Pediatric OT Models and Frames of Reference

Occupational therapists use models and frames of references to facilitate clinical reasoning and guide the evaluation and intervention process.

What is the difference between a model and a frame of reference?

 Model:

• A model (or practice model) is a broad guide used to organize the occupational therapist’s clinical reasoning.
• Models are based on theories (scientific principles used to explain phenomena).
• All the occupational therapy models are based on the core concept of occupation.
• The occupational therapy practice models remind occupational therapists to consider the broad picture of each patient and to keep occupation (and the patient’s occupational performance) as the central focus during evaluation and intervention.

Frames of Reference:

• Frame of references guide the occupational therapist’s evaluation and intervention.
• Frames of reference are backed by research and offer evidence-based tools and techniques.
• Frames of reference provide occupational therapists with specific assessments and intervention tools to guide their treatments.

Three Occupational Therapy Practice Models:

The Model of Human Occupation (MOHO):

• MOHO is the most popular and widely researched occupational therapy model.
• This model was published in the American Journal of Occupational Therapy (AJOT) in 1980 by Kielhofner, Burke, & Heard.
• MOHO is occupation-focused and client-focused.

 The Model of Human Occupation has four main concepts:

1. Human occupation is multifaceted – occupational performance depends on:
   1. The human
   2. The environment
   3. The task
2. Each person is made up of different elements:
   1. Volition: motivation to choose an occupation; based on personal causation, values, and interests.
   2. Habituation: patterns of behavior; based on habits and roles.
   3. Performance Capacity: ability to perform a task; based on mental and physical capacities as well as experiences.
3. Environment can impact occupational performance either positively or negatively; environment can be divided into different categories:
   1. Physical environment
   2. Social environment
   3. Political environment
   4. Cultural environment
   5. Economic environment
4. Occupational performance is “doing” all the activities that make up a person’s lifestyle

Person-Environment-Occupation-Performance (PEOP) Model:

• The Person-Environment-Occupation-Performance Model (PEOP) was developed by Christiansen & Baum and first published in 1991.
• The PEOP model explains the interconnectedness of the relationship between person, environment, and occupation.
• In this model, the outcome of the relationship between person, environment, and occupation is defined as occupational performance.

The Person-Environment-Occupation-Performance Model (PEOP) has four main elements:

Person:

Each person has intrinsic factors:

• Physiological factors: sleep, stress, health, nutrition, strength, etc.
• Cognitive factors: executive functioning, attention, memory, organization, reasoning, awareness, etc.
• Psychological factors: theory of mind, emotional state, self-esteem, self-efficacy, etc.
• Neurobehavioral factors: visual, auditory, gustatory, olfactory, proprioceptive, tactile, motor planning, motor control, etc.
• Spiritual factors: give purpose and meaning to an individual’s life

Environment:

The environment is made up of extrinsic factors:

• Physical factors
• Cultural factors
• Societal factors
• Economic factors
• Natural factors
• Social factors

Occupation:

The occupation describes what the person wants or needs to do and is made up of the person’s:

• Abilities
• Tasks
• Roles (social and occupational)
• Actions

The main areas of occupation according to the PEOP model are:

1. Work
2. Home maintenance
3. Personal care
4. Sleep
5. Recreation
6. Leisure
7. Performance: the outcome of the relationship between person, environment, and occupation is occupational performance or “doing”

Canadian Model of Occupational Performance and Engagement (CMOP-E):

• The Canadian Model of Occupational Performance and Engagement (CMOP-E) was developed by Polatajko, Townsend, and Craik and published in 2007.
• The CMOP-E is based on learning, environmental, humanistic, and developmental theories.
• This model is client-centered and emphasizes the collaboration between therapist and client to facilitate occupation.

The Canadian Model of Occupational Performance and Engagement (CMOP-E) has three main elements:

Person:

Each person has three performance components:

1. Physical
2. Cognitive
3. Affective

Spirituality is the central aspect of each person; spirituality is what motivates individuals to act.

Occupation:

Occupation is divided into three broad categories:

1. Leisure
2. Self-care
3. Productivity

Environment:

The environment is divided into 4 categories:

1. Cultural
2. Social
3. Institutional
4. Physical

• The CMOP-E emphasizes the idea that each of the elements (person, occupation, and environment) is interdependent which means that when one of these elements changes this causes changes in the other two elements.
• When the relationship between the three elements is “harmonious,” function is the result.

Three Occupational Therapy Frames of Reference:

Ayres’ Sensory Integration (ASI) Frame of Reference:

• Ayres’ Sensory Integration Frame of Reference was created by Jean Ayres in the 1970s.
• According to this frame of reference, each person’s body processes and organizes sensory input from within the body and from the environment to produce a meaningful response.
• When the body is unable to process sensory input effectively, “dysfunction” results which can lead to issues with development, behavior, and learning.
• The aim of the ASI frame of reference is to integrate and expand the sensory systems to help an individual process sensory input effectively.
• The sensory system includes eight senses: tactile (touch), auditory (sound), gustatory (taste), vision (sight), olfactory (smell), vestibular (balance and spatial orientation), proprioceptive (body awareness), and interoceptive (internal sensation).
• The interaction between all eight sensory systems leads to specific behavior.
• Occupational therapists may use the ASI frame of reference with children who have sensory processing disorder (SPD) or sensory integration challenges.
• Occupational therapists who utilize the ASI frame of reference facilitate their patient’s exposure to a variety of experiences through play that incorporate each of the sensory systems.
• Over time, exposure to varied sensory experiences leads to an improvement in the body’s ability to process sensory input.

The Developmental Frame of Reference:

• This frame of reference describes the sequence of stages each child grows through over their lifespan.
• The Developmental Frame of Reference is based on the theories of a number of psychologists including Freud, Jung, Erikson, Gessell, Piaget, Kohlberg, Wilcox, and Gilligan.
  • Frued: Psychosexual theory
  • Jung and Erikson: Psychosocial theory
  • Gessell: Physical & emotional developmental milestones
  • Piaget: Cognitive milestones
  • Kohlberg, Wilcox, and Gilligan: Moral reasoning
• In occupational therapy, the Developmental Frame of Reference is typically used with children who have a developmental delay.
• Children can experience delays in multiple areas including:
  • Gross motor skills
  • Fine motor skills
  • Language and speech skills
  • Social and emotional skills
  • Cognitive skills
• Developmental delays can be caused by developmental conditions including autism spectrum disorders, Down syndrome, cerebral palsy, language and learning disorders, infection, injury, or unknown reasons.
• Function results from a child’s progression through the stages of development. When a child does not progress through the stages of development or progresses more slowly this results in dysfunction.
• The progression through the stages of development occurs in a sequential manner.
• Occupational therapists can facilitate progression through the stages of development through interventions that create the “just-right” challenge for each individual client.

The Behavioral Frame of Reference:

• The Behavioral Modification Frame of Reference describes the idea that behaviors can be shaped through behavior modification.
• This frame of reference is based on psychologist B.F. Skinner’s theory of operant conditioning.
• Behaviors are learned and can be reinforced by outcomes in the environment.
• Behavior can be shaped through rewards and punishments.
• Occupational therapists can use behavioral concepts to guide their interventions and the way that they respond to clients during treatment:
  • Occupational therapists can reinforce positive behaviors by praising the client (e.g. “Good job!”), smiling, or offering rewards.
  • Backward chaining is a technique used to help clients develop new behaviors; the occupational therapist completes all steps in a task besides the final step which the client completes.
  • Forward chaining is a technique in which the client completes the first step of the task and the occupational therapist completes the remainder of the steps.
  • Token economy is a system that reinforces positive behaviors by providing rewards in the form of tokens (or stickers, food, etc.)