

    —> —> —> provide

    • Provide services that promote participation through activity selection or environmental modification

• 3. Collaborative occupational therapy services

  • Shared responsibilities, decision-making, and goals with multiple disciplines

  • Hanft & Shepherd (2008) concluded:

    • Added benefits to collaborative interventions

    • Effective collaboration is established via blended services, team communication, respect, sharing of information and resources, and using evidence-based practices

• 4. Mental health

  • Support the emotional well-being, mental health, and social competence of children

  • EI therapists help parents develop routines, utilize positive behavioral supports, and promote independence and self-efficacy

  • Zero to Three Policy Center (2004): a center that does a lot of research on kids aged 0-3 (early intervention)

    • Healthy social-emotional development in early childhood is as important to school readiness as literacy, language, and number skills

  • School-based therapists collaborate with teachers to develop classroom strategies, individualized schedules and routines, and facilitate participation in recess to support social participation of all students

• 5. Secondary school transitions

  • IDEA stipulates that special education and related services are intended to prepare students with disabilities for ‘further education, employment, and independent living’ (601(d))

    • law to follow when working with kids

    • prepare kids not just for education, but for them to integrate into the community even after school (skills should be able to carry these skills throughout life)

  • Best practices in transition include interventions that promote work experiences in the community, family involvement, social skill development, independent living skills, self-determination, employment preparation, and community collaboration (Landmark et al., 2010)

is the child actively participating in this activity the way this goal is written?

• no, it’s passive (all the child has to do is maintain an upright sitting posture)

rewritten goal

• child must sit for 5 mins

• during an activity

• shows effort that must be maintained while having an upright posture

EBP pyramid/tiers- 

RTI/MTSS Tier

Pyramid:

• bottom-

  • description:

    • every child

    • universal interventions for all students (e.g., classroom-wide supports)

  • parallel in EBP pyramid: 

    • foundational information or general best practices

• middle-

  • description: 

    • children at risk w/ more target interventions

    • targeted group interventions for those needing extra help

  • parallel in EBP pyramid: 

    • mid-level evidence (e.g., observational or quasi-experimental studies)

• top (tier 1)-

  • description:

    • children who require individualized intensive interventions and/or specialized services (e.g., 1-on-1s w/ therapists)

  • parallel in EBP pyramid: 

    • high-level evidence guiding individualized decision-making (e.g., RCTs, systematic reviews)

Universal design

We are designing education for all children, considering children at all levels of the EBP pyramid