Quiz 2: Models and Frame of References

Allen Cognitive Levels (ACLS) - Cognitive Disability Model: Focus & Approach

1. Cognitive challenges in dementia & mental disorders

2. Assessment + interventions based on observed behavior

3. Application of self-regulation methods & strategies to changing thinking & behavior

4. Empathetic understanding of needs & perspective of persons w/ cognitive problems

Allen Cognitive Levels (ACLS) - Cognitive Disability Model: Wellness Model

• 6 cognitive levels of wellness: Automatic, postural, manual, goal-directed, exploratory, planned actions

• EX: Used to reorganize task environments for greater efficiency; have applied principle of brain conservation to simplify daily routines, reserving higher level cognitive skills for learning & processing new info in class

Allen Cognitive Levels (ACLS) - Cognitive Disability Model: Assessment Tool

Provides quick estimate of learning + problem-solving abilities during performance of 3 visual motor tasks of increasing complexity. Scores on the screening assessment verified thru further assessment & interpreted within the framework of the cognitive disabilities model.

• Assessment Tool: ACLs (Cognitive Level Screen - Leather Lacing Task) = 3 tasks

• Scoring from 3.0 (following basic instructions) to 5.8 (skill acquisition)

• Participants complete 3 tasks, 20 minutes to administer, ages 6 and up!

Allen Cognitive Levels (ACLS) - Cognitive Disability Model: Change & Motivation

1. Adapting environment: In the training manual, Allen describes a usable task environment for different levels.

2. Assistance: observing by looking for where help is needed

3. Cueing: sensory input

4. Probing: questions to guide, “How is yours different?”

5. Rescue: correcting the error if needed

Allen Cognitive Levels (ACLS) - Cognitive Disability Model: Intervention

• Maximizing strengths & creating an enabling environment.

• EX: Client is a 64-year-old male w/ Alzheimer’s with a cognitive disability level of 3, with severe impairments in attention and memory but can still participate in ADLs. The OT teaches the caregiver how to provide cues for toothbrushing. The caregiver places a toothbrush and toothpaste in front of the sink and provides step-by-step cues as needed.

Allen Cognitive Levels (ACLS) - Cognitive Disability Model: Name Changes Over Time

• Cognitive disability: restricted motor actions due to limitations in brain

• Functional Information Processing Capacities: focus on ability, not disability

• Functional Cognition: global patterns of brain function across activities

Biomechanical Frame of Reference/Rehabilitative: History 💪

• Once called the Reconstruction, Orthopedic, and Kinetic approach

• OTs didn’t want to provide diversional therapy/be basketweavers. Arts & Crafts Movement waning; Rehabilitation Movement rising

• Biomedical model resulted from a drive to be more scientific. ADL training, range of motion, strengthening, coordination, and work tolerance became a vital part of therapy

• New interventions: prosthetic training, splinting, constructive of adaptive equipment.

Biomechanical Frame of Reference/Rehabilitative: Kinetic Model 💪

• Kinetic analysis of crafts & occupations → activity analysis

• Focus on ROM, strength, endurance, coordination

Biomechanical Frame of Reference/Rehabilitative: Overview & Goals 💪

• Remedial approach to intervention focusing on impairments inhibiting functional performance (functional movement, joint ROM, muscle strength/endurance)

• Goals: use therapeutic & occupation-based activities (ADL training) to remediate existing movement-related impairments, prevent further deterioration (contractures, muscle atrophy), provide compensatory/adaptive strategies for loss of movement

• Population & Disabilities Focus: people across age span, focusing on physical & neurological disabilities.

Rehabilitative Frame of Reference (FOR): Overview

• Comprehensive approach to treatment so a person becomes as independent as possible despite residual dysfunction.

• Focus: adaptation to facilitate independence

Rehabilitative Frame of Reference (FOR): Interventions

1. Self-care evaluation + training

2. Acquisition & training in assistive devices

3. Adaptive devices

4. Adaptive clothing

5. Work simplification & energy conservation

6. Orthotics and prosthetic training

7. Environmental modification

8. Wheelchair modification & management

9. Ambulatory devices

10. Community transportation

11. Architectural adaptations

Canadian Model of Occupational Performance and Engagement (CMOP-E) = International Model

• Occupation is the core of OT; influences by person, environment, spirituality (essence of self)

• Focus: client centered practice + engagement (not just performance) in meaningful occupation; environmental + developmental/learning theory

Canadian Model of Occupational Performance and Engagement (CMOP-E) = Key Concepts & Ideas

Concepts

1. Person (cognitive, affective, physical)

2. Spirituality (core of the person/essence of self; motivation for occupation)

3. Environment (physical, cultural, institutional, social)

4. Occupations

Key Words/Ideas

1. Introduces spirituality as central

2. Developed alongside COPM assessment

3. Interventions: facilitating, guiding, coaching, listening, reflecting, collaborating

4. Focus on client-defined goals and subjective experience of occupation

Cognitive Behavioral Therapy (CBT)

• Used by OT to help someone better participate in occupations (motivational interview: open-ended, reflective questions that guide clients to make a thought to change on their own “Where do you want to be with this behavior? How would you get there?”); primarily used in psychology

• Talk therapy which helps people change negative thought and behavior patterns to manage conditions like depression, anxiety, and other mental and physical health issues

• EX: “I’m not going to pass this fieldwork. My fieldwork educator doesn’t like me. They pay more attention to the other student. I passed them in the hall this morning and they didn’t even look at me.” Think about some ways this student might change their thinking and behavior patterns!

Ecology of Human Performance (EHP): Overview

• Context (environment) is central; performance results from person-context-task interactions

• Focus: task performance depends on context + person's skills and abilities

Ecology of Human Performance (EHP): Core Concepts + Key Ideas

Core Concepts

1. Person (unique values abilities, experiences, values)

2. Context (temporal, physical, social, cultural)

3. Tasks (objective sets of behaviors necessary for performance)

4. Performance (result of person engaging in tasks within context)

Ideas

1. Strong emphasis on context/ecology

2. Focus on task modification and environmental supports

3. Task performance > occupation

Ecology of Human Performance (EHP): Intervention

1. Establish/restore → build person's skills

2. Alter → change context to better match person

3. Adapt/modify → adjust task or context

4. Prevent → minimize barriers before problems occur

5. Create → promote enriching contexts

Model of Human Occupation (MOHO): Goal & Focus

1. Occupational performance = result of dynamic interactions between a person's internal systems and their environment

2. Goal: restore occupational identity

3. Focus: how motivation + habits + performance capacity influence engagement in occupation

Model of Human Occupation (MOHO): Core Concepts + Ideas

1. Volition (motivation for occupation: values, interests)

2. Habituation (habits + roles that structure daily life)

3. Performance capacity (physical + mental abilities)

4. Environment (physical, social, cultural, economic, political, etc.)

Ideas

1. Focus on motivation + internal drive

2. Emphasis on systems theory: person + environment continuously interact

3. Levels of change: exploration → competence → achievement

4. Considers occupational identity + occupational competence

Motor Control/Motor Learning Rehabilitative FOR

• Internal processes associated w/ practice or experience that lead to permanent, long-lasting changes in motor behavior

• Learning Indicators: Retention & transfer of skills

• EX: Client who learns to put on a hospital shirt should be able to transfer this learning and put on different shirts after being discharged. The acquisition phase may indicate performance

Neurodevelopmental Theory (NDT): Focus

Restore skilled voluntary movement for patients with developmental or acquired neurological health conditions

1. Focus: internalizing sensation of movement to create motor sequences/patterns & avoiding abnormal movement

   1. Problem solving approach

   2. Client-centered and team based

   3. Manage muscle tone through control of primitive reflexes

   4. Work towards functional performance

   5. Intervention through Handling and Reflex-Inhibiting Patterns/Postures (RIPs)

   6. Discourage one-handed and compensation techniques

Neurodevelopmental Theory (NDT): Interventions

1. Increasing functional use of affected side

2. Maintaining normal postural control and movement

3. Inhibiting unwanted movements

4. Initial movement training to incorporate specific movement strategies and patterns

5. Progress to using movement patterns for increasing in independence in ADLs

Occupational Adaptation (OA): Overview + Focus

1. People have an innate drive to adapt; occupational performance improves via process of adaptation + occupations used to promote internal adaptive process

2. Focus: interaction between person + environment via process of press for mastery

Occupational Adaptation (OA): Core Concepts + Ideas

1. Person: desire for mastery

2. Environment: demand for mastery

3. Interaction/Mastery: 'press for mastery' → occupational challenge

4. Adaptive response: process of finding new ways to perform occupations

Ideas

1. Adaptation = key mechanism for change

2. Adaptive response subprocesses: generation, evaluation, integration

3. Focus on process, not just performance

4. Change in occupational adaptation

5. OT facilitates the adaptive process (not just skill acquisition)

Occupational Behavior - Mary Reilly (Frame of Reference): Foundations, ECA

1. Exploration: search for new experience leads to development of new skills

2. Competence: sufficient behavior to meet demands of the situation and master skills

3. Achievement: attaining proficiency that goes beyond competency

Occupational Behavior - Mary Reilly (Frame of Reference): History

• Believed OT treatment had become reductionist, treating body parts & diseases instead of the whole

• Purpose of OT: prevent & reduce disruptions & incapacities in occupational behavior resulting from injury and illness (Cole & Tufano)

Occupational Behavior - Mary Reilly (Frame of Reference): Theoretical Base

1. Need to master, alter, and improve environment

2. Occupation intrinsically motivating  

3. Psychological need for occupation; people suffer when they lack occupation

4. Normal development influences occupational behavior: play to work continuum

5. Culture influences specific occupations chosen by person

6. Occupational behavior involves daily routine of work, play, and rest

7. Through participation in occupations, people learn to cope and adapt

8. Health achieved by balance and habits

9. Occupational base includes physical, subjective and affective experiences

10. Learning occurs by comparing internal, subjective self to external facts

Occupational Behavior - Mary Reilly (Frame of Reference): Function

• Person capable of seeking, undertaking, adapting occupations to meet personal and societal needs

• Health (functional occupational behaviors): person engages in variety of roles + behaviors that meet norms, expectations, obligations

Occupational Behavior - Mary Reilly (Frame of Reference): Dysfunction

disruption in occupational behaviors = suffering

Occupational Behavior - Mary Reilly (Frame of Reference): Change & Motivation

When client sees value in achieving goals and outcomes and can identify benefits, they are more likely to engage in therapeutic process

Person-Environment-Occupation (PEO) = International Model, Focus

1. Optimal occupational performance occurs when person, environment, and occupation are aligned

2. Focus: transactional relationship among the three elements (P, E, O)

Person-Environment-Occupation (PEO) = International Model, Core Concepts & Ideas

1. Core concepts:

   1. Person (unique being w/ roles, values, abilities)

   2. Environment (external contexts - physical, social, cultural, institutional)

   3. Occupation (clusters of meaningful activities)

   4. Occupational performance (outcome of the P-EO- interaction)

2. Key words/ideas:

   1. Performance strongest when PEO fit is highest

   2. Interaction = dynamic and fluid

   3. Useful for addressing contextual barriers (contrasts contextual congruence)

Person-Environment-Occupation-Performance Model (PEOP): Focus

• Expansion on PEO w/ emphasis on performance + participation as outcomes of complex interactions over time

• Focus: holistic, client centered approach considering intrinsic & extrinsic factors that influence participation

Person-Environment-Occupation-Performance Model (PEOP): Core Concepts & Ideas

1. Core concepts:

   1. Essential components: occupations, occupational performance, narratives, person factors, environment

   2. Intrinsic factors (cognition, physiological, psychological, spiritual, motor skills)

   3. Extrinsic factors (physical envm, social support, cultural values, policy)

   4. Performance (the actual doing)

   5. Participation (engagement in life roles)

2. Key words/ideas

   1. Distinguishes between performance and participation

   2. Top-down model (starts w/ what client wants/needs to do; narrative phase)

   3. Positive feedback loop

   4. Emphasis on well being and quality of life

Psychodynamic Theory

ALL psychological theories of human functioning & personality; can be traced back to Freud’s original formulation of psychoanalysis

Psychoanalytic theory

• sub-theory of psychodynamic theory

• Personality development is driven by conscious and unconscious factors

• FOCUS

  • Social relationship

  • Emotional expression + motivation

  • Self-awareness

  • Defensive mechanisms

  • Projective arts and activities

Rood’s Sensorimotor Approach: Overview

1. Basis of Ayre’s Sensory Integration and Bobath’s Neurodevelopmental Theory. First patients were children w/ cerebral palsy

2. Focus: Regulate motor control through facilitating reflex & voluntary movement reflex

3. Principles: normalization of muscle tone (use of stimuli for desired response)

   1. Ontogenetic Developmental Sequence: Motor control is developed in levels

   2. Purposeful Movement: Helps develop a movement pattern

   3. Repetition of Movement: Practice is necessary for learning

Rood’s Sensorimotor Approach: Interventions

1. Facilitation techniques for hypotonic disorders or unconscious patients: Activation of ANS

2. Inhibition techniques for patients with spasticity: Activation of PNS

3. Purposeful activities that grade up over mastery

4. Use of mats, bolsters, and therapy balls in sessions

Sensory Integration (Ayres): Theoretical Framework

1. CNS plasticity. Brain adapts, integrates sensory input. 

2. Phases of development follow a hierarchy

3. Brain works as integrated whole

4. Adaptive interactions critical to sensory integration

5. Inner drive to develop sensory integration through sensorimotor activities

Sensory Integration (Ayres): Focus

• Sensory integrative Dysfunction

• Attention, hypersensitivity to sensory stimuli, poor postural control & balance, apraxia, tactile defensiveness, inefficient cognitive processing, autism spectrum disorder, sensory modulation

Sensory Integration (Ayres): Function

• Engaging in age-appropriate play, learning, self-care, rest & sleep, social participation

• Ability & opportunity to engage in self-directed activities

Sensory Integration (Ayres): Dysfunction

1. Vestibular, proprioceptive, tactile problems = problems like poor bilateral integration & sequencing, visual-perceptual deficits, somatosensory deficits, dyspraxia 

   1. Overreaction/underreaction to stimuli

Sensory Integration (Ayres): Change & Motivation

Sensory input according to needs → Inner drive toward maturity; may avoid some overstimulating activities

Sensory Integration (Ayres): Intervention Planning

1. Delivered by an OT

2. family-centered

3. founded on evaluation & interpretation of sensory integration dysfunction

4. safe environment, rich in sensation

5. Just right challenge, “activities are their own reward”

Example: Testing for J, age 4, revealed hyperresponsitivity to tactile, vestibular, oral-sensory, and auditory stimuli. He ate only a few foods, had exaggerated emotion, behavioral & fear responses to sensation & everyday activities (playground activities), and expressive language delays. Hesitant & fearful w/ many gross motor activities; passive & observant.

Social Learning Theory (Bandura) - Applied Behavioral Frames Example: Behavior, personal factors, environmental factors

Adults with type-2 diabetes initially lacked motivation to improve health-promoting habits. A peer-led group based on lifestyle redesign principles was held, and after 2 months, improved glycemic control and self-perception of being prepared to manage diabetes occurred. Changes in the Diabetes Self-Efficacy, Empowerment, and Attitude Scale improved.

Social Learning Terms

1. Observational Learning: what are perceptions or misperceptions about persons who use a wheelchair or who are aged? (EX: Fall prevention program)

2. Modeling: teaching by example, positive or negative (Teach skill for getting in/out tub)

3. Methods of Reinforcement: continuum of concrete rewards to internal satisfaction (EX: Success in showering alone, walking in park)

4. Self-control and self-regulation: physiological (pulse, heart rate), feelings (anger, stress), directing life (setting goals, planning)

5. Self-efficacy: belief in one’s abilities

6. Self-awareness: realistic understanding of strengths & weaknesses & effect of behavior on others (EX: Realistic evaluation of abilities, when to use cane or slow down)

7. Insight: acknowledging one’s own barriers & motivations

8. Human agency: acts done intentional; self-determination 

Social Cognitive Theory: Basic Assumptions

1. Origin: Social Learning Theory by Bandura, but developed into Social Cognitive Theory in 1986. Learning occurs in a social context with a dynamic, reciprocal interaction of the person, environment, and behavior. 

2. Unique feature: emphasis on social influence & emphasis on external/internal social reinforcement. Considers way which people acquire & maintain behavior while considering social environment where people perform that behavior

Social Cognitive Theory: Key Concepts

1. People learn by observing others.

   1. Learning is an internal process

   2. People are motivated to achieve goals

   3. People regulate and adjust their own behavior

   4. Positive and negative reinforcement may have an indirect effect on behavior

Social Cognition & 3rd Wave Cognitive Frames of Reference

1. Focus = thought process, self-determination, social participation (roles, relationships, identity, support)

2. Population = Mental Health

3. Concepts

   1. Human Agency: acts done intentionally; ability to be autonomous and self-determined

   2. Self-efficacy: beliefs about one’s own abilities

3. Intentionality: deliberate, planned behaviors which may or may not result in desired outcomes

Social Cognitive Theory: Change & Motivation

1. Others see a problem, consider pros and cons of action, decide to change (or not), put decision into practice, maintain change

2. Precontemplation (not ready), contemplation (getting ready), preparation (ready), action, maintenance

Social Cognitive Theory: Assessment & Intervention

1. Assessment: Self-efficacy scales, informal interviews, “Draw your wall” assessment

2. Intervention: support for self-management, social identity, realistic self-image; strengthening problem-solving, social, occupational skills; learn to cope w/ relapses and emergencies; education about resources

Model

• Representation of the system that integrates elements of theory and practice; helps us organize our findings in a way that is unique to our profession

• Shows relationship between concepts; bridge between paradigm to practice

Theory

1. Describes, explains, and predicts behavior and/or the relationship between concepts or events; the "because"

2. More proof; generalized statement

Frame of Reference (FOR)

• System of compatible concepts from a theory which guides a plan of action within a specific occupation domain

• Very specific; recipe or instruction manual comparison

Kawa Model (International Model)

1. Applies mainly to working with people from Eastern cultures to explain the relevance & purpose of OT interventions

   1. Culturally Relevant OT

   2. Metaphor of a river with different contextual elements to represent human life

   3. Understand contexts of the client, help to prioritize the problems, and provide relative intervention

   4. The information will help to widen the space for the client’s life flow without completely removing the other elements in the river and, eventually, the client will have a stronger and smoother life.

Recovery Model (Health and Wellness Model)

1. Person-centered approach that focuses on an individual's journey toward health and wellness, allowing them to live a self-directed life and reach their full potential, even with limitations

   1. Self-determination

   2. Self-direction

   3. Individualized, person-centered

   4. Empowerment

   5. Holistic, nonlinear, strength-based, peer-support, respect, responsibility, hope

Occupational Justice

Promotion of social & economic change to increase individual, community, and political awareness, resources, and equitable access for diverse occupational opportunities that enable people to meet their potential & experience well-being

Cognitive Behavioral Frames: application of self regulation methods and strategies to changing thinking and behavior.

• Focus: Used when there are psychological barriers to activity engagement or disengagement. Can be used with all ages.

• Useful for: Developing/changing performance patterns/habits

1. Cognitive Behavioral

2. Social Cognition

3. Allen Cognitive Levels

4. Sensory Integration

5. Beck’s Cognitive Therapy: Focus - Current life problems (not past)

   1. Concepts: Psychological issues stem from faulty thinking/learned behaviors. People can learn better coping strategies

An occupational therapist helps a child with Autism Spectrum Disorders (ASDs) participate in vestibular swinging to organize and calm his neurological system to sit still in his classroom. What model is being used and explain why?

Ayres Sensory Integration; Focus: Sensory integrative Dysfunction, including ASD.

An OT administers the screening test to determine how much assistance a patient with moderate dementia will need to follow total knee replacement surgery precautions. What model is being used and explain why?

1. Allen Cognitive Levels (ACLS) - Cognitive Disability Model

2. Need to address cognitive challenges in dementia & mental disorders. Empathetic understanding of needs & perspective of persons w/ cognitive problems

While working with a man who has right-sided hemiplegia following a stroke, an OT performs a quick stretch and tapping facilitation technique to the man's affected triceps, followed by weight-bearing on the affected arm.

Rood’s Sensorimotor Approach concentrates on sensorimotor intervention = tapping, quick stretching

An OT interviewed a client with obsessive compulsive disorder (OCD) who exhibits dysfunctional behavior due to an imbalance among the three personality parts. The client traces his behavior back to a strained relationship with his parents. The OT used a projective test to allow him to express unconscious emotions and teach him how to express sources of anxiety and relaxation techniques.

Psychodynamic Theory: ID, Ego, Superego

An OT positions a two-year-old child with cerebral palsy on his hands and knees while the child reaches to play with blocks.

Neurodevelopmental Theory (NDT): Bobaths

An OT has a patient complete upper body strengthening exercises to improve the patient's ability to push up from a chair during transfers.

Biomechanical Frame of Reference