OCTH 6130 Psychosocial Occupational Therapy: Framing and Evaluation (copy)

1. Development of PEO Model

   • PEO = person, environment, & occupation

     • Person: mind, body, emotion, spirit

     • Environment: Broad

       1. “Context in which occupational performance takes place.”

       2. What are elements of the environment?

       3. Physical location, local social situations (family & neighborhoods, community, provincial/state, national and institutional (health insurance, transportation systems, employment opportunities)

     • Occupation: activities & tasks people engage in carrying

   • Interactive Frameworks

     • Environmental press

       1. Forces in the environment, together with individual needs, evoke a response

     • Adaptation

       1. Skill and challenge are right = good behavior

Cause/effect 🡪 behavior, doesn’t account for occupations

• Flow (Csikszentmihalyi)

  • Losing self in an activity

  • Nested in social systems (Bronfenbrenner)

    • Individual influenced

      1. Microsystem (immediate, family, school, peers)

      2. Mesosystem (interconnections, relationship child’s home and school)

      3. Exosystem (external, partners workplace)

      4. Macrosystem (institutions, government, values, customs)

  Mutually accounts for occupations

• P x E x O fit and interactions

  • Person x Occupation

  • Occupation x Environment

  • Person x Environment

• Occupational performance

  • dynamic relationship between PEO over a lifespan

    1. Choose and participate in occupation for enjoyment

    2. Things shift over time – not static – continually changing

• Dimensions of time and space

  • Time: experience present, remember past, hold ideas and dreams for the future = embody all three at once

  • Space: emotional element and meaning

    • Location = physical space people can engage in occupation

Takeaways: client-centered approach & reflective (evidence-based)

1. Introduction to the Person

   • Recovery model

     • Promotes optimism and hope that individuals with psychiatric conditions can achieve wants and needs

     • Person first language

   • Performance skills

MNEUMONIC: Colorful Butterflies Soar, Captivating Radiant Mesmerizing Eyes, Creating Serene Peacefulness, Radiating True Happiness

• Cognition (how people think about themselves)

  1. Attention

  2. Memory

  3. Executive function

  4. Impacted with schizophrenia, autism disorder, and depression

  • Cognitive beliefs (How you review self and world)

    1. How people think about themselves and the world

    2. CBT=altering cognitive distortions

    3. Impacted with schizophrenia and eating disorders

  • Sensory processing

    1. Environment

    2. Reduce restraints and seclusion

       • Reduce noise level

       • Calmer environment

  • Coping and resilience

    1. Strategies:

       • Emotion or problem focused

       • Approach or avoidance oriented

  • Motivation

    1. Practitioner address motivation as a performance skill

       • It doesn’t have to be a stigmatizing factor of mental illness

    2. MoHO as volition

  • Emotion

    1. Regulate emotion

       • Essential to health and occupational engagement

         • Dialectical behavioral therapy

• Communication and socialization

  1. Collaboration = occupational performance

  2. Communication

     • Impacted by autism, anxiety disorder, and schizophrenia

  • Pain regulation

    1. Reciprocal relationships

       • Pain sensitivity increases in individuals with Alzheimer’s disease.

       • Pain sensitivity decreases in individuals with schizophrenia.

       • Chronic pain often co-occurs with depression.

  • Time use and habits

    1. Activity initiation

    2. Occupational balance

  • Narrative (assessment and intervention)

    • Assessment:

      1. OPHI-II

         • Occupational Performance History Interview

      2. Role checklist

         • Self-assessment

      3. COSA Children’s Occupational Self-assessment

    • Intervention:

      1. Person’s story

         • Collaboration and understanding

         • Promote conversations

  • Purpose of Evaluation:

    • Data gathering and measuring occupational performance

    • Occupational profile: summarize persons occupational history

    • Analysis of occupational performance: practitioner uses therapeutic reasoning to determine areas of occupational performance that need to be assessed.

  • Evaluation Process Steps

    • 1: screen data to guide therapeutic reasoning

      1. Who is the person? What do I know? What are their concerns?

    • 2: choose assessments

      1. Consider:

         • Utility (quality of life)

         • Validity (measure what intends to be measured)

         • Reliability (consistency of measure)

    • 3: administer assessment

      1. Obtain consent

      2. Gather material

      3. Establish rapport

    • 4: occupational profile

      1. AOTA template structure

      2. Identify occupational importance

    • 5: analyze occupational performance

    • 6: synthesize data and set goals

      1. Specific

      2. Measurable

      3. Attainable

      4. Relevant

      5. Time

    • 7: reevaluate

      1. Ongoing process

      2. Measures outcomes

      3. Is the intervention effective

      4. Builds body of evidence that supports occupational therapy

  • Assessment Methods

    • Interviews

      1. Canadian Occupational Performance Measure

      2. OPHI-II

      3. Occupational Circumstances Assessment Interview and Rating Scale

      4. Kawa River Model

  • Self-Report Assessment

    • Role checklist

    • Occupational self-assessment

    • Child-occupational self-assessment

    • Adolescent/adult sensory profile

  • Performance Assessment

    • Allen Cognitive Level Screen

    • A M P S

    • Executive Function Performance Test

    • Performance Assessment of Self-Care

    • Volitional Questionnaire

1. Cognition

   1. Schizophrenia and cognition (miss input)

      • Begins in late teens or early 20s

      • Visual processing impairments

        • Perceiving motion and speed of motion

          • Eye tracking

        • Social difficulty

          • Interpret emotional expression

          • Auditory processing

            • Meaning of intonation and rhythm of speech

            • Interpreting facial expression

2. Components of cognition

   • Cognition: Processes associated with perceiving, making
     sense of, and using information

     • Attention

       • Automatic and controlled processing 🡪 simplify tasks, repeated practice

       • Selective attention 🡪 reduce irrelevant stimuli, use cues

       • Divided attention 🡪 separate tasks to focus attention

       • Vigilance 🡪 incorporate breaks

3. Components of memory

   • Memory

     • Semantic: memory for facts

       • Episodic: memory for events that happen to you

       • Procedural: memory about how to do something

         • Strategies:

           • Short term 🡪 memory aids

           • Long term 🡪 mnemonics

           • Working 🡪 simplify tasks, assistive devices

4. Executive function

   • Requires a level of awareness and conscious effort

   • Strategies:

     • Concept formation & Categorization

     • Cue sheets, exemplars

5. Schemas

   • Mental representation that includes relationships of a concept (mental image)

   • Simple maps

6. Scripts:

   • What happens when you get to a place (steps) predicts what happens next

   • Simple maps

• Models and techniques for cognitive impairment

  • Requires a level of awareness and conscious effort

  • Strategies:

    • Concept formation & Categorization

      • Cue sheets, exemplars

    • Schemas

      • Mental representation that includes relationships of a concept (mental image)

      • Simple maps

    • Scripts:

      • What happens when you get to a place (steps) predicts what happens next

      • Simple maps

  • Problem-solving

    • Involves overcoming obstacles that interfere with goal attainment

    • Decision-making

      • Metacognition

      • Strategies:

        • Problem solving 🡪 eliminate common problem

        • Decision making 🡪 limit options

        • Metacognition 🡪 promote reflection

      1. Models and techniques for cognitive impairment

         • Cognitive remediation: improve/restore specific cognitive skills

           • Letter cancellation task

         • Dynamic interactional approach

           • Functional information processing

             • Strategy across different activities that gradually change

         • Cognitive adaptation

           • Adapting tasks and environments

         • Cognitive adaptation training

           • Apathetic behaviors

             • Strategies: checklist, labels, prompts, cues, etc.

           • Disinhibited behaviors

             • Strategies: removal of distractions and organization of materials

• Cognitive Orientation to Daily Occupational Performance (CO-OP)

  • 1. Goal–what do you want to do?

    • 2. Plan–how will you go about doing it?

    • 3. Do–carry out the plan

    • 4. Check–did the plan work? Does it need to be modified?

  • Cognitive Disabilities Model

    • Best for for individual to promote participation

      • What a person can do, will do, and may do.

  1. Assessments to test cognitive skills

     • Test of Everyday Attention–eight everyday tasks

       • Adults and children with ADHD or Neuro/Psych

       • Attention whit engaging

• Multiple Errands Test–administer in a shopping mall

  • Adults with brain injury, stroke, or psych

    • Executive functioning in natural environment

    • Dynamic Loewenstein Occupational Therapy Cognitive
      Assessment (DLOTCA)–assess orientation, visuomotor
      organization, and thinking

• Dynamic Loewenstein Occupational Therapy Cognitive
  Assessment (DLOTCA)–assess orientation, visuomotor
  organization, and thinking

  • Adults with brain injury or pysch, geriatric version for 70 years+

  • Person’s ability to learn

• Executive Functioning Performance Test (EFPT)—assesses
  cognition and executive functioning

  • Adults with neuro/psych

    • Executive impairment for independency

• Assessments associated with Toglia’s dynamic
  interactional approach—assesses categorization and
  conceptualization using everyday objects

  • Contextual Memory Test

    • Adults with brain injury or pysch

    • Awareness and memory (awareness & recall)

  • Toglia Category Assessment

    • Adults with brain injury or psych

      • Establish categories and switch conceptual sets and ability to apply strategies

• Allen Cognitive Level Screen (ACLS)–measure global
  cognition as it affects occupational performance

  • Adults with psych disorders, dementia, and disruption of cognitive processing skills

• Do-Eat–measure task performance, sensory motor skills,
  and executive function

  • Children 5 to 8

• Continuous Performance Test (CPT)–measure cognition as
  it affects occupational performance

  • Adults with dementia

Intervention:

• 6 hierarchical levels of functioning

  1. conscious but unresponsive -🡪 comforting interventions

  2. confusion (loss of time) & passive participation 🡪 simple repetitive activities (rocking, music)

  3. minimal attention & devoid of goal direction 🡪 fall prevention programs, simple verbal and tactile cues

  4. significant impairments in memory and attention – disoriented 🡪 caregiver training essential (structured, routine, no distractions)

  5. deficits in executive functioning and processing information, difficulties with IADLs 🡪 modify IADLs or replacement of activities (direct, concrete, and verbal cues)

  6. absence of cognitive disability (can plan, problem solve, and learn) 🡪 help learn new occupations or activities as needed

1. Sensory processing

   1. Four steps of sensory processing IMPORTANT

      • Step 1 Nervous system detects sensory stimuli.

      • Some individuals may be hyperresponsive or hyporesponsive.

      • Step 2 Brain recognizes or classifies a stimulus.

      • Step 3 Meaning attributed to the information received.

      • Step 4 Behavioral response can occur at the level of conscious or unconscious awareness and usually includes cognitive and motor processing.

   2. Sensory modalities (systems)

      • Visual system

      • Auditory system

      • Tactile system

      • Taste (gustatory) & smell (olfactory) systems

      • Proprioceptive system

      • Vestibular system

   3. Sensory processing disorders

      1. Over-responsivity

         • Exaggerated response of nervous system (motion sickness-vestibular)

      2. Under-responsivity

         • Lack of response (daydreaming or unfocused)

      3. Sensory seeking

         • Needs intense input

   4. Sensory processing and children with psychiatric conditions

MNEMONIC: Ants Always Try to Steal My Oreos

“to” refers to trauma and schizo type (2).

• ADHD

  • Autism spectrum disorder

  • Developmental trauma disorder

  • Schizophrenia and schizoaffective disorders

  • Mood disorders

  • Posttraumatic stress disorder

  • Obsessive-compulsive disorder

PTSD high in: low registration, sensory seeking, and sensation avoiding.

Depression low in all four DUNN quadrants.

Bipolar disorder highest in sensation seeking

• Assessments

• Informal observation

  • While participating in occupations to look for responses to the sensory stimuli

• Sensory profiles

  • Use with Dunn’s Model of Sensory Processing

  • Four quadrants of processing preferences

MNEUMONIC: Rabbits Hop Playfully. Squirrels Hide Acorns. Stinky Little Pigs. Ants Love Picnics.

• Low registration [high stimulus, passive response]

• Sensory seeking [high stimulus, active response]

• Sensory sensitivity low threshold, passive response]

• Sensation avoiding [low threshold, active response]

  • Modify environments to help the person be successful

  • Matching the sensory processing preferences of the
    individual by understanding the environmental features

• Sensory processing measure

  • Assesses the different sensory modalities

• Highly sensitive person scale

  • Rates how respondents relate to environmental features

  1. Interventions

     • Sensory integration

       • Selection of activities guided by needs and responses

       • Focuses on 3 areas of sensory processing

         1. Tactile

         2. Vestibular

         3. Proprioceptive

     • Sensory based intervention

       • Identify level of arousal

       • Alert program 🡪 manage levels of alertness or arousal

       • Deep pressure touch strategies = tactile sensory input

1. Motivation

   1. Theories of motivation

      • Maslow’s hierarchy of needs

        • Biological (food, water, sleep) (PRIORITY)

        • Safety (health, financial security)

        • Affiliation (friends, family, belonging)

        • Esteem (self-efficacy, confidence)

        • Self-actualization (meaning, purpose, self-acceptance)

Intervention: address lowest level of unmet need. Establish rapport and demonstrate safety for client.

• Self-Determination Theory

  • Intrinsic (self) & extrinsic (obtain an outcome)

    • Competence – your knowledge and mastery

    • Autonomy – source of motivation

    • Relatedness – connection

    • Self-Regulation – 3 levels

      1. External – rewards and punishments

      2. Introjected – avoidance of guilt and anxiety; enhance self esteem

      3. Regulation through identification – activity consciously and personally valued

      4. Integrated regulation – activity is for self

    • Procrastination – waiting last minute

Intervention: group activities, mentorship, and role modeling

• Flow

  • Intense and concentrated on activity

    • Action and awareness

    • Loss of self-consciousness

    • Distortion of time

Intervention: JUST RIGHT FIT

• Transtheoretical Model (mostly for substance abuse but can be used for life changes)

  • MNEUMONIC: Playful Cats Pounce and Meow Regularly

    • Precontemplation

      • Contemplation

      • Planning

      • Action

      • Maintenance

      • Relapse

Intervention: identify stage of change and use strategies to help them move to next level

• Self-Efficacy

  • Belief in your own capability, which motivates you to act.

    • Mastery

    • Modeling

    • Social persuasion

    • Somatic/emotional states

Intervention: avoid criticism, provide positive, specific and sincere feedback. Break down activities for multiple opportunities for success

• Approach & Avoidance

  • Approach: Behavioral Activation System

    1. What can I do

    2. What can go well

    3. Active in individuals who are impulsive

  Slow them down

  • Avoidance: Behavioral Inhibition System

    1. What can go wrong

    Person who is overly cautious

    Positive feedback

• Intervention: address negative emotions and impulsiveness. Support positive emotions and help change emotional associations, incorporate rewards and remove punishments associated with the activity.

• MOHO – Model of Human Occupation

  • How occupations are motivated and organized into daily life patterns and performed within a person's environment.

  • Dynamic systems theory

    1. Performance

    2. Habituation

    3. Volitional

       1. Interests

       2. Values

       3. Personal causation

• Intervention: target intervention at the factor that interferes with performance

• Motivational interviewing

  • Open-ended questions

    • Conversation to understanding perspectives of client

  • Reflective listening

    • Paraphrased statements

    • Client provides feedback for accuracy

  • Affirmation

    • Acknowledge clients strengths and efforts towards chanfe

  • Eliciting change talk

    • Questions focus on desire, ability, reasons, and needs

• Motivation and psychiatric disabilities

  • MNEUMONIC: Squirrels And Mice Scurry Incessantly.

    • Schizophrenia

      • ADHD

      • Mood disorders

      • Substance Abuse

      • Intellectual Disabilities

    • Assessment, including BAS/BIS

      • BIS/BAS Scales

        • Adolescent & adult

        • Motivated by rewards or punishment

      • Dimensions of Mastery Questionnaire

        • 6 months to 19 years old

        • Persistence while engaging in challenging activity

      • Goal Attainment Scaling (GAS)

        • Adults with mental health but universal

        • Is goal set achieved?

      • Leisure Motivation Scale

        • Adolescents & adult

        • What motivates you to participate in activity

      • Volitional Questionnaire and Pediatric Volitional Questionnaire

        • Older children, adolescents, and adults

        • Pediatrics: 2 to 7 years

        • Persons motive and how environment affects choices

1. Mood disorders (features and impact on occupational performance.

   • Major depression

     • Episodically

     • Onset mid 20s but can occur anytime

     • High rate of recurrence

   • Bipolar I and II disorder

     • More than 50% show symptoms before age of 19

     • Type 1:

       1. Manic episode with or without major depressive disorder

     • Type 2:

       • hypomanic disorder with a major depressive disorder

       • cyclothymic disorder

       • 2-year period – chronic fluctuating hypomanic symptoms and depressive symptoms

2. Hypomania

   • periods of elevated, expansive, or irritable mood, but symptoms are at a lower intensity and without marked impairment in social or occupational functioning.

   • Prevalence

     • Depression is high

     • Diagnosis of bipolar disorder is rising sharply among children and adolescents

     • Men 7% women 12% 2 to 1 ratio

     • Lifetime prevalence for bipolar disorder is 1% 1 to 1 ratio

     • Caucasian less likely to seek help

       • Stigma

3. Suicide risk factors

   • Most frequently in males

   • Peaks in adolescents

     1. 15-29 years old

   • Improve

     • Easier access to healthcare

     • Depression is the highest risk factor

4. Emotion

   • Modal Model of Emotion

     • Interactive process between person and situation

     • situation —> attention —> appraisal —> response

• Emotional regulation and dysregulation

  • Performance skill (emotional regulation)

    • dysregulation

      • Negative or unpleasant experience that interferes with goal-oriented activity

      • Impairment in modulation

  • Neurophysiology of emotion regulation

    • Mind-body phenomenon – nervous and endocrine system

      • Polyvagal theory

        • how our nervous system responds to stress, danger, and safety

  • Emotional regulation in adolescence

    • Starts in early childhood

      • Difficulties with self-regulation 🡪

        • Poor stress response

        • hyperreactivity

• Emotional dysregulation and psychiatric disorders

  • Borderline personality disorder

    1. Responds quickly and intensely

  • Depression

    1. Avoid and suppress negative emotions and experiences

  • Anxiety

    1. Worry about future experiences

    2. Mindfulness training and skill development

  • Substance abuse

    1. Impulse control

  • Bipolar disorder & disruptive behavior disorders

  • Assessment

    • DBT Diary Cards (dialectical behavior therapy)

      • Adolescents and adults

      • Measures quality of engagement, pleasure, & capacity to regulate emotional responses

    • Difficulties in emotion regulation scale

    • Emotion regulation skills questionnaire

    • Self-compassion scale

    • Cognitive emotion regulation questionnaire

    • Emotion Regulation Questionnaire

      • Adults

      • Differences in habitual use of 2 emotion regulation strategies

      • Cognitive appraisal

      • Suppression of emotional expression

    • Mindful attention awareness scale

    • Five facet mindfulness questionnaires

    • Dialectical behavior therapy

      • Has to want to change or won’t be effective

      • Behavior that’s targeted is understandable

      • Group setting and training manual should be followed

        1. Mindfulness taught first 🡪 CORE skill of emotional regulation

        2. Interpersonal effective skills

        3. Distress tolerance skills

           • Contemplating pro/con

           • Distracting

           • Self-soothing

           • Improving movement

      • Modification

        • Acceptance and change

• Mindfulness-based occupational therapy

  • Pay attention to present moment and nonjudgmental