Golden Study Guide PDF

IRM /Taylor Application of modes to case scenario Advocating Mode - Ensures clients have needed interpersonal and material resources. Acts as a facilitator, case coordinator, defender of justice, or consultant rather than as a service provider. Ensures opportunities for participation and access by c...

IRM /Taylor Application of modes to case scenario Advocating Mode - Ensures clients have needed interpersonal and material resources. Acts as a facilitator, case coordinator, defender of justice, or consultant rather than as a service provider. Ensures opportunities for participation and access by connecting clients with peer mentors and role models. May engage in consciousness-raising about legal rights and disability oppression. Normalizes the client’s experience of disability as part of the natural continuum of human experience. Collaborating Mode - Expect clients to choose their own activities and goals during therapy, even if the therapist disagrees. Expect clients to drive the therapeutic reasoning behind the therapy process. Expect clients to actively participate. Solicit ongoing feedback from clients. Change the approach in response to the client’s feedback. Encourage autonomy in thought and independence in action. Empathizing Mode Significant effort in striving to understand a client’s perspective accurately by - - Making summary statements that recap the client’s story or experience; this defines the most painful or troubling element of that moment or story. Asking questions that show your curiosity about the client’s perspective and/or deepen your understanding of the client’s experience, provided that the client is comfortable responding. Validating the client’s experience or viewpoint, even if it is negative or maladaptive. Quietly bearing witness to the client’s experience. Showing congruence with the client in mood and affect. Notice and respond to nuances in clients’ affect and behavior. Accept and validate negative emotions—do not rush to alter or fix. Approach interpersonal difficulties by listening and striving for understanding. Encouraging Mode - Statements and actions that instill hope Praising and reinforcing desired behaviors Responding to a client’s use of humor or preference for humor Celebrating successes with a client Using play, song, dance, or other entertaining actions to engage a client, if appropriate Instructing Mode - Share information. Train, coach, guide, and model behavior for the client. Make expectations from the client clear. Provide structure to the therapy process for the client, including outlining what will happen before it happens. Provide evidence for your approach or perspective. Provide the client with corrective feedback, when necessary. Be unafraid to make recommendations, set limits, or disagree with clients. Assign activities for the client to do outside of the immediate therapy session. Function as an outward leader by showing a sense of conviction. Problem-Solving Mode Strategic questions that probe and clarify a client’s beliefs about an issue for three central purposes: - To guide the client to approach a problem in a more adaptive way To free a client from thoughts and beliefs that inhibit his or her ability to engage in occupations To help a client clarify his or her own thinking about an issue in order to see a wider range of options, consequences, or dimensions List pros and cons, or strengths and weaknesses, of a client’s plans or approach. Use other strategies, such as making lists, in order to facilitate anticipatory thinking and planning. Caution with Modes There are three circumstances that characterize suboptimal mode use: a mode mismatch, mixed mode use, and incongruent mode use. Mode mismatch occurs when a therapist communicates within a mode that does not meet the client’s interpersonal needs or is inconsistent with the client’s interpersonal characteristics or any interpersonal events that happen to be occurring in that moment. Mixing modes occurs when a therapist is not clear about his or her intended message and conveys two modes simultaneously within a single moment of communication (typically within the same sentence). Incongruent mode use occurs when a therapist shows emotional incongruence when communicating with a client. - Emotional incongruence occurs when a person is communicating one statement verbally and the same person’s emotional expression, facial expression, or body language contradicts or does not support what the person is saying. No Mode Is Inherently Problematic BUT... Any mode can be if used... - Too frequently or inflexibly With the “wrong” client When inconsistent with a client’s interpersonal needs When the timing is not right... May interfere with the process and outcome of therapy. Elements of the IRM IRM: Four Central Components 1. 2. 3. 4. Client’s interpersonal characteristics Inevitable interpersonal events of therapy Therapist’s use of the six modes Occupational engagement Empathic listening Empathic listening involves the process of recounting, accepting, and affirming any perception or experience a client offers. Its purpose is to allow the therapist to learn about the clients’ inner experience and to engage clients more fully in the therapy so their communications are more consistent with their actual emotional experience. To listen empathically, you must first grasp the meaning and purpose of empathy in occupational therapy practice. Empathetic listening - Provides a means by which to summarize and clarify the content of what a client is communicating. - Shows a client that a therapist is continually striving to understand his or her thoughts, feelings, or behaviors - Can be used effectively to repair rifts and resolve conflicts Client-centeredness - - Responding to clients’ interpersonal needs and characteristics in a custom-tailored way Striving for an empathic understanding of the client’s inner experience Knowing when to use or not use communication strategies that promote structure, direction, empathy, hope, empowerment, activation, independence, and so on Recognizing when one’s approach is not leading to a safe, open, and trusting interaction and changing it Concepts and guidelines for strategic questioning Strategic questioning is an approach to asking clients questions that originated within the tradition of cognitive therapy. Applied within the Intentional Relationship Model (IRM) strategic questioning involves asking clients questions in a way that intends to influence their perspective, convey a certain message, or cause them to reflect upon and evaluate their thinking about a given topic. Through this type of questioning, clients examine their thinking from a more objective and logical standpoint, and they are encouraged to test the validity of their ideas by attempting new behaviors. Strategic questioning relies heavily on the Socratic approach. Socratic questioning is an approach originally developed by Socrates to teach students of philosophy how to think critically about information. Most important to this process is the timing and context in which these questions are presented to clients. Because of the potential to threaten or challenge a client's existing behaviors and beliefs, strategic questioning should be offered only to clients who are not exceptionally sensitive or vulnerable at the time and then only when it is clear that the client is ready to be questioned in this way. Asking these questions with poor timing or in an inappropriate context may lead to empathic breaks or, more significant, ruptures in the therapeutic relationship. Groups and History, Dynamics, Interactions Difficult behaviors (Cole and Taylor) According to the IRNt, difficult interpersonal behavior is defined as any recurring, enduring, or high intensity communication or other behavior that prompts one or more negative emotional reactions in another individual. 8 Categories of behaviors - Manipulative behavior - Excessive dependence - Symptoms focusing - Resistance - Emotional disengagement - Denial - Difficulty with rapport and trust - Hostility Resolution of difficult behaviors 1. 2. 3. 4. 5. 6. Anticipate Identify, cope, and strive for understanding Determine if a mode shift is required Choose a response mode 5. Draw on any relevant interpersonal skills associated with that mode 6. Gather feedback Group Leadership Styles Overview Types of occupational therapy group leadership - Directive Facilitative Advisory Directive Leadership Therapist determines structure, activity, and processing Therapist takes an active role in shaping member participation Group goals are achieved through active leadership Most group roles are performed by the leader Feedback to members given mostly by the leader Directive Leadership is Appropriate When… - Cognitive impairment - Poor capacity for insight Immaturity Poor verbal skills Low motivation Topic is educational and requires therapist expertise/demonstration Facilitative Leadership is Appropriate When… Middle-high level of cognition and capacity for insight, maturity and verbal skills Members are capable of making choices of activity, topic, structure Members can learn from experience Therapist can delegate some leadership roles to members Members are encouraged to give each other feedback Therapist/leader does not do anything for the group that they can do for themselves Advisory Leadership is Appropriate When… OT’s role is consulting, wellness, or caregiver education Members have high cognition, verbal skills, insight capacity, and motivation Members have selected a specific activity or topic area Members can seek advice from leader on as-needed basis Members lead their own group and experience natural consequences from the environment 7 Steps: Overview 1. 2. 3. 4. 5. 6. 7. Introduction Activity Sharing Processing Generalizing Application Summary Step 1—Introduction: Names Why is it important to have group members introduce selves? - Acknowledge each member by name Self as OT leader, title of the group activity Ask members to greet each other by saying their names in turn Important even if members know each other Shows recognition of each individual as important Reinforces inclusion in the group Creates a friendly atmosphere Step 1 —Introduction: Warm Up What is the purpose of a warm up? - Prepares members- alertness Prepares for starting new experience Captures attention of members Refocuses member thoughts May be informal or imaginative Prepares group for activity to follow (match) Step 1 —Introduction: Setting the Mood - Lighting Seating (having the correct number of chairs) Getting rid of clutter and distractions Having needed supplies ready Therapist features: - facial expression gestures tone expectations of group: serious or light- hearted? Step 1: Expectations of the Group - Therapist’s manner and expression reflect the expectation Role model to members Step 1 —Introduction: Explaining the Purpose - The purpose is the primary task of introduction: Never leave out! Include main therapeutic goals Why is the purpose so important? - Clients need to know how proposed activity can help them Encourages member cooperation Step 1 —Introduction: Brief Outline of the Session - Include time frame, media, and procedures Example: 1 hour session Draw yourself (15 minutes) Sharing and discussion (25 minutes) I will be keeping your drawings after we finish Artistic talent isn’t important Focus is on discussion and learning Don’t reveal anything you don’t want to share Step 2—Activity: Selection - A very complex process Includes activity analysis and synthesis Based in occupational therapy theory (FOR’s) and research evidence Meets therapeutic goals of the group Step 2 —Activity: Timing Activities should be short and simple - Activity portion should last no longer than one-third of the total session (15 minutes) Must be challenging and complex enough to produce meaningful discussion and learning Individual goals can be set before group begins Group goals should be chosen to meet the needs of individual members Clients and therapist collaborate to set and accomplish goals Once goals are defined, an activity is chosen to help meet the goals Step 2 —Activity: Therapeutic Goals - Individual goals can be set before group begins Group goals should be chosen to meet the needs of individual members Clients and therapist collaborate to set and accomplish goals Once goals are defined, an activity is chosen to help meet the goals Example: Personal growth may best be accomplished through creative activities, such as drawing, drama, or storytelling Example: Social goals may best be worked on through activities involving interaction of members, such as communication exercises or group problem solving Step 2 —Activity: Physical and Mental Capacities of Members - Activity should match capacities of members Choose an activity challenging enough to hold their interest, but not beyond their capacity- just right challenge Persons with cognitive limitations require simplified instructions and discussion topics Persons with physical limitations require adaptations in materials and environment Focus on learning something new and meaningful Students typically choose an activity with which they are comfortable – at first Capitalize on individual talents and skills Go with strengths and experience Select a growth facilitating activity All potential activities need to be adapted Activity analysis: Breaking down activity into components or steps - Modifications are made to compensate for disability or need for added challenge (synthesis) Activity should be presented in a systematic way Simple and direct language Instructions sequenced step by step Get feedback from members to check understanding (repeat back instructions) Keep materials hidden until needed and removed when activity phase ends. Choose to participate as leader (encourages trust) or not (if it distracts you from giving needed assistance or making observations) Give warning when time is up (1 minute); stop even if some members are not finished Step 3—Sharing How can a therapist facilitate sharing? After completing activity, each member is invited to share his or her own work or experience with the group - Ask for volunteer to start (or OT can model) Once begun, go around group in order (so no one is forgotten) Acknowledge each member’s contribution - Verbal and nonverbal responses For some activities, sharing is not a separate step, but incorporated into the activity Discussion is involved as part of the activity Requires opinion giving, discussion, and group decision making Leader must make sure everyone participates in discussion in lieu of sharing step Step 4—Processing Most difficult step to learn Involves how members feel about the experience, the leader, and each other Ask questions to facilitate expression of both positive and negative feelings Include recognition of non-verbal communications and their meaning Example: How do you think the anxiety symptoms you described impact your relationship with co-workers?’ Step 5—Generalizing Addresses cognitive learning aspects of group Therapist mentally reviews groups responses then verbalizes a few general principles learned from activity Leader asks open questions to generate learning issues Principles often resemble original goals Some ways to facilitate generalizing: - What are similarities or areas of agreement? What are areas of difference/disagreement? What issues energized the group? Follow up on areas that generate spontaneous conversation. Ask open questions that reveal the meaning of activity for members Step 6—Application Helps group apply learning to everyday life Each member explains how this group experience applies to real life situations or has meaning for him or herself Ask open questions to facilitate application of specific aspects of this activity Answers may be different for each member Relates back to individual as well as group goals Step 7—Summary Summarize learning Summarize emotional responses Acknowledge member participation (thank them for participating, sharing, trusting, disclosing, taking risks, etc) Verbally emphasize most important aspects of the group (can ask members to help) No way to pre-plan Leader shares own feeling responses End on a positive note (also, end on time!) Steps in writing a protocol - Group title Author Frame or model Purpose Group membership and size Group goals and rationale Outcome criteria Methods Time and place of meeting Supplies and cost References Group Norms/Culture Definition: Standards of group behavior, participation, and interaction Evidence tells us group culture must be established by the leader right from the first group session Once established, norms (culture) are exceedingly difficult to change How Does the Leader Shape Norms? - Attendance - Preparation Participation Self-disclosure Confidentiality Nonjudgmental acceptance Expectations of time, place, etc. Respect for others Structure of session Encourage members to give and receive feedback and interact with each other Members as Agents of Help Why Group Norms Change Group is moving toward greater maturity Group’s level of trust (cohesiveness) has progressed Unspoken tensions are blocking group progress One or more members play individual roles Leader intervention usually necessary to: - Support members who take risks Discourage members who behave in ways that block group progress Mosey’s Levels of Theory Three different levels of theory in occupational therapy based on Mosey: 1. Fundamental body of knowledge (Paradigm): Includes philosophical assumptions, an ethical code, a theoretical foundation of both theories and empirical data, a domain of concern, and legitimate tools. 2. Applied body of knowledge (Occupation-based models): Sets of guidelines for practice. Not specific in guiding an evaluation or intervention approach. How we see the person or how we should approach a particular situation. Could be applicable across different practice areas. 3. Practice (Frame of Reference): Action sequences, use of applied knowledge, the clinical reasoning process, and the art of practice. Task oriented group The task is not so much the focus as the vehicle around which discussion, problem solving, compromise, and therapeutic changes in self-identity take place. The task becomes the context in which all of the ego-adaptive skills can be discussed, evaluated, and strengthened. Three phases: 1. Planning: focuses on facilitation of group brainstorming, persuasion, and decision making as members decide on a meaningful task for the group 2. Doing: the actual doing of the activity or task, is then organized and carried out by the group members, with selective interventions by the OT group leader. 3. Evaluating: involves a discussion of the process, including feels about the task and outcome FOR’s, Models, Theory Frame of Reference OT perspective and application Articulates how frame of reference will be used in treatment Describes how to move from theory to practice May include examples for intervention Theory and evidence must always guide practice (we must always be evidence based!) Without the foundation of theory, based in the evidence, assessment and intervention lack focus and direction Interventions must be theory based for credibility of profession Frame of Reference is theoretical blueprint for evaluation and intervention Without basing practice in Models and assessments and interventions may achieve the desired outcome, but not as effectively or efficiently, resulting in lower satisfaction for both the client and the clinician. Components Theoretical base: describes static phenomena that define and describe relationships and how change occurs- how it can be initiated, maintained, or inhibited. Assumptions: Ideas that are held to be true and are questioned or tested Postulates: Statements that describe the relationship between 2 or more concepts Function/Dysfunction Continuum: What the therapists expect the child to be able to do and what represents disability Hypothesis: Used to examine theory and measure change Frame of Reference: Method or organization theoretical material and translating Assessment: Can use the function/dysfunction continua as a guide Used to facilitate change: Postulates Dynamic systems theory Components work as a system and can not be separated. (think Toglia FOR person, occupation, and environment) Biomechanical and Rehab FORs Biomechanical Principles - Most frequently used in practice Applies the principles of physics to human movement and posture with respect to the forces of gravity Considered a remediation approach Biomechanical Concepts Range of Motion (ROM): involves the angles and direction of human movement, including extension, flexion, abduction (awaY from the body), adduction (toward the body), and rotation. Kinematics: addresses the amount, direction, speed, and acceleration of human movement. Torque: is the effectiveness of a force in causing rotary movement, which depends on the amount of force (strength), the amount of resistance (weight of limb and object and position with respect to gravity), and the distance of the force from the axis (joint). Endurance: involves the ability to sustain muscular activity. Ergonomics: focuses on the study of work performance with an emphasis on worker safety and productivity. Also called human factors engineering, ergonomics “applies human factors to the design of tools, machines, systems, tasks, jobs, and environments for safe, comfortable, and effective human use” Rehabilitative Principles - Top 5 of most frequently used - Includes concepts of adaptation, compensation, and environmental modifications Goal = Maximizing client strengths and independence This FOR is used when the client is unable to go back to where they were before their disability. Rehabilitative Concepts Adaptation and compensatory strategies Motor Control NDT – in adults NDT techniques Neurodevelopmental therapy (NDT)/ Motor Control The focus is the restoration of skilled voluntary movement for both children and adults with either developmental or acquired neurological health conditions. NDT is considered a preparatory or problem-solving sensorimotor performance component that are prerequisites for occupational performance. Basic assumptions of NDT: Movement control progresses from head to foot (cephalocaudal), from trunk to limbs (proximal to distal), and from large to small (gross to fine) - Children gradually gain control over primitive reflexes Children internalize the sensation of movement in recovery of movement; stability precedes mobility Stability is created by co-contraction of complementary (opposite) muscle groups Mobility represents a way to engage the environment After brain injury, abnormal movement and tone must be inhibited before normal movement and sensation can be restored Flaccidity Spasticity Splinter skills: skills within a bigger picture example: kid can write his name but his name only Philosophical Tenets of NDT - Treatment should be functionally oriented and integrated into ADL. Evaluation and treatment are an ongoing problem-solving process. Client and family needs should be respected and addressed in the treatment process. - NDT treatment is based upon knowledge of normal movement, posture, tone, biomechanics, and sensorimotor processes, such as praxis. When possible, generalization of treatment should be sought by training the client and family in appropriate everyday activities. NDT is a holistic approach involving an interdisciplinary team. NDT is an individualized approach. Strategies/Interventions/Techniques Change occurs through the application of specific techniques and strategies. Handling: Uses hands on technique of addressing problems with tone and movement control. The occupational therapist will place the client in positions that decrease spasticity and activate normal patterns of movement. Inhibition techniques: Includes lengthening the spastic muscles, positioning to decrease excessive tone, preventing unwanted movements, and teaching clients methods for preventing abnormal postures and postions. Facilitation: include giving clients the sensation of normal movement. Placement: refers to the OT placing hands on key points of control, those that have the most influence over client movements. The goal of placement is to inhibit abnormal movements and influence the status of tone. Reflex-inhibiting patterns or postures (RIPs): refer to positioning the clients in ways that reduce tone by inhibiting specific primitive reflexes. In NDT, typically occupational therapists will us RIPs to inhibit spasticity while training normal movement patterns in specific body areas PNF techniques Proprioceptive Neuromuscular Facilitation (PNF) Patterns and application —Developed by Herman Kabat, MD, PhD —Uses diagonal and spiraling patterns of movement —Guides thinking about the sequence of normal development —Uses two diagonal patterns crossing the midline for each major body part (D1 and D2), often incorporating verbal commands Diagonal patterns occur in arms and legs and every joint in these extremities (e.g., elbow, wrist, digits) for this course focus is on shoulder and hip** In using diagonals, always crossing the midline of body. Shoulder D1 flexion: Pick apple and feed yourself. D1 extension: Go from feeding yourself to pick up another apple. D2 flexion: Reach across body and pull a sword from your hip (right hand to left hip) D2 extension: Put sword away. When referring to these diagonals, need to clarify direction (flexion or extension), which limb (right or left) and by which diagonal (D1 or D2). *If on the test need to include all 3 components. Hip Sitting and put ankle on knee. D1 flexion: bringing ankle from ground up to knee. D1 extension: bringing ankle from knee to ground. D2 flexion: start with feet crossed and bring foot behind you like picking gum off of shoe. D2 extension: start with foot behind you, bring it back to position with ankle crossed. Motor Learning Application Principles Motor Learning Theories A set of processes associated with practice or experience leading to relatively permanent changes in the capacity for producing skilled action; combines neuroscience with systems and learning theory A rehabilitative approach Draws on theories from psychology, behavioral sciences, neurology, medicine and allied health research Motor learning directly relates to task performance Task-oriented, top-down, client-centered THE PATIENT MOST CARE ABOUT THE TASK Focus Restoring functional movement Applicable to broad range of health conditions Meaningful tasks of the client’s own choosing provide the greatest motivation for repeated efforts to recover Even if it is a child if they do not want to do what their mother wants them to do they will not do it. Don’t use this frame Theoretical Concepts Nonlinear science Neuroplasticity & brain self-organization Recovery of function How learning occurs Learning Theory These concepts contribute to occupational therapists' understanding of how environmental cues affect motor responses, as well as guidelines for reinforcing desired movement behaviors. Associative Learning: in which the learner associates one thing to another. - - Procedural learning: refers to learning tasks that can be performed without attention or conscious thought. Develops slowly through many repetitions and eventually becomes habitual. Declarative learning: in contrast, results in knowledge that can be consciously recalled and thus requires awareness, attention, and reflection. This type of motor learning allows individuals to mentally practice a movement sequence before performing it Nonassociative Learning: occurs below the level of consciousness, related to human movement. - - Habituation: refers to a decrease in responsiveness (or desensitization) that results from repeated exposure to a non painful stimulus. In therapy, occupational therapists might wish to desensitize clients to stimuli that trigger abnormal or nonfunctional motor responses. Sensitization: is an increased responsiveness following threatening or noxious stimuli. In therapy, occupational therapists often wish to increase a client’s sensitivity to environmental cues that affect safe movement, such as water on the floor or obstacles in one’s path Task-Oriented Motor Learning Theory Schema theory: hypothesizes that motor learning involves sets of general rules (as opposed to specific movement patterns) that can apply in a variety of contexts. A schema is a generalized motor program that consists of 4 parts. 1. The initial situation (body position and task demands) 2. The parameters used (muscle groups, weight shifts, eye hand coordination) 3. The outcome or knowledge of result 4. The sensory consequence, or the knowledge of performance The movement schema is only only temporarily recalled, but the sensory experience is stored for later use (recognition schema). Ecological theory: clarifies the role of perceptions in motor learning. Practicing tasks promotes learning of an optimal motor strategy through increased coordination of perception and action in response to environmental constraints. Perception provides the following information for motor learning: - Recognition of the goal or task Recognition of regulatory cues - Knowledge of performance, or feedback during a task Knowledge of results, or feedback on goal achievement, outcome, or consequence Task-Oriented Training Timmerman’s training components: Contextual interference: refers to practice of movement skills in random order. Random practice leads to learning and application of skills under novel conditions. Transfer of learning: important for all motor relearning programs, occurs more easily when conditions are similar. The more closely the clinic conditions resemble the home environment, the more likely that motor skills will adapt. Recovery: refers to regaining the same level of functioning as before the onset of injury or illness. - Spontaneous recovery: occurs without benefit of intervention Forced recovery: refers to function gained through therapeutic intervention Adapted/functional recovery: altering the methods or mechanism through which one accomplishes a task. Concept of ‘Practice’ and application Cognitive stage: client develops a thorough understanding of the task, its demands, and the required skills and strategies. Fixation stage: practicing and refining selected motor strategies for doing a task (e.g. hitting a tennis ball so it will land within the boundaries on the other side of the net) Autonomous stage: the motor skill becomes relatively automatic and no longer requires sustained attention. 4s a starting point, Vygotsky (1978) suggests that the therapist define a client-specific range of performance expectations based on the client’s zone of proximal development. This begins with the tasks that currently can be performed independently and moves toward those tasks that can be performed adequately with therapist assistance. Comparison of Motor Learning and Motor Control Differences Motor Learning directly relates to task performance, the client must care about the task. It is task-oriented, top-down, and client-centered. While…. using the Motor Control FOR the client does not have to be motivated and the restoration of voluntary movement is unrelated to occupation. Motor learning intervention can be Constraint-Induced Movement Therapy or Cognitive Orientation to Occupational Performance Approach (CO-OP). While…. Motor control intervention can be Neurodevelopmental Therapy (NDT) or Proprioceptive neuromuscular facilitation (PNF). Interventions for motor learning need to be done in the context/environment in which the task or occupation takes place. While…. Interventions for motor control do not need to be in the natural context or environment because it is not occupationally focused. Similarities Both can be used for neurological conditions/dysfunctions. Ayres Sensory Integration Principles of Ayres Sensory reactivity: - also known as sensory modulation or sensory responsivity - refers to the child’s individual abilities to respond adaptively to sensation over a broad range of intensity and duration - The ability to modulate sensation is a complex process of filtering perceived sensory information and regulating the response. - Response to one or more sensations contributes to the capability to sustain engagement despite variability in the intensity of sensations from the body or environment, and contributes to emotional stability, behavior, arousal, activity level, and attention - Unusual sensory responses can be sensory or situation specific and vary according to the well-being of a child and the external environmental or social supports. - Atypical sensory reactivity (over-, under-, or fluctuating reactions) occurs when the child routinely shows dysregulated responses to typical sensory experiences Sensory perception (primarily tactile, vestibular and proprioceptive as well as auditory, visual, taste, and smell): - discrimination refers to the individual’s ability to interpret and differentiate between the spatial and temporal qualities of sensory information—or the “where is it,” “what is it,” and “when did it occur” response. - The ability to discriminate sensory information allows the development of perceptions of events and self in action and contributes to skill development, learning, social interactions, and play especially play that involves fine, discrete responses such as object manipulation. - Each individual sensory system has discriminative functions that contribute to the individual’s knowledge of sensory input and preparation for a response. - The timing of sensations, the child’s interest, attention, memory, and motivation affect the ability to process data that leads to perception. Postural-ocular control - - Involves activating and coordinating muscles in response to sustained positions or dynamic movements of the body during transitions and while moving relative to gravity. Postural responses are required for any action needed during physical engagement. Postural control emerges as the child develops activation and co-activation of muscle groups that support movement. - - Postural control is dependent not only on adequate muscle strength, endurance, or the ability to co-activate muscle synergies but also on the integration of multisensory information before and during movement from the vestibular, proprioceptive, tactile, visual, and auditory systems. Balance and equilibrium are components of postural control that are modulated by the vestibular, proprioceptive, and visual systems. Bilateral integration and sequencing - - The ability to coordinate the lateralized sensory information and motor functions from both sides of the body. Lateralized sensory information is linked to a lateralized motor skill such as handedness. - For example, in right-handers, the right ear has slightly faster and better hearing than the left, although they work together to provide the perception of a single event. Bilateral integration forms the foundation for projected action sequences, i.e., a sequence of motor acts put together to accomplish a goal in future time and space such as running to catch or kick a ball Praxis - - The ability to conceive of, plan, and organize goal-directed actions. Praxis enables people to adapt and react quickly to novel environmental demands in a meaningful and efficient manner. Ayres felt that praxis was a cognitive, perceptual ability that required adequate sensory integration to create and update the somatic map or schema of the body Praxis allows the child to plan and organize future actions by figuring out what the body can do relative to the perception of the external environment through auditory, visual, or tactile information. Praxis provides children with information about how to effectively use objects as tools, How to organize time and space, And adapting to changing or unpredictable environmental demands including social interactions Primary Systems involved for ASI The unique contribution of the sensory integration theory is its emphasis on the “body related” senses - Tactile (touch) Vestibular (gravity and movement) knowing where your body is proprioceptive sensations (muscle and joints) These systems provide integrated information that contributes to increasingly complex learning and behaviors or “end products” Application STAR Focus/ Purpose STAR is a parent-centered approach that addresses the child’s challenges through focusing on the parent-child relationship and coaching parents in sensory-based strategies or developing a sensory lifestyle. Star is flexible and individualized to each child’s needs and each parent's priorities. Kevjcuhis approach is separate parent-only education sessions with parents participating actively in all treatment sessions. DIRFloortime highlight understanding relationship and engagement challenges to promote the emotional, social, and developmental growth of the children and their families. The theoretical base of the STAR frame of reference has three sections: theories related to development, theories related to the disorder, and theories related to the intervention. The first section includes three theories related to development regulation theories, relationship theories, and sensory integration theories. The three primary concepts underlying intervention are regulation, relationships, and sensory integration. The STAR frame of reference is dependent on building the relationship between children and caretakers. Play is the platform for all the principles using the STAR frame of reference. The focus of treatment is always having fun even though the therapist's goal is to support relationships, to extend social-emotional abilities, and to increase developmental abilities. Problem-solving model of ASECRET, Attention, Sensation, Emotion Regulation, Culture, Relationship, Environment, and Task, to provide parents with tools Condition Children with sensory processing difficulties. STAR includes an intervention intended for children with sensory processing challenges, including children who have conditions that include sensory and relationship needs, such as autism spectrum disorder, attention-deficit hyperactivity disorder, or other developmental and behavioral diagnosis Applied Behavioral Theoretical base and differentiate between these This frame of reference applies the scientific method to human behavior, focusing on only the external features of human functioning that can be observed and measured. This FOR is useful for anyone who wishes to form a new habit or to break a bad one. Classical Conditioning (Pavlov) - Pavlov’s dog experiment demonstrates the most basic level of conditioned learning, associational learning, the association of a stimulus (bell), with a response (drooling), motivated by external reinforcement (food). Operant Conditioning (B.F. Skinner) - Refers to learned behaviors that occur in one's natural environment as a result of reinforcement. - A reinforcer is defined as anything that increases the likelihood that a behavior will be repeated. - Use punishments and rewards to increase or decrease behaviors - Operant conditioning can help occupational therapists understand why clients behave in the ways that are self-destructive or otherwise nontherapeutic, even when our treatment approach comes primarily from another frame. Shaping and Chaining - An outgrowth of operant conditioning. - Skinner demonstrated these principles by teaching a pigeon to turn around. Each time the bird turned in the desired direction, it was given a morsel of food (shaping). Eventually the bird turned all the way around (chaining) and learned that repeating this behavior brought continued reinforcement. - In occupational therapy, we often modify tasks to make them less difficult. - As clients improve we we increase difficulty and complexity Prompting and Scaffolding - When a client performs a sequence of steps, the occupational therapist may either visually or verbally prompt the client to remind him or her what needs to happen next, such as pointing to an item on a checklist or a button that is undone or asking a pointed question like “How will you get the shampoo out of your hair?” - Scaffolding is “a method of grading an activity by providing assistance to the client at times that he or she might struggle or be unable to successfully complete a step. Observational Learning (Bandura) - Children learn vicariously (i.e., by watching others, especially when the observed behaviors are reinforced or rewarded). - Vicarious learning also gave birth to modeling (role modeling) as an effective teaching tool. Reinforcement Types - Continuous Reinforcement: Giving rewards every time a desired behavior is seen - Fixed-ratio Reinforcement: Giving rewards after a specie number of attempts or successful use of skills - Fixed-interval Reinforcement: Giving rewards at specific time - Intermittent Reinforcement: Giving rewards at random or unpredictable times - Negative Reinforcement: Withdrawal of attention or other expected outcome - Token Economies: System in which a token is given for desired behaviors; tokens are saved like money and may be cashed in for a choice of rewards - Self-Reinforcement: Internalized good feelings that result from successfully reaching a desired goal Techniques and strategies Intervention tends to be specific to the target behavior, either developing new skills or coping strategies or systematically eliminating unwanted behaviors. Teaching skills - Applies early learning theory. - Mew behaviors may be learned through chaining steps of a task and shaping the new behavior through reinforcement. Behavioral contracts - This is a written agreement defining what both client and therapist will do with regard to working on specific, defined goals. - Behavior contracts are especially helpful when working with mental health clients because they specify the consequences for meeting or not meeting certain expectations, making them more objective (as opposed to emotion based). Relaxation training - A common therapeutic approach for coping with anxiety. - Some contemporary methods include deep breathing, progressive muscle relaxation, self-hypnosis (meditation, mantra), and autogenic training (body awareness). - These techniques can be used to treat insomnia, pain, anger, ADHD, and impulse control problems. Systematic Desensitization - This treatment always begins by inducing a state of relaxation through slow breathing, progressive muscle relaxation, or hypnosis. - Then, the therapist introduces images of approaching the feared situation through visualization. - Visualizing each step in the sequence that the client identifies as the least to the most anxiety-producing event for him or her is called successive approximation, or gradually approaching and facing one's greatest fear (phobia). - The systematic desensitization approach uses both behavior modification and cognitive behavioral concepts, therefore bridging the gap between traditional and current approaches. Exposure and Ritual Prevention - Another approach specifically designed to extinguish rituals in OCD is exposure and ritual prevention (ERP) - Is a self-management approach to reduce or eliminate repeating rituals using the behavioral concepts of habituation and extinction. Collaborative Therapeutic Homework - Collaborative homework strategy enhances generalization of lessons learned in social skills or life skills groups or any other type of occupational skill training. - Homework involves a precise set of written instructions to be completed before the next occupational therapy session, with client and therapist choosing together the skill to be practiced. Conditions addressed by these FORs In today’s occupational therapy practice is useful in working with mental health conditions such as obsessive-compulsive disorders (OCD) or phobias. Cognitive Behavior and Social Cognition (3rd wave) Theoretical base Cognitive Behavior This frame of reference builds upon earlier behavioral theory with the addition of thoughts (cognition) as behaviors that can be modified Cognitive behavioral psychologists conceptualized thinking as an intervening factor influencing behavior. Bandura’s Social Learning Theory - Social learning interaction involves the behavior, person, and environment. - Observational Learning: helps us to understand how learning occurs continually throughout life in ways that we may not be aware. This becomes important in occupational therapy when clients fail to progress because of unacknowledged social observations. - Modeling: teaching by example. In occupational therapy, we use modeling to demonstrate the steps of a task or to suggest a possible solution to a problem. Imitation is more likely when positive consequences are observed in others - Methods of reinforcement - Initial – external (money) - Symbolic – internal (images of failure) - Social contract – self control bec of social consequences) - Personal satisfaction – self produced (feeling competent is a reward) - Self-control and Self-regulation: Self-regulation refers to the ability to direct one's own life by setting goals, creating strategies for achieving them, and building self-reinforcement into one’s schedule. - Self-Efficacy: refers to the belief in one’s own ability to interact effectively with the environment. Self-efficacy involves the cognitive ability to anticipate consequences. - Self-awareness: involves a realistic understanding of one’s strengths and weaknesses and the realization of the effect of one’s own behavior on others. - Insight: as a cognitive behavioral concept involves an understanding of the changes in one’s own abilities and disabilities as the result of a health condition. - Human Agency: The way social learning has incorporated the complex systems and non linear concepts of the current scientific paradigm Agency stands for acts done intentionally. Beck's Cognitive Therapy - Cognitive Behavioral Therapy (CBT) ABC method (A = Stimulus, B = Beliefs, C = Response) - - - Cognitive distortions: are exaggerations or misinterpretations of an environmental interaction. Automatic thoughts: are thoughts that reflect habitual errors in logic. Using the scientific Method of Therapy: Client identifies a problem, each problem has an operational definition of variables and hypothesis. The Socratic Method: Questions that guide the investigation of their beliefs and assumptions. This method encourages the client to reexamine the beliefs and assumptions that caused the emotional response. Guided discovery: 3 Socratic questions to facilitate guided discovery 1. What is the evidence for and against the belief? 2. What are alternate explanations? 3. If the belief is accurate what are the implications/consequences? Core Schema: These are absolute core beliefs, such as “I am bad” or “1 am good,” upon which clients often base their judgments about their own experiences, emotions, and behaviors. Therapy focuses on emotions or behaviors directly. Instead, therapy focuses on emotions or behaviors unwanted emotions or behaviors and challenging their assumptions or interpretations of target events. Albert Ellis’s Rational Emotive Therapy - - Built on Beck’s technique, expanding it to the ABCD method. D stands for “disputing” irrational beliefs. Often uses humor and exaggeration to help clients to discover “crooked thinking.” Ellis developed a technique called cognitive restructuring, a step-by-step process for disputing irrational beliefs: 1. Acknowledging our responsibility for creating our own problems 2. Accepting our ability to change 3. Recognizing that emotional problems stem from faulty thinking 4. Clearly perceiving our beliefs 5. Rigorously disputing beliefs 6. Working hard to change beliefs 7. Continued cognitive monitoring and restructuring Ellis’s cognitive restructuring can be understood as reframing the problem—that is, looking at it from a different perspective. Contemporary Cognitive Behavioral Therapy: Relevance for Occupational Therapy - Phenomenology: refers to the critical role of the clients perspective about the problems he or she brings to therapy. Collaboration: client centered approach. Activity: not just verbal interaction, is another shared principle of occupational therapy and CBT. - Empiricism: refers to use of the scientific method, emphasizing the client’s ability to apply reasoning to situations in his or her own life. Generalization is another shared goal of occupational therapy and CBT. Both seek to apply the benefits learned in therapy to life in the client’s real world. Cognitive Orientation to Occupational Performance Model (CO-OP)*** - - Views cognition as bridging the gap between inherent ability and actual performance. In its focus on motor tasks of the child’s own choosing, this approach also uses the principles of motor learning theory. The therapist encourages the development of global or domain-specific cognitive strategies through a process of “guided discovery” By asking children questions during task performance the therapist helps them pay attention to key features of the task and environment in order to solve problems whenever they get stuck. The therapist, in observing and interacting with the child during a performance attempt, looks for the following: - Motivation: does the child want to do the task? - Knowledge: does the child know how to do the task? - Ability: Can the child do the task competently? - Breakdown: what are the problems with performance? - Task demand: what adaptations can/should be made? - Environment: what supports are needed; what barriers can/should be removed? Social Cognition 1st wave – Early Behaviorism 2nd wave – Cognition added 3rd wave – Added complex systems theory, wider scope of focus The third wave dramatically changed the nature of cognitive therapies through the application of complex systems theory, widening the scope of focus to not only targeting problem behaviors such as avoidance or repeating rituals but also addressing the entire range of valued life activities. Problem behaviors became “barriers” to the higher goal of “living a valued life.” It illustrates the impact of complex systems theory and nonlinear sei* ence within this well-established and evidence-based feme of reference. Human Agency, a more recent addition to Bandura's theory, provides a bridge to the 3rd wave cognitive behavioral approaches. - Agency adds to our understanding of human learning, the important role of the client’s intentions, beliefs, values, and overall life narrative into the complex systems of human experience that both psychologists and occupational therapists must address in therapy. 5 Basic Assumptions: 1- People learn by observing others 2- Learning is an internal process 3- People are motivated to achieve goals 4- People regulate and adjust their own behavior 5- Positive and negative reinforcement may have an indirect effect on behavior. Concepts from 3rd Wave CBT: Holism: person, environment, occupation cannot be separated. Functional contextualism: focuses on the function of cognitive rather than its form. Constructivism: knowledge and social reality are constructed by individual observation. Relational frame theory: Explains how long-term memories are stored and how people associate and retrieve them when encountering everyday situations. Cognitive fusion and diffusion: Cognitive fusion: Ability to build relational frames by associating various aspects of events in memory. Cognitive diffusion: Breaking apart of the internal relational framework. Pragmatism: Focuses on the relationship among individuals, their artifacts, environments, and societies as represented by their actions and well-being. Mindfulness: Full awareness of events in the here and now. Techniques and strategies Cognitive Behavior CBT Techniques Helps clients manage anxiety/emotions and remove barriers caused by distorted thinking. - - Relaxation training: has been effectively used in dealing with client anxietyThere are a number of ways to do this, including deep breathing, progressive muscle relaxation, and the application of Eastern movement disciplines such as yoga and tai chi. Decatastrophizing: Uses exaggeration as a way of challenging catastrophic emotional responses (typical of persons with depression). Challenging absolutes: is a technique used by both Beck and Ellis as a way of uncovering irrational beliefs. Visualization: refers to the use of mental imagery in dealing with anxiety and fear Thought stopping: is a technique for preventing automatic thoughts. - Self-instruction: is a strategy used in Toglia’s dynamic interactional FOR It involves teaching the client to mentally talk him or herself through a task. Strategies/Interventions Psychoeducational Groups Occupational therapists play the role of educator-facilitator in designing educational and skill-training experiences for groups of clients with mental health issues, requiring them to use rational thinking to apply new knowledge and skills through group problem solving. - Dedication management Living on a budget Meal planning and preparation Care of clothing and personal items Money management (banking skills, paying bills) Using public transportation Household safety Parenting and caregiving skills Keeping relationships; how to manage anger Social and Life Skills Group Lieberman’s social skills training strategies for social and independent living: - Basic conversation skills (places where there are people co talk to, people who are willing to talk, topics to talk about) Verbal and nonverbal communication behaviors Starting a friendly conversation (opening lines/topics) Keeping a friendly conversation going (active listening, asking questions) Ending a conversation pleasantly (knowing when to stop, what to say) Putting it all together (practicing skills in real life, using skills to have better relationships with everyone, helping to make new friends) For children and adolescents, Case-Smith et at (2010) suggest the following group activities to encourage social skills through occupation as means: - Yoga dyads (pairs of children help one another assume a variety of yoga postures) Arts and crafts (working together to create one product, such as a mural) Social skill themes (topics chosen by teens, such as popular movies or music lyrics) Cooking groups (children or teens preparing break’ fasts, lunches, or afterschool snacks) - Job coaching (high school students practice social skills needed to succeed at a job) Self-regulation Programs Self-regulation programs use a cognitive, rational approach to problem behaviors. Some occupational therapy interventions combine cognition and sensory awareness to help children identify their own emotional states during a normal school day. Stress management programs are another good example of self-regulation. Stress management, coping skills, and emotion regulation training are cognitive behavioral strategies that have been used with: depression, schizophrenia, pain, substance abuse, eating disorders, ADHD, autism, PTSD Coping Model of Pediatric Occupational Therapy Coping model in pediatric occupational therapy emphasizes the child’s use of coping resources to meet challenges posed by the environment. These resources are both internal and external. - Internally the child’s sensory reactions, developmental skills, and emotional state guide environmental exploration and self initiated behaviors. Confidence level is based on previous experiences and preferences. Through building on successful coping experiences, the child develops a unique coping style - Externally, the family provides material resources and support well as physical and emotional safety. Parents and primary caregivers provide the child’s most significant support for coping by buffering the child’s exposure to stress, making demands, modeling coping behaviors, encouraging coping efforts, and giving feedback. This approach identifies the following postulates to facilitate effective coping: - Grade the activity and modify the environmental demands to match the child’s adaptive capacities. - Design intervention activities that promote the development of self-efficacy, including providing social and physical supports that foster use of the child’s own strengths and resources. - Timely and explicit feedback appropriate to coping efforts, to support self-directed coping efforts and co encourage child-initiated activities that extend and elaborate emerging coping skills. Because children with disabilities tend to adopt passive roles, encouraging them to choose and begin activities in group settings is especially important. Social Cognition Some of the third wave cognitive therapies, such as DBT and ACT, have been added in this revision to illustrate the complex nature of the new contextual and experiential change strategies, which “reformulates and synthesis previous generations of behavioral and cognitive therapy and carries them forward into questions, issues, and domains previously addressed primarily by other traditions (psychodynamic), in hopes of improving both understanding and outcomes.” Acceptance and Commitment Therapy (ACT) Change the focus and the goal of therapy. The focus of ACT becomes the acceptance of the presenting problem as a part of the client’s life narrative and the process becomes a cycle of detecting cognitive fusion and avoidance and de-fusion and letting go. Client’s create more flexible and adaptive patterns of effective behavior. Dialectical Behavior Therapy (DBT) A specialized form of CBT designed to target self-destructive behaviors. Begins with acceptance that life is full of anxiety and sometimes overwhelms us; therefore, it is okay to feel anxious and overwhelmed and client’s are accepted as they are. Involves 4 core areas 1- core mindfulness, 2- interpersonal effectiveness, 3- emotional regulation, 4- distress tolerance. Conditions addressed by these FORs Cognitive Behavior Occupational therapists should consider this frame of reference whenever psychological barriers to activity engagement are encountered. This FOR has been identified as the one most often used in behavioral health settings because it is especially effective in dealing with issues of motivation and emotion. Social Cognition Especially useful for individual and group interventions for populations with mental health issues. Can guide OTs in addressing issues of health promotion and well-being across the spectrum of populations. Psychodynamic Focus Focuses on the ego, the clients inner drive toward growth, development, and mastery. Occupations have a direct impact on ego development; therefore, therapeutic activities have a goal of understanding and strengthening the functions of the ego and promoting clients sense of self The ego identity of our clients affect not only their choices of occupation but also their motivation to engage in any occupations This frame often targets: - Self-identity - Self-direction and motivation - Self-awareness - Self-management - Social identity and relationships Ego: Focuses on the conscious rather than the unconscious aspects of personality, so it is more observable and measurable. Best understood as the self and has been called “the executive branch of the mind” providing coherence, identity, and organization to the personality Application Evaluation - Assessments addressing ego-adaptive functioning - Role checklist: determine clients social roles - Self-assessment of Occupational Functioning: determine clients interests, values, personal causation, roles, habits, and skills - Kohlman's Evaluation of Living Skills: assess IADLs, both self-report and observation of performance - Comprehensive Occupational Therapy Evaluation (COTE): 26 behaviors are assessed regarding, appearance, activity level, responsibility, reality orientation, interpersonal and task behaviors - Magazine picture collage: assesses interests, ego organization, concept of self and others - Goodenough Harris Draw a Person Test: self- concept and general intelligence - Kinetic-House-Tree-Person Drawings: self-concept, level of ego integration, relationships with others - Interviews and narrative analysis - Semi-structured interviews (Canadian Occupational Performance Model [COPM]) - Observational assessments - Useful for comparison with self-reporting Interventions Clients who lack ego integration need to be approached with great care, with the OT providing a safe environment and inviting them to experience artistic materials as a way to communicate their needs, perceptions and emotions. - Interventions that influence self-identity - Self-direction interventions - Self-awareness interventions - Self-management interventions - Interventions that influence social identity and relationships - Mindfulness in ego-adaptive interventions - Task-oriented group interventions Trauma informed care The ego-adaptive frames focus on self-development makes it a good fit for OTs to use within broader theories of recovery and trauma. A client's sense of self can determine his or her degree of involvement in occupational therapy intervention If a client defines themself as a victim from a trauma survivor, she will struggle to identify any meaningful occupational goals. The ego is seen as a powerful motivating force that can either resist or facilitate therapeutic change. Psychoanalytic Focus Offers both insight and effective strategies to guide occupational therapists in dealing with our clients emotional issues and barriers. This frame focuses broder today beyond just mental health: - Social participation and relationships - Emotional expression and motivation - Self-awareness - Defensive behaviors - Projective arts and activities. Id (primary process thinking) The Id is defined as the unconscious. It is part of the personality that houses primitive drives and instincts, as well as needs and conflicts that the ego is unable to integrate. The ego (secondary process) Component in contact with the external world. Works for balance between internal drive and external expectations. The ego operates through a secondary process, one that is learned through experience in reaching compromises and applying logic and discipline in an attempt to adapt to the environment. Application Creative media, such as drawing, sculpture, and finger painting have formed the basis of a number of test batteries. Drawings can measure outward qualities, such as motor control, or perceptual qualities, such as spatial awareness, as well as internal qualities, such as self-esteem or mood. Some assessments include: - Kinetic-House-Tree-Person-Drawing (KHTP): instruct the client to draw a house, tree, and draw a whole person (not a stick-figure). A pencil with eraser and 8.5 x 11 inch paper are used. Questions about the drawing and interpretations vary. - Former Vocational Assessment: ask the client to finish incomplete sentences in 12 work-related categories such as goals, job turnover, reactions to criticism, reactions to authority, and coworker relations - This assessment uncovers some psychosocial issues related to occupational performance area of work - Kinetic Family Drawing and Kinetic School Drawing: ask the client to draw his or her family or classmates doing something together. Intervention - Using activities to to test reality Symbolic and transitional objects Activities to express emotions Vivaio Model: incorporates the unconscious into the relationship between therapist, client, and doing an activity or occupation Pet therapy Symbolic Legacies in Hospice care Documentation COAST Client Occupation Assistance level required Specific conditions Timeline for achieving the goal Client: Using COAST, the goal is written to specify what the client will do. Occupation: The goal needs to reflect the occupation the client will perform. Assistance Level Required: Level of assistance required for the client to perform the desired occupation. Assistance can be physical, verbal, or gestural. Specific Conditions: Corresponds to the specific conditions that need to be in place for the client to meet the goal. Conditions can be modifications to the environment, equipment, or technique. The A and S together make the goal measurable. - Example: By using a dressing stick with 2 or fewer verbal cues. - 3 out of 5 attempts during the evening meal (level of assistance) Timeline for Achieving the Goal: Should be reasonable and achievable. For LTG it may be discharge date. These are client and facility specific. Example: Within 2 weeks, by 5th session. SMART Significant Measurable Achievable Related Time-Limited Significant: Means that achieving this goal will make a significant difference in this person’s life. This implies that you know your client’s strengths and need areas so well that you know what will matter most to her (or him); in fact, your goals would ideally be developed in collaboration with the client, ensuring significance. -Simple: More likely to achieve. -Simple: Easier to understand. Measurable: Means that you have a clear target to aim for, and that you will know when the client gets there. So you know when the goal is achieved. Achievable: It must be reasonable that the client could achieve this goal in the time allotted for it. Related: The goal has a connection to the client’s occupational needs as stated in the evaluation report. Long- and short-term goals need to relate to each other. Time-limited: Means the goal has a chronological end point. You know when to evaluate whether the goal is met. Purpose and reason for different types of documentation Written documentation of ongoing intervention comes in different sizes and formats but are intended to provide a record of intervention sessions. In most cases they are written in following each intervention session however in some cases they may be written weekly or at other time intervals. Typically, a progress note covers a longer time interval than a daily, contact, or encounter note. Progress notes should be more than simply a list of the types of activities in which a client has engaged. They are called progress notes because they are supposed to show progress. Contact notes, are intended to be shorter, and reflect the clients response to intervention during the day or that intervention session. Narrative notes are written in paragraph form, and often read as if one is telling a story. COTA/OTR responsibilities in eval In the OTPF the term occupational therapy practitioner is used in the document to refer to both occupational therapists and occupational therapy assistants. OTPF: Although it is the responsibility of the occupational therapist to initiate the evaluation process, both the occupational therapist and occupational therapy assistants may contribute to the evaluation, following which the occupational therapist completes the analysis and synthesis of information for the development of the intervention plan. Discharge summary – purpose A discharge summary (also called a discontinuation report) is used to summarize the changes in the clients ability to engage in occupation and to make recommendations for referral or follow-up care if needed. discharge notes often follow a format of their own, stating the date and purpose of the referral and giving a summary of the initial findings, the course of treatment, a summary of progress, and any recommendations for follow-up care. Discharge summaries may be done as SOAP or narrative notes, or the facility may have a particular form that is used. Pg 180 Differentiate eval and assessment – purpose Evaluation: To determine which assessment tools will be best yield the necessary information and which pieces of information obtained are most important in understanding the clients needs, one can not forget that evaluation is a fluid process. To obtain a comprehensive picture of the client, the evaluation process requires ongoing clinical reasoning and a combination of both standardized and nonstandardized assessment tools. *An evaluation is larger than just an assessment; it is comprehensive. Assessment occurs once there is a need for comprehensive evaluation. Usually one part of this comprehensive evaluation and we can use a specific tool to gather more information. If a formal screen was not done at the starting point and it did not go from screen to assessment, it can go from referral to assessment, a screen is not always necessary. Can go from a referral to an assessment. Purpose of written documentation Documentation is an important legal and professional component for all occupational therapy services, and it has an important function within the evaluation process. Reimbursement Documentation is intricately linked to payment Regardless of the payment source, documentation is a mechanism to obtain approval for payment through objective client measures. The type and frequency of documentation is generally determined by the payment source (e.g., federal or state programs, third-party payers, grant funding). - Thus, to minimize the possibility of claim denial, the practitioner needs to be fully aware of the rules and requirements, including any updates or revisions, prior to report completion. Legal requirements Any written communication produced by occupational therapy personnel with regard to a client’s care is considered a legal document and should be kept confidential in adherence to professional standards The purpose of documentation is to: - Describe and explain why occupational therapy is needed for a patient and how these interventions will impact the patient’s function. Communicate the occupational therapist’s clinical reasoning and professional judgment Ethical Considerations If productivity expectations can also lead to ethical dilemmas. Productivity is measured by comparing the number of units or minutes billed to the number of hours worked. Many settings have stringent productivity targets with the expectation that clients will be treated concurrently or in groups. While treating multiple clients simultaneously is not unethical, the services must be documented and billed appropriately. Occupational therapy practitioners may find themselves torn between meeting the productivity expectations of their employer and providing quality, individualized care to their clients. Examples of ethical issues related to occupational therapy practice and documentation include the following: - Placing or keeping clients on caseload who do not need skilled services or meet payer coverage criteria - Administrative mandates regarding treatment frequency, duration, or intensity - Providing treatment without client consent - Counting non-billable time as treatment time - Inappropriate coding or changes to coding without approval of the treating therapist - Falsifying or changing documentation to misrepresent services delivered or time spent with client Suggestions for therapy practitioners who find themselves faced with ethical dilemmas such as those listed previously: - Stop the questionable practice - Contact an administrator or corporate compliance officer for the facility - Contact state and national professional associations for guidance. - Consider seeking legal counsel - If appropriate, consider reporting information to CMS or the Office of the Inspector General for the HHS Allen’s Cognitive Theoretical background including conditions This frame of reference focuses on the role of cognition (a process skill), the role of habits and routines, the effect of physical and social contexts, and the analysis of activity demand. Types of health conditions that include cognitive deficits that this FOR can be applied to include: - Alzehiemer’s and other dementias - Stroke - Acquired head injuries - Chronic mental illness, e.g., schizophrenia and other psychotic disorders, anxiety, and substance abuse disorders - Personality disorders - Chronic diseases affecting the nervous system - Developmental disabilities, such as autism - Mental retardation Function/dysfunction ACL 4.6 is the minimal level for living independently with the condition that dangerous items in the environment are removed or disabled and some supervision is available. Levels of Wellness Level 1: Automatic Actions Lowest end of the cognitive disability scale. Client can move fingers and toes, blink eyes with bright light, moan or make sounds to indicate if uncomfortable. Attention to sensory cues is subliminal (hunger, thirst, pain, or temperature) Motor actions are mainly reflexive, and the blankness of a person’s eyes implies not much information processing is occurring. Therapy might be done to arouse the client through sensory stimulation activities, such as a bright balloon to capture their attention, then popping the balloon to see if they react. Level 2: Postural Actions Clients respond best to proprioceptive cues (moving a client's arm to reach for a railing) Not always physically disabled, but one of their main concerns is body comfort and stability. At the midrange of this level, clients are able to imitate movements, but their imitations are approximate not exact. Can attend to an activity for several minutes at a time. However, they may not sit for an entire meal. Motivated by comfort (will rock in a rocking chair because it makes them feel good) At the beginning of this level, clients need a great deal of physical assistance and guidance. As they move toward level 3, OT activities such as simple exercises, motor games such as batting a balloon or kicking a beach ball, or simplace dances to music are possible. Level 3: Manual Actions Manipulation of objects is necessary to accomplish most self-care tasks. Some selfcare can be done independently. Tactile cues work best for clients at this level (in addition to proprioceptive) Client will imitate manual actions that are demonstrated. At this level it is important to give tactile cues for self-care tasks that are stored in procedural memory. Many tasks are culture specific. New learning is NOT in place; therefore, clients need frequent cues when performing unfamiliar tasks. Clients are motivated to do simple craft projects that involve manipulating interesting objects and textures. Will need each step to be demonstrated one at a time. Clients can concentrate for up to 30 minutes and will continue repeating a step until they reach the end or all the materials are used up (stringing beads, stuffing envelopes, folding laundry) Modes of Performance ACL 3.0: Grasping objects ACL 3.2: Distinguishing among objects ACL 3.4: Sustaining acts on objects ACL 3.6: Mptomg the effects of actions on objects ACL 3.8: Using all objects and sensing completion of an activity Level 4: Goal-Directed Actions Main difference between levels 3 and 4: goal directedness. In terms of ADLs, it marks the change from being dependent on others to being self-directed. Many self-care tasks can be performed independently at level 4! Working memory functions longer in the immediate situation, making it possible for the client to recall a sequence of steps toward a goal. Visual cues work best with level 4!!! Demonstrations are still necessary for performing unfamiliar tasks, but the OT can now demonstrate several steps at a time. Longer-term activities up to 1 hour can be done. Visual field is very significant. Things not noticed at level 3 now become distractions. When working in a cluttered environment, it is difficult for clients to select relevant or needed items, and their occupational performance will be slow and inefficient. Best ability to function is when only items needed for a task are visible. Modes of Performance ACL 4.0: Sequencing self through steps of an activity. ACL 4.2: Differencing among parts of an activity. ACL 4.4: Completing a goal. ACL 4.6: Scanning the environment. ACL 4.8: Memorizing new steps. Mode 4.6 is significant because it is the lowest level a client should be left alone; however, they still need a great deal of protection and supervision. ACL 4.4-4.6: “At 4.4 you can see all the way to the edge of the table and a little bit of your neighbor in front of you. At 4.6 you pick up your head and look around the room.” At 4.4 the client will ask “where is the coffee pot?” at 4.6 they will get up and pour themself a cup. Loss of abstract thought, do not understand the concept of growth, electricity, or written words. Level 5: Exploratory Actions Thinking at this level is inductive or trial and error. Understand 3 dimensions. May skip instructions and immediately begin a task to attempt to do it through trial and error. This makes them very accident prone. Overt trial and error means they have to actually do it to know if it works. Unable to anticipate or plan ahead, making them impulsive. Spontaneous actions are called exploratory because level 5 clients like to try new things and create unique or individual projects (not following the sample). Always give them choices. Can learn by relating all types of cues up to and including verbal instructions. Longer-term projects that last for more than one session are possible and learning carries over from one weekly session to the next. Clients have issues with self-control and precautions need to be taken for clients to adhere to safety guidelines when doing activities. Modes of Performance ACL 5.0: Learning to improve effects of actions. ACL 5.2: Improving the fine details of actions. ACL 5.4: Engaging in self-directed learning. ACL 5.6: Considering social standards. ACL 5.8: Consulting with other people. Level 5.6 is significant because it is the point clients begin to have insight and become aware of the social and physical consequences of their actions. This makes an understanding of the perceptions of others possible. Relationships with friends and family have far less turmoil after this level, although there may still be verbal conflicts and a win/lose perception of disagreements with others. Activities that require anticipation are menu planning, shopping, and caring for children are difficult for clients at this level. Level 6: Planned Actions Clients are not geniuses, but they do not have a cognitive disability. Clients can think deductively (they can generalise or think on an abstract level). Covert trial and error means that these people can visualize how the pieces of the woodworking project fit together without having to actually do it. This allows them to anticipate problems and takes steps to avoid them. Can attend to symbolic cues, such as written words. Anyone below a level 6 cannot be counted on to read or to follow written instructions!! Can consider the past, present, and future when making decisions or judgements. Clients at this level can be counted on to follow OT recommendations and apply them appropriately. Identify the functional performance at each level and the strategies/techniques that can be used Level 1: Clients will only be able to attend to themselves and internal cues. An occupational therapist's main focus would be to arouse the client through sensory stimuli, such as making a loud noise, which was discussed earlier in this presentation. Level 2: Clients are aware of their body, and they are able to overcome gravity, stand, walk, or use railings depending on the mode of performance they are at. Their main focus is on the comfort and stability of their body, and they respond best to proprioceptive cues. They may need an extended amount of physical assistance and guidance. Examples of possible occupational therapy activities for clients at this level that involve postural movements include batting a balloon or kicking a beach ball. Level 3: Clients will require the supplies for the task to be within an arm's reach. It is important to consider that they are unable to complete multiple steps of an activity, they can only do one step at a time. They will need each step to be demonstrated one at a time. Therefore, an important consideration for these clients is to only have the materials necessary for that specific step within each. Clients will also require many cues throughout the task to keep them focused and move to the next step. Offer assistance as needed. Remove materials/tools when no longer needed. Do not expect clients to share materials. Supply a finished sample to demonstrate correct task completion. Unable to perform goal-directed actions. Clients at this level are only able to concentrate for approximately 30 minutes. Level 4: Clients can concentrate for about 1 hour. An intervention technique for these individuals is to provide them with a completed sample of the task they are going to perform for an exact match. They are able to sequence and complete multiple steps of an activity, yet will still require cues to move to the next step as needed. Demonstrate several steps at a time. Keep sharing to a minimum. What is not in their visual field does not exist to them, therefore supplies should be placed in view for the client to know they are there. Remove unnecessary clutter from the visual field before the group begins. Clients can learn by watching each other. Level 5: Clients are now aware of their immediate task environment. Provide diagrams or written instructions for the task. Give verbal instructions for the task. Basic materials may be collected by clients for selected tasks. Clients at this level utilize overt trial and error and they are unable to plan ahead. This makes them very impulsive, so a key goal for intervention for clients at this level is on safety and planning. Offer choices within guidelines. Discuss safety precautions before beginning task, OTs should make clients aware of their impulsive behavior to prevent disruption. This can be done by encouraging clients to take the activity slowly and to be reminded to read the written instructions sometimes multiple times to ensure their understanding. The Allen Diagnostic Module purposely includes more complex materials, such as an iron, for clients to demonstrate their proper understanding of safety when using these types of materials. The cautious use of hot irons, power tools, ovens, or hot plates under supervision is suggested so that OTs can observe the client’s knowledge and use of caution when handling items. Set time limit for group tasks. Provide stand-by assistance Group projects involving cooking, grilling outdoors, hiking, swimming, boating, or fishing, can also be used therapeutically to learn/evaluate safety. Level 6: Clients have an awareness of their potential task environment. They can comprehend abstract thought and can utilize covert trial and error. Individuals can also be counted on to understand recommendations made by an occupational therapist and act on these in an appropriate way. Clients at level 6 may be placed in craft groups for assessment purposes or included in Level 5 groups if possible decline is suspected. Usable Task Environment: Level 1: Self Level 2: Body Level 3: Arm’s reach Level 4: Visual field Level 5: Task environment Level 6: Potential task environment Level 2 is the lowest that can be treated effectively within a group. Level 3 is the lowest level at which group interaction can be expected. Visual perception Impact of deficit Visual perception is NOT attained by vision alone - Contributes to planning movement as vision is needed as a guide until a motor plan is formed “seeing” involves input from other senses Vision involves interaction between individual and environment Used with children who have difficulty interpreting and using visual sensory information Goals focus on attending to and processing visual information for task performance Visual perceptual and visual perceptual motor skills are essential aspects of academic performance, such as reading and writing. There are many other implications of visual perceptual problems on the occupations and life activities of children in addition to education, which include ADLs, work, play, leisure, and social participation. Nonverbal communication can be impaired in children with visual perception problems. Perception Visual Perception (VP) is the total process responsible for the reception and cognition of visual stimuli Visual perception is NOT attained by vision alone Visual perception consists of both visual receptive and cognitive components. - Visual receptive components: ocular motor enables reception of visual stimuli. Cognitive consists of interpretation and use of visual information. Visual perception consists of both visual receptive and cognitive components. - Visual receptive components: ocular motor enables reception of visual stimuli. Cognitive consists of interpretation and use of visual information. Visual Receptive Function Acuity: Discriminate fine details. 20/20 person can perceive at 20 ft. Accomodation: Ability for each eye to compensate for blurred image. Focus on objects at varying distances, such as a teacher/blackboard and transition to near points, such as a book. Binocular Vision: Mental ability to combine images from two eyes into 1 single perceptive. Includes motor fusion and sensory fusion (coordination of extra ocular eye muscles and size and clarity must be compatible). Convergence: Turning eye inwards as object moves toward observer. Oculomotor Skills: Efficient eye movements. - Fixation: Coordinated aiming of the eyes when shifting rapidly from one object to another. Pursuit/tracking: Continued fixation on moving objects. Saccadic Eye Movement: or scanning, is the rapid change of fixation from one point in the visual field to another. Stereopsis: Refers to the monocular or binocular depth perception or 3D vision. Visual Field: Extent of visual field visible to the eye in a given position. Visual Cognitive functions Visual Attention: Attend to visual stimuli, is composed of alertness, selective attention, vigilance, and divided attention. Visual Memory: Integrating visual processing information with past experiences. Visual Discrimination: The ability to detect distinctive features of a visual stimulus (is it different or the same as others). Involves recognition, matching, and sorting. Visual Imagery/visualization: allows children to picture people, ideas, and objects in their mind's eye. Differentiate types and application There are two types: Object and spatial perception Object perception: temporal part of the brain; there is form constancy, visual closure, and figure ground. Is concerned with what things are. - Form Constancy: recognition that forms remain the same in various environments, positions, and sizes. Find it when is larger, smaller, rotated , hidden - Visual Closure: recognition of a form/object from incomplete presentations - Figure Ground: perceive a form visually and find it, differentiate foreground and background - Spatial perception: parietal part of the brain; position in space, spatial relations, depth perception, topographic orientation Position in Space: spatial relationship of objects/figures to oneself and other objects/forms - Relation to observer/perception of direction in which it is turned Discrimination of reversals and rotations of figures Important in in understanding directional language Spacing of letters in a word & between words Spatial Relations: the analysis of forms and patterns in relation to one’s body and space and helps judge distance - - 2 types categorical and coordinate - Categorical: includes concepts of above/below, left and right, on/off - Coordinate: specific locations that can be used to guide movement Depth Perception: determination of relative distance between objects, figures, landmarks, observable changes in planes of a surface Crucial to ability to locate objects in visual fields, accurate hand movement under visual guidance, negotiate stairs (move in space & how far is something) Topographic Orientation: connection of the location of objects and settings - Route to the location - Find our way depends on the cognitive map of the environment - (can the child safely return from the drinking fountain to class) Eye hand coordination - Discrete motor skill that enables the coordination of the visual stimulus with corresponding motor action Also depends on visual perception Vision and function vs perception and application Oculomotor Function: Proficient oculomotor skills - Coordinated aiming of eyes while rapidly shifting from one object to another (fixation) - Fixate on a stationary object. - Fixate on a moving object (tracking/pursuit) - Able to change point of visual fixation from 1 point in the visual field to another (saccadic or scanning) Oculomotor Dysfunction: Ineffective oculomotor skills. - Decreased ability to control or correct gaze - Turns head while reading, loses place, omits words. - Overshoots; undershoots Effective Visual Reception, Indicators of function - Discriminates the fine details of objects (acuity) - Able to focus on an object at varying distances - Focus on an object of varying distances - Combines the images of both eyes - Turns eyes inward - Depth perception - Awareness of visual physical space Difficulty with Visual Reception - Words blur, holds book too close, blinks frequently and squints - Words blurry, loses place - Seeing double - Excess-turns inward - Insufficiency-eyes drift outward (discomfort) - 3D; does not see approaching stimuli Toglia Dynamic Interactional Approach Joan Toglia’s dynamic interactional approach to cognitive rehabilitation. Toglia and Abreu (1987) developed a cognitive rehabilitation approach for the treatment of traumatic brain injury (TBI). Toglia continued her research in the area of generalization of learning and, in the 1990s, renamed her approach “multicontextual,” implying that cognitive strategies may be generalized and applied to a broader range of life situations if each strategy is applied in multiple contexts during therapy. Kielhofner (2004) called Toglia’s approach “cognitive perceptual,” whereas Toglia, Golisz, and Goverover (2014) refer to the “multicontext approach” Metacognitive functions Higher-level cognitive skills necessary for performing occupations also called executive functions - Anticipatory awareness: which allows the person to anticipate problems and plan strategies for compensation - Intellectual awareness: which encompasses a realistic knowledge of ones own deficits, also known as insight. - Intention: which includes forming the idea of doing something, motivation, and initiation. - Planning: which includes the capacity for sustained attention (concentration), and identification and organization of steps needed to reach a goal, to control impulses, and to choose among alternatives (flexibility and decision making) - Monitoring: which includes the ability to continually judge ones own performance during purposive action, to self-correct, and to regulate the intensity, tempo, and other qualitative aspects of performance. Application of transfer of learning Near transfer: Beginning of the continuum, targeted strategies are applied to a similar situation Intermediate transfer: Moves to somewhat similar activities Far transfer: Moves to physically different activities Very far transfer: Ends with very different applications, including situations of everyday life. Conditions and diagnosis All types of acquired brain injuries including trauma and stroke, as well as some mental health and developmental disability populations. Social Participation Function/Dysfunction There are 6 function/dysfunction continua in this FOR: emotional regulation, family habits and routines, environmental support at home, environmental support in school, environments for peer interaction, and peer interaction. 1. Emotion Regulation At the functional end of the continuum, children can identify their emotional state and control emotional expression to support prosocial goals. Children at the dysfunctional end of the continuum are unaware of their emotional signals and cannot control emotional expression to support prosocial goals. The ability to regulate emotions in prosocial ways is a foundation for children to build positive relationships with peers and teachers and for academic achievement. 2. Habits and Routines A family has functional habits and routines when they can complete daily living activities while maintaining relationships among members. Caregivers provide instruction, support, and assistance to children as needed, and children positively respond to caregivers’ instructions. Children demonstrate the basic habits for social interaction within these daily family routines including making eye contact and verbally and nonverbally responding to questions and directions. Families who exhibit function in this area report regular participation in mutual activities that are pleasurable to family members. Families who exhibit dysfunction in this area do not have daily family living routines or routines for daily activities are excessively stressful, causing disharmony among family members. Children do not: - Participate in daily living routines Respond to caregiver instruction, support, or assistance Do not demonstrate the basic habits for social interaction with family activities. Families do not report regular participation in mutual activities that are pleasurable to family members. 3. Environmental Support At the functional end of the continuum, a home environment provides safety, security, support, and developmental stimulation to the children. The physical living space of the home is safe from intruders, has no safety hazards, and is relatively clean. It includes materials for participating in developmentally appropriate activities. The caregivers are interested and focused on keeping children safe and meeting their developmental needs. Problems in this area are evident when there is an unsafe physical environment, or the caregivers are not meeting the developmental needs of the children. Functional school environments include teachers who support children's development of academic, social, and living skills. - A functional school environment is safe and has adequate space and materials for learning. - Teachers facilitate and support positive interactions among children and adjust their teaching styles sensitive to the learning needs of various children. - Problems in the school environment arise when space and materials are inadequate for learning or when a teacher is unable to facilitate positive interactions among children and has an inflexible teaching style. 4. Peer Interaction Within a functional environment for peer interaction, children have opportunities to participate in a variety of activities with peers and the opportunity’ to help peers as well as to receive help from them in their mutual activity. Children also have time and space to develop friendships with preferred peers. Caregivers support children as they learn to manage conflict and the ability to negotiate with peers. In a dysfunctional environment for peer interaction, children do not have opportunities to participate in a variety of activities with peers and do not have the opportunity to help and be helped by peers in activities reciprocally. Children are not afforded the time or space to develop friendships with preferred peers. Application with interventions and specific strategies/techniques Types of activities Activities need to be done in a social context/ social interaction. Social interaction is “the interweaving of occupations to support desired engagement in community and family activities as well as those involved with peers and friends. In this FOR occupational therapists help the child increase participation, and improve their performance in family, academic, and community based occupations. Family activity example: preparing Sunday family dinner with parents Academic activity example: Working collaboratively with classmates on a science experiment This FOR is designed to be useful to OTs working in a variety of school-based and community settings to support the social participation of children who have a range of physical or psychiatric disabilities and have typical to mildly deficient cognitive functioning. What is addressed Interaction Between Caregivers and Children The theoretical base begins with the importance of children's social development and how early relationships influence their skill and habit formation for social participation. Children’s skills, habits, and routines are then discussed relative to how they affect peer interaction and friends in early and middle childhood. - Caregivers shape children's social ecology by promoting habits and routines. The presence of habits and routines in the family’s daily living promote competence in caregivers and children alike. Emotional Regulation While temperament is not a focus of this frame of reference, it is important to consider the construct when working to enhance children's social participation. - - Temperament is also one’s underlying propensity for self-regulation. Reacting is automatic, but self-regulation (also referred to as effortful control) is an active process of shifting and focusing attention and inhibiting thoughts and behaviors. Skill at regulating emotions in challenging situations makes social problem-solving possible. If children can manage their emotional reactions, they can access and evaluate several potential responses before acting. Children with disabilities are likely to develop effortful control more slowly than those without disabilities. High emotionality with poor regulation predicts poorer social functioning while children with high emotionality and good regulatory were not at risk for behavior problems Emotional regulation relates to children's ability to take action and modify their feelings to accomplish interpersonal goals. - Emotional regulation facilitates focusing attention and problem-solving. Reading the emotional cues of others and sending emotional cues to others are essential social-cognitive skills and precursors to emotional regulation. Children's age and developmental levels influence their emotional regulation. - - At the functional end of the continuum, children can identify their emotional state and control emotional expression to support prosocial goals. Children at the dysfunctional end of the continuum are unaware of their emotional signals and cannot control emotional expression to support prosocial goals. The ability to regulate emotions in prosocial ways is a foundation for children to build positive relationships with peers and teachers and for academic achievement. Facilitating Children’s Emotional Regulation - The Zones of Regulation curriculum is designed to help students gain skills in consciously regulating their actions. In the curriculum students learn how to use strategies or tools to stay in a zone or move from one to another. Developing Habits and Routines Children must develop habits and routines to facilitate their acceptance by others to successfully participate in society. - - - - Habits of social interaction include behaviors such as making eye contact to engage others before speaking and scanning the feces of others to gather nonverbal cues about openness and emotional states of others. Most children imitate the behaviors of caregivers, and the behaviors quickly become habitual ways that children use to engage or maintain engagement with others. Social routines are complex sequences of behavior such as the series of behavior that people consistently use to engage others and maintain their everyday social exchanges. Children learn social routines through continual exposure and observations of others as well as through caregivers direct teaching and reinforcement of their appropriate behavi