STUDY CHAPTERS.docx

**Ch. 6** **Activity Analysis** Helps elucidate the complexities of each step for an individual child\ Analyzing steps and considering activity demand, context, and meaning - insight about barriers and supports for promoting participation including modification of the steps **General Activity Analysis** Generic properties of an activity as typically performed including steps, materials, context, activity demands, possible meanings **Client-focused Activity Analysis** Individualized analysis of the personal way in which an activity or occupation is performed in real-life contexts - current and potential occupations\ Occupations that the client wants to no and need to do are targeted\ Specific aspects of performance that are problematic and successful **Observational Assessment** Activity analysis relies on observation to provide valid info about occupation performance\ Includes descriptions of the elements of the activity as well as child\'s performance (what and how she did)\ Observed in natural setting or ask parents to bring materials or record performance\ A primary frame of reference helps prioritize components to observe **Assessment Through Activity Observation and Analysis** Purpose: provide level of specific detail that feeds clinical reasoning, means to approach understanding of occupational meaning Children might have developmental and language barrier for expressing values and goals o Pediatric Volitional Questionnaire Clarify supports and barriers Peds - activity analysis accounts for age and experience **Determining Activity Parameters** What to analyze\ Input from client and caregivers to determine what activity to observe **Implementing Activity Analysis with Observations** General activity analysis - ID steps and demands and context Client-centered includes client relevance and performance **Building Skill in Activity Analysis and Observation** Perform activity oneself, watch others, videos of oneself, Using form or worksheet\ Repetition **Activity Synthesis and Intervention** By analyzing barriers and strengths in different activity components OT IDs potential intervention options Activity synthesis: integrates info in alt. ways to customize the activity to enable occupational performance **Activity Synthesis for Selection and Design** Choose occupation, therapeutic activity for prep skill building, or activity based on observations and analysis\ Activity analysis to determine activity\'s therapeutic capacity, age appropriateness, safety, gradeability, min. skill level, supplies, space, time **Activity Synthesis for Modifications** OT considers every barrier and support for possible modification\ Commercial or created\ Activity analysis findings - used to modify activity to adapt or remediate client\'s needs or increase strengths to compensate,\ Can modify any aspect of activity such as steps, materials, demands, context\ Modifications based on feasibility, preferences - engage parties and collaborate **Activity Synthesis for Grading** Grading: process of making portions of the activity easier or more difficult based on client\'s performance , target client factors, develop performance skills\ May grade steps, requirements, environment, type and amount of assistance\ Change the requirements for just right level Continual and dynamic\ Determine next steps in service for increasing skills, decreasing mods, and fading support **Ongoing Activity Analysis and Synthesis** As activity adapted, activity analysis is revised with updated info\ Occupational form: objects, materials, environment, human context (movement, speech) and time Activities may take on new, renewed, or revised meaning **Ch. 7** Standardized tests have uniform procedures for administration and scoring\ OT must be aware of protocols as well as limitations of standardized tests in providing information in comprehensive eval **Purposes of Standardized Tests** - Screening - Assist in determination of medical or educational diagnosis - Document developmental, functional and participation status - Aid in planning intervention - Measure outcomes **Screening** Assess large numbers of children quickly and briefly identify delays or need for further testing Assess several developmental domains\ Can typically be administered by professionals or classroom aides, nurses aides, or teaching assistants in \~20-30 min EX: revised Denver Developmental Screening Test, Ages and Stages Questionnaire-3 and FirstSTEP Screening Test for Evaluating Preschoolers **Determination of Medical or Educational Diagnoses** Normative scores compare child's performance with that of age-matched sample of children to assess for disability or delay\ Funding agencies and insurance providers use standardized tests results to determine eligibility In schools, standardized tests can determine eligibility for special ed **Documentation of Developmental, Functional, and Participation Status** Many funding agencies require period reassessment to determine if child still qualifies for services; parents are also interested in seeing progress\ Standardized testing is preferred method for re-eval because scores can be compared for the child each time they take the test to measure progress Structured/Unstructured observation and interviews can accompany standardized tests WARNING: - retesting period -- repeating the test too soon can result in practice effect - using norm-referenced results -- as child gets older, comparison group also ages. Even if **Planning Intervention Programs** Standardized tests provide information about child's level of function to inform intervention planning\ Criterion-referenced standardized tests are basis for developing goals and objectives for children Used in schools **Measuring Program Outcomes** Data from several children all participate in similar intervention program can be combined and analyzed to provide outcome data about the intervention\ Data can be used for program development/modification **Becoming a Competent Test User** **Choosing the Appropriate Test** Standardized tests in peds population address wide age span and performance skills and occupations\ OT chooses test by determining needs of client, time and space, cost and therapist's qualifications Many standardized tests have specialized areas of function\ Some children may be able to complete standardized tests based on behavior, cognition, motor skills or attention\ Some standardized tests provide protocols for adapted use for children with different disabilities Consult other sources for information about descriptions, critical reviews, reports of validity and reliability of the standardized tests you are using **Understanding the Clinical Usefulness of the Test** Assessments that measure occupational performance are most useful for understanding effectiveness of OT intervention\ Keep an ongoing dialogue to ensure standardized testing meets needs of child, family and therapist Use previously collected data to inform test selection Questions to ask to inform test selection: - What important info does it give? - What info needs to be collected through other techniques? - For which children does it work well? Not so well? - Can it be adapted for children with special needs? Is it valid? - Do other tests do a better job at measuring same thing? - Helpful for planning or program evaluation? - How long does it take? Materials needed? Is it practical? - Qualifications required for administration? - Does it measure the occupation of interest? **Learning the Test** An OT must understand the structure of the test then observe and practice administration **Understanding the Structure of the Test** Study test manual to obtain knowledge of assessment, administration procedures, psychometric properties and logistics to determine if it is suitable for child\ Create "Assessment Fact Sheet" with info to determine which assessment is best fit\ Pay attention to size and composition of normative sample, reliability coefficients, validation data and intended population for the test **Observing Test Administration** Observe administration done by experienced examiner\ Helpful to watch several administrations to children of different ages/abilities\ Discussion with examiner about interpretation of child's performance is helpful for understanding how observed behaviors are translated into conclusions and recommendations Online videos demonstrate proper administration **Practicing Administration** Test several children around age of intended test subject -- not adults -- to provide realism of mechanical, behavioral, and management issues that may arise\ Consider necessary adaptations for efficient test administration -- preparing cue card with specific criteria and instructions is common **Selecting and Preparing the Optimal Testing Environment** Well-lit room free of visual/auditory distractions\ Scheduled for a time child will perform optimally -- can consult caregiver to find out, consider school and after-school activities\ Test environment should be ready before child arrives\ Child-sized table chairs used, if child uses wheelchair they remain in it, young children may sit in parent's lap\ Test kit should be in reach of administrator but NOT in reach of student **Administering Test Items** Focus must be on child and not mechanics of test administration, otherwise valuable information can be missed\ Attention span of young children is short, OT shouldn't miss window of attention because they are focused on mechanics of administration Familiarity w/ test allows examiners to change pace of activity if needed for breaks or to split the test up for administration over multiple sessions **Preparation and Skill Development for Administering Standardized Assessments** OTs need to develop skills to ensure competency in standardized test administration Preparation = key **Strategic Interview** Primary source to understanding child's occupational performance and levels of participation while engaging in occupations\ Opportunity for OTs to understand a child and caregiver's perception of abilities, family routines/values, and discuss issues on personal level OT must be trained to ask questions and probe for info Used to help establish therapeutic relationship\ **Using Interview-Based Assessments\ **Used to obtain necessary information EX: COPM, COSA, School Setting Interview -- all semi structured with rating scales Some children \< 8 may struggle identifying difficulties in their daily lives, caregivers step in here Allow OTs to identify occupations important to child and family\ Explain process and reason for interview to child and parent prior to administration\ If taking notes, explain why and ask permission Multi-tasking is important skill while watching child play and incorporating observation into questions; OT must be familiar with the assessment to be successful in multitasking **Interview Strategies** 15 Interpersonal guidelines for conducting interview: Comfortable and supportive environment\ Confidence and take-charge attitude on behalf of the OT reduces anxiety for child and caregiver Matching language to child's comprehension levels makes them feel heard\ Assess emotional reactions and behaviors, using impressions and intuitions to discontinue interview\ When to stop an interview: child demonstrating aggressive behaviors, verbal hostility or emotional for extensive time period **Skilled Observation** Occurs from the moment OT meets child/caregiver and occurs throughout the eval\ Uses observation skills to evaluate child's occupational performance\ Can be accomplished by using an observation-based measurement or observing children in less structured environment i.e. playing freely in natural environment **Using Observation-Based Assessments** Comprehensive Observations of Proprioception (COP) -- observation-based assessment guiding OTs in observing child's behaviors and sensory-motor abilities while engaged in free play Includes 4 areas (muscle tone, postural motor control, behavioral manifestations, motor planning) with 17 items to be observed Suggested a therapist have 2 years of clinical experience and brief training to reliably administer COP findings meant to supplement not replace standardized measures of proprioception **Observation Strategies** Key Competencies: - Do not interfere with natural course of events - Pay attention to physical and social features of environment that support/limit - Record child's behavior in observable and neutral terms **Considerations of Contexts and Environment** Consider context and environmental factors when creating occupational profile and analyzing occupational performance **Types of Standardized Tests and Measures** Ipsative Assessment, Norm-References Assessment and Criterion-References **Ipsative Assessment** Standardized procedures used to eval performance or perception against prior eval outcomes No norm or criteria with which to compare results, only compare scores to previous scores Interview and observation are common\ Example of interview assessment is SSi and example of observation assessment is Kawa Model **Norm-Referenced Assessment** Developed by giving test to large number of children to generate average scores used for comparison\ Purpose is to determine child's performance in relation to average performance\ Variety of geographic locations, ethnic and racial backgrounds, socioeconomic levels should all be included so sample is representative Normative sample does not typically contain children with developmental delays/conditions Address one or more area of behavior\ Performance on each item is not as important as overall subtest or area score\ Standardized protocols for administration and scoring, essential for comparison; if examiner must make changes, results cannot be compared to normative sample **Criterion-Referenced Assessment** Designed to provide info on how children perform on specific tasks; child's performance is compared with level of performance of skill Determines what child can/cannot accomplish thus determining focus of intervention Is detailed and often relates to specific behavioral/functional outcomes Administration/Scoring procedures may or may not be standardized\ No mean score/normal distribution is calculated Some tests are norm- and criterion-referenced\ Self-report tests collect data on child's performance, behavior or participation in daily activities and natural environments from child and caregivers Advantage -- score represents typical or usual behavior based on multiple observations Disadvantage -- respondents may not carefully read/understand the question or answer based on what they think therapist wants to hear **Characteristics and Testing Mechanics** 4 types of assessments: interview, observation, performance and self- or parent- report Standardized tests come with test manual describing purpose of the test, intended population and info about the test regarding development, and establishment of reliability and validity Items cannot be added or subtracted w/o affecting the standard procedure; typically a rule about number of items that must be administered to ensure standardization\ Fixed Protocol for Administration -- way each item is administered and the number of items administered **Scoring Methods** Scoring guidelines accompany administration guidelines\ Passing performance may be described using text, picture or diagram **Types of Scores** Z-scores, T-scores, deviation intelligence quotient scores, developmental index scores, percentile score, and age-equivalent score **Measures of Central Tendency and Variability** Who fucking cares???????????????\ Bell curve -- greatest number of scores fall in the middle with some falling above or below average\ The measure of central tendency indicates middle point of data distribution\ The mean (are you fucking kidding me) is the sum of all sample scores divided by number of scores\ Median (Jesus Christ) is middle score of distribution, preferred method when outliers are involved\ The measure of variability determines how much the performance of the group deviates from the mean; used to compute standard scores in tests\ The variance is the averaged of squared deviations of the scores from the mean; measure of how far the score of individual deviates from group mean\ The standard deviation (ok here we go AGAIN) reveals how far scores can be expected to range from mean value **Standard Scores** Z-Score is computed by subtracting mean for the test from individuals score and dividing it by the SD\ Z-Score of -1.5 generally indicates delay or deficit\ T-Score is derived from Z-Score Deviation IQ Scores have mean of 100 and SD of 15 or 16\ Children with scores 2 SD below the mean in 2 or more areas require remedial services; 1.5 SD below the mean may be recommended for OT services **Rasch Scores** Derived from assessments based on Rasch methodology\ Generates a hierarchic ranking of items on the test from easiest to most difficult and creates a linear scale of items from ordinal observations\ Predicts that more difficult items on continuum are mastered only after easier items have been learned Assume that most appropriate goals for intervention will be items or skills above the items successfully passed by the client **Percentile Scores and Age Equivalents** Computed directly from raw scores and give indication of a child\'s performance relative to that of the normative sample\ Percentile score: percentage of people in standardized sample whose score is at or below a raw score ex. 60th percentile \-- 60% of people at or below the raw score Disadvantage: percentile ranks are not equal in size across score distribution (50-55th is not equal to 5th- 10th) Improvement in performance at the lower end may not be reflected of the percentile score the child acheives Age equivalent: age at which the raw score is at the 50th percentile, expressed in years and months, least psychometrically sound, misleading, use w/ caution May provide general developmental level but misleading because age-equivalent score may be average across several developmental domains (i.e. 4.5 in one area but 1.5 in other\...may not reflect 2.5 yo) A child who is performing w/in normal limits but is below 50th percentile would receive age- equivalent score lower than real age \-- this may cause parents to conclude incorrectly that the child has delays **Reliability** Definition: test describes the consistency or stability of scores obtained by one individual when tested on two different occasions with different sets of items or under examining conditions\ Error variance: the difference between two scores, result of random fluctuations in performance between two tests **Test-Retest Reliability** Definition: measurement of stability of a test over time, obtained by giving the same individual test on two different occasions\ Time span between must be short but not too short\ Correlation coefficient - between the scores is measure of test-retest reliability Improvement in performance at the lower end may not be reflected of the percentile score the child acheives May provide general developmental level but misleading because age-equivalent score may be average across several developmental domains (i.e. 4.5 in one area but 1.5 in other\...may not reflect 2.5 yo) A child who is performing w/in normal limits but is below 50th percentile would receive age- equivalent score lower than real age \-- this may cause parents to conclude incorrectly that the child has delays High test-retest - yield stable scores over time\ Children highly influenced by variables such as sleep, hunger, irritability Negative influence: rapid and variable development of kids affect stability **Interrater Reliability** Definition: ability of two independent raters to obtain the same scores when scoring the same child simultaneously, generally measured by subset of the sample\ One rater admin while another observes and scores at the same time\ Important if scoring requires judgment Scoring differences can arise but check with experienced colleague Interrater reliability is not meaningful indicator for self-report tests **Acceptable Reliability** No agreement on minimum acceptable coefficient for test and inter reliability\ Reliability coefficient of entire test likely higher than that of subsets because reliability increases w/ more items\ May vary when tested in different contexts or different experience of tester **SEM** Statistic used to calc the expected range of error for the test score of individual, based on range of scores individual might obtain if tested several times w/ no practice or fatigue effects so this is just a theoretical construct\ Creates normal curve for scores with obtained score in middle Important when differences between two scores are evaluated (after progress in therapy) Larger SEM - range of scores greater - degree of possible error is greater **Validity** Extent to which test measures what it is supposed to measure\ Ex. Test for fine motor skills actually measure FM and not GM\ **Construct Related\ **Extent to which test measures a theoretical construct ex. FM, GM, self-care\ Can be done by investigating how well a test discriminates among different groups of individuals, factor analysis to determine relationship among test items, or third method requires using construct validity with repeated admin of test before and after intervention **Content Related** Extent to which the items on test accurately sample a behavior domain , examiners must have confidence that self-care skills, for example, are adequately represented **Criterion Related** Ability of test tp predict how individual performs on other measurements or activities Checked about a criterion\ Concurrent: how well test scores reflect current performance Determine relationship between new test and existing that measure the same construct Predictive validity: relationship between test given in present and some measure of performance in the future - establishing is lengthier because several years must elapse Multiple investigations must be undertaken Validity important but sometimes elusive **Interpreting test scores** Consider test properties, client factors, contextual factors to draw conclusions about clid\'s performance Must consider if their response to test was typical, optimal, congruent with other scores, concur with other tests, reasons for discrepancies, provide complete picture\ Must ask parent if performance was typical for child **Minimal Clinical Important Difference (MCID) and Minimal Detectable Change** **(MDC)** ID clinically meaningful change between admin and discharge is part of responsibility\ MCID: smallest difference in score in domain of interest which patients perceive as beneficial and which would mandate in the absence of troublesome effects and excessive cost, a change in pt. management MDC: refers to the smallest change between test scores that fall outside the measurement of error, smallest change represents a true change between pre and post intervention that is not due to measurement errors when using any outcome assessments\ OT should be aware of measurement error a test contains so range of performance can be estimated for each child - now trend is to report confidence intervals rather than individual scores **Ethical considerations** Examiner competency Must know when test is appropriate or not and aware of variables that affect performance Client privacy HIPAA, parent must provide consent for minors, don\'t talk about private info inuf said Communication of test results Understandable and minimum jargon, objective, clear recommendations, aware of communication style and emotional response Cultural Consideration Children w/o test experience may not understand unspoken rules about testing ex. Doing task in time limit or following instructions, motivation Have caregiver or interpreter present, use cautiously, may be underrepresented in sample Awareness of family values **Advantages of Standardized Testing** Allows variety of professionals to speak the same language\ Monitor developmental progress\ Used for program evaluation to determine response to intervention across many clients Data can contribute to EBP and strengths and weakness about intervention program **Disadvantages** Cannot stand alone as measure of child\'s abilities, still need less structured evaluation procedures Only a brief snapshot during 1 hour assessment\ Must alleviate test anxiety\ Tests usually don\'t provide accurate indication of how child performs daily, must speak with caregiver Testing rigidity procedures difficult for some kids Purpose of testing is to provide a structured format for describing performance Ch. 8 **Evaluation** OT address many concerns such as identifying children that would benefit for service, develop goals, selecting interventions\ Dynamic\ Areas: Occupations, performance skills, performance patterns, client factors, contexts and environment Plan is influenced by child\'s age development level and medical condition Purpose: allows for the therapist to collab with the client and family to establish need for OT, goals, methods Conduct evals for Screening, determining scope, setting goals, document progress **Screening** Whether child would benefit from a more comprehensive eval Could be derived from standardized tools, checklists, communication with child or others, observation Often focus on acquisition of developmental milestones **Determine Scope and Frequency of OT Services** Conduct eval and collect data from child, parent, teacher and multiple methods (observation, interview, standardized tools)\ How data is collected and mechanisms determined by practice setting\ Frequency and duration determined by experience working with children, developmental trajectories, legal parameters **Documenting Progress Towards Goals** Eval purpose: establish baseline and postintervention measures associated with the progress **Top-Down Evaluation** Child\'s overall pattern of occupational engagement in relation to context Occupational profile - child, parents, providers frames critical occupations Attend to environment Which aspects of occupational performance inhibit participation\ If hypothesis performance skill deficit s are result of underlying cause \-- further eval (ex. Sensory) **Capturing the Parent\'s and Child\'s Perspective** Client constellation: pair or group of individuals who provide input regarding therapeutic process and benefit from the outcomes related to OT\ Parents - favor participation-related outcomes\ Focus on values, interests, priorities **Evaluation Process** Problem- solving dynamic ongoing process **Occupational Profile** Synopsis of child\'s occupational history, interests, values, patterns of engagement and participation and areas of concern\ Guides rest of eval\ Then generates hypothesis why child is having specific occupational performance concerns (use frame of reference or theory) Evaluation plan: performance areas of concern and performance skills that need further evaluation ID methods and assessment tools **Analysis of Occupational Performance** ID child\'s strengths and potential problems **Methods of Evaluation** **Observation** Naturalistic setting preferred over clinical\ Performance skills, patterns, client factors as guideposts\ Observation for baseline - define behavior indicator that is target focus and how it will be measured (frequency counts, duration, checklists)\ **Assessment tools\ **Contributes to understanding of strengths and needs\ Doc progress and outcomes\ Inform development of intervention goals and plans ***Standardized Assessment Tools*** Provide scores and behavioral indicators for comparison to other points in time Standard procedure and protocol ***Non-standardized*** Do not require the use of standard instructions or materials Allows OT to customize the admin to match needs of child **Interviews** Confirm or validate findings from observation or assessment tools Open-ended, private setting, free of language that conveys judgement Important question: what is desired outcome for OT **Interpretation** Synthesize info from occupational profile and other evaluation methods from analysis of occupational performance\ Would child benefit from OT? Appropriate outcomes? Theory or FOR? Best context for OT services? Referral? More info from family? **Refine Hypothesis** Develops hypothesis about reasons child having occupational performance difficulties Use FOR or theory PMI strategy Synthesize eval in child\'s strengths (plus), deficits (minus) interesting aspects **Document Findings** Purpose: communicate info about client, recommendations, record of services\ Reflects decision making strategies and clinical reasoning\ Eval reports include: referral info, client info, description of OPI, tools, findings, interpretation, recommendations\ Objective, snapshot of child\'s strengths and needs, actual scores, terminology for setting **Using Evaluation Findings to Drive Intervention Planning** Direct connections between concerns, tools, goal areas, intervention focus, and discharge qualification **Goal Writing** Observable, occupation-based, measurable meaningful to client constellation, Focused on occupational performance or co-occupations\ Based on progress trajectory predicted\ Assessed to determine how much progress child has made in timeline **Goal Components** Person + daily occupation/routine + specific context Observable and measurable target behavior (verb) Context: when certain skills will be performed, where, who **Objective versus Benchmarks** Short-term objectives and benchmarks provide logical breakdown of long-term goals and serve as guideposts\ Short-term objective: discrete skills leading up to more of a functional outcome\ Benchmarks: consider one long-term goal and break it down into chronological steps Ch. 9 Ch. 14 **Overview of Social Participation** Engagement in activities with community, family, peers or friends in interpersonal interactions and relationships\ Promoting social participation for children in natural context is vital\ Develops and changes across lifespan **Relationship Between Social Interaction, Social Skills and Social Participation** *Social Interactions --* processes by which people act and react to those around them\ Through social interactions children learn cultural expectations, social norms, and appropriate behaviors *Social Skills --* socially acceptable learned behaviors enabling person to interact with others and elicit positive responses\ Skills can be verbal or non-verbal\ Social skills are necessary for effective social interaction\ **Social Participation and Identity Development\ **Social participation can lead to positive disability identity through mentorship, support and modeling\ When interacting with someone with similar disability, a child can learn new skills and insights for dealing with similar problems as well as identify and appreciate valuable aspects of their disability\ **Friendships\ **Infant social relationships begin with caretakers; this relationship can set template for relationships throughout the child's life\ 2 y.o.: share and engage in prosocial behaviors\ 3 - 12 y.o.: develop self-awareness, communication and understanding of thoughts and feelings increasing their social skills; children fit in with group sand develop interpersonal relationships\ Adolescence: friendships become more complex and, shaped by need for reciprocity, intimacy, self-disclosure and emotional support\ Overall, students with disabilities experience fewer social interactions and invitations\ Element of choice is essential component of friendship between children w/ and w/o disabilities **Environmental Influences on Social Participation\ **Social-emotional dev progresses as students become more aware of themselves and others\ Barriers: physical layout of spaces, lack of adequate space for individualized attention/assistance, lack of transportation outside typical school day (field trips)\ Social aspect of environment: proximity of adults, negative attitudes of others, socioeconomic status Negative attitudes of adults can limit participation of child w/ disability if they are underestimating their ability to participate\ IDEA guarantees child w/ disabilities LRE, encouraging practices that may lead to increased social participation US dept. of ed requires equal opportunity for students w/ disabilities to participate in school sports, providing opportunity for increased social participation\ Students from higher income families are more likely to be involved in extra curriculars, have friends and be invited to activities\ **Parent and Family Perspective and Parental Influences on Social Participation\ **Parents want their children to form meaningful relationships with others -- often a main goal\ **Outcomes of Successful Social Participation\ **Children and adolescents use social skills to successfully engage in education, work, community life, religion and citizenship, recreation and leisure\ **Postsecondary Education and Work\ **Postsecondary settings require students to interact with others to achieve learning outcomes\ Acquiring work fulfills a societal role and provides means to become economic participant in society Students with disabilities are less likely to attend post-secondary education than their peers and experience social isolation, reduced social participation and high unemployment rates\ Postsecondary transition program outcomes are promising\ **Community Life, Religion and Citizenship** Community orgs offer opportunity for children to engage outside of family/school environment and may contribute to identity development\ During adolescence, child may become more or less involved in family's religion (or new religion) and become more involved in civic life Opportunities to engage in community service can increase social networks and support transition to adulthood for students with disabilities\ Children with disabilities are less likely to belong to religious based youth groups which provide the opportunity to expand their social network **Recreation and Leisure** Involvement in rec/leisure activities provides children opportunity to develop negotiation, compromise and emotional regulation skills\ Engagement in these activities is strongly correlated with QoL in individuals with ASD\ **Theoretical Basis of Social Skill Challenges** 4 Dominant theories explaining social skill challenge and participation limitations\ *Theory of Mind Hypothesis --* proposes social skills challenges result from disruptions in processes leading to acquisition of capacity to conceive other people's and one's own mind *Weak Central Coherence Hypothesis --* tendency to process all stimuli in fragmented fashion; focus on details rather than whole picture *Joint Attention --* process of sharing one's experience of observing an object/event by following gaze or pointing gestures - involves gaining, maintaining and shifting attention - key component of social interaction - EX: mom points to the sky and says look at the stars and a child looks - Limitation in this skill impacts social, language and cognitive development *Executive Dysfunction Hypothesis --* focuses on lack of self-organizing elements required in general learning thought to guide attention, inhibit irrelevant responses, understand rules and generate goals - Important for managing emotional regulation - Students with executive dysfunction struggle to complete new tasks in unfamiliar contexts with **Assessments of Social Participation and Social Skills for Children and Adolescents** OTs assess habits, routines and levels of social participation in which children engage\ Social skill assessments include info regarding child engagement in activity, preference for being alone, eye contact, understanding of nonverbal communication, response to humor, turn taking, etc\ **Goals for Social Participation and Social Skills\ **Intervention may be focused on social skills or social engagement\ Social participation goals fall into these categories: social skills, awareness of social rules, sensory processing, awareness of others (theory of mind), self-regulation, problem-solving and environment\ Goal attainment scaling (GAS) is used to identify and measure progress\ **Social Interventions\ **OTs use knowledge of activity analysis to describe required skills and synthesize what is needed to create effective intervention plan based on child's strengths and weaknesses **Approaches for Social Skills Interventions** Five factors that contribute to social skills challenges: 1. Lack of knowledge 2. Lack of practice or feedback 3. Lack of cues or opportunities 4. Lack of reinforcement 5. Presence of interfering problem behaviors OT will assess where child is being challenged and base intervention on that factor\ Intervention plans are based on theory and current evidence\ Six approaches underlying social participation interventions are: social cognitive, sensory intervention, behavioral modification, self-determination, peer-mediated intervention and MOHO\ **Sensory Interventions\ **Atypical sensory processing is highly correlated with social impairment\ Children with atypical sensory processing benefit from effective habits for modulating sensory processing needs in safe, acceptable manner during social situations\ *Interoception --* ability to perceive and process internal state of one's body including internal visceral and emotional signals i.e. tension, tight stomach, rapid breathing etc\ Difficulty with interoception limits social interaction i.e. not being aware of one's voice intonation may communicate wrong message\ Sensory interventions include: Ayres Sensory Integration (ASI) and specific sensory techniques\ Ayres defined sensory integration as: "neurological process that organizes sensation from one's own body and from the environment and makes it possible to use the body effectively within the environment"\ Difficulty integrating stream of sensory input can lead to issues with self-esteem, self-actualization, socialization and play\ Weighted vests or slow swinging can raise or lower arousal level in children so they can better self-regulate and attend to social interactions\ **Model of Human Occupation\ **Begin by examining volition\ Empower child by focusing intervention on meaningful activity\ OT may engage child in exploration activities so they can find out what activities they enjoy\ Addressing coping strategies with social supports can be beneficial\ Examines environmental resources, barriers and supports\ Examines performance capacity including abilities and subjective experiences **Self-Determination** *Self-Determination Theory* -- satisfaction of needs for autonomy, competence and relatedness promote well- being\ *Autonomy --* having a sense of choice, initiative and endorsement of one's activities\ *Competency --* represents a sense of mastery over one's capacity to act in the environment *Relatedness --* denotes feelings of closeness and connectedness to significant others This approach supports competency in social situations through just right challenges **Social Cognitive\ **Groups include 2 phases: acquisition and performance During acquisition, child observes behavior of others and the consequences During performance, child performs behavior based on their perception of situation and consequences Theory typically used as basis when working on behavior changes Groups are designed so all participants work together on social skills EX: video modeling and social scripts\ **Behavior Modification** *Behaviorism --* behavior is a response to an environmental stimulus and is reinforced by environmental consequences\ Behavior Modification uses positive/negative reinforcement to lessen maladaptive behaviors Commonly used to promote development of skills with Children with ASD **Peer-Mediated Intervention** Partners typically developing children with children with disabilities to promote behavioral changes Premises of intervention: - Peers are just as good, or better, at promoting skills than adults - Contexts created by peers are more natural - Abundance of peers creates natural opportunities for child to learn - Natural variability of peers' methods creates many opportunities for children to learn under "loose" training conditions facilitating generalized outcomes **Interventions for Social Skills** **Social Coaching** Interactive process promoting care provider's ability to support child's participation in everyday experiences and interactions across settings by developing new skills\ Uses reflections and questioning of behaviors\ Focuses on triggers of maladaptive behaviors Used to empower children to organize and execute responsibilities **Relationship Development Intervention** Parent-based, cognitive-developmental approach\ Primary caregivers are trained to function as facilitators and provide daily opportunities for successful social interactions\ Works on simple interactions first (attending to nonverbals) and moves on to more complex interactions (adapting and altering plans)\ **Applied Behavior Analysis\ **Helps children with ASD and other mental health conditions perform social behaviors through reinforcement training\ Discrete Trial Training (DTT) is most widely recognized form of ABA and works on developing learning readiness by teaching fundamental skills i.e. attention, compliance, imitation and discrimination\ Typically conducted in structured teaching environment but can be modified to take place in natural situations\ **Early Start Denver Model\ **Comprehensive behavioral early intervention approach for children between 12 and 48 months with ASD Uses relationship-focused developmental model with ABA principles to identify skills to be taught at specific times along with set of teaching procedures\ ESDM training and certification required\ **Program for the Education and Enrichment of Relational Skills (PEERS)\ **Parent-assisted social skills group intervention for high-functioning adolescents with ASD\ Utilizes concepts of CBT to improve social functioning\ Applies psychoeducation, role-play demo, cognitive strategies, behavioral rehearsal, performance feedback, homework assignment/review and parent involvement in **group** format Structural Options for Social interventions Social Skills Group Groups to improve social skills and social participation in children\ Improve social skills, improve greeting and play skills, increase empathy, improve facial recognition\ Goal: social skills interventions for children and youth to participate in group and social situations appropriately Process of Developing the Social Skills Group\ Where: schools most convenient, but location is determined by employer Who: who do not have aggressive behaviors who have adequate language to interact with others in adequate motivation to interact, children within 3 years of each other\ When: social groups should meet at least two times per week for at least one hour per session. Optimal impact: groups scheduled at least twice a week for 60 to 90 minutes over a 14 week session or daily for at least two weeks over the summer Key Characteristics of Social Skills Group *Parent Involvement* Parents should be oriented to theoretical approaches, format of sessions, and what they will be expected to do to support the homework\ Pretests and assessments for effectiveness\ Parents and children choose goals, focus goals for each session and for homework, use goal chart *Schedule* Daily visual schedule outline the activities of a group, activities include sensory modulation to promote optimal arousal levels, didactic social skills, social skills application activity, and a snack\ It is graded to meet child\'s needs and ensure success\ *Themes and activities* Activity theme provides participants with fun and enjoyable opportunities in which to practice social skills, strong motivator for participation Environmental focused interventions Environment is a primary contributor so participation and disability\ These interventions need to involve you some selves and actively generating and working to achieve solutions to challenges EX. pulling a cart by a wheelchair to transport snacks\ Project team (teens making environment and activity modifications) - Research based that empowers use for disabilities to identify environmental barriers and supports, generate modification strategies, and request reasonable accommodations - The Game Plan: solving in south monitoring process that post the steps of cool plan do check to facilitate participation in post secondary education and training employment and community living Influence of common mental health conditions on social participation Fetal alcohol spectrum disorder - Social anxiety disorder is characterized by emerged in persistent fear and or avoidance of social situations in which one peers being negatively evaluated by others are subjected to embarrassment - intervention: CBT Learning disabilities Difficulty with interpersonal understanding and social interactions, difficulty in appreciating components that make up context of interpersonal conflict, in devising alternative solutions to resolve conflict, and appreciating the consequences of solutions Mood Disorders Oppositional defiant disorders and conduct disorder Ch. 15 **Occupational Therapy Evaluation in Schools** Occupational profile, top down approach, consider specific aspects of educational performance, use COSA to determine problem areas and importance to students\ Consider specific skills and client factors strengths and weaknesses\ Use both in formal informal assessment methods, observations to identify learning challenges related to school-based practice. List of Assessments is in Appendix A **Areas of occupational therapy evaluation in the schools** Based on what student needs for formal educational participation. May include academic non-academic extracurricular pre-vocational are vocational activities. Academic considerations include reading or literacy test math communication social interaction play and self-care needed for school success. This chapter focuses on hand scale visual perception and visual perception motor integration and self regulation for learning since they are pre-reqs for other academic tasks. 15.2 for process and motor skills **Cognitive challenges and assessment** May impede academic learning because it interferes with following directions, completing a shared activities, or presenting with behavioral challenges working memory executive function pronunciation attending problem-solving and social situations\ Growth mindset: a dynamic developed through dedication and effort rather than affects you want abilities allows to see challenges and failures as opportunities for learning Cognition is typically assess your observation of organization, planning, initiating tasks, and memory functions. Formal assessments in appendix a. **Visual perceptual challenges in assessment** Visual perception: process responsible for reception and cognition of visual stimuli. Important for learning pick a student must analyze interpret and use information once received.\ Important for hand skill and developing new motor skills\ Visual spatial: ability to make judgments about location of objects in space in relation to ones in body includes depth perception topographic orientation space and spatial relations Visual analysis: to determine a distinct features of visual forms including size shape color in orientation includes visual discrimination form constancy visual figure ground Fishel closure of visual memory and visualization\ Visual perception assessed in school through observation everything has a completion and assessment tools **Self-regulation challenges and assessment** Self-regulation: viewed as ability to manage and control emotions and behavior in response to situation, from emotional control learned behaviors and motivation.\ Sensory processing abilities often impact ability to self regulate; affects writing moving about the classroom physical and social activities adaptation may present as negative behaviors Interoceptive awareness of internal body states such as hunger may contribute to behavioral outbursts or self regulatory issues\ Assess through observation of student behaviors, appendix A, may use CSEA: a tool that fosters collaborative discussion about sensory information **Motor skill challenges and assessment** Includes hand skills by motor skills coordination abilities and endurance. Can impact participation in writing using scissors to use navigating hallways changing classes, recess or sports **Hand skills** Do observation and formal assessment of grip strength and her manipulation and sensory motor functions of tactile proprioceptive are necessary for evaluating tool use and hand writing\ Holding objects manipulating objects for five minutes pinch hand strength impact dressing skills for Jim ability to open lockers use utensils pencils paint brushes protectors Can be observed during arts and crafts free play, ADLs **Visual motor skills** Throwing and catching a ball cutting out shapes of scissors placing puzzle pieces together\ Requires vision ocular motor abilities sensory perception movement language attention Assessments require a copy of a picture showing a person writing in print or can be observed during classroom tasks or recess **Handwriting** Need in hand manipulation strength pencil grip proprioception motor planning visual motor skills Evaluation needs to include domains of hand writing legibility components writing speed ergonomic factors\ Considers students performance skills and client factors contextual elements hand reading instruction methods and curricula **Social Skill Challenges and Assessment** Making friends working groups adapting to routines following rules\ includes self-awareness self management social awareness relationship skills and responsible decision making\ Observe during lunch recess hallway formal assessments are in appendix a **Interventions** Top down, natural context, multiple contexts\ Interventions to modify, maintain, establish, create, prevent\ Outcomes: performance, prevention, participation, health and wellness **Approaches** Remediation: improve deficit skills, can improve deficit skills, involve intervention of underlying causes (bottom up) or structured practice of specific skills so skills can develop and become automatic (top down)\ Strategy use: overlaps with remediation, use for search or scanning, attention ex. Put tape on left side of paper so know where to start typing Environmental adaptations: made in tasks as accommodations so success is possible\ Compensation: any practical environmental adjustment such as assistance from others, training procedures, strategies, environmental adaptations\ Education of student, parents, teachers to increase awareness of limitations and functional implications **Universal design for learning** UDL: proactive shaping teaching methodologies to students\' strengths and knowledge\ Key aspect: engagement - tapping into the interests, facilitate persistence through just right challenge **Preparatory activities** Little evidence w/o engagement in occupations\ Modulate muscles ex. Chair push up, slow rocking\ Poor handwriting frequently exhibit poor proximal stability and strength - encourage cocontraction through neck, elbows, wrist - animal walking, pushups, yoga weight bearing on UE **Seating and Positioning** Address ergonomics, feet on floor while writing provide weight shifting and postural adjustments Consider adjusting height of desks and chairs, footrests, seat cushions, prone positioning - increase proximal joint stability and dissociation of the hand and digits from the forearm **Safety** Must be addressed for navigating halls, ADLs, field trips, transportation **Environmental Adaptations** Assist student to participate, self-determination, self-regulation Rest and sleep important - change start times in school district **Hand skill development** May benefit from developing more coordination synergies of intrinsic and extrinsic muscles Hand strengthening activities: knot tying, games, carry heavy cases with thick handles\ Best learned and reinforced in real context\ Box 15.2 has great in-hand manipulation activities **Handwriting** Remedial or compensatory approach or use computer technology **Instructional Approaches** Comprise a combination of sequential techniques including modeling, tracing, stimulus feeding, copying, composing, and self monitoring\ First may need many visual and auditory cues then proceeds to copping letters in words from model finally will advance to generate words in sentences for practice Handwriting programs taught to all students Handwriting strategies - 15.8 **Writing tools, writing surfaces, positions** Different kinds of pens, pencils, crayons, chalk, - influence positive attitudes Writing surfaces **Pencil grip** Can be influenced by variety of devices for better manipulation and positioning digits Research does not support pencil grasp as major component in poor handwriting **Paper** Lined paper improves legibility compared to unlined\ Different spaced lines, experiment with different textures\ Should be slanted on desktop so it is parallel with writing hand to see work and avoid smearing Writing instrument should be held below baseline and nonpreferred hand is holding the paper **Sensory considerations** All sensory systems should be tapped within handwriting intervention as well as interesting materials Could use clay, pipe cleaners, beads Ch. 20 **Introduction\ **Sensory integration: refers to neural organization of sensory information for functional behavior, and as FOR which include assessments and strategies - Neural processes as they relate to functional behavior - Organization of sensation for use - Ayres Sensory Integration (ASI) uses neuroscience and OT concepts of functional perform. **Neurobiologically based concepts** Brain designed to take in sensory information and malfunctions if deprived\ Serious cognitive, social, emotional functioning result when children are in environments impoverished of sensory experiences, nurturing caregiver, sensorimotor exploration\ Too much stimulation can generate stress detrimental to brain development\ Sensory input must be organized by child to act on and respond to environment **Sensory Integration and Adaptive Responses** Brain processes sensory info \--\> Child also organizes goal directed action on environment\ Adaptive response: organizing successful, goal-directed action on environment after organizing incoming sensory information Ex. Riding a bike, child integrating vestibular and proprioceptive sensation to learn to balance Therapeutic activities to engage child\'s inner drive **Neural Plasticity and Environmental Enrichment** When child makes an adaptive response change occurs in neural synapses and circuits\ Plasticity \--ability of structure to be changed gradually by its own ongoing activity\ Neural Plasticity \-- ability of experience to shape development of neural circuits both structurally and functioning Enriched environment leads to increases in synaptic connections, efficiency, tissue size\ More primitive parts of CNS develop before maturation of higher-brain centers Enhancing foundational functions related to the proximal senses has a positive influence on higher-level cortical functions **Sensory Integrative Development and Childhood Occupations** Ayres believed that proximal senses (vestibular, tactile, and proprioceptive) are important in shaping interactions with world\ By time child is 7-8 scores of sensory integration capabilities are mature as adult\'s\ Just right challenge-nervous system organizes sensory info and searches for more challenges **Sensory Integration Problems** When sensory integration does not work well children may experience challenges with occupations, reject sensory or motor challenge, and if long-term child may miss important experiences\ Can occur w/ or w/o diagnosed disorders\ Integrative differences involve the CNS (nuclei) rather than peripheral sensory functions (ex. Semicircular canals) Four Categories: sensory reactivity, sensory discrimination and perception, vestibular-bilateral function, praxis **Sensory Reactivity Problems** Sensory reactivity problem = sensory modulation problem\ Modulation: CNS regulation of own activity\ Sensory modulation: tendency to generate responses that are appropriately graded in relation to incoming sensory stimuli rather than over/under responding to them TABLE 20.1 Problems with Sensory Reactivity Limited sensory registration: does not notice relevant stimuli - Oblivious to touch, pain, movement, taste, smell, sound - May not notice injury and potential for self-injurious behavior - Usually more than one sensory system Tactile defensiveness: hyperreactivity to ordinary touch sensations, can be threatening if cannot see source, self- applied input tolerated better, light touch stimuli are aversive especially in sensitive areas - Irritation and discomfort, anxiety, anger, tantrum, distress - Most comfortable with deep touch - Participation in self-care, classroom, or social is impacted Gravitational insecurity: hyperreactivity to vestibular sensations involving linear movement, from pull of gravity and vertical movement through space - Moves slowly, fear during whole body movement activities Refusal to use stair, ladder, elevator etc. - Fear of heights (even slightly) - Overwhelmed or avoid changes in head position - Resist lifting feet off ground - Community mobility, leisure, sports Auditory/visual/olfactory and gustatory defensiveness: hyperreactivity to sound, sight, smell, taste - Distress w/ loud sound, bright light, strong smell or taste - Events - bday parties, classrooms, cafeterias, meals **Sensory Registration Problems and Hyporeactivity\ **When CNS works well - it knows to when to pay attention to stimulus and when to ignore it\ Sensory registration problems: person does not notice or register environmental stimuli\ Interferes with child\'s ability to attach meaning to activity because critical info is not being noticed \--\> ex. May impact play or language development\ Important to consider whether problem is perceptual or cognitive difficulty rather than lack of registration **Sensory Hyperreactivity\ **Can be general response to all types of sensory input or specific sensory system\ Child overwhelmed by ordinary sensory input and reacts strongly to it\ Genetic, sociodemographic factors\ Anxiety is common with sensory hyperreactivity **Sensory Discrimination and Perception Problems** Discrimination: brains ability to distinguish between different sensory stimuli ex. Two points touch on skin simultaneously\ Perception: brain\'s process of giving meaning to sensory information\ Reactivity problems often coexist with perceptual problems - child who has registration problems may have limited perceptual skills owing lack of experience interacting with sensory information Table 20.2 Problems with Sensory Perception Tactile Perception - Difficulty interpreting the location, intensity, 3D properties, or direction of movement of tactile stimuli precisely and effectively Proprioceptive Perception - Difficulty interpreting body position and the position and movement of muscles and joints\ o Appears clumsy, awkward, excessive input, breaks toys, too much or too little force, relies on visual guidance or cognitive strategies - Participation in school impacted Ch. 23 **Definition and Purpose of Early Intervention Programs** Early intervention: birth - three, refers to programs and services designed to enhance the child\'s development, for those who have an established risk developmental delay or are environmentally or biologically a risk\ Purpose: enhancing development of infants and toddlers with disabilities, minimizing their potential for developmental delay, and recognizing the significant brain development that occurs during a child\'s first three years of life Enhance capacity of families to meet the needs of the infants and toddlers **Legislation** EHA 1986: established incentives for states to develop systems of coordinated family centered care for infants with disabilities\ Part C IDEA: States must develop and make available comprehensive services for all infants and toddlers who have developmental delays, are required to maintain and implement comprehensive, coordinated, multidisciplinary, inter-agency systems of EI services - Entitlement program: acknowledges one\'s rights to services\ Within 45 days of receiving referral to EI families and service providers develop an individualized family service plan with child and family specific goals and identification of service providers\ IFSP defines the environments in which the child is to receive services and provides a statement of justification if services are not provided and in natural environment - Specifies who the provider will be, frequency, intensity, duration of services, and funding States must report data on children who improve in positive social emotional skills, acquisition and use of knowledge and skills, use of appropriate behaviors to meet their needs - Must also report families who improve in knowledge of rights, ability to communicate child\'sneeds, ability to help child develop and learn **Importance and outcomes of EI** - Influencing early development can significantly change a child\'s lifelong health in learning potential neural plasticity is at its greatest\ it can reduce caregiver stress\ can also reduce the need for special ed when child transitions to school **Occupational therapy services in EI systems** - Include services to address the functional needs of the child related to adaptive development self-care, adaptive behavior and play, including social interaction, and sensory motor and postural development And include improve developmental performance increase participation and enhanced quality of life 96% of services occur in home or community based setting - Interventions embedded in routine of faily **Best Practices in EI** **Partnering with Families** - Family Centeredness encompasses several meanings: families are treated with respect, importance placed on family strengths, not deficits, families have control and make choices regarding the care that their child receives, and families and providers work together to ensure provision of optimal early intervention services - Goals are developed collaboratively - Degree of family involvement may fluctuate, Family priorities need to be honored and services must follow the priorities, OT must be aware and respect differences in beliefs and values based on culture - Practices regarding feeding, toileting, and bathing. And cultures as well as different values and beliefs, goals should reflect and consider cultural diversity **Partnering with Professionals** - Teamwork is critical because the interrelated needs of a developing child and caregiving family are complex and culture skills and resources of a team of professionals\ Transdisciplinary model where one service provider is primary and other team members serve as consultants - Work together to make sure intervention considers child within the family unit\ Coaching form of early intervention consultation that allows team members to reinforce intervention strategies designed by other team members **Evaluation and Intervention Planning** - A collaborative process of collecting, analyzing and gathering information about the infant and family to identify specific needs and to develop goals\ The purpose is to determine eligibility of EI programs and to develop goals and potential outcomes to guide the services **Eligibility Determination** - Some infants with certain diagnoses become automatically eligible for EI services\ Those suspected of having a developmental delay are entitled to an evaluation that must be completed within 45 days - Family Centered practice should include: treated with respect, evaluation should be individualized flexible and responsive to family culture and preferences, the child and family strengths should be emphasizes rather than deficits, families expertise should be valued and they should be included in decision-making **Initial Evaluation:** team introduces families to intervention system, completes semi- structured interviews, gather data about natural environment and family priorities RBI include: beginning statements introduces the interview process and his family about concerns, discussion about daily routine, info about daily routine and child participation in these routines, family satisfaction with daily routines, families concerns and **Standardized Assessments:** of cognitive communication motor social emotional and adaptive self-care development, play is often context or component of the assessment, therapist may use informal assessment through observing the child playing with caregivers or peers\ Criterion Referenced tests are favored because child may not respond to a standardize protocol and comparing a child\'s ability with those of their same age peers because children receiving early intervention services may not follow typical normal development HELP and AEPs are favored\ Assessments are chosen by teams and vary from state to state\ Part C regulation include informed clinical opinion as essential to evaluation process Informed clinical opinion is the final opinion of the multidisciplinary team and establishing eligibility for EI, informed through multiple sources (history, interviews, observation) Recommendations for importance of integrating family practice Assessment on integrative developmental model, done in different contacts, involves multiple sources and multiple components of information parents and child contribute, understanding of typical child development is essential, emphasize child\'s functional capacities, identify current abilities, parent present supports the child and begins the collaborative process, warmup to child before assessment, assessments that are limited are not complete, assessments are not determining factor Once team has identified eligibility further assessment is important for OT and family to determine which intervention strategies and services **Development of IFSP** Map of family services in informs everyone who will be working with child and family about which services will be provided where and who\ Meeting facilitated by the service coordinator and attended by family and at least one member of the evaluation team Provider describes their assessments and results to create overall description of the child and family needs for service and families provide feedback during discussion and encouraged to collaborate Forms varies state to state, BOX 23.3 shows the required components of the IFSP\ Reviewed every six months or more often if necessary **Writing Goals and Objectives** Outcomes are written for my family centered perspective and identify child out occupational performance as it relates to family daily routines\ Outcome: statement of changes desired by the family they can focus on any area of child development Before developing outcome must collect information about natural environment, routines, activities Criteria: outcome statement is functional, reflects real life contextualize settings, jargon free, clear, outcome is discipline free (not specific for PT, OT), avoid the passive use of words, emphasizes positive - Lily will go fishing with her family and hold own fishing pole\ next step is to describe what is happening now and what will happen when the outcome is achieved, strategies are listed to address the outcome - strategies link to the practice areas of specific disciplines\ Outcome: feed self food at meal, problem: unable to hold food, OT strategy: hold food and bring to mouth - Sample of goals and outcomes in table 23.2 **Transition Planning** Turns 2 the EI team begins to develop a plan for child\'s transition Characterized by stress due to change in environment different service providers different philosophy between your programs in schools Stress is decreased when transitions are well planned and support to families is provided throughout process OT has important role in transition planning because they understand how contexts influence participation Activities in OT for transition might include: prepare caregivers for changes in rules and routines, teaching caregivers how to work with her children to develop specific skills needed in preschool, visiting preschool classroom to assess needs for environmental modifications, ensure adaptive equipment is sent to new setting and providing team members in new setting with video of child doing care means **Payment for Occupational Therapy Services** OT bills for time spent directly with client; time spent in meetings and other non-direct activities, including travel, may not reimbursed\ OT payment varies by state and OTs may be employed by a state agency providing EI or self- employed\ For EI programs, state funding is payment of last resort; typically families pay out of pocket determined on a sliding scale based on their income and Medicaid or private insurance picks up rest\ EI telehealth can be reimbursed by Medicaid, private insurance or IDEA Part C fund **Working in Natural Environments** Services provided in location convenient to family and include typically developing children of same age (i.e. play group, mother's morning-out program, childcare center) with outcomes linked directly to family routines and contexts\ If working with child in the home or daycare setting, bring toys/equipment that make sense for the environment and are familiar to the famiy. In a clinic setting, provide opportunities for caregivers to learn/practice strategies and interventions to promote generalization to their natural environment **Occupational Therapy Early Intervention Practices** Promote development and independence in physical, cognitive and psychosocial functions as well as guide and support caregivers to provide opportunities for child to participate in natural learning environment with typically developing peers. **Occupational Therapy in Natural Environments** Natural environments may include grandparents' home, swimming pool, local library -- take advantage of actual context in which occupations occur, interventions in natural setting promote acquisition of functional motor, social and communication skills\ Grandparents, childcare providers and siblings can be present during therapy session Opportunities for learning in natural environment should be interesting, engaging and provide children with contexts for exploring, practicing and mastering competence Natural intervention strategies incorporate incidental learning opportunities during typical activities and interactions with peers/adults -- follow child's lead and use natural consequences Skills learned in natural setting are more likely to be generalized\ Key advantages of the natural environment are (1). Child level of comfort (2) easy to offer natural learning opportunities w/I daily family routines flexible and creative Challenges of the natural environment are (1). Family-centered do not always consistently implement family-centered practices in natural environment (2). OTs must be extremely\ OT should observe the natural environment first to create realistic goals for environment and assess available resources and problem-solving skills utilized by family **Family-Centered Intervention** Make program relevant to family's lifestyle and time commitments and respect level of involvement parents/caregivers choose to have\ Support families by listening and give positive feedback regarding parenting skills\ Provide suggestions for making family routines quicker or more efficient i.e. adapting bath seat to make bathing less taxing; parent can encourage bilateral coordination or ROM at bath time and older sibling can encourage child to reach for toys **Coaching Families** Family-centered approach that takes advantage of adult learning styles, may also be implemented w/ other professionals\ OTs can coach caregivers in natural environment to promote self-confidence and responsibility in child's daily care\ Coach has specialized knowledge and skills to share about growth/development to share with the learner who has intimate knowledge of child's abilities, challenges and typical performance Process of coaching families: 1. Initiation: need is identified by coach or learning and joint plan is developed withspecific learning outcomes 2. Observation: four different types 1. Learner demonstrates existing challenge or practices new skill while coach observes 2. Coach models technique/strategy/skill while learner observes 3. Learner thinks about how to support child's learning while performing activity 4. Coach and learner observe aspects of environment to determine how to influence situation. 3. Action: activities that take place when coach and learner are in contact 4. Reflection: questioning and reflective listening and provision of reflective feedback to help learning understand how to analyze practice and behavior. Coach reviews discussion or observes learner to assess their understanding 5. Evaluation: coach evaluates effectiveness of coaching with learner; may not take place every time coach and learner meet, but coach should always self-evaluate 6. Continuation: results of coaching session are summarized and plan is developed for what happens next 7. Resolution: learner and coach agree specified outcomes were achieved. Especially useful technique when one EI team member is primary provider for child and family Requires good communication skills, trust and respect\ OT may work with caregivers to plan and carry out therapeutic interventions for child to improve child and parent outcomes i.e. coaching parents in methods for dev finger grasp as it relates to finger feeding or play **Use of Telehealth to Facilitate the Coaching Model** OT can observe caregiver strategies, provide instruction regarding therapeutic techniques and provide feedback on implementation of techniques Telehealth in EI promotes family participation, supports child and family outcomes and results in high levels of family satisfaction\ Promotes collaboration for interdisciplinary evaluation, care coordination and team-to-team consultation Significant cost savings because decreased need to travel to specialty clinics\ Before using telehealth, consider the following: complexity of child's condition, child's context/natural environment, family's preferences and technology access, nature and complexity of intervention, requirement of practice setting and knowledge/skill/competence of OT **Occupational Therapy Interventions** Primary occupations for infants/toddlers are play, social participation and self-care **Play as an Intervention Outcome** Open-ended, self-initiated, self-directed and unlimited in variety\ Exploratory, symbolic, creative or competitive in nature\ Play can be impacted by limited opportunity, lack of social and pretend elements, limited object manipulation, limited cognitive function or the lack of mobility to fully engage in sensorimotor play -- all varies by condition\ OT models playfulness in interactions with child to increase their initiation and participation Activity should elicit sense of fun and enjoyment **Play as a Means to Learning Specific Skills** Participation in play activities allows child opportunity to practice mastered skills and learn new ones that are the foundation for engagement in other occupations\ Object manipulation, problem-solving and attention to tasks can all be learned through play and applied to other occupations Use objects and materials typically found in natural environment i.e. plastic containers or wooden spoons)\ Plastic containers can be used to play while also developing specific arm movements **Engaging the Child in Play** Activities should: 1. Arouse and engage the child 2. Encourage and prompt practice of emerging developmental skills 3. Reinforce learning of higher-level skills 4. Promote transfer of play skills to multiple activities **Arousal and Engagement** Key to optimal arousal is comfortable environment with sensory elements promoting self- regulation including modifying environment to lower arousal\ Infants at optimal arousal level are alert and attentive and can engage in an activity\ Use child's preferred objects or activities to engage children and sustain interest -- ask caregiver for help in identifying these Preferred play contexts creates and facilitates meaningful social interaction between child and OT\ Once engaged in meaningful play, OT can introduce variations that elicit and challenge emerging skills **Allow Practice of Emerging Developmental Skills** OT design activities to target, practice, and extend specific skills i.e. building train track on carpet and filling sand bucket\ Unstructured play can be easily adapted and graded to promote higher-level response i.e. child can line up and stack blocks but can also build houses and bridges Play activities that fit well into caregiver/family routine are more likely to be repeated and incorporated into family life **Reinforce Higher Level Skills** OT provides appropriate reinforcement for play through positive affect and enjoyment, which is minimal because play itself is internally reinforcing\ Peer interaction can provide modeling, reinforcing child's effort\ OT plans activities intrinsically reinforcing i.e. climbing up and jumping into pillows OT times reinforcement -- delayed feedback can help sustain performance\ Children generally benefit from specific feedback rather than faded and general feedback, which is more appropriate as child becomes more independent **Facilitate Generalization of Play Skills** Goal in encouraging new skill development is that child can generalize performance to range of activities\ OTs coach caregivers to use variety of toys/activities to support child in generalizing skills **Adapting Play: Role of Assistive Technology** Adapted seating, adapted stander, adapted toys or modified environment enhance play for children w/ physical disabilities\ Supported seating and prone standers can promote child's use of hands and eyes together in play if they have low postural tone Battery operated toys with adapted switches or iPads/touch screens for children with minimal arm and hand movement, can be accessed in supported sitting or side-lying position Technology and media promotes social interaction between children and their peers\ OT collaborates with family (BIG shock) to select AT or help create inexpensive adapted devices **Social Interaction and Participation** Social competence can be delayed when child has cognitive delays\ Environment can constrain social-emotional development i.e. caregivers with mental health disorders, limited social supports and limited parenting skills **Parent-Child Interaction** Infants with SPD or ASD may show delay communicating discomfort or hunger, which is difficult and stressful for caregivers\ OTs observe interaction between child and caregiver, listen to caregiver concerns, and coach caregivers on reading cues, responding with sensitivity and supporting infant's communication effort OTs can teach massage or touch-based intervention to help calm infant to promote optimal arousal\ Relationship-based interventions encourage caregivers to become more sensitive to child's cues and more responsive to communication efforts; nonverbal interaction and imitation are emphasized; positive impact on mother's responsiveness and child's self-reg, social competence and adaptive behavior Modeling and coaching are key strategies to promote caregiver sensitivity and responsivity Most parent-child interactions occur during joint activities when child is a toddler, requiring child to attend to caregiver and activity\ OTs promote joint attention by designing context that supports joint engagement, selecting activity of high interest, modeling for caregiver and child and supporting child's engagement with positive affect and reinforcement **Peer Interaction Interventions** Around 3 y.o. child becomes more interested in peers\ OTs use specific strategies to promote social competence in context of naturalistic play Computer and tablet activities can increase engagement of young children in small groups Puppets, dress-up, dolls, trucks, housekeeping toys can promote social interaction for those with cognitive delays, especially when paired with children with higher cognition\ In groups, OT models and reinforces social interaction skills and promotes interactions by designing activities that require sharing, imitation, or social interaction **Adaptive Behaviors: Eating and Sleeping** Eating and sleeping are behaviors strongly linked to health, development and growth Primary concerns of caregivers **Feeding and Eating Problems** Feeding problems linked to oral sensorimotor problems, oral structural abnormalities, aspiration, self-feeding delays, failure to thrive, and selective eating\ Children with CP may have difficulty sucking, jaw stability, coordination of swallowing and breathing Premature infants may have oral sensitivity, low muscle tone, problems with suck-swallow- breathe coordination\ Dysregulation and irritability also negatively impact eating and sleeping **Interventions to Improve Feeding Mechanics** Positioning, oral support, and pacing have positive effect on infants' feeding performance \*\*once again, to no one's surprise\*\* OT works with family to determine most acceptable/successful strategies to promote competence in self-feeding OT can attend and coach caregivers in natural environment during mealtimes and provide recommendations for environmental adaptations and modifications to support feeding success Examples include adapting high chair to provide additional trunk support or purchasing adapted equipment -- always consider family's resources and priorities when making recommendations **Caregiver-Infant Interaction During Feeding** OT can coach parents in methods/strategies to improve communication and interaction during feeding\ OT makes recommendations about holding infant, pace feeding, read infant's cues, respond to nonverbal cues and maintain infant engagement OT observes and reflects to identify goals and strategies to improve eating success and provides emotional support to caregivers **Sleeping and Rest** Sleep problems in infancy are reported to predict emotional behavioral difficulties at 5 y.o. Infants with SPD or ASD have disrupted sleep -- with hypersensitivity and sensory modulation issues seeming to be contributing factors to sleep problems\ Family functioning and QoL are negatively affected when child or family's sleep is disrupted Interventions to promote sleep include behavioral and sensory strategies OT and family discuss nighttime routine, problem-solve antecedents and consequences of child's bedtime behavior\ Difficult for children with high arousal to filter sensory stimuli out to fall asleep\ Sensory strategies like rocking, music, total darkness or fan may help Ch. 24 *Federal Legislation and State-Led Initiatives Influencing School-Based Practice* - EHA caused influx of OTs working in schools *Individuals With Disabilities Education Act* *Eligibility* May include children with various impairments or children with significant ![A paper with text on it Description automatically generated](media/image2.png) *Free and Appropriate Public Education* - "Appropriate services" does not guarantee students receive most advance/innovative/high tech materials to meet needs Requires students receive education with gen ed students to maximum extent possible Does not guarantee all students are placed in gen ed classrooms all day Placement decisions may not be based on availability of space/resources *Evolution of IDEA* *Section 504 of the Rehabilitation Act and Americans with Disabilities Act* *Elementary and Secondary Education Act (ESEA) and Every Student Succeeds Act (ESSA) of 2015* ESEA -\> ensures all children, in all public schools, have equal opportunity to participate in and receive good education in school ESSA -\> authorized to replace NCLB; allows local education agencies to establish own accountability goals -- less reliant on standardized and single measures of performance o OTs are "specialized instructional support personnel" (SISP) - Expected to engage with team members to support academic achievement and promote professional dev. *Common Core Standards: A State-Led Initiative* - ESSA requires schools establish academic standards to guide educational outcomes *Private Schools and Federal Legislation* Students in private schools are not guaranteed FAPE Public schools are required to give some of their federal funding to students in their district, requiring services in private schools \$\$\$ is allocated based on the number and needs of eligible students -\> still does not mean all students in who need services in private schools will get them Students enrolled in private schools may be transported to the public schools to receive services with funding from public schools Private schools who accept federal funding, even thorugh the public school, must comply with ADA *Occupational Therapy Services for Children and Youth in Schools* *o The Educational Model and Occupational Therapy* *OT and OTA Collaboration* *Shifts In Occupational Therapy Service Provision* A diagram of a pyramid Description automatically generated *Occupational Therapy Process in General* Education MTSS Model *o* Most are 3 tiers (1). Universal or core instruction, (2). Targeted intervention, (3). Intensive intervention *o* Tier 1 = instructional, behavioral and social supports for all students; may include handwriting curriculum or schoolwide character dev. program *o* Tier 2 = interventions are developed to address specific student needs; may include small groups or tutoring *o* Tier 1 allows OTs opportunity to generate change at systematic level Ch. 26

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