Alison Nelson MOccThy, BOccThy; Clinical Educator. Jodie Copley PhD, BOccThy (Hons); Lecturer and Clinic Manager. Kerry Flanigan MOccThy Studies; Graduate Entry Masters Student. Katherine Underwood MOccThy Studies; Graduate Entry Masters Student.
Occupational therapists prefer combining multiple intervention approaches for children with learning difficulties
Article first published online: 18 MAR 2008
© 2008 The Authors. Journal compilation © 2008 Australian Association of Occupational Therapists
Australian Occupational Therapy Journal
Special Issue: Paediatrics
Volume 56, Issue 1, pages 51–62, February 2009
How to Cite
Nelson, A., Copley, J., Flanigan, K. and Underwood, K. (2009), Occupational therapists prefer combining multiple intervention approaches for children with learning difficulties. Australian Occupational Therapy Journal, 56: 51–62. doi: 10.1111/j.1440-1630.2007.00712.x
- Issue published online: 12 FEB 2009
- Article first published online: 18 MAR 2008
- Accepted for publication 1 August 2007.
- learning difficulties;
- occupational therapy
- Top of page
- Limitations and future research
Background/aim: Research to date has not fully explored how occupational therapists provide intervention for children with learning difficulties in their day-to-day practice. The purpose of this study was to provide an in-depth description of the approaches and techniques used and how they are applied and combined to meet the complex and multifaceted needs of these children.
Methods: In-depth interviews and short questionnaires were completed by seven occupational therapists who had provided intervention to children with learning difficulties. Observations of therapy sessions were also conducted. Thematic analysis gained insight into the approaches and techniques therapists used and how these were applied in practice.
Results: Therapists use a wide range of approaches in various combinations because they feel that these best meet the needs of individual children. Sensory-based and cognitive approaches were most frequently drawn from and combined with other approaches such as visual information analysis, biomechanical and psychosocial approaches added for particular purposes. Approaches were usually combined simultaneously within an activity or session.
Conclusions: Therapists create their own ‘multimodel’ approach in order to best meet the needs of their clients. They are able to articulate the theoretical basis behind these choices, although lack of clarity exists about the frames of reference being used.
- Top of page
- Limitations and future research
Occupational therapists play an integral role in addressing the difficulties experienced by children with learning difficulties (LD) by assisting them to participate in their daily occupational roles. Various terms have been used to describe children with LD in the literature, such as developmental coordination disorder (DCD), minimal cerebral dysfunction (MCD), developmental dyspraxia and perceptual motor dysfunction and these terms are sometimes used interchangeably with LD (Mandich, Polatajko & Rodger, 2003). Children with LD may struggle to achieve educational skills, coordinate their movement, maintain attention, remember information or interact appropriately with others (Clark, Getchell, Smiley-Owen & Whitall, 2005; Humphries, Wright, Snider & McDougall, 1992; Rogers, Gordon & Schanzenbacker, 2001; Skinner & Piek, 2001; Wallen & Walker, 1995). These children are referred to occupational therapy in order to address handwriting, coordination, learning and self-management concerns, along with associated social, behavioural and self-esteem issues. This client group is not homogenous and each child may present with a unique combination of difficulties (Wallen & Walker). It has therefore been challenging for researchers and practitioners to identify how to draw from existing frames of reference in a way that best meets the complex needs of this group (Wallen & Walker).
Adding to this challenge is the apparent lack of clarity and consistency in the terms used to describe practice such as frames of reference, models of practice and intervention approaches. A frame of reference has long been an accepted way for therapists to organise their knowledge for use in intervention planning (Mosey, 1970). Greber, Ziviani and Rodger (in press) have suggested that therapists select an intervention approach that reflects the theoretical assumptions of their chosen frame of reference. This intervention approach comprises a collection of ideas and actions that results in the application of specific treatment techniques (Greber et al., in press; Hagedorn, 2001). However, there is little knowledge about the ways in which therapists implement their chosen frames of reference, intervention approaches and techniques in everyday practice with children with LD.
A review of the literature was conducted in order to identify frames of reference, intervention approaches and techniques that are commonly applied with children with LD. Cinahl, OT Seeker, PubMed and Cochrane Library databases were searched using the following key search terms: occupational therapy and children, occupational therapy and paediatric/paediatric, learning difficulties, learning disabilities, developmental coordination disorder/DCD, occupational therapy practice, occupational therapy interventions, occupational therapy approaches, occupational therapy frameworks, and occupational therapy techniques. Results from the above searches were then narrowed using the following terms: sensory integration (SI), family-centred practice, biomechanical, cognitive, Cognitive Orientation to Occupational Performance (CO-OP), psychosocial, neurodevelopmental theory/NDT and group therapy.
Some frames of reference and intervention approaches have been specifically developed for use with children with LD (Brown, Rodger, Brown & Roever, 2005; Rodger, Brown & Brown, 2005; Storch & Eskow, 1996). These include SI, which aims to address sensory-processing deficits that impact on a child's ability to produce an adaptive response (Kimball, 1999). CO-OP is a cognitive approach targeted towards children with DCD that emphasises problem-solving and guided discovery (Mandich et al., 2003; Miller, Polatajko, Missiuna, Mandich & Macnab, 2001). The perceptual motor training approach involves using practice and verbal guidance to train specific motor skills (Humphries et al., 1992).
Studies that have evaluated the use of these approaches have generally examined one treatment approach in its ‘pure’ form (Edwards, Millard, Praskac & Wisniewski, 2003; Polatajko, Mandich, Miller & Macnab, 2001). However, there is evidence that, rather than using one approach in isolation, therapists use a number of approaches (or a ‘multimodel approach’) in their everyday practice with children (including children with LD, children with other diagnoses such as cerebral palsy and children from economically disadvantaged backgrounds) (Berry & Ryan, 2002; Brown et al., 2005; Davidson & Williams, 2000; Humphries, Snider & McDougall, 1997; Stonefelt & Stein, 1998; Storch & Eskow, 1996; Peterson & Nelson, 2003). One study has attempted to evaluate the use of an approach that combined perceptual motor training and SI (Davidson & Williams). However, the extent to which this particular combination of approaches/frameworks is representative of current practice is unclear.
Studies that have attempted to determine the frames of reference, theoretical models and intervention approaches used by therapists have used predetermined response categories which may have limited exploration of the range of approaches used and the way in which therapists applied them. Brown et al. (2005) and Rodger et al. (2005) identified SI, Multisensory Approach/Sensory Processing Model and the Occupational Performance Model as theoretical models that were most commonly used in Australia, particularly for children with LD (Brown et al., 2005). However, this study did not explore how these models were applied or combined, nor how therapists translated these models into therapy techniques when treating children with LD.
Previous studies have therefore established that a variety of theoretical models, frames of reference and intervention approaches are used for children with LD (Berry & Ryan, 2002; Brown et al., 2005; Storch & Eskow, 1996). However, there is little literature describing how therapists are interpreting and implementing particular approaches. In addition, research describing the way in which intervention approaches are combined, and why they tend to be combined, is currently limited. In-depth description of the way in which therapists practise with these children has the potential to illuminate the clinical reasoning process and provide a platform for efficacy studies into a mixed or multimodel approach to paediatric occupational therapy practice.
The current study aimed to explore and describe therapists’ perceptions regarding how they apply and combine frames of reference and intervention approaches for children with LD.
- Top of page
- Limitations and future research
Qualitative research methods were used in this study to enable researchers to explore the meaning of each individual's perceptions and experiences when providing therapy for children with LD (Patton, 2002).
Context of research
This research was undertaken at a university-based paediatric clinic. Children seen at the clinic are predominantly referred because of difficulties with learning and motor skills, with or without social skills concerns. Children generally attend a 10-week therapy block for 1 h per week and participate in small groups, with two to four children of similar age in each group. Session plans are developed on the basis of assessment information, discussion with each child and family regarding occupational issues of concern and identified goals. Sessions are tailored to address each individual child's goals, and the group context is used to target social and attentional goals (Wallen & Walker, 1995).
Participants in this study were a purposive convenience sample of occupational therapists who provide (or have previously provided) therapy at the clinic. Seven occupational therapists were provided with an information sheet about the study and gave written consent. Participants were all female and had between 3.5 and 24 years of experience (with an average of 11.5 years) (see Table 1). Targeting an experienced group of therapists was considered important for this study as it was assumed that they had been practising long enough to develop their clinical decision-making and their own practice style. Each participant was interviewed, and four of the seven participants were observed conducting therapy sessions (as three therapists were not currently conducting group therapy). Parents of children who received therapy in these sessions also provided consent for observation of their child by the researchers.
|Participant||Therapy experience (year)||Paediatric therapy experience (year)|
Data collection methods and tools
Data were collected using four different methods to enable triangulation and provide a rich description of therapists’ practice: short questionnaires, in-depth interviews, observations of therapy sessions, and documented therapy plans (Patton, 2002). Ethics approval was obtained from the University of Queensland Behavioural Sciences Ethical Research Committee.
Throughout the process of data collection, it was considered important to use the lexicon of the participants. Within the context of the university clinic, therapists commonly referred to both the frames of reference and the intervention approaches they used as ‘approaches’. Thus, the term ‘approaches’ was routinely used in the questionnaire and interview questions. Questionnaire and interview data were collected on a single occasion for each participant. The short questionnaire contained a series of brief demographic questions and a blank table in which therapists listed intervention approaches they used with children with LD. The main purpose of the questionnaire was to prepare participants for the nature of the interview to follow and to provide background information regarding their experience.
A semistructured interview guide was used which included questions such as: Which intervention approaches do you generally use in your everyday practice? How and when do you apply these approaches? What governs your decisions about which approach to use with each child? Can you describe a therapy session in which you have combined different approaches? These questions related to therapists’ practice in general, rather than just the specific sessions observed. After this open-ended exploration of their practice, four brief case scenarios were used to further explore how therapists applied these approaches for children of different ages and with different areas of concern. Data from in-depth interviews were audiotaped and transcribed verbatim. Each interview transcript was de-identified, coded and stored securely. In order to maintain the rigour of the research process, participants were sent copies of their interview transcripts to verify the completeness and accuracy of the data (Patton, 2002).
Observations of 16 therapy sessions were recorded on a session observation form which included a description of each activity completed in the session and the therapeutic techniques used to facilitate and grade activities. The documented therapy plan for each observed session was also collected as it provided activity descriptions, session objectives and in some cases, the intended therapeutic techniques. Any identifying information was removed from the session observation forms and the therapy plans prior to analysis.
Thematic analysis was used to identify themes emerging from all the data combined together (Ulin, Robinson & Tolley, 2005). Each of the four researchers reviewed the data independently and drafted an initial set of themes. Themes were then compared and differences discussed until all researchers agreed on an initial coding tree with which to begin coding the data. Descriptions of each code were developed to avoid ambiguity in meaning and to increase the reliability of subsequent coding. Themes were determined based on the language used by the therapists, rather than being preselected from existing literature. At times, different therapists described similar techniques, but ascribed them to different approaches. In these cases, data were coded under both the approach therapists stated and the approach that best reflected the theoretical base underpinning those techniques.
Selected sections of interview transcripts were then independently analysed using the initial coding tree to check for interrater consistency and to ensure that all themes had emerged. Most of the data from session plans and observation sheets reflected the interview data and could clearly be coded according to the approaches therapists described (e.g. ‘therapist asks the group “What can we do to write quickly and still be fairly neat?” then uses verbal prompting to lead the group in brainstorming possible answers’ was coded under cognitive approaches). Researchers then discussed any differences in coded data until a common understanding was reached (Patton, 2002) and a final coding tree developed and used to complete the analysis. The computer software program Nvivo 2.0 was used to assist in the organisation of data (Richards, 2002).
- Top of page
- Limitations and future research
Because of the voluminous nature of the information generated by this study, two of the four main themes identified from the data will be reported in this paper and are described in Table 2. They were ‘approaches and techniques used by therapists’ and ‘approaches are usually used in combination’. The remaining two themes (‘factors affecting intervention choice’ and ‘embedded practices’) are reported elsewhere (Copley, Nelson, Turpin, Underwood & Flanigan, 2007).
|1. Approaches and techniques employed by therapists|
|• Sensory-based approaches and techniques, including|
|Aspects of sensory integration such as sensory modulation and techniques to enhance underlying sensory components such as low muscle tone, proprioception and bilateral integration.|
|• Cognitive approaches and techniques (including CO-OP or aspects of CO-OP)|
|• Psychosocial approaches and techniques (including managing behaviour and group dynamics, promoting social skills and self-esteem, and motivational techniques)|
|• Visual information analysis approach and techniques (including reducing or emphasising visual information in the environment or task)|
|• Biomechanical approaches and techniques (including use of workstation ergonomics, strength and endurance)|
|• Perceptual-motor approaches and techniques (including practice of fine or gross motor tasks)|
|2. Approaches are usually used in combination|
|• Approaches commonly combined in practice|
|• Perceived need to draw from a number of approaches to increase effectiveness, or to meet multiple needs of children in the group|
|• Therapists combined approaches simultaneously within one activity, or within the session|
|• Approaches were occasionally used singly within one activity|
Approaches and techniques employed by therapists
During interviews, therapists articulated how and why they used a range of approaches to address the child's needs. They illustrated their application of each approach by describing specific techniques, and these techniques were also identified in session plans and observations. While the range of approaches used by each participant varied, some approaches were more commonly referred to and observed in sessions, notably sensory- and cognitive-based approaches. Table 3 presents the approaches used by each therapist. The content of subthemes was developed based on therapists’ explanations rather than textbook definitions. For this reason, there is at times some notable departure from theoretical definitions of approaches and significant overlap of techniques used under the guise of several approaches.
|Approaches and techniques used|
|Therapist||Sensory- based (SB)||Cognitive (Cog)||Psychosocial (Psych)||Biomechanical (Bio)||Visual information analysis/visual perception (VIA/VP)||Perceptual motor (PM)||Approaches combined|
|1||x||x||x||x||x||SB + Cog SB + Cog + bio VIA + Cog Psych + Cog + SB|
|2||x||x||x||x||Cog and PM PM and SB|
|3||x||x||x||x||x||SB + Cog PM + SB Cog + SB + PM Cog + psych + bio + SB PM + Cog|
|4||x||x||x||x||x||x||SB + Cog Psych + all others SB + Psych|
|5||x||x||x||x||x||x||Therapist stated combinations not easily identified|
|6||x||x||x||x||x||SB + Cog VIA + Cog|
|7||x||x||x||x||x||x||SB + bio|
Table 4 presents a summary of the areas of child performance that therapists intended to address with the use of each approach, the ways in which they felt the approach was addressing these areas, and specific techniques they employed within each approach.
|Sensory based||Cognitive||Psychosocial||Biomechanical||Visual information analysis||Perceptual motor|
|Areas of child performance intended to be addressed with this approach||Attention Allow learning of motor skills||Allow learning of motor skills, e.g. posture, letter formation/handwriting, other motor skills, e.g. skipping Memory and organisation||Develop social skills Develop self-esteem Self-management Facilitating behavioural change/behaviour management||Motor skills||Organisation Improve copying skills Improve spelling and writing, reading, maths||Motor skills Sports and PE|
|Ways in which therapists felt these approaches address areas of child performance||Task mastery Arousal/relaxation Develop ability to regulate sensory responses Build tone/proprioception/ bilateral integration to prepare the body for functional tasks Improve postural stability Develop appropriate force, speed and direction of movement||Task mastery Need to educate child Self-knowledge, bring issues to their awareness Teach them to manage or regulate themselves better Communicates respect for the child To gain attention/prepare for a task Interest, control, motivation||Educate child about specific social skills Give sense of achievement and success Awareness of therapist/child dynamic Communicates respect for the child Encourage child's self- expression Relaxation Develop ability to move between activities Understand child within social context Encourage appropriate classroom behaviour e.g. sitting still Improve motivation Improve attention||Posture, stability and strength Co-contraction and stability in upper body Shoulder stability with distal fluency Pencil grip Ergonomics Isolation of movement/in-hand manipulation Increase endurance at computer or desk Increase joint mobility, e.g. lengthen hamstrings Manage shoulder and neck problems due to muscular fixing for stability||Visual attention Visual memory Educate child/develop self- awareness and skills to manage daily tasks||Assists with motor planning and muscle tone Assists with force and direction when throwing and catching Balance Eye–hand coordination|
|Techniques used||Facilitatory/inhibitory techniques (gross motor activities/weight-bearing/ vestibular stimulation/ chewing/breath-ing/ positioning on floor/music/touch) Self-verbalisation for planning of movement Working on task components Using tactile cues for planning e.g. writing in shaving foam Compensatory strategies, e.g. strengthening to account for low tone Physical guidance, e.g. guiding the hand through letter formation Grading of tasks and equipment, e.g. pencil grip for increased awareness Multisensory cueing Teacher education regarding classroom environment and teaching practices to cater for sensory modulation issues Visual and verbal cueing before or during instruction giving||Self-verbal cueing during motor tasks Auditory and visual cueing, e.g. rhymes, songs, verbal rehearsal, checklists, prompts to use stabilising hand, counting how many bounces you can do in a row Rules for task preparation e.g. cutting rules, knife and fork rules Task breakdown/evaluation of the task, the strategies used and the product, e.g. handwriting/use of imagery Relaxation Group discussion/ brainstorming of ideas to approach task Editing their own work or other's work/discussing the purpose/importance of a task Testing out solutions, e.g. pressing hard on pencil to see effect on writing Verbal questioning, reflection and restatement of child generated ideas/responsibility for time management Child-generated strategies to remember or plan what needs to be done/develop child's awareness of own abilities and the purpose of therapy activities||Teaching social skills directly (eye contact, listening, turn-taking) Team/group activities Social skills worksheets Positive reinforcement Opportunities for success Reward charts ‘Rules’ for appropriate group behaviour Child-directed goals/ activities/structured choices Teach child to be aware of body's responses||Songs to remind re: upright stable posture Appropriate table and chair heights Tilt stools, tilt cushions, slope boards, foot stools, Swiss balls, change angles of surfaces Use of vertical surfaces (e.g. writing in shaving foam on mirror) Sport or physical activity Alternative ways to stabilise rather than fixing shoulder and neck muscles Computer set up Homework station set up Desk and chair set up at school Developing pencil grip Graded weight-bearing activities Resistance activities Weight-bearing posture during everyday tasks In-hand manipulation activities||Multisensory cueing rather than relying on vision only Using ‘rules’, e.g. for letter reversals Highlighting visual information (borders, highlighter pens, torches) Reducing visual information on the blackboard, page and in the classroom Mnemonics/stories/memory hooks/songs to help retain visual information Chunking of written information to assist copying Teacher education about visual simplification or modification of classroom and task||Visual cues to assist motor tasks, e.g. scissor jumps with coloured band on one arm Balance beam Practising skills, e.g. ball skills, hopping Skipping, jumping in hoops Scooterboard Jumping over hurdles Side-walking Throwing quoits in kneeling position Dribbling ball between cones, kicking ball to each other Ten-pin bowling Balloon tennis|
All therapists documented ‘sensory integration’ in the short questionnaire as an approach they used. When questioned about this approach in the interviews, they described using a variety of techniques, some of which appeared to clearly reflect an SI frame of reference, and others which appeared more congruent with a sensory motor approach. They tended to interchange the terms ‘sensory integration’, ‘sensory motor’, ‘sensory-processing’ and ‘sensory modulation’, sometimes using these terms together in the same phrase (‘I would use a lot of sensory motor/sensory modulation approach ...’I1). It appeared that therapists thought about ‘all things sensory’ in a collective manner, using terms such as ‘sensory stuff’ or ‘sensory type things’ to denote this grouping of sensory-based techniques. Despite this, there remained subtle differences in the types of techniques categorised as sensory integration, as opposed to sensory motor techniques.
Sensory Integration: Although all therapists documented ‘sensory integration’ as an approach they used, they all reported in the interviews that they did not use SI in its ‘pure’ form, but drew upon SI theory to help them better understand the child's difficulties and facilitate task mastery.
I don't use sensory integration in its true sense. I'd say now that I use that idea of sensory modulation and understanding that some kids aren't so good at sensory-processing and adjusting to their environment. (I3)
Therapists mentioned the use of sensory integrative techniques related to balance, eliciting automatic reactions, and modifying or adding to the tactile, proprioceptive and vestibular input experienced by the child. The use of sensory integrative techniques was always connected with increasing the child's attention and/or facilitating learning of motor skills. Sensory modulation theory was by far the most common aspect of SI drawn upon by therapists. They used techniques that would help ‘calm’ or ‘alert’ the child, and placed emphasis on modifying the visual, auditory, tactile and movement stimulation in the child's environment to reduce either sensory sensitivity or sensory-seeking behaviour. For example, the use of deep touch, slow and quiet verbal prompts and dimmed lights were described as inhibitory to the child. Therapists reported that they used knowledge about the child's sensory modulation to explain their behaviour to teachers and parents and to suggest strategies for use in their daily environments.
Second to sensory modulation, therapists most frequently referred to the use of sensory integrative techniques to address underlying performance components such as muscle tone, bilateral integration and motor planning they saw as foundational to motor performance.
You’re not going to achieve the writing and cutting unless you start with their general arousal and their readiness to learn, then you think about posture, then you think about arm stability .... and THEN you get to the writing. (I5)
When discussing this subtheme, therapists were not always clear about whether they were working on underlying performance components or subskills that make up the task. Therapists sometimes used terminology such as ‘skills’ and ‘components’ interchangeably, and appeared to be focussing on both simultaneously in their intervention.
If they can't skip, they may not be able to jump or hop, or they may not be able to balance. I'd skill back. So can they do a two-footed jump in a balanced, coordinated way ... I'd go back and check that they can do the base activities which prepare you for skipping. Skill building, if you think if it that way. Bilateral integration, motor planning, those kinds of things. (I4)
Sensory motor: The term ‘sensory motor’ was at times used in a general manner during interviews (e.g. discussed in relation to general performance of motor skills such as ‘hopping and jumping’[I3] or ‘stability and awareness and planning and execution of movements’[I6]). However, this term was predominantly associated with techniques aimed to heighten the child's sensory awareness during task performance. Techniques included self-verbalisation and writing in different textures to assist the learning of letter formation, and combining verbal and visual cues to assist mastery of gross motor skills.
... this idea of a sensory motor approach where I'm doing things like giving tactile cues through the shaving foam of what the letter looks like. I'm giving verbal cues and I'm giving visual cues. So I might say ‘around, up, down’ or something like that. (I1)
The use of multisensory cueing was not, however, confined to the sensory motor approach. Rather, it seemed to permeate all areas of practice and was a pervasive theme throughout discussion of many approaches and techniques, including cognitive and visual information analysis. The implication was that this technique did not ‘belong’ to any one framework.
Some participants reported using aspects of the CO-OP framework (Sangster, Beninger, Polatajko & Mandich, 2005) including the ‘Goal, Plan, Do, Check’ model (Camp, Blom, Herbert, & Vandoorwick, 1976, as cited in Miller et al., 2001). Others identified routinely integrating guided discovery and self-evaluation as general cognitive techniques but they did not specifically attribute these to the CO-OP framework.
I would ask them [the children], ‘I wonder what we can do to make this look better? How do you think you went with that?’ Asking them to self-evaluate but not giving ... them the idea that you have the answer, because the answer needs to come from them. (I6)
Therapists indicated that a cognitive approach was useful for addressing concerns in two major areas: motor skills and memory/organisation. Techniques that therapists ascribed to a cognitive approach included self-cueing, task breakdown, and developing ‘rules’ for completion of particular tasks. There was an emphasis on task evaluation and developing child-generated strategies through the use of group discussion and brainstorming, questioning and reflection of the child's ideas, and testing out of possible solutions.
So we’ll come up with a plan ... the top line's a firewall so I can make my little letters go up to the firewall, or the bottom line's like magma, so I can't let my lower letters go down to that line or they’ll get burned. And each word is like a force shield, and you can't have the words getting too close to each other, cause they’re surrounded by a force shield. So that was the plan he came up with, so he was able to internalise which is part of the approach, rather than me imposing that on him. (I1)
Therapists perceived that they used these techniques to improve the child's self-awareness and self-regulation, with the aim of better preparing themselves for tasks and increasing task mastery. Some therapists also felt that a cognitive approach communicated respect for the child's ideas, had the potential to increase their feelings of control, and motivated them towards goal achievement.
The more cognitive you are in your approach ... it communicates a great deal of respect for the child, that their ideas are important, and that what they want is important, and that you have faith and belief in them that they can manage themselves in some way... (I6)
Visual information analysis (VIA)
Visual information analysis (VIA) is an approach that utilises children's cognitive skills to allow them to extract visual information from the environment and integrate it with other sensory modalities (Todd, 1999). This approach draws on developmental, sensory-processing and cognitive analysis approaches but is recognised as a frame of reference in occupational therapy literature (Todd). Although only five of the seven therapists reported using VIA, all therapists described or were observed to use techniques which drew from aspects of this approach. Some therapists reported using a visual perceptual approach as opposed to VIA specifically, while describing similar techniques.
Participants described their use of VIA in the presence of visual attention, visual memory or organisation difficulties to allow mastery of academic tasks such as reading, writing, maths and copying. Specific difficulties addressed through VIA included problems referring to written information on the board at school, problems with spacing letters and words in written work, and difficulty assembling items required for a task. They aimed to help children through techniques such as reducing visual information and providing extra visual emphasis to particular features of the task. Some of these strategies appeared to most reflect the sensory-processing component of VIA.
... You might use visual strategies like highlighting the line that they have to write on so they have their attention focussed on that. Or putting a coloured border around what they have to copy from (on) the board so they know ... to attend to that bit. (I1)
Therapists also reported using verbal techniques to assist recall of visual information, for example, using mnemonics and songs to assist recall of the sequence of letters for spelling words. These techniques reflected the cognitive analysis skills that are part of a VIA approach (Todd, 1999).
Teaching them little rules about the way they face a ‘b’ and a ‘d’. And using strategies for visual memory as well, so using things like mnemonics, or practising chunking, so you can copy small chunks. (I1)
While only one therapist specifically identified using a ‘psychosocial approach’, all therapists reported psychosocial factors, such as self-esteem, that may need to be addressed. They further noted that as part of a psychosocial approach it was important to understand the child's feelings and the reasons for the child's occupational performance issues, including his or her social context.
The way I work is with the psychosocial aspect over-riding everything ... I spend a lot of time understanding what's going on to cause this problem. You can find planning difficult for many reasons. You might just be disorganised, you might have sequential based difficulties, you might have auditory problems ... You might just have a really shit home environment where it is so chaotic that you just don't know what you are doing. (I4)
Several participants identified that they addressed social skills and self-esteem in therapy. These issues are acknowledged as common secondary difficulties experienced by children with learning difficulties (Smyth & Anderson, 2001; Wallen & Walker, 1995).
Dealing with the LD population, most of the children we would see would have some sort of social impairment and self-esteem impairment based on their difficulties, and (we are) including and incorporating strategies around that. (I4)
Therapists used techniques such as facilitating a supportive environment in which children could experience success with their peers, and providing children with control, choice and frequent verbal encouragement for efforts and achievements.
Regardless of each child's goals, therapists used a psychosocial approach to assist children with self-management and to help manage group dynamics. Techniques used to achieve this were the use of group rules, reward charts, using child-directed goals and structured choices, and positively reinforcing appropriate behaviours.
Other psychosocial techniques used by therapists included providing direct education to the child about specific social and classroom behaviours through the use of team activities and worksheets.
I'd certainly teach them about what is appropriate social behaviour and teach them the skills of listening when someone is talking and giving eye contact ... (I1)
Three out of the seven participants used the term ‘biomechanical approach’ or ‘biomechanics’ during interviews but conveyed that it was an adjunct to other approaches rather than a dominant approach in their intervention. Therapists associated this approach with the use of equipment and external supports to facilitate stability and control of the child's posture and movement. The main purposes of employing a biomechanical approach related to handwriting or general desk work, for example promoting a stable pencil grip or considering the ergonomics of the child's workstation to allow more upper body stability and distal control without excessive muscular ‘fixing’. Adapted furniture and specialised equipment were most commonly employed to do this.
Setting up the environment for them ... having an appropriate chair and table at the appropriate height and trying things like tilt stools or tilt cushions or slope boards to change the angles of surfaces to help the child get in a better position. (I1)
Therapists also aimed to increase the child's strength and endurance for tabletop tasks and physical tasks by working on musculoskeletal and biomechanical aspects of the child's movement. This included increasing joint mobility, cocontraction and shoulder stability, and in-hand manipulation through techniques such as weightbearing and resistive activities.
Developing good co-contraction and stability in your upper body is a biomechanical concept ... biomechanics is about making your shoulders stronger and your back stronger ... (I6)
Three of the participants who did not specifically identify that they used a biomechanical approach nonetheless described using equipment such as tilt stools, desk slopes and pencil grips in the same manner as described above. However, they ascribed these techniques to different frames of reference such as sensory integration.
Using tilt stools, you could say, is basically Bobath. A Bobath therapist uses things to stabilise the hips to help the child position a certain way. And you can say it's SI, because you’re giving them feedback. By putting them in a more highly weighted position, they are getting more feedback from their body. (I4)
Five participants described using a perceptual motor approach to address concerns with general motor skills, or participation in sports and physical education, through practice and verbal guidance.
Motor skills are in themselves still a goal for some kids where sports and PE are a problem ... then we work on practising those skills, e.g. ball skills. (I3)
The therapy plans and observational data revealed that therapists were largely able to follow structured plans for such activities. However, it appeared that therapists were likely to incorporate additional unplanned strategies — such as physical cueing, or organisational strategies — to grade activities, maintain the attention of the group, or address other non-motor goals simultaneously. In one session, for example, the therapist required children to throw a ball at a target while spelling a word, with one letter for each throw of the ball.
While most therapists identified the use of a perceptual motor approach, they sometimes appeared not to discriminate between the terms ‘perceptual motor’ and ‘sensory motor’.
So I might decide that I'm going to do some perceptual motor-based activity. I might do an obstacle course to address the sensory motor issues ... (I2)
Approaches are usually used in combination
All participants reported that they combined intervention approaches. The combinations reported or observed for each therapist are included in Table 3. It appeared that some approaches were combined more frequently than others, with six participants reporting combining sensory-based approaches with cognitive approaches. Sensory-based approaches were combined with a number of other approaches including: biomechanical, perceptual motor, and VIA together with cognitive strategies.
... and you work at the occupational performance level at the same time as perhaps working from a sensory perspective on calming them or increasing their level of alertness ... at the same time using some cognitive strategies so that the child has some self-knowledge and ability to regulate themselves better as time goes on. (I6)
Perceived benefits of combining approaches
Therapists suggested several key benefits of using a combination of approaches: to increase the effectiveness of the intervention, to address the multiple needs of each child, and to address the various needs of the children in the group.
Most of these children don't come with one issue that fits neatly into one framework. They come with issues that reflect a range of frameworks; they come with issues about organisation; they come with issues [about] sensory modulation and that affects their social skills. (I1)
Furthermore, participants reported it was difficult in some activities to separate the intervention approaches applied because there was much overlap in the techniques used among different approaches. This was also evident in session plans and observation sheets, which made some of these data difficult to code. Table 4 illustrates that the use of similar techniques was attributed to a number of different approaches, for example, verbal self-cueing was used within both sensory-based and cognitive approaches, and multisensory cueing within both sensory-based and visual information analysis approaches. In addition, there was some overlap in the perceived mechanisms of effect of different approaches, for example both sensory-based and cognitive approaches were intended to assist task mastery, and both cognitive and psychosocial approaches were seen to communicate respect for the child.
I don't think the approaches themselves are mutually exclusive. (I6)
Ways in which approaches were combined
Predominantly, therapists reported they would combine two or more approaches simultaneously within an activity, or within the session as a whole.
[In] the task of handwriting in a group situation you would have all the kids set up ... with tilt chairs, wedged cushions ... and you would be looking at cueing them into good elements of posture and core stability. Also, looking at visual information analysis ... and [having] highlighting between the lines if they have trouble with spacing, and you would also be looking at the cognitive mediation approach. After the children have written something, you might be getting them to go back and proof read the work and say, ‘Let's look at our handwriting’ and, ‘Are there any errors?’ (I7)
To a lesser extent, therapists reported sometimes using one main approach to form the basis for a single activity within a session, or to underpin an entire session. For example, some therapists were able to describe sessions in which single approaches were used in series.
You would focus on using a sensory motor approach to help build tone for posture, but then, you sit at the table, and you’re using more CO-OP cognitive strategies for writing. (I1)
Participants identified that they felt that some approaches lent themselves to singular use, while other approaches needed to be combined to be effective.
I would never just do SI, whereas I could just do CO-OP ... with a kid if that is all that is needed. (I3)
Therapists described examples in which a single approach was used predominantly within one activity, with additional approaches used when necessary to grade the difficulty of the activity, for example with the use of sensory cueing to assist a child who was having difficulties completing a perceptual motor task.
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- Limitations and future research
The information gathered in this study through open-ended questioning rather than predetermined response categories provides a rich description of the approaches occupational therapists use for children with LD and the specific techniques they use within these approaches. These findings confirm and extend what earlier researchers have suggested: that approaches are often used in combination or as a ‘multimodel’ approach rather than as single approaches in their ‘purist’ form when addressing the needs of children with LD (Humphries et al., 1992; Stonefelt & Stein, 1998; Wallen & Walker, 1995).
Therapists appeared comfortable moving between and combining approaches. Moreover, therapists indicated that they felt they needed to use a combined approach to best meet the multifaceted needs of their clients. Therapists did not appear to be concerned about what label they gave to what they were doing (e.g. framework, model, approach) and they did not always see approaches as being completely distinct from one another.
Connecting theory to practice
Therapists need to connect theory to practice in order to ensure they are using therapeutic techniques in an effective and occupation-centred manner (Greber et al., in press; Kramer & Hinojosa, 1999). At times, different therapists in this study used the same techniques but ascribed them to different approaches or frames of reference. This may suggest that therapists did not fully understand the theory underpinning each approach.
However, this apparent lack of clarity may reflect the overlapping nature of frames of reference and approaches, that is, that a frame of reference may draw from one or more theories and several different frames of reference may be enacted through the same therapeutic technique (Greber et al., in press; Kramer & Hinojosa, 1999). Given that this group of participants comprised an experienced group of therapists, it is perhaps more likely that, rather than not being sure of the theory behind their practice, they created a new conceptualisation of theoretical information in a way that was meaningful to assist the child (Kramer & Hinojosa). In other words, therapists may not identify with or place much importance on adhering to a specific frame of reference because they are ‘creating their own’.
In doing this, therapists may also be responding to the need to incorporate new knowledge into their practice as different frames of reference develop over time. While particular frames of reference may dominate when they complete their undergraduate training, ongoing professional education is likely to stimulate therapists to continually modify and refine their own multimodel approach. An example of such modification is seen in this study, where participants placed more emphasis on the use of VIA than has been documented in previous research.
Top-down and bottom-up approaches
Therapists in this study drew from both top-down and bottom-up approaches, most notably cognitive approaches and SI. However, rather than using these approaches in their purist form, they appeared to be taking concepts from or elements of these approaches and applying them to the unique needs of the child. For instance, they reported drawing on aspects of SI theory to help understand the child's occupational performance difficulties but then used a combination of bottom-up and top-down techniques to address these difficulties. Therapists also drew heavily on cognitive techniques as a way of assisting children to reach their goals. This may have been in part because these techniques align with core occupational therapy processes such as task break-down and scaffolding of skills to achieve occupational task performance.
Occupational performance models were not explicitly identified by therapists in this study despite earlier research identifying their common use by paediatric therapists (Brown et al., 2005). Participants did, however, frequently discuss addressing occupational issues in their practice. This may suggest that they viewed occupational performance models as underpinning all aspects of their practice, rather than as an approach to therapy. Given the tendency to combine top-down and bottom-up approaches, further research should specifically investigate to what extent therapists are maintaining an occupational focus with children with LD.
Interestingly, therapists did not, for the most part, discuss the use of evidence-based practice in their decision-making about which approaches to use. They nonetheless asserted that a multimodel approach was most effective to meet the needs of children with LD. This raises the question of how they are reaching this conclusion. Evidence-based practice has been described as incorporating the use of research evidence, clinical expertise, and patient's values and preferences (Sackett, Strauss, Richardson, Rosenberg & Hayes, 2000). The types of evidence used by therapists, and the way in which their clinical reasoning interacts with evidence use, need to be further investigated to clarify how therapists are evaluating the effectiveness of their intervention.
Implications for practice and education
The results of this study suggest that, in relation to occupational therapy intervention for children with LD, there may be gaps in therapists’ translation of theory to frames of reference, and in turn to the use of intervention techniques. While these gaps may indicate the need for further professional education to ensure accountable practice, the time and funding required to train busy clinicians in such an ongoing manner may be prohibitive. In addition, it is not clear whether these ‘gaps’ have any real impact on the effectiveness of intervention. In the absence of this knowledge, it may be important for therapists to be diligent in identifying their reasoning for intervention planning. This may include the use of documentation tools which explicitly outline the links between treatment techniques and theoretical information. Therapists also need to use outcome measures which will inform them about how effective a multimodel approach has been for each of their clients.
Participants in this study placed importance on tailoring their intervention to the unique needs of the child and family, using various approaches and techniques as their tools to do this. The routine use of a multimodel approach by therapists in this study questions whether it is useful to teach each approach in isolation and in its purist form. The overlaps among various frames of reference and approaches could be made more explicit. There may also be a need to provide both students and practitioners with more opportunities to learn how to integrate these approaches. Teaching skilled clinical reasoning to address individual needs may therefore need to be an equal focus of undergraduate training and continuing professional education.
Limitations and future research
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The context of the study was a clinic which incorporated a high level of student input, and this factor may have impacted on the skill with which techniques were implemented in therapy and consequently, the content of the observational data obtained. Similarly, as data were only collected on group therapy, there may have been a bias towards using certain approaches or combining approaches. This is unlikely to have influenced the data in a significant way, however, as the approaches reported largely reflected those identified in previous research.
The previous experience of therapists in this study was quite varied (e.g. some therapists had more psychosocial experience) and this may have impacted on their choice of approach. In addition, data was collected from a single context, possibly limiting the generalisability of the results. Future research should collect data across a range of settings and consider in more depth how factors such as therapists’ backgrounds and service settings may impact on their practice. Other factors that influence their choice of approach for each child and family should also be described.
As participants were interviewed only once the breadth of data obtained may also be limited. The lack of participant-initiated discussion around occupational performance models and EBP could have been further probed during interviews, particularly in view of the strength of this theme in previous research. Exploration of how therapists combine approaches whilst still practising in an evidence-based and occupation-based manner is warranted across a broader range of therapy settings. In light of the way in which therapists appear to be practising, it seems there is a need for further research into the efficacy of using a multimodel approach to therapy for children with LD.
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This paper adds to existing knowledge about occupational therapy intervention for children with LD by providing an in-depth description of the intervention approaches therapists choose and how they are applied and combined. Therapists indicated that they frequently used approaches in combination, creating their own ‘multimodel’ approach in order to best meet the needs of their clients. Therapists are able to articulate the sometimes complex and multifaceted clinical reasoning behind these choices. As occupational therapists continue to seek and accumulate evidence to better guide practice, it may be appropriate for research to follow practice to some extent, by investigating the efficacy of the approaches that therapists are choosing to use. The description provided in this study may be a starting point for investigating the efficacy of therapists’ approach of choice. This is important as there needs to be a continuous focus on the planning, selection, application and evaluation of intervention in clinical practice.
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