Comprehensive Study Notes – Frames of Reference

Overview of Frames of Reference (FoR)

  • “Frame,” “model,” and “framework” are used interchangeably across OT literature; do not over-interpret wording on the exam.
  • Each FoR provides
    • A particular “lens” through which to view a client’s strengths/needs.
    • Guidelines for evaluation, intervention planning, and outcome measurement.
  • Choice of FoR is influenced by
    • Age group (pediatric, adolescent, adult, geriatric).
    • Practice setting (school, acute care, community mental health, etc.).
    • Diagnoses, performance problems, and client goals.

Selecting an Appropriate FoR

  • Start by identifying the main performance barrier:
    • Sensory–motor difficulty? → consider SI, NDT, Motor Skill Acquisition.
    • Developmental gap? → Developmental FoR.
    • Maladaptive thoughts/behaviors? → Cognitive-Behavioral or Behavioral.
    • Environmental/contextual barrier? → EHP or Occupational Adaptation.
  • Then confirm that the FoR’s assessment & intervention tools fit your setting and the client’s values.

Pediatric Frames of Reference

Sensory Integration (Ayres Sensory Integration – ASI)
  • Population: ASD, SPD, ADHD, other neurodevelopmental conditions.
  • Core concepts
    • Adaptive response = successful, goal-directed interaction with sensory environment.
    • Remediation of sensory input focuses on skills not yet possessed (vs. rehabilitation for skills that were lost).
    • Four frequently targeted subsystems
    • Praxis (motor planning).
    • Proprioception (body position sense).
    • Postural control.
    • Self-regulation.
  • Intervention characteristics
    • Play-based, child-led activities (e.g., climbing, swinging) that are graded to elicit adaptive responses.
    • Example: Child who crashes into peers because of poor proprioception → therapist grades heavy-work activities to increase joint feedback.
Developmental Frame of Reference
  • Assumes skills emerge in a linear sequence of milestones.
  • Key rule: Master precursor skills before progressing (e.g., static standing precedes walking).
  • Intervention
    • Assess developmental age vs. chronological age; identify gaps.
    • Provide activities at the “just-right” developmental level, then gradually elevate complexity.
    • Example: Six-month-old still using palmar rake to pick up cookies → practice pincer-grasp activities until skill emerges, then advance to utensil use.
Motor Skill Acquisition Frame of Reference
  • Goal: Teach task-specific motor strategies through practice, feedback, and environmental structuring.
  • Environment distinctions
    • Closed task = no variability (brushing teeth each morning in same bathroom).
    • Open task = variable, unpredictable (youth soccer game, fall festival).
  • Hallmarks of intervention
    • Repetitive practice in both closed & open environments.
    • High value on client feedback and self-evaluation (e.g., child sequences picture cards of tooth-brushing, then practices activity).

Mental Health Frames of Reference

Behavioral Frame of Reference
  • Based on operant conditioning: behavior ↑ when followed by reinforcement.
  • OT focuses almost exclusively on positive reinforcement.
  • Key techniques
    • Conditioned vs. unconditioned reinforcers (tokens vs. snacks).
    • Extinction = withhold reinforcement until maladaptive behavior disappears.
    • Chaining
    • Forward chaining: Client performs first step, therapist completes rest.
    • Backward chaining: Therapist performs all but final step; client finishes → immediate success/reward.
  • Example: Student gets token for every math problem completed without nail-biting; goal is extinction of nail-biting.
Cognitive-Behavioral Frame of Reference (CBT)
  • Principle: Maladaptive thoughts create maladaptive feelings/behaviors; thoughts can be identified, challenged, and replaced.
  • Common OT tools
    • Cognitive restructuring, positive affirmations.
    • Coping skills training (deep breathing, guided imagery).
    • Graded activity scheduling: Re-introduce pleasurable tasks in small, feasible doses to combat avoidance (e.g., 1010-minute dog walk twice daily while studying).
    • Systematic desensitization, thought journals, activity diaries.
  • Exam example: Candidate anxious about scoring 450450 retest → reflective exercise compares past vs. current coping strategies.
Psychodynamic Frame of Reference
  • Draws on Freud’s id–ego–superego conflict and unconscious processes.
  • OT focus areas
    • Enhance self-awareness, emotional expression, and empathy through creative, task-oriented group work.
    • Address defense mechanisms (e.g., denial vs. rationalization).
    • Denial = refusal to accept reality ("I don’t drink that much").
    • Rationalization = create excuses to justify behavior ("I’m just borrowing the candy").
  • Intervention: Structured craft/cooking groups emphasizing sharing materials, problem-solving, peer feedback.

Physical Dysfunction Frames of Reference

Occupational Adaptation (OA)
  • Emphasizes ability over disability; success = mastery of occupations via adaptation.
  • Therapist role: Provide tools, environmental mods, and strategies to enable mastery.
  • Example: Worker with T4 SCI in pre-ADA building → extended button-pusher for elevator, lightweight chair, padded gloves; focus on re-establishing work role, not on pathology.
Ecology of Human Performance (EHP)
  • Performance = interaction of person, task, and context.
  • Five intervention approaches: establish/restore, alter, adapt/modify, prevent, create.
  • Task-enhancement lens: Modify context to optimize performance.
    • Ex: Noisy household disrupts study → alter context (library, noise-canceling headphones).
    • Cafeteria overwhelms child with ASD → move lunch to quiet room to improve feeding.
  • Distinct from PEOP by its relentless focus on manipulating context rather than person variables.
Neuro-Developmental Treatment (NDT)
  • Population: CVA, TBI, CP; goal = normalize movement patterns through therapeutic handling.
  • Core elements
    • Facilitation & inhibition via tactile cues (tapping, weight bearing, deep pressure).
    • Emphasize proximal stability → distal function.
    • Practice of missing components in developmental positions (prone, quadruped, sit, stand).
  • Example: Child with CP bears weight through UE on therapy ball while therapist provides directional cues to enhance scapular stability.

Cross-Cutting Concepts & Terminology

  • Remediation vs. Rehabilitation
    • Remediation = build a skill never acquired.
    • Rehabilitation = regain a lost skill.
  • Closed vs. Open Tasks
    • Closed: stable, predictable environment.
    • Open: variable, unpredictable demands.
  • Forward vs. Backward Chaining (behavioral FoR).
  • Adaptive Response (ASI): Successful sensory-motor interaction with environment.
  • Defense Mechanisms (psychodynamic):
    • Denial, rationalization, projection, displacement, etc.
  • Graded Activity Scheduling (CBT): systematically insert pleasure activities to counter depression/anxiety.

Example Applications & Exam Tips

  • Positive token board for completing worksheet → Behavioral FoR (positive reinforcement).
  • Reflective journaling about test anxiety + coping plan → Cognitive-Behavioral.
  • Toddler must master pincer grasp before utensil feeding → Developmental.
  • Sequencing picture cards, then practicing brushing → Motor Skill Acquisition (emphasis on feedback & practice).
  • Provide anti-tippers & axle adjustment for wheelchair after bilateral LE amputation → Occupational Adaptation.
  • Add climbing rope to jungle gym for heavy work input → Sensory Integration (proprioception remediation).
  • Structured craft group with explicit roles to build social skills → Psychodynamic (task-oriented group).
  • Therapist taps triceps during prone weight-bearing to facilitate UE extension post-stroke → NDT.
  • Move meal from noisy café to small room to support eating → EHP (alter context).

Key Numeric Facts & Formulas

  • NBCOT passing scaled score: 450450.
  • Alcohol guideline cited: >11 drink/night considered "too much" in example.
  • Developmental snippet: pincer grasp typically emerges 99–1212 months; palmar rake 66–99 months.
  • Closed vs. open environment examples use concrete ADL timelines (e.g., daily tooth-brushing).