The Impact of Heterogeneity in a Clinical Trial: Motor Outcomes after Sensory Integration Therapy

The effect of a therapeutic intervention in a clinical trial may be obscured by heterogeneity in the study subjects. This paper examines the results of a randomized clinical trial to evaluate the effects of 6 months of sensory integration therapy, perceptual-motor treatment, and no program (control) on learning disabled children with sensory integrative dysfunction. Contrary to expectations, Polatajko, Law, Miller, Schaffer, and Macnab (1991) found no significant differences between the groups on motor performance. However, overall, the children made motor gains; indeed, some children made very large gains. Others did not make gains or deteriorated. Change scores indicated that approximately half of the children improved more than can be expected by maturation alone while half did not. The heterogeneity of the response of individual children to treatment appeared to have led to an overall non-significant result. The heterogeneity was examined using a backward elimination regression procedure. The importance of this heterogeneity for assigning children to programs and designing outcome studies in occupational therapy is discussed.

Participation in Out-of-Home Environments for Young Children With and Without Developmental Disabilities

This study examines caregivers' perceptions of participation patterns and environmental supports and barriers for young children with and without developmental disabilities within their child care/preschool and community settings. The Young Children's Participation and Environment Measure (YC-PEM) was completed by 151 parents of Singaporean children (0-7 years old) with and without developmental disabilities. Setting-specific summary and item-level scores of these children were compared using ANCOVA, Mann-Whitney U, and Pearson chi-square tests. Children with developmental disabilities had significantly lower participation and environment summary scores in both settings as compared with children without developmental disabilities (p < .05; [Formula: see text] = 0.03-0.31). Group differences were also evident at the item level, particularly when comparing the percentage of parents who desire change in their child's activity participation. Adequate financial support, public awareness, programs, and services have been identified as environmental factors that are potentially important to parents of children with developmental disabilities.

Mothers of Children with Disabilities: Occupational Concerns and Solutions

Mothers of children with disabilities have identified multiple challenges associated with achieving occupational balance in their lives. Occupational therapists are just beginning to explore the occupational and time use strategies that mothers use to successfully care for their children and get through the day in a positive manner. The Person—Environment—Occupation model was used to guide an occupational therapy intervention program called “Project Bien Estar,” which was designed to increase the satisfaction, time use, and occupational performance of mothers of school-aged children with disabilities. This article focuses on the rich content of the group discussions and individual reflections, providing insight into the world of women caring for children with disabilities. Thematic analysis was used to identify person, environment, and occupation factors that contribute positively and negatively to the mothers' well-being, and the effects of the occupational therapy intervention are discussed.

Mysteries and Mazes: Parents' Experiences of Children with Developmental Coordination Disorder

Background. Children with Developmental Coordination Disorder (DCD) represent 5 to 6% of the school-aged population and are often seen by occupational therapists in the school system. Although a family-centred approach has been identified as best practice in pediatric care, the perspective of parents is often overlooked both in research and in practice. Purpose and Method. In this study, a qualitative, phenomenological approach was adopted to explore the insights and experiences of 13 parents of children with DCD. Each parent participated in two in-depth interviews and completed a set of questionnaires. Results. Analysis of the study findings led to three primary themes that captured the experience of parents as they attempted to understand and get help for their child. The theme of unravelling the mystery highlights parents' impressions of their child's difficulties. The second theme of negotiating the maze refers to the many pathways followed by families as they sought to affirm their perceptions and obtain services for their child and the final theme of parenting dilemmas underscores some of the common challenges faced by parents in trying to deal with their child's limitations. Practice Implications. For occupational therapists, the study findings illustrate the importance of focusing on occupational performance issues for children with DCD, facilitating the understanding of parents, and the need for early intervention.

Implementing Client-Centred Practice: Why is it so Difficult to Do?

This paper explores the challenges of implementing client-centred occupational therapy practice. While many occupational therapists believe in the principles of client-centred practice and espouse them, it seems much more difficult to implement these into everyday practice. Findings from three qualitative studies with three different populations (i.e., family-centred care for children and their families, community-based home care, facility-based care for older adults) are used to illustrate the challenges which are divided into three broad categories: challenges at the level of the system, at the level of the therapist and at the level of the client. Suggestions for change at each level are addressed. Organizations, therapists and clients must work together to facilitate these changes and ensure that each occupational therapy client receives respectful, supportive, coordinated, flexible and individualized service.

The reliability and validity of a revised version of the Erhardt Developmental Prehension Assessment

The Erhardt Developmental Prehension Assessment (EDPA) was designed as a measure of hand function for use with developmentally and physically disabled children. In this study the EDPA was revised (EDPA-R) by changing some of the test items, standardizing the procedures for administering the test and developing an objective scoring system. The inter-observer reliability of the EDPA-R, and the concurrent validity of the EDPA-R with the fine motor scale of the Peabody Developmental Motor Scales (PDMS) were evaluated. Thirty developmentally disabled children ranging in age from 3 to 18 months were tested in this study. The results indicate that the EDPA-R has high levels of inter-observer reliability, and that it has concurrent validity with the PDMS in this population. Further test revisions are necessary, however, to improve the EDPA-R's discriminative power.

Validation of the Klein-Bell Activities of Daily Living Scale for Children

Occupational therapists require reliable and valid activities of daily living assessments to describe patient performance and to aid in treatment evaluation and planning. A recently developed instrument, the Klein-Bell ADL Scale has been shown to have acceptable reliability and validity for use with adults. This paper reports the results of an initial study designed to evaluate the utility of the Klein-Bell ADL Scale for use with children. Developmental ages reported in the literature were used to adapt the scale for use with children ages six months to adulthood. Its reliability, construct validity and responsiveness were tested in a total sample of 10 normal and 10 cerebral palsied children. Results indicate that the scale is reliable, is able to differentiate normal from handicapped children and demonstrates acceptable agreement with parental ratings of change in ADL skills. The Klein-Bell ADL Scale was also found to be an effective communication tool between therapists and parents of disabled children.

The Meaning of Play for Young People with Physical Disabilities

As a primary area of occupation, play is central to the lives of children. Emerging views of play reflect the complexity of the area, and focus on the relationship between the person and the environment during play. This paper reports the results of a qualitative study of twenty adolescents with and without physical disabilities. The participants were interviewed about their perceptions and personal experiences of play.

Through a textual analysis of the data, significant themes related to the nature of play, environmental barriers and supports, and personal influences on play were identified. Clinical implications are discussed in relation to these themes.

The Effectiveness of a Multisensory Writing Programme for Improving Cursive Writing Ability in Children with Sensorimotor Difficulties

Children with sensorimotor difficulties experience significant challenges in the ability to write adequately. A single case experimental design with multiple baselines across behaviours was used to evaluate the effectiveness of a multisensory writing programme for improving the cursive writing ability of four children with sensorimotor difficulties. Five distinct letter groups were taught in random order, one group every two weeks. Repeated measurements of writing speed and quality for each letter group were made. Visual analysis indicated that specific letter groups for all of the children changed following intervention. Statistical analysis indicated that quality scores of one child changed significantly while there were no significant changes in overall speed scores. Teacher reports before and following the programme suggest that intervention may have had a positive effect on self-confidence in written output. Further research is needed to evaluate the use of multisensory writing programmes by occupational therapists working with this specific population.

Targeted Applications of the Canadian Occupational Performance Measure

Background. The Canadian Occupational Performance Measure (COPM) is an outcome measure designed to assess performance and satisfaction with occupation. It was developed to coincide with the occupation-focused, client-centred Canadian Model of Occupational Performance. Purpose. The COPM has been a feature of the occupational therapy landscape for approximately 15 years and has pervaded the consciousness of occupational therapists around the world. In this paper, we examine issues associated with application of the COPM in targeted clinical and non-clinical situations. Results. The paper suggests considerations required to ensure that the highest quality of information is derived from the COPM in all situations. Practice Implications. Although the paper emphasizes the centrality of the client-centred approach, it also demonstrates the flexibility and adaptability of the COPM to different situations, clients, settings and purposes.

An Occupational Performance Process Model: Fostering client and Therapist Alliances

Occupational therapists, known for their ability to coach others through difficult changes, now find themselves in changing environments that include clients' desire for participation in service delivery, and the need for evidence of the outcome of occupational therapy intervention. This paper proposes a process model that is based on core concepts of occupation and client-centred practice, that incorporates theoretical approaches, and can be applied to all clients. The process model coaches the occupational therapist through a client-centred problemsolving process. It represents a description or plan for occupational therapy assessment and intervention that leads to a collaborative approach to client-identified occupational performance issues. Examples of the application of the process to occupational therapy practice are included. This model helps to articulate core concepts and values, and provides guidance for occupational therapy practice within changing environments and expectations.

Knowledge and Use of Theory among Occupational Therapists: A Canadian Survey

Recent interest in occupational therapy theory has focussed attention on the utility of theory for clinical-practice and for research. However, for many therapists, knowledge and use of theory have changed notably since their educational days, and the process of keeping up to date on theory development may be difficult.

This paper presents the results of a survey aimed at identifying the extent of use of theory and the level of knowledge about theory among practicing therapists in Canada. A random sample of 187 therapists from across the country was surveyed to ascertain their knowledge of authors and ideas in the occupational therapy theory literature. Results indicate that overall knowledge level is moderate. Factors which significantly predict theory knowledge include year of graduation, training in or outside Canada, academic qualification, and self-assessment of theory knowledge. There were no significant differences in theory knowledge according to area of clinical practice.

The Canadian Occupational Performance Measure: A Research and Clinical Literature Review

Backround. It has been 13 years since the Canadian Occupational Performance Measure (COPM) was published. In that time there has been a remarkable growth in its acceptance as an outcome measure within the occupational therapy practice and research. Purpose. The purpose of this paper is to review the emerging research and clinical literature related to the COPM since 1994 and to document its impact upon occupational therapy practice and research throughout the world. Method. A systematic search was conducted to the professional and research literature in English publications (primarily occupational therapy). Eighty-eight papers that met the inclusion criteria were reviewed, 86% of which examined the COPM in relation to its psychometric properties (19 papers), research outcomes (33 papers) or practice (33 papers). Results. Overall, although there are a few limitations discussed in the review, the conclusion is that the COPM is a valid, reliable, clinically useful and responsive outcome measure acceptable for occupational therapist practitioners and researchers. Practice Implications. The COPM is used with a wide variety of clients, enables client-centred practice, facilitates evidence-based practice and supports outcomes research.

Occupation, Health and Well-Being

Occupational therapists believe that there is a relationship between occupation, health and well-being but there is little evidence in the occupational therapy literature to support this belief. This paper describes the results of a critical review of research examining the relationship between occupation and health and well-being. Twenty-two studies from the health and social sciences literature were reviewed using specific methodological review criteria. The findings of these studies provide moderate to strong evidence that occupation has an important influence on health and well-being. Because most of this research has been completed with persons without disabilities, further research is required to explain the nature of the relationship between occupation and health and well-being for persons who experience a disability which affects their daily occupations

Evidence-Based Occupational Therapy

“Is evidence-based health care just a passing fad, promoted by managers and purchasers enjoying their influence over clinical practice, but doomed to fail as a far too cumbersome method for dealing with the complexity and imprecision of real-life clinical decisions? ”

The Person-Environment-Occupation Model: A Transactive Approach to Occupational Performance

Occupational therapy theory, practice and research has increasingly emphasized the transactional relationship between person, environment and occupation. Occupational performance results from the dynamic relationship between people, their occupations and roles, and the environments in which they live, work and play. There have, however, been few models of practice in the occupational therapy literature which discuss the theoretical and clinical applications of person-environment interaction. This paper proposes a Person-Environment-Occupation Model of occupational performance which builds on concepts from the Occupational Therapy Guidelines for Client Centered Practice and from environment-behaviour theories. The model describes interactions between person, occupation and environment, outlines major concepts and assumptions, and is applied to a practice situation.

The Effects of Family-Centred Functional Therapy on the Occupational Performance of Children with Cerebral Palsy

Background. Family-Centred Functional Therapy (FCFT) is a comprehensive approach to paediatric occupational therapy that considers and addresses the skills of the child, the requirements of functional tasks and the elements within the tasks environment, including family goals and preferences. Purpose. The purpose of the present study was to determine if interventions based on FCFT, but limited to addressing elements of the task and environment, would improve task performance. Method. A single subject, multiple baseline design was applied to three children, for three tasks each. Tasks were selected by parents and measured during baseline and intervention phases. Results. Results indicate that for each child at least one of the two tasks for which intervention was provided demonstrated improved performance. Parents reported a clinically significant improvement in satisfaction with their children's performance in the tasks that were addressed. Practice Implications. This study provides preliminary evidence of the effectiveness of the FCFT approach.