case study pediatric occupational therapy

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Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review

1 Cerebral Palsy Alliance, Discipline of Child and Adolescent Health, The University of Sydney, Camperdown North South Wales, Australia

Associated Data

Introduction.

Paediatric occupational therapy seeks to improve children's engagement and participation in life roles. A wide variety of intervention approaches exist. Our aim was to summarise the best‐available intervention evidence for children with disabilities, to assist families and therapists choose effective care.

We conducted a systematic review (SR) using the Cochrane methodology, and reported findings according to PRISMA. CINAHL, Cochrane Library, MEDLINE, OTSeeker, PEDro, PsycINFO were searched. Two independent reviewers: (i) determined whether studies met inclusion: SR or randomised controlled trial (RCT); an occupational therapy intervention for children with a disability; (ii) categorised interventions based on name, core components and diagnostic population; (iii) rated quality of evidence and determined the strength of recommendation using GRADE criteria; and (iv) made recommendations using the Evidence Alert Traffic Light System.

129 articles met inclusion ( n  = 75 (58%) SRs; n  = 54 (42%)) RCTs, measuring the effectiveness of 52 interventions, across 22 diagnoses, enabling analysis of 135 intervention indications. Thirty percent of the indications assessed ( n  = 40/135) were graded ‘do it’ (Green Go); 56% (75/135) ‘probably do it’ (Yellow Measure); 10% ( n  = 14/135) ‘probably don't do it’ (Yellow Measure); and 4% ( n  = 6/135) ‘don't do it’ (Red Stop). Green lights were: Behavioural Interventions; Bimanual; Coaching; Cognitive Cog‐Fun & CAPS; CO‐OP; CIMT; CIMT plus Bimanual; Context‐Focused; Ditto; Early Intervention (ABA, Developmental Care); Family Centred Care; Feeding interventions; Goal Directed Training; Handwriting Task‐Specific Practice; Home Programs; Joint Attention; Mental Health Interventions; occupational therapy after toxin; Kinesiotape; Pain Management; Parent Education; PECS; Positioning; Pressure Care; Social Skills Training; Treadmill Training and Weight Loss ‘Mighty Moves’.

Evidence supports 40 intervention indications, with the greatest number at the activities‐level of the International Classification of Function. Yellow light interventions should be accompanied by a sensitive outcome measure to monitor progress and red light interventions could be discontinued because effective alternatives existed.

Occupational therapy intervention for children promotes engagement and participation in children's daily life roles (Mandich & Rodger, 2006 ). Children's roles include, developing personal independence, becoming productive and participating in play or leisure pursuits (Roger et al .). Inability to participate because of disease, disability or skill deficits, can cause marginalisation, social isolation and lowered self‐esteem (Mandich & Rodger, 2006 ). Occupational therapists select interventions for children based upon an analysis of the child's performance of daily life roles, how their performance is affected by their disability, and how their environment supports or constrains their performance (Mandich & Rodger, 2006 ).

The practices of paediatric occupational therapists have evolved and changed based on research and theory (Rodger, Brown & Brown, 2005 ), such as family centred care and the World Health Organisation's (WHO) International Classification of Functioning, Disability and Health (ICF; World Health Organisation, 2001 ). These frameworks have led many occupational therapists to move away from impairment‐based interventions at the body structures and functions level aimed at remediating the child's deficits (known as ‘bottom‐up’ interventions), and instead to focus on improving functional activity performance and participation (‘top‐down’ interventions) (Weinstock‐Zlotnick & Hinojosa, 2004 ), as well as partnering with parents to deliver therapy embedded within daily life.

Clinicians will always have different expertise and preferences, but there are financial and ethical ramifications of delivering interventions. Ensuring the latest research findings are easily accessible to families and clinicians is vital. Occupational therapists positively embrace evidence‐based practice, but on the ground, implementation can lag (Flores‐Mateo & Argimon, 2007 ; Upton, Stephens, Williams & Scurlock‐Evans, 2014 ). Systematic reviews (SR) indicate that the translation of the latest evidence into routine clinical care lags 10–20 years in all countries and specialities ( Flores‐Mateo & Argimon ), which for paediatric patients is an entire childhood. Multiple paediatric occupational therapy interventions exist to address children's specific goals. In partnership with parents, it is the therapist's role to choose and tailor the intervention choices to match the child and parent's goals, preferences and potential for improvement based upon their diagnosis. Staying up‐to‐date is time‐consuming. Furthermore, appraising evidence and up skilling in new interventions requires reallocation of time and resources.

The aim of this paper is to systematically describe current intervention options available to paediatric occupational therapists across different child diagnostic populations, rating the quality and recommendations for use of each intervention, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system (Guyatt et al ., 2008 ) and the Evidence Alert Traffic Light System (Novak & McIntyre, 2010 ). The purpose of reviewing and rating the entire evidence‐base is to provide a ‘one‐stop’ access guide for clinicians and policy‐makers, allow for the easy comparison of interventions, encourage the uptake of evidence‐based interventions, to confer better outcomes for children. We sought to answer the following ‘PICOs’ question: What is the effectiveness of occupational therapy intervention for children with disabilities? P opulation = children with a disability (including arthrogyposis OR attention deficit hyperactivity disorder OR autism spectrum disorder OR behaviour disorders OR brachial plexus OR brain injury OR burns OR cerebral palsy OR cancer OR chronic pain OR developmental coordination disorder OR developmental disability OR down syndrome OR fetal alcohol spectrum disorder OR learning disability OR mental health OR muscle diseases; OR intellectual disability OR obesity OR preterm infants OR physical disability OR rheumatoid arthritis OR spina bifida); I ntervention = occupational therapy (including all specific named occupational therapy techniques); C omparison = none specified; O utcome = all outcomes accepted; and S tudy Design = SR OR randomised controlled trials (RCTs).

Study design

A SR of reviews was conducted, to provide an overview of the best available evidence. RCTs not included within the SRs were also appraised.

Search strategy

This review was carried out according to the Cochrane Collaboration methodology (Higgins & Green, 2011 ), incorporating the recommended quality features for conducting SRs of reviews (Smith, Devane, Begley & Clarke, 2011 ), and is reported according to the PRISMA statement (Moher, Liberati, Tetzlaff & Altman, 2010 ). Relevant articles were identified by searching: CINAHL (1983–2016); Cochrane Database of Systematic Reviews ( http://www.cochrane.org ); Database of Reviews of Effectiveness (DARE); EMBASE (1980–2016); ERIC; Google Scholar; MEDLINE (1956–2014); OTSeeker ( http://www.otseeker.com ); and PsycINFO (1935–2016). Searches were supplemented by hand searching and retrieval of any additional articles meeting eligibility criteria that were cited in reference lists. The search of all published studies was performed in March 2014 and updated in August 2018. Interventions and keywords for investigation were identified using the contributing authors’ knowledge.

Inclusion criteria

Published studies fulfilling the following criteria were included: (i) Type of study: All SRs and RCTs meeting inclusion criteria were appraised. SRs were preferentially sought since they provide a summary of large bodies of evidence and help to explain differences amongst studies. Plus, SRs limit bias. We also included RCTs not included within the SRs, because they are the gold standard design for measuring the effectiveness of interventions. Lower levels of evidence were only included if: the SR reviewed lower levels of evidence; (ii) Types of interventions: Studies that involved the provision of any type of occupational therapy intervention; and (iii) Types of participants: Studies that explicitly involved humans in which 100% of the participants were children of any childhood disability diagnosis.

Exclusion criteria

(i) Studies about typically developing children or adults; (ii) diagnostic studies OR prognostic studies OR about outcome measure psychometrics OR about theoretical frameworks NOT intervention; (iii) interventions that primarily fall under the skillset of another profession, for example pharmacotherapies, psychotherapy, speech therapies, etc. (iv) a second publication of the same study (Note: RCTs that met inclusion criteria but were also cited within included SRs, were treated as duplicates and not reported on twice); (v) studies were unpublished or non‐peer reviewed; and (vi) full‐text was not available in English.

Data abstraction

A data abstraction form was devised based on the Cochrane's recommendations (Higgins & Green, 2011 ). Abstracts identified from searches were screened by two independent raters. Both independent raters reviewed full‐text versions of the articles and articles were retained if they met inclusion criteria. Agreement on inclusion and exclusion assignment was unanimous. Data extracted from included studies comprised: authors and date of study; type of intervention (if named), core components and diagnostic population; who delivered the intervention; location of where the intervention was carried out; intensity of the intervention; study design and original authors’ conclusions about efficacy across study outcomes (Table  S1 ). In addition, based on intervention description and ICF definitions, reviewers assigned an ICF domain to each intervention outcome sought by study authors (World Health Organisation, 2001 ). Where multiple SRs or RCTs existed, we noted when the older research was superseded by newer evidence. Interventions with the same name and/or similar core components, and that were administered to the same diagnostic populations, were grouped together. All data required to answer the study questions were published within the papers, so no contact with authors was necessary. All the supporting data are included with Table  S1 .

Quality of the evidence

Quality ratings were assigned by two independent raters for each publication using GRADE (Guyatt et al ., 2008 ), which is endorsed by the World Health Organization. Within GRADE randomised trials are initially rated high, observational studies low; and other levels of evidence very low. However, high quality evidence is downgraded if methodological flaws exist, and low quality evidence is upgraded when high rigor and large effect sizes exist ( Guyatt et al . ). Ultimately, a high score indicates ‘further research is unlikely to change our confidence in the estimate of effect’; moderate scores indicate ‘further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate’; low scores indicate ‘further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate’; and very low scores indicate ‘any estimate of effect is very uncertain’ ( Guyatt et al . ).

Strength of recommendation

Unlike SR frameworks, the GRADE framework does not solely examine effect size to determine efficacy of intervention. Instead, effect size makes up just one component when weighing up the benefits and harms of each intervention. In line with the GRADE framework, the following factors were considered by both independent raters when evaluating the body of evidence for the intervention and arriving at a strength of recommendation for each diagnostic group: (i) methodological quality regarding likely benefits vs. likely risks; (ii) inconvenience; (iii) importance of the outcome that the intervention prevents; (iv) magnitude of intervention effect (effect size); (v) precision of estimate of effect; (vi) burdens; (vii) costs; and (viii) varying clinician and family values (Guyatt et al ., 2008 ).

The Evidence Alert Traffic Light System (Novak & McIntyre, 2010 ) was then applied based on the strength of recommendations by both independent raters. The Evidence Alert Traffic Light System is a GRADE‐complementary knowledge translation tool designed to assist clinicians and families to obtain easily readable, clinically useful answers within minutes (Campbell, Novak, McIntyre & Lord, 2013 ), because the alert uses a simple, three‐level colour coding that recommends a course of action. Green signifies ‘go’ because high quality evidence indicates effectiveness; red signifies ‘stop’ because high quality evidence indicates harm or ineffectiveness; and yellow signifies ‘measure’ because insufficient evidence exists to be certain about whether the child will benefit. Yellow can be assigned in three scenarios: (i) promising evidence (weak positive), (ii) unknown effectiveness because no research exists, or (iii) evidence suggests possibly no effect (weak negative).

Ethics and data

The study did not involve contact with humans, so the need for ethical approval was waived by the Cerebral Palsy Alliance's National Health and Medical Council Human Research Ethics Committee. This SR was not registered.

3138 citations were identified using the search strategy, of which 129 articles met the inclusion criteria for review. Of the 129 included articles, 58% ( n  = 75/129) were SRs; 42% ( n  = 54/129) were RCTs. Note, more than 54 RCTs exist in the paediatric occupational therapy evidence base, but we treated any RCT that was cited within an included SR as a duplicate. Flow of information is presented in the PRISMA diagram (Fig.  1 ).

PRISMA Flow Diagram

The results are now presented using PICO question format headings.

P opulation (Participants)

Included studies were across the following childhood disability diagnoses: arthrogyposis; attention deficit hyperactivity disorder (ADHD); autism spectrum disorder (ASD); behaviour disorders; brachial plexus injury; brain injury (BI); burns; cerebral palsy (CP); cancer; chronic pain; developmental coordination disorder (DCD); developmental disability (DD); Down syndrome; foetal alcohol spectrum disorder; learning disability (LD); mental health; intellectual disability (ID); obesity; preterm infants; physical disability; rheumatoid arthritis; and spina bifida. Some studies included samples from a variety of the aforementioned diagnoses. Consistent with childhood disability population incidence data, more research existed about ASD ( n  = 32/135; 24%), ADHD ( n  = 8/135; 6%), CP ( n  = 38/135; 28%) and DCD ( n  = 9/135; 7%), than other conditions.

Paediatric occupational therapy involves working with the child, the parent and the family unit: The child was the primary client for 87% ( n  = 45/52) of the interventions, i.e. therapy focussed on improving the child outcomes (e.g. an orthotic worn by the child to improve hand function), whereas the parent was the primary client for 13% ( n  = 7/52) for the interventions (e.g. parent education, aiming to improve knowledge, skills and confidence).

I nterventions

Included studies, researched the effectiveness of 52 occupational therapy intervention groups: (1) Acupuncture; (2) Assistive Devices; (3) Assistive Technology; (4) Behavioural Interventions including Applied Behavioural Analysis (ABA) and Positive Parenting Program (Triple P); (5) Bimanual Training; (6) Biofeedback; (7) Coaching; (8) Cognitive Interventions including CogFun, CogMed, (9) Cognitive Orientation to Occupational Performance (CO‐OP); (10) Conductive Education; (11) Constraint Induced Movement Therapy (CIMT); (12) CIMT &/or Bimanual; (13) Context Focused; (14) Ditto™ (hand held education & distraction device for burns patients); (15) Early Intervention, including a Developmental Approach, Neurodevelopmental Therapy (NDT) and Goals Activity and Motor Enrichment (GAME); (16) Electrical Stimulation (ES); (17) Family Centred Care; (18) Feeding Interventions; (19) Goal Directed Training, including Task Specific Training, Functional Training, Neuromotor Task Training (NTT) and Motor Imagery; (20) Handwriting Interventions; (21) Hippotherapy [Therapeutic Horse Riding]; (22) Home Programs; (23) Joint Attention; (24) Massage; (25) Meditation and/or Mindfulness; (26) Mental Health Interventions; (27) Neuro‐Developmental Therapy (NDT); (28) Occupational Therapy after BoNT; (29) Orthotics; (30) Pain Management; (31) Parent Counselling; (32) Parent Education/Parent Training; (33) Picture Exchange Communication System (PECS); (34) Play Therapy; (35) Positioning; (36) Pressure Care; (37) School Therapy; (38) Self‐Management; (39) Sensation Training; (40) Sensory Approach, including brushing, therapy balls, weighted vests, warm‐ups, sensory stimulation; (41) Sensory Integration, including sensory diets, swinging, brushing, therapy balls, weighted vests, body socks; (42) Skills Training via Mental Imagery; (43) Sleep Interventions; (44) Social Skills Training; (45) Stretching, including passive: self‐administered, therapist‐administered and device‐administered; (46) Treatment and Education of Autistic and Communication Handicapped Children (TEACCH); (47) Therapeutic Listening; (48) Treadmill Training; (49) Visual Motor Interventions; (50) Weight Loss; (51) Whole Body Vibration; and (52) Yoga.

Of the 12 included articles, authors measured the effectiveness of 52 occupational therapy interventions, across 22 diagnoses. From this, 136 intervention outcome indicators were identified, whereby an intervention, with an individual target outcome was administered to specific diagnostic groups. Insufficient data was available for analysis on one of these outcome indicators (number 74 in Table  S1 , where the SR authors found no publish data examining the effectiveness of hand orthotics in children with brain injury and therefore no recommendations could be made), (Jackman, Novak & Lannin, 2014 ) resulting in 135/136 intervention outcome indicators available for analysis.

Of the 135 intervention outcome indications: 30% ( n  = 40/135) were graded ‘do it’ (Green Go) (Arbesman, Bazyk & Nochajski, 2013 ; Bellows et al ., 2011 ; Bleyenheuft, Arnould, Brandao, Bleyenheuft & Gordon, 2015 ; Brown, Kimble, Rodger, Ware & Cuttle, 2014 ; Chang & Yu, 2014 ; Chen, Pope, Tyler & Warren, 2014c ; Chen et al ., 2014b ; Christmas, Sackley, Feltham & Cummins, 2018 ; Crompton et al ., 2007 ; Estes et al ., 2014 ; Fehlings et al ., 2010 ; Frolek Clark & Schlabach, 2013 ; Hechler et al ., 2014 ; Heinrichs, Kliem & Hahlweg, 2014 ; Hoare & Imms, 2004 ; Hoare, Imms, Carey & Wasiak, 2007 ; Hoare et al ., 2010 ; Hoy, Egan & Feder, 2011 ; Huang, Fetters, Hale & McBride, 2009 ; Inguaggiato, Sgandurra, Perazza, Guzzetta & Cioni, 2013 ; Kamps et al ., 2015 ; Kasari et al ., 2016 ; Kaya Kara et al ., 2015 ; Kurowski et al ., 2014 ; Lannin, Scheinberg & Clark, 2006 ; Lidman, Nachemson, Peny‐Dahlstrand & Himmelmann, 2015 ; Lin & Wuang, 2012 ; Madlinger‐Lewis et al ., 2014 ; Maeir et al ., 2014 ; Novak, 2014a ; Park, Maitra, Achon, Loyola & Rincón, 2014 ; Speth et al ., 2015 ; Spittle, Orton, Anderson, Boyd & Doyle, 2012 ; Spittle, Orton, Doyle & Boyd, 2007 ; Stavness, 2006 ; Stickles Goods, Ishijima, Chang & Kasari, 2013 ; Vroland‐Nordstrand, Eliasson, Jacobsson, Johansson & Krumlinde‐Sundholm, 2016 ; Zwaigenbaum et al ., 2015 ); 56% (75/135) were graded ‘probably do it’ (Yellow Measure) (Armstrong, 2012 ; Au et al ., 2014 ; Auld, Russo, Moseley & Johnston, 2014 ; Bialocerkowski, Kurlowicz, Vladusic & Grimmer, 2005 ; Bodison & Parham, 2018 ; Cameron et al ., 2017a , 2017b; Chacko et al ., 2014 ; Chantry & Dunford, 2010 ; Chen, Lee & Howard, 2014a ; Chiu, Ada & Lee, 2014 ; Cole, Harris, Eland & Mills, 1989 ; Copeland et al ., 2014 ; Dagenais et al ., 2009 ; De Vries, Beck, Stacey, Winslow & Meines, 2015 ; Duncan et al ., 2012 ; Fedewa, Davis & Ahn, 2015 ; Grynszpan, Weiss, Perez‐Diaz & Gal, 2014 ; Hahn‐Markowitz, Berger, Manor & Maeir, 2017 ; Hammond, Jones, Hill, Green & Male, 2014 ; Huang et al ., 2014 ; Jackman et al ., 2018 ; James, Ziviani, Ware & Boyd, 2015 ; Janeslätt, Kottorp & Granlund, 2014 ; Jones et al ., 2014 ; Krisanaprakornkit, Ngamjarus, Witoonchart & Piyavhatkul, 2010 ; Lannin, Novak & Cusick, 2007 ; Malow et al ., 2014 ; Maskell, Newcombe, Martin & Kimble, 2014 ; Mast et al ., 2014 ; Matute‐Llorente, González‐Agüero, Gómez‐Cabello, Vicente‐Rodríguez & Mallén, 2014 ; McLean et al ., 2017 ; Meany‐Walen, Bratton & Kottman, 2014 ; Miller‐Kuhaneck & Watling, 2018 ; Montero & Gómez‐Conesa, 2014 ; Morgan, Novak, Dale & Badawi, 2015 ; Morgan et al ., 2016a ; Morgan, Novak, Dale, Guzzetta & Badawi, 2016b ; Pfeiffer B & Arbesman, 2018 ; Polatajko & Cantin, 2010 ; Reeuwijk, van Schie, Becher & Kwakkel, 2006 ; Schaaf, Dumont, Arbesman & May‐Benson, 2018 ; Smith et al ., 2014 ; Snider, Majnemer & Darsaklis, 2010 ; Storebø et al ., 2011 ; Tatla et al ., 2013 ; Tatla, Sauve, Jarus, Virji‐Babul & Holsti, 2014 ; Vargas & Lucker, 2016 ; Westendorp et al ., 2014 ; Whalen & Case‐Smith, 2012 ; Xu, He, Mai, Yan & Chen, 2015 ; Zadnikar & Kastrin, 2011 ; Ziviani, Feeney, Rodger & Watter, 2010 ; Zwicker & Mayson, 2010 ); 10% ( n  = 14/130) were graded ‘probably don't do it’ (Yellow Measure) (Wallen & Gillies, 2006 ; Wells, Marquez & Wakely, 2018 ); and 4% ( n  = 6/135) were graded ‘don't do it’ (Red Stop) (Gringras et al ., 2014 ; Katalinic et al ., 2010 ).

The 40 green light ‘do it’ interventions indications included: (1) Behavioural Intervention using ABA for children with ASD; (2) Behavioural Intervention using Triple P for children behaviour disorders; (3) Behavioural Intervention using token economy contracts for children with a brain injury; (4) Bimanual Training for children with hemiplegic CP; (5) Coaching for parents of children at risk of disability to promote development; (6) Coaching for parents of children with ASD to promote function and behaviour; (7) CAPS cognitive intervention for children with brain injury to improve long term executive function; (8) Cog‐Fun intervention for children with attention deficit disorder to improve executive function; (9) CO‐OP for children with DCD for functional motor task performance; (10) CIMT for children with CP to improve hand function; (11) CIMT plus Bimanual for children with CP to improve hand function; (12) Context Focused intervention for children with CP for functional motor task performance; (13) Ditto hand held devices for children with burns to provide procedural distraction and self‐management education; (14) Early Intervention using ABA for children with ASD; (15) Early Intervention using Developmental Care for preterm infants; (16) Family Centred Care for children with brain injury or CP, to improve children's function; (17) Parent education feeding intervention for children with disability to improve feeding competency and growth; (18) Physiological feeding intervention for children with disability; (19) Goal Directed Training for children with CP, to improve functional task performance; (20) Goal Directed Training for children with DCD, to improve functional task performance; (21) Handwriting Task‐Specific Practice for children with DCD; (22) Home Programs for children with CP, to improve functional task performance; (23) Home Programs for children with ID, to improve functional task performance; (24) Joint Attention for children with ASD to improve social interactions; (25) Mental Health interventions for children with ASD; (26) Mental Health interventions for children with developmental delay; (27) Mental Health interventions for children with mental health disorders; (28) Occupational therapy after botulinum toxin injections for children with CP to promote hand function; (29) Kinesiotape for children with CP to improve hand function; (30) Pain Management for children with chronic pain secondary to physical disability and or chronic health conditions; (31) Parent Education using mindfulness for parents of children with ASD to reduce parental stress; (32) Parent Education using problem solving for parents of children with ASD to reduce parental stress; (33) Parent Education for children with disabilities to promote parenting confidence; (34) Parent Education for children with behaviour disorders to improve parent well‐being; (35) PECS for children with ASD to promote communication; (36) Positioning in NICU for preterm infants to promote normal movement development; (37) Pressure Care for children with CP using mattresses and cushions; (38) Social Skills Training mediated by peers for children with ASD; (39) Treadmill training for children with Down Syndrome to accelerate the onset of independent walking; (40) Weight loss using a family education and activity program called ‘Mighty Moves’ for children with obesity.

We assigned an ICF category to the primary and secondary intervention outcome of each intervention. Using the primary ICF level code, we mapped the profile of the paediatric OT evidence base to the ICF framework (Fig.  2 ). Green light effective interventions existed at the body structures and function ICF level ( n  = 14/74 indications (19%)), the activity level ( n  = 14/27 indications (52%)) and the environment level ( n  = 12/34 indications (35%)). When we compared the proportions of green light to yellow light to red light interventions by ICF levels, the activity level contained the largest number of green lights. At the activity level where there was 27 indications, green lights outweighed the number of yellow and red lights (Gree n  = 14/27; Yellow = 13/27; Red = 0/27), meaning the most common traffic code at the activity level was green, which we illustrated by green shading in Figure  2 . At the body structures and function ICF level, the most common traffic code was yellow, which we illustrated by yellow shading in Figure  2 . All the red lights within the evidence base existed at the body structures and function level. At the environmental level, the most common traffic code was also yellow, which we illustrated by yellow shading in Figure  2 . Two intervention's primary ICF code was at the participation level (Willis et al., 2010 ) and none at the personal level, indicating gaps in the occupational therapy evidence base, which we illustrated using grey shading in Figure  2 . The two participation codes were weak positive, but these were based on trials that used activity‐based interventions and assumed an upstream participation gain, which was not well‐supported.

Occupational Therapy Interventions and the International Classification of Function

C omparisons

In the included papers, consistent with conventional beliefs about it being unethical to withhold early intervention from children, rarely did researchers design studies where the control group received no intervention. In most studies, the controlled comparison was usual care. Some researchers carried out short duration studies using a wait‐list control design, where the control group received the experimental intervention after study completion.

CIMT for children with CP, was the only intervention comprehensively and empirically compared to other intervention options, using head‐to‐head RCT comparisons identified in our search strategy. CIMT was: (i) compared head‐to‐head with Bimanual Training showing no difference between the approaches (Sakzewski et al ., 2015 ; Tervahauta, Girolami & Øberg, 2017 ); and (ii) combined with Bimanual Training and/or Botulinum toxin A, showing no additive benefits occurred from a combined intervention approach (Hoare et al ., 2013 ). These researcher's concluded ‘intensity’ of practice was the key ingredient of these effective CP approaches ( Sakzewski et al . ; Tervahauta et al ., 2017 ).

A meta‐analysis of intervention options for children with DCD compared the relative effect of DCD motor interventions by calculating and comparing effect sizes (Smits‐Engelsman et al ., 2013 ). The authors calculated that ‘top‐down’ approaches (effect size = 0.89) were more effective than ‘bottom‐up’ approaches (effect size = 0.12).

To assist with comparative clinical decision‐making across the paediatric occupational therapy evidence base, we created bubble charts. We mapped the 52 identified paediatric occupational therapy interventions, across 22 diagnoses, spanning 135 intervention indications, which sought to provide analogous outcomes, by diagnosis, into separate bubbles. In the bubble charts, the size of the bubble indicated the volume of published evidence, which was calculated by counting the number of published studies on the topic. The location of the bubble on the y ‐axis of the graph corresponded to the GRADE system rating. The colour of the bubble denoted the Traffic Light Evidence Alert System rating (Fig.  3 ).

Bubble Charts Comparing the Effectiveness of Different Occupational Therapy Indications for Different Diagnoses

We set out to systematically summarise the current intervention options available to paediatric occupational therapists across different childhood disability populations. We found 40 interventions that received a ‘strong’ recommendation for use, indicating a high‐quality evidence base with more benefits than harms. These ‘green light’ interventions included: Behavioural Interventions (including ABA, Triple P and Token Economies); Bimanual; Coaching; Cognitive Cog‐Fun and CAPS; CO‐OP; CIMT; CIMT plus Bimanual; Context‐Focused; Ditto; Early Intervention (including ABA and Developmental Care); Family Centred Care; Feeding interventions (including coaching and physiologic); Goal Directed Training; Handwriting Task‐Specific Practice; Home Programs; Joint Attention; Mental Health Interventions; occupational therapy after BoNT; Kinesiotape; Pain Management; Parent Education; PECS; Positioning in NICU; Pressure Care; Social Skills Training Peer Mediated; Treadmill training and Weight loss ‘Mighty Moves’.

The paediatric occupational therapy evidence base is under immense growth and expansion. The SRs and trials greater than 10 years old were predominantly about CP with one study about Brachial Plexus and DD. Almost always these older studies showed that the ‘bottom‐up’ interventions were ineffective with no difference between the experimental and control groups.

Clinical Implications

Occupational therapists working with children and their parents have several evidence based interventions to choose from. The strength of this paper is that it provides a systematic, clear and concise summary of all the available interventions by diagnosis with an easy to interpret summary of efficacy. There are some important learnings:

A. Parent partnership within occupational therapist intervention is effective and worthwhile

Occupational Therapists embrace the principles of family centred care (Hanna & Rodger, 2002 ) where the parent is the decision‐maker and the expert in knowing their child and the therapist is a technical resource to the family. We found that 13% of paediatric occupational therapy interventions are directed at the parent, so parents can deliver intervention at home within daily parenting. Evidence suggests that parent‐delivered intervention is equally effective to therapist‐delivered intervention (Baker et al ., 2012 ), which is not surprising given parent's knowledge of their children's preferences and engagement style, and the volume of caregiving they carryout (Smith, Cheater & Bekker, 2015 ). In the diagnoses studied (ADHD, ASD, At risk, Behavioural Disorders, BI, CP, DD, LD, obesity), it was very clear that parents respond well to parent education and training (Antonini et al ., 2014 ; Barlow, Smailagic, Huband, Roloff & Bennett, 2012 ; Case‐Smith & Arbesman, 2008 ; Dykens, Fisher, Taylor, Lambert & Miodrag, 2014 ; Feinberg et al ., 2014 ; Hanna & Rodger, 2002 ; Howe & Wang, 2013 ; Kuhaneck, Madonna, Novak & Pearson, 2015 ; Lawler, Taylor & Shields, 2013 ; Tanner, Hand, O'toole & Lane, 2015 ; Zwi, Jones, Thorgaard, York & Dennis, 2011 ), consistent with family centred philosophy about parents’ aspirations of parenting well, to help their children (Hanna & Rodger, 2002 ). Moreover, parents and children carry out intervention effectively at home, and therefore home programs (Novak & Berry, 2014b ; Novak et al ., 2013 ; Sakzewski, Ziviani & Boyd, 2013 ; Sakzewski et al ., 2015 ; Wuang, Ho & Su, 2013 ) and self‐management programs (Lindsay, Kingsnorth, Mcdougall & Keating, 2014 ; Moola, Faulkner, White & Kirsh, 2014 ) are an effective method for increasing the intensity of therapy.

When carrying out parent education, literature tells us that parents need and want: knowledge of the condition and intervention options; help accessing support services; and advice about coping strategies, via a collaborative partnership (Smith et al ., 2015 ). Even though family centred practice has existed since the 1990s, parents still experience some resistance to their input from health professionals ( Smith et al . ). Unclear expectations about roles further elevate parental stress (Coyne, 2015 ). Occupational therapists therefore need to be mindful of parent's experiences and aim to clearly communicate information and coach parents to guide care, to optimise family outcomes ( Coyne ).

B. Activities‐based, ‘top‐down’ interventions deliver bigger gains

Numerous occupational therapy interventions exist, aiming to improve motor, behavioural and functional outcomes (Fig.  3 ), affording a lot of choice to families and clinicians. The greatest number of effective green light interventions was at the activity level of the ICF, indicating that daily life skills training using a ‘top‐down’ approach is a strength of the occupational therapy profession. Examples include: Bimanual Training; CIMT; CO‐OP; GAME; Goal‐Directed Training; Handwriting Task Training; Home Programs using Goal‐Directed Training; Social Skills Training; and Task Training. Consistent with current knowledge about the conditions for inducing neuroplasticity (Kleim & Jones, 2008 ), the green light, ‘top‐down’, activity level interventions all have the following key ingredients in common: (i) begin with the child's goal, to optimise motivation and saliency of practice; (ii) practice of real‐life activities in natural environments to optimise the child's learning and the variability of the practice; (iii) intense repetitions to activate plasticity, including home‐based practice; and (iv) scaffolded practice to the ‘just right challenge’ to enable success under self‐generated problem‐solving conditions, to optimise enjoyment.

In contrast, some of the most established paediatric occupational therapy interventions NDT/Bobath and SI were originally developed as ‘bottom‐up’ interventions. NDT/Bobath and SI originated in an era of medicine when intervention aimed to remediate the child's body structural deficits, thinking function would emerge (Rodger et al ., 2005 ; Rodger et al ., 2006). However, over time the NDT/Bobath and SI approaches have been broadened to also accommodate use of ‘top‐down’ functional training approaches. Fidelity to the original NDT/Bobath and SI approach therefore varies greatly (Mayston, 2016 ), and as such, a leading Bobath expert has recently stated that Bobath ‘no longer stands for a valid universal therapy approach’ (Mayston, 2016 , p. 994). This means that interpreting the meaning of historical NDT/Bobath and SI research evidence about efficacy within the context of contemporaneous clinical practice is challenging. The efficacy of both NDT/Bobath and SI have been critiqued within SRs (Boyd & Hays, 2001 ; Brown & Burns, 2001 ; Case‐Smith & Arbesman, 2008 ; Case‐Smith, Clark & Schlabach, 2013 ; Case‐Smith, Weaver & Fristad, 2015 ; Lang et al ., 2012 ; May‐Benson & Koomar, 2010 ; Novak et al ., 2013 ; Sakzewski, Ziviani & Boyd, 2009 ; Sakzewski et al ., 2013 ; Steultjens et al ., 2004 ; Watling & Hauer, 2015 ; Weaver, 2015 ) and these data mostly relate to older trials. SR authors have concluded that NDT/Bobath and SI rarely confer motor gains superior to no intervention, but the RCTs contain so many methodological flaws that recommendations for use or discontinuation of use within practice cannot be made with certainty (Boyd & Hays, 2001 ; Brown & Burns, 2001 ; Case‐Smith & Arbesman, 2008 ; Case‐Smith et al ., 2013 ; Case‐Smith et al ., 2014; Lang et al ., 2012 ; May‐Benson & Koomar, 2010 ; Novak et al ., 2013 ; Sakzewski et al ., 2009 , 2013 ; Steultjens et al ., 2004 ; Watling & Hauer, 2015 ; Weaver, 2015 ). Some therapists have interpreted the uncertainty of the NDT/Bobath and SI systematic evidence as justification of continuance, whereas others in the profession recommend discontinuance because of the growing body of ‘top‐down’ evidence that offer effective alternatives (Rodger et al ., 2006). A Bobath expert has recommended that the common‐sense way forward for the profession is to choose interventions that promote activity and participation outcomes (Mayston, 2016 ) and to use consistent language to describe intervention options. For example, describing interventions by clear uniform terminology (i.e. ‘splitting’) might be more helpful than ‘clumping’ interventions into expanded NDT/Bobath umbrella terms.

We analysed the breakdown of the effectiveness of motor interventions, above and below the worth it line (Fig.  3 ), in terms of ‘bottom‐up’ vs. ‘top‐down’, and a trend favouring ‘top‐down’ emerged. Of the seven motor intervention indications below the ‘worth it line’, coded on GRADE as weak negative or strong negative (red), 7/7 (100%) were ‘bottom‐up’ approaches. Of the 22 motor intervention indications above the ‘worth it line’ eight were green and 14 were yellow: 8/8 (100%) green indications (strong positive) were ‘top‐down’. A similar trend emerged in the comparative effectiveness analysis of functional interventions. Of the seven functional intervention indications above the ‘worth it line’, coded on GRADE as strong positive (green), 4/4 (100%) were ‘top‐down’. There were a small number of studies using SI and the sensory approach to improve function coded on GRADE as weak positive, but the studies had a high risk of bias and SR authors recommended interpreting the positive results with caution (Case‐Smith et al ., 2014; Case‐Smith et al ., 2015 ; Watling & Hauer, 2015 ).

Research Implications

The following areas of the evidence‐base would benefit from more research: (i) Parent Education : None of the parent education approaches were ineffective. Thus, more research is worthwhile exploring parent's preferred learning styles and levels of support required to manage the stress of raising a child with a disability. There are potential financial gains to the health system by thoroughly understanding effective parent interventions, because parent‐delivered intervention is equally effective and less expensive; (ii) Head‐to‐head comparisons : Head‐to‐head comparisons of different interventions aiming to achieve the same outcomes, in well‐controlled trials with cost‐effectiveness data, would enable determinations about best practice to be made from good evidence, and thus inform parent and policy‐maker's decision‐making; (iii) ‘Dose’ comparison studies : ‘Dose’ comparison studies using well controlled intensity trials would enable occupational therapists to better inform parents about ‘how much’ intervention is enough; and (iv) Participation Interventions : There is a clear gap in the evidence‐base about interventions that directly improve a child's participation in life and should be the focus of future RCTs and other rigorous methodologies. CIMT, Bimanual and Home Program occupational therapy interventions were measured to confirm whether or not they conferred participation gains, and the clinical trials demonstrated no between group differences (Adair, Ullenhag, Keen, Granlund & Imms, 2015 ). These results indicate that there is a clear need to develop interventions that specifically target participation, rather than anticipating activities‐based interventions will confer upstream participation gains. Changes in participation are multifactorial and involve individual factors, contextual factors, the nature of the participation activity and the environment in which the activity is being performed (Imms et al ., 2017 ). Any new participation intervention invented, will need to address all of these factors to be successful.

Limitations

Our review has several limitations. First, we only included SRs and RCTs because we aimed to analyse best‐available evidence, but means some intervention approaches will have been excluded and overlooked because no trials or reviews existed. Second, this was an analysis of secondary data sources and reporting bias and publication bias may be in operation, because positive findings have a higher chance of being published. This evidence may exist suggesting some interventions are ineffective which we were unable to review. Third, our search terms included ‘occupational therapy’ and thus will have excluded other effective interventions used by occupational therapists, but not invented or published by occupational therapists e.g. ‘Triple P’ for children with CP. Fourth, our paper was designed to provide an overview for clinicians indicating which interventions are effective, however, it does not provide enough detail about any one intervention to guide administration or training in any specific intervention. Clinicians need to refer directly to the cited article and more widely in the published literature for this information. Our findings must be interpreted within the context of our study limitations.

Conclusions

This review provides a high‐level summary of effective paediatric occupational therapy interventions. Thirty‐nine effective intervention indications exist, offering both families and clinicians many choices to match their preferences and expertise. The paediatric occupational therapy evidence base suggests a growing trend towards activities‐level, ‘top‐down’ approaches and parent education, over and above ‘bottom‐up’ approaches. There are important ethical implications of translating these effective evidence‐based occupational therapy intervention options into clinical practice to give children the best chance at achieving their goals.

Key points for occupational therapy

• Collaboration with parents is effective and worthwhile.
• Activities‐based, top‐down interventions confer larger clinical gains, than bottom‐up approaches, when aiming to improve a child's function.

All authors declare that this is original work and that they meet the criteria for authorship. Iona Novak designed the study, extracted the data, conducted the analyses and wrote the manuscript. Ingrid Honan conducted the analyses and wrote the manuscript. All authors read and approved the final manuscript.

The study was unfunded and there are no competing financial disclosures.

Conflict of interest

The authors have no conflicts of interest to disclose.

Supporting information

Table S1. Main results table.

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Occupational Therapy Pediatric Case Study Examples

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• 1 Sensory integration activities
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• 4 Social skills building exercises
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• Published: 16 January 2024

Effects of school-based occupational therapy program for children with disabilities in elementary school in Korea: a case study

• Eun-Hwa Jeong 1  

BMC Psychology volume  12 , Article number:  26 ( 2024 ) Cite this article

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Metrics details

The purpose of this case study was to explore the effects of a school-based occupational therapy on children’s attention, school adaptation, sensory processing, and motor function for children in special classes in elementary school in Korea.

Case presentation

The subjects of this study were a 7-year-old boy with autism spectrum disorder and a 9-year-old girl with intellectual disability. The school-based occupational therapy program consisted of 10 sessions and was conducted once a week for an hour and a half. The program consisted of classroom activities, use of school facilities, emotional management, and activities based on sensory integration, and was conducted as individual and group programs according to sessions. As a result of the study, all improved when the pre- and post-scores of the two children’s attention assessment, school adjustment scale, sensory processing evaluation tool for the children in school and BOT-2-SF were compared.

Conclusions

Although the results from two cases cannot be generalized, the findings suggest the school-based occupational therapy program may help a positive effect on the school life of children with disabilities. Further investigation is necessary.

Peer Review reports

Introduction

It is difficult for children with disabilities to properly perform learning activities, school rules, and social interactions due to physical difficulties, difficulty in controlling emotions, impulsivity, and poor attention in school life [ 1 ]. Also, when accompanied by sensory processing disorder, difficulty in following instructions, learning, and controlling behavior can cause school adaptation problems [ 2 ].

Occupational therapists prepare students for and participate in important learning and developmental activities within the school environment through school-based occupational therapy [ 3 ]. Occupational therapists can help children with disabilities prepare for learning and carry out other related activities in schools. It provides academic and non-academic interventions, including social skills, academic and behavior management, and athletic participation [ 4 ].

It has been reported that 90% of occupational therapists in school-based occupational therapy practices perform sensory integration interventions based on ‘Ayres’ theory [ 4 ]. Sensory integration is a way to help children improve their adaptive ability to interact with their environment. Therefore, the fundamental purpose is to prevent non-adaptive behaviors or difficulties and improve the quality of life and performance by appropriately interacting with the environment and the body [ 2 , 3 , 4 ]. However, when applying these sensory integration interventions to school-based occupational therapy, it is necessary to appropriately apply other intervention for improving school adaptation according to needs. And it is more reasonable to establish an intervention plan based on this after identifying students’ performance skills and non-adaptive behaviors [ 4 , 5 ].

School occupational therapists in Korea mainly provide intervention based on the medical model, focusing on improving children’s occupational performance problems by improving deficits in subcomponents such as cognitive, motor, and sensory. In previous studies, it was found that writing for learning skills, fine motor and visual motor integration were most often implemented as interventions of school-based occupational therapy [ 6 ]. However, most children with school adjustment problems need interventions for overall school performance, such as following rules and instructions, paying attention, and interacting with peers, rather than academic skills [ 7 ]. In other words, school-based occupational therapy requires occupational therapists to deal with non-adaptive behaviors that hinder children’s adaptation to school in the natural environment of the classroom. It can potentially lead to a positive impact on academic performance [ 4 , 5 , 6 ]. In developed countries where school based occupational therapy was implemented before Korea, school occupational therapists emphasize that therapy services should be provided in natural environments such as classrooms, playgrounds, cafeterias, and hallways in order to achieve academic and functional goals [ 8 ].

The role of occupational therapists in schools and educational systems is to facilitate students’ ability to perform tasks or perform meaningful and purposeful activities as students. Therefore, it is necessary for occupational therapists to cooperate with teachers to evaluate students’ functional performance problems in the classroom and to provide necessary interventions to students by discussing effective programs. In this respect, this case study was to confirm the effectiveness of a school-based occupational therapy program that applied a client-centered approach. Therefore, the purpose of this study was to explore the effects of a school-based occupational therapy intervention focusing on school adaptation on children’s the attention, school adaptation, sensory processing, and motor function for children in special classes in elementary school in Korea.

Participants

The subjects of this study were two children from a special class at Elementary School in Korea. Subject A was a 7-year-old male with autism, and subject B was a 9-year-old female with intellectual disability accompanied by autistic features. Subject A did not have social interaction including eye contact, frequently stared into space, and had a very short attention span. There were problems in that they often left their seats during class, showed stereotyped behaviors such as going around the classroom in a circle, and frequently made meaningless sounds such as shouting during class. In addition, he was unable to hold a pencil for writing and was unable to use a spoon for eating, so he had to eat with assistance. Subject B often expresses crying and anger when she is not allowed to do what he wants, and often leaves her seat during activities. These characteristics caused problems in peer relationships due to difficulties in controlling and expressing emotions during school life. In addition, problems with social interaction often occurred due to difficulties in conversations appropriate to the situation.

This study was designed to conduct pre- and post-tests on attention, motor function, school adaptation, and sensory processing function of each subject to confirm the effectiveness of the school-based occupational therapy program. This study used convenience sampling. Therefore, the criteria for selecting subjects were students from special classes at the elementary school where the experiment was conducted, who were able to participate in the study. Subjects in this study did not take any additional treatment or psychopharmacological medications.

The intervention program was implemented for 10 sessions from March to June 2022. During the intervention period, the intervention was conducted every Friday from 2:00 to 3:30 p.m.

The program was planned and executed by an intervention team composed of occupational therapists. The intervention goal for each subject was set by the elementary school special class teacher and the intervention team. The evaluation of attention, school adaptation, and sensory processing function was conducted by special class teachers. And The evaluation of motor function was conducted by the intervention team.

Pre- and post-assessments were conducted in sessions 1 and 10, respectively, and were included in the intervention session. Additionally, the evaluator and intervention provider were the same.

Intervention

The school-based occupational therapy program of this study was constructed based on the framework of sensory integration theory and the school-based occupational therapy model. There were two students in the group, three occupational therapists and one special education teacher running the sessions. The teacher only participated in goal setting, and direct intervention was conducted by occupational therapists. According to the purpose of each session, an individual program suitable for the intervention goal and a group program in which two children participated were conducted. The goal of this school-based occupational therapy program was to improve school adjustment, including learning activities, school rules, and interactions, by mediating each child’s problems. The intervention goal of subject A was to improve attention, and provide an experience of school assignments during activities for school adaptation. The intervention goal of subject B was to improve school adaptation and self-expression skills through school assignment experiences (Table  1 ).

Assessments

Attention assessment.

In this study, sub-items of the Korea-Child Behavior Checklist (K-CBCL) were used to evaluate the subject’s attention. K-CBCL is a standardized child and adolescent behavior assessment tool that translated the Child Behavior Checklist developed by Achenbach and Edelbrock (1983) into Korean [ 9 , 10 , 11 ]. The Cronbach alpha value of K-CBCL was 0.62-0.86. It is evaluated for children between the ages of 4 and 17, and is divided into a social ability scale and a problem behavior syndrome scale. The social ability scale consists of 13 items of 3 categories (sociality, academic performance, and total social ability). The problem behavior syndrome scale consists of 117 questions in 13 categories (deterioration, physical symptoms, anxiety/depression, social immaturity, thinking problems, attention problems, delinquency, aggression, internalization problems, externalization problems, total problem behavior, sexual problems, and emotional instability). Each item is on a 3-point scale (0 points; never, 1 point; occasionally or infrequently, 2 points; frequent or severe), with a score ranging from 0 to 234 points. Scoring and interpretation of results can be done by creating a profile to ensure that it falls within the clinical range [ 10 , 11 ]. In this study, 11 items of attention problem among the subscales of the Problem Behavior Syndrome scale were evaluated to evaluate children’s attention. It is interpreted that the higher the score, the lower the attention.

School adjustment scale

The school life adjustment scale consists of 4 areas: class attitude, friendship, positive personal behavior, and school rules, with a total of 20 questions [ 12 ]. The scale was a 4-point Likert scale of not at all (1 point), a little not (2 points), a little bit yes (3 points), and very yes (4 points). In this study, a total of 10 questions were evaluated by reorganizing them into questions suitable for school life adjustment of children in special classes. It is interpreted that the higher the score, the higher the adaptation to school life.

Sensory processing assessment tool for schools

A sensory processing assessment tool for schools was developed to evaluate behaviors related to sensory processing difficulties in school life of school-age children [ 13 ]. The evaluation items consisted of 42 items in the general learning activity area, and the detailed areas consisted of tactile processing, movement processing, visual processing, auditory processing, olfactory processing, and multisensory processing. In addition, the arts and sports activity area consist of 15 questions, and the meal time and break time activity area consists of 21 questions, totaling 78 questions [ 13 ]. The scale consists of three-point scales of 1 (not so), 2 (normal), and 3 (very so). The score can be calculated by summing the total score for each area and the total score. A higher score indicates difficulty in sensory processing.

Bruininks-Oseretsky test of motor proficiency-2-SF

The Bruininks-Oseretsky Test of Motor Proficiency-2-SF (BOT-2-SF) was used to measure children’s motor skills. In its short form, the assessment includes 14 items from eight subtests, reflecting different motor domains: (a) fine motor precision(drawing lines through crooked paths, folding papers), (b) fine motor integration(copying a square, copying a star), (c) manual dexterity(transferring pennies), (d) bilateral coordination(jumping in place—same sides synchronized, tapping feet and fingers—same sides synchronized), (e) balance(walking forward on a line, standing on one leg on a balance beam), (f) speed and agility(stationary hops), (g) upper-limb coordination(dropping and catching a ball with both hands, dribbling a ball with alternating hands), (h) strength(knee push‐ups, sit ups) [ 14 ]. The raw score of each item was converted according to the inspection manual, and the total score was obtained by adding the scores of these items.

According to the characteristics of this study, the pre- and post-change values ​​of each subject were presented in a table and graphed. Attention assessment and school life adjustment scale were compared to check changes in variables related to each subject’s list of problems by comparing changes in all items. The analysis of the sensory processing evaluation for school aimed to identify the intervention effect on detailed factors by confirming the change in each area and the total score. BOT-2-SF compared the change in conversion score and total score for each item of the subject.

The changes in the pre- and post-scores of each subject’s attentions, school adaptation, sensory processing, and motor function are shown in the Table  2 . There was a positive change in scores for attention, school adaptation, and sensory processing of all subjects. Subject A was not performed in the BOT-2-SF because He had difficulty following instructions due to his symptoms. Subject B had a positive score change in the BOT-2-SF.

The change in scores for all items of each subject’s attention assessment is shown in Fig.  1 . Subject A had positive score changes in the items of hyperactivity, maladaptive daydreaming, impulsiveness, tension, and anxious gestures. Subject B had positive score changes in hyperactivity, stupor, maladaptive daydreaming, and poor motor function.

Results of attention assessment

A1: acting younger than one’s age, A2: attention problems, A3: hypercactivity, A4: stupor, A5: maladaptive daydreaming, A6: impulsiveness, A7: tension, A8: anxious gestures, A9: poor schoolwork, A10: poor motor function, A11: stare blankly into space

Gray means no change in pre-post scores

The change in scores for all items of each subject’s school life adjustment scale is shown in Fig.  2 . Subject A had positive score changes in the following items: ‘The student has relationships with several friends.’, ‘The student has appropriated physical contact with peers.’, ‘The student uses school facilities carefully.’, ‘The student is orderly when using the bathroom.’, ‘The student greets the teacher well.’ Subject B had positive score changes in the following items: ‘The student has relationships with several friends.’, ‘The student induces the other person’s interest in an appropriate way.’, ‘The student is good at controlling his mood.’, ‘The student uses school facilities carefully.’, ‘The student greets the teacher well.’

Results of school adjustment scale

SA1: The student listens attentively to the teacher’s assignment instructions or explanations. SA2: The student has relationships with several friends. SA3: The student has appropriated physical contact with peers. SA4: The student responds appropriately to praise, blame, and punishment. SA5: The student induces the other person’s interest in an appropriate way. SA6: The student is good at controlling his mood. SA7: The student keeps their school hours and class hours well. SA8: The student uses school facilities carefully. SA9: The student is orderly when using the bathroom. SA10: The student greets the teacher well. Gray means no change in pre-post scores

The results of each subject’s sensory assessment tool for schools are shown in Table  3 . According to the total score, there was a positive score change for sensory processing in both subjects. Negative score changes appeared in the arts and sports activity area of ​​subject A, but positive changes in the pre- and post-scores of the two subjects were found in all other evaluation items.

Discussion and conclusion

This study explored the effects on children’s attention, school adaptation, sensory processing, and motor function through a school-based occupational therapy program consisting of classroom activities, use of school facilities, emotional management, and activities based on sensory integration. The concept of school adjustment is understood as a complex concept consisting of several sub-variables. In summarizing various studies, learning activities, school rules, peer relationships, and teacher relationships are classified as sub-variables [ 15 , 16 , 17 ]. In this study, a school-based occupational therapy program aimed at school adaptation was constructed, and the occupational therapy team and the special class teacher cooperated to identify each child’s problems. And it was composed of individual and group programs according to the session.

As a result of this study, both children showed positive change in attention. Both children showed improvement in hyperactivity and maladaptive daydreaming items. This is influenced by handicrafts and physical activities aimed at improving attention, based on previous studies that sensory integration-based activities can cause self-regulation and attention improvement [ 18 , 19 , 20 ]. Subject A showed a decrease in scores in the items of impulsivity, tension, and anxious gestures. ASD children like subject A are known to show high correlations with lack of sociability, negative emotions, and anxiety [ 20 ]. These factors manifest in the form of self-injurious behavior, aggression, and lack of self-control that negatively affect school life. Therefore, the results of this study can be supported based on previous studies that the process of regulating and processing senses in children with autism can affect the regulation of behavior and emotions [ 20 , 21 ] In addition, it is thought that not only sensory integration-based programs but also programs implemented for school assignment experience and adaptation to school facilities improved adaptability to activities and places. Subject B showed a positive score change in motor dullness in the attention assessment. Also, subject B showed improvement in the BOT-SF score. These results are considered to have been helpful through the group session applied physical activity, gross motor activity, and sensory integration-based physical activity.

Both children showed positive results on the school adjustment scale. After the intervention, both subjects had relationships with various friends, showed a tendency to use school facilities carefully, and greeted teachers better. In particular, subject A came to have proper physical contact with friends and was found to keep order better when using the bathroom. On the other hand, subject B showed improved emotional regulation. It may be due to the method in which this program identified problems of each subject through a client-centered approach and operated in individual and group sessions. These results are considered to have been induced by the effect of intervention programs aimed at adaptive behaviors for school life, such as school rules, social skills, and use of school facilities, rather than specific academic skills.

The total score of the two children’s sensory processing assessment tool for schools showed a positive change, but there were some differences in the scores of the detailed items. Subject A had relatively improved eye contact during classroom interaction, attention to visual stimuli, and recognition of visual stimuli. In addition, performance improved when lifting and moving the food tray, food or drink did not spill easily while eating, and hyperactivity decreased during breaks. Therefore, it was confirmed that the adaptation behavior in school life was improved. These results can be inferred that various sensory stimuli through fine and gross motor activities influenced visual processing and attention [ 22 ]. In addition, it is thought that the meal utensil training and school facility use program influenced the improvement of subject A’s adaptive behavior during meal and break time activities. Subject B showed some improvement in the movement processing score due to reduction in hyperactivity during class activities, improvement in postural control, improvement in both-handed task performance, and improvement in pencil grip. In addition, it showed improvement in visual processing scores by improve attention on visual stimuli and improved spatial arrangement organization during writing. And there was improvement in music and physical activity. These results are supported by previous studies that in the process of receiving and processing various sensory stimuli, motor function, self-regulation ability, and concentration are improved, which affects the performance of activities, cognitive function, and communication function [ 18 , 19 , 20 , 21 , 22 ].

Children with disabilities in special classes have different characteristics for each disease, and there are differences in school adaptation according to age, school type, and severity. Therefore, it can be considered to operate a school-based occupational therapy program by grouping and operating according to the child’s characteristics, age, or intervention goal, or dividing individual and group sessions as in this study. However, in Korea, occupational therapists often provide treatment support services in treatment rooms based on existing medical models rather than supporting students’ school life in a cooperative team with teachers in a school environment. In order for children to adapt to school, it is necessary for teachers to focus on the child’s educational aspects and for occupational therapists to cooperate based on the goal of improving children’s occupational skills [ 23 ]. In this regard, active efforts are needed for school occupational therapy through the development of educational programs and establishment of systems to enable interdisciplinary cooperation.

This study conducted a single group program as a case study, and it is very limited to generalize. Additionally, the effects of exogenous variables such as children’s maturation and development cannot be ruled out regarding the results of this study. Therefore, there is a need to expand randomized controlled trials using the school-based occupational therapy intervention program applied in this study. It could be a school-based occupational therapy program targeting all children in special classes or a group of children with a diagnosis different from the subjects of this study. There is also a need to standardize the procedures of school-based occupational therapy programs by organizing the process of evaluation-intervention-outcome and developing a protocol in which this process is progressively repeated.

Occupational therapists working at school need to cooperate with teachers to evaluate students’ functional performance problems in school and provide necessary interventions for students’ school adjustment. At this time, it can be effective that combined intervention of individual and group programs under the intervention goal of school adjustment. In addition, activities based on sensory integration can be helpful to improve non-adaptive behaviors such as hyperactivity, impulsivity, and reduced attention in children with disabilities. It is hoped that this study will emphasize the need for occupational therapy services in the educational field, thereby building a system for collaboration with teachers and demonstrating the expertise of occupational therapists in the school life of children with disabilities.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Acknowledgements

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This work was supported by the 2022 Far East University Research Grant (FEU2022S05).

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• School adaptation
• School-based occupational therapy
• Sensory processing
• Sensory integration

What is Pediatric Occupational Therapy? Scenarios of OT for Kids

by Niagara Therapy, LLC | September 12, 2022

What is Pediatric Occupational Therapy? Pediatric OT Scenarios 

Occupational therapy is a form of physical and mental rehabilitation that focuses on performing activities required in daily life. In the case of pediatric occupational therapy, this generally focuses on getting children to engage in play, school, and peer interactions. Pediatric occupational therapy helps children develop skills including vision, perception, coordination, strength, sensory processing, writing, emotional management, and social interaction. 

The overall goal of occupational therapy is to improve a child’s ability to effectively interact with and learn from the environment in order to develop skills necessary for daily function.  Often this simply looks like play to a bystander, but play is the way children learn! An occupational therapist can use many fun materials or even games to encourage development of new skills in a fun and creative way.  

What Specific Areas Can OT Address? 

Occupational therapy can help children with many different aspects of life. For example, it can help children with using appropriate social skills and regulating emotions. Being able to dress oneself and having the appropriate self care fine motor skills to use utensils, pencils, button a button or zip up a zipper, are all areas of focus in occupational therapy.  Many children have difficulty with knowing left from right, which can affect the ability to orient clothing for dressing, scan to read a book or know how to tie shoes. Occupational therapy can address this left/right awareness or “laterality” in daily activities.   

Sensory integration is another area that occupational therapy can address.  Improved sensory integration is often achieved by expanding the variety of textures and tastes in a child’s diet and improving tolerance to various clothing textures. An OT could help develop a sensory “diet” with the goal to improve attention or transitions between tasks that are necessary in the school setting. 

Many times kids will present with difficulty with visual perception and ocular motor skills .  OT can provide exercises and activities to improve these skills which can affect school and homework activities as well as participation in many sporting activities.  OT can also address gross motor skills, motor planning and executive function.  

There are times children exhibit symptoms of retained primitive reflexes in their function. Primitive reflexes are involuntary motions that often help to protect infants. Typically these are integrated into more mature and voluntary responses; however, if not integrated, these reflexive patterns can create functional concerns. Retained reflexes can look like difficulty paying attention, anxiety, impaired fine or gross motor coordination, difficulty with balance or reading, difficulty with left-right awareness or a multitude of other concerns.  Occupational therapy can provide guidance to integrate primitive reflexes.  With this developmental foundation, children can improve the skills needed to make daily function more efficient.  

There are times that the most effective way for a child to complete a task is to utilize adaptive equipment.  Some examples of adaptive equipment are adapted eating utensils or pencil grips, slant boards, wheelchairs or crutches, and splints.  An OT will also often recommend sensory equipment for the home or school setting as well.  

Does My Child Need Occupational Therapy? 

Occupational therapy can be helpful for a wide variety of challenges that children face, and can help children improve skills related to school, play, and daily life in general. Occupational may be helpful for your child if they are dealing with any of the following:

• Sensory integration difficulties or limited emotional management
• Limited diet and food sensitivity
• Weak and uncoordinated movements
• Poor handwriting
• Difficulty focusing in school
• Difficulty reading
• Difficulty tying shoes, buttoning, and dressing
• Spasms/Muscle Cramps/Spasticity
• Needing specialty equipment (writing, eating, sensory tools, etc.)

Feel free to get in touch with us to learn more about how our team of expert occupational therapists can help your child reach their maximum potential. 

Common Scenarios and Case Studies of Pediatric Occupational Therapy 

Niagara Therapy’s team of occupational therapists has helped many children over the years. We’ve outlined some common scenarios to help give you a better understanding of what occupational therapy looks like in the real world. 

JH is a 6 year old girl who has a difficult time playing on the playground.  Her teacher noticed that she falls frequently and seems clumsy.  She loves the social aspect of tee ball, but has a hard time connecting the bat to the ball.  

She was referred to occupational therapy, and we noted that she had difficulty with visual perception, using both hands together, and had a hard time crossing midline in activity. Each of these areas is vital when trying to swing a bat or catch a ball. She also had some retained primitive reflexes that have affected development of these skills.  

We determined that occupational therapy intervention would be helpful for JH. Treatment would focus on improving visual perception, bimanual use, midline crossing, and primitive reflex integration.  

Scenario 2 

PR is really struggling with handwriting and copying his assignments from the board at school. His OT found that he has hand weakness and poor fine motor skills as well as limited core strength affecting sitting posture and balance.  He also demonstrates difficulty with visual perception and ocular motor skills which contribute to the challenge of handwriting.  

We determined that occupational therapy services would help to improve core strength, fine motor skills, and address visual concerns. By regularly completing tasks or exercises as recommended by an OT, PR should gain skills to improve his abilities in these areas, and his parents and teachers should see improvements in school work.  

HC is an 8 year old who cannot tie his shoes or button a shirt. He also requires some assistance to put on his clothing and has trouble crossing midline in activity. In OT, he demonstrates impaired hand strength and fine motor skills as well as some retained primitive reflexes.  

We determined that occupational therapy can help him learn left/right and spatial awareness to

improve his ability to orient clothing.  He is also given exercises and activities to do at home to improve strength and fine motor skills that would allow him to more easily tie a shoe or button a button. Reflex integration can also develop underlying skills to help to make these tasks easier.

YG sustained a concussion, has been experiencing headaches, and has difficulty organizing schoolwork or cleaning her room.  When evaluated in OT she was found to have ocular motor and visual perceptual impairments that are contributing to headaches and difficulty with reading.  

We determined that occupational therapy can help to improve visual deficits and address executive function.  

Scenario 5 

KL is unable to tolerate wearing various textures of clothing and is a very picky eater.  This has made getting ready for school and mealtimes very frustrating for everyone in the house.

Our occupational therapist had KL’s caregiver complete a sensory profile to evaluate the various areas of sensory processing in order to determine how those sensory abilities affect daily function. The OT also observed and interacted with the child to determine how to plan the best intervention for KL. We evaluated sensory preferences and assisted in exploring strategies to make these areas less stressful for both the child and parent.   

What Do All of These Children Have in Common? 

Each of these children has some observable functional difficulties with underlying causes that can be addressed in occupational therapy! As you can see, OT addresses a variety of areas. Undeveloped or underdeveloped skills can make everyday tasks challenging.  Determining and addressing these areas is crucial for improved function. An occupational therapist will look at the big picture to help determine what skills may need improved to ultimately affect function.  

Pediatric Occupational Therapy with Niagara Therapy 

Your kids are important to us at Niagara Therapy, and we love to get to know them and their interests in order to help them enjoy every moment and be as independent as possible every day.  We utilize tools and techniques that are not available anywhere else in the region. Interactive Metronome and Brain beats are computerized programs that can help improve coordination and attention as well as auditory processing.  The Neuro Sensoriomotor Integrator or NSI is a fun & interactive technological tool we can use to improve letter and number recognition as well as ocular motor and visual perceptual skills.  Our therapists use various programs to improve body awareness, visual perception, handwriting, emotional regulation and explore new foods.  

We offer speech, physical and occupational therapies at Niagara Therapy and use a team approach driven by your goals.  We offer sessions between 7 AM and 7 PM and focus on only one client at each session.  If your child is experiencing difficulties with independent function or meeting developmental milestones, call us at 814-464-0627.  

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Case Study: Paediatric Moving & Handling

by Tess Whitehead

Jack is 5 years old and lives at home with both parents and his twin brother. Jack suffered hypoxia at birth resulting complex physical and cognitive disabilities which impact on every aspect of his life. Jack is developmentally delayed, wheelchair dependent and reliant on his family for all personal care, transfers, to keep him comfortable, safe and provide him with opportunities for fun and learning.

The family were previously living in a 3 bed semi-detached property that presented many challenges in terms of wheelchair access, carrying him up and down the stairs and lifting him on and off the floor, bed and bath. His mother in particular was experiencing back and shoulder pain due the amount of repetitive lifting. Statutory Services had provided basic aluminium ramps for the front door, however these could not be left in situ and were heavy to manoeuvre into position. A mobile hoist was also provided but not used due to the space constraints in the property and lack of appropriate training; Jack’s parents has only been shown once how to use the equipment and consequently lacked confidence and could not remember how to fit the sling correctly or what colour sling loops to use.

The family were actively looking for a more suitable property to meet Jack’s long-term needs. His Case Manger was keen to find an Occupational Therapist skilled in the adaptation design process and moving and handling who could work with the architect to ensure Jack got the maximum benefit from the adaptations and provide bespoke training to the care workers who were being recruited to work with him.

Using the extensive knowledge of specialist equipment and a good network of contacts and suppliers, the therapist was able to work collaboratively with the architect and specialist adaptations company to provide assessment, design and installation, taking into account the space requirements, client and carer needs, the building type, equipment being considered and budget.

The therapist recommended H Frame ceiling track hoists systems in Jack’s bedroom, bathroom, living room and therapy room as these provide full room coverage, ideal when a number of transfers need to be achieved. The additional advantage of being able to re-position furniture or re-design room layouts without having to consider the track hoist positioning offers flexibility without the additional cost of re-siting when circumstances change. Transition gates were also recommended between Jack’s bedroom and bathroom as this allowed the hoist to run between rooms for more seamless and comfortable transfers.

Including overhead hoisting in the living room was recommended to enable Jack to spend time on the floor or sofa with his brother and remain an integral member of the family, rather than remain in his wheelchair.

The therapist selected a hoist system with a two strap design that does not have an obstructive spreader bar. This is much easier for his family and carers to use and eliminates the risk of Jack injuring himself on a spreader bar due to involuntary limb movements.

The slings chosen were made from a breathable, stretch material to allow the sling to accommodate Jack’s body shape and to work with contours within his seating. It was designed to stay in place under Jack at all times meaning it did not need to be removed and re-applied every time he wanted or needed to be moved.

Jack loves all things sensory, especially water. The local authority OT Service only offered the option of a level access shower in his previous property. His mother felt this would not afford him the therapeutic benefits he derives from bathing and the spray of the water increases his tone and extensor spasms. The therapist recommended a height adjustable bath that could be raised to a comfortable working height for parents and carers. It was positioned so that carer access each side of the bath could be gained and over-head hoisting equipment was used to raise and lower Jack into the bath.

Upon completion of the adaptations, the family and support workers received comprehensive moving and handling training specific to Jack’s needs and were provided with written and photographic instruction for each task to ensure they are following the recommended handling techniques to keep themselves and Jack safe. The therapist recommended that any new support workers shadow shifts until they are deemed competent and they feel confident to work on their own.

Those involved in looking after Jack continue to receive on-going Moving and Handling input to assess any changes to his needs, to train any new carers, to update existing carers, to review slings as he grows and to advise on future equipment.

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Cases in Pediatric Occupational Therapy: Assessment and Intervention 1st Edition

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• Publisher ‏ : ‎ Slack Incorporated; 1st edition (November 15, 2014)
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Telehealth OT: Using Pediatric Case Studies to Inform Practice

Telehealth is becoming an increasingly used service delivery model in pediatric OT due to a myriad of reasons however; it does present some unique challenges when servicing the pediatric population. This course is a presentation of case studies offering clinicians an opportunity to strategize intervention and problem solve real clinical scenarios applicable to general practice.

Course created on May 28, 2020

Course Type : Video, Audio, Text

CEUs/Hours Offered: AOTA/0.1 Intermediate, OT Service Delivery; CE Broker/1.0 Home Study, General (FL), Patient Related (AL), General Continuing Education (GA), Direct Client/patient Services In Occupational Therapy (SC), Related To OT (AZ), Related To OT (LA), Directly Related To OT (MS), Directly Related To OT (TN), CE Broker #20-781682; IACET/0.1; NBCOT PDUs/1.25 Intermediate, Pediatrics; RESNA/0.1 Intermediate

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Presented By

Aditi Mehra DHSc, OTR/L

Dr. Aditi Mehra graduated with a Bachelor's in Occupational Therapy from Western Michigan University and pursued her Doctorate in Health Sciences at Midwestern University in Illinois. She has practiced as a pediatric OT for the past 23 yrs in various settings. During her Doctoral Studies, Dr. Mehra also pursued a certification in Behavior Analysis to gain a better understanding of behavioral challenges in OT. Once she delved deeper into this field, Dr. Mehra discovered Fit Learning, an academic program that combines the science of building fluency and charting data to optimize learning. Once she realized the ease and profound effectiveness of this charting system, Dr. Mehra implemented this charting system in her own practice. This soon became her passion, and she now offers classes and consultations to other professionals seeking to become more data-driven in their practice. 

She offers several data-based free resources on her website,  www.DrAdititheOT.com . Dr. Mehra is the director of the Chicago Fit learning lab, an adjunct professor at Lewis University, and continues to work in the school setting as a pediatric OT.

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The Role of Play in Pediatric Occupational Therapy

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Kari J. Couch , Jean C. Deitz , Elizabeth M. Kanny; The Role of Play in Pediatric Occupational Therapy. Am J Occup Ther February 1998, Vol. 52(2), 111–117. doi: https://doi.org/10.5014/ajot.52.2.111

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Objective. This study examined the roles that play occupies within current occupational therapy practice with preschoolers .

Method. Two hundred twenty-four pediatric occupational therapists completed mail questionnaires designed to ascertain how they use play in their practice, their knowledge and use of play assessments, and potential constraints on their use of play .

Results. Although respondents indicated that play was important in motivating children and frequently used play as a treatment modality or reinforcer, they Less frequently assessed play behaviors or wrote treatment goals and objectives related to play. Differences were found between school-based and non-school-based respondents regarding the discipline or model that addresses play in the work setting, the use of play assessments, and constraints that Limit the use of play in the work setting .

Conclusion. The results suggest a need for increasing the emphasis on play in entry-Level curricula and continuing education, improving clinician access to valid and reliable play assessments, and completing studies designed to examine the use and efficacy of play in occupational therapy intervention .

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