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Occupational Therapy, Thesis I - HO1T27 - S19 Thesis

Evelin Fischer

1

Version approved by examiner

Occupation as means and ends in early

childhood intervention – A scoping review

Evelin Fischer

Thesis, 15 credits, one-year master

Occupational Therapy

Jönköping, May, 2019

Supervisor: Dido Green, Professor

Examiner: Anita Björklund Carlstedt, Professor


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Abstract

Background: Occupational therapy (OT) plays an important role in providing early

childhood interventions for children with developmental delay. While paediatric OT has

long been guided by developmental principles, occupation-centred interventions have

been promoted during the last decades, but no unifying definition exists about the core

features. Aims/Objectives: The aim of this paper is to (a) identify and describe how

occupation-based and occupation-focused interventions are demonstrated in paediatric

occupational therapy for infants and young children with developmental delay, (b)

identify which outcomes these interventions address and (c) analyse which outcome

measures are used. Material and Methods: Eight databases and 15 OT journals were

searched. Included studies were peer-reviewed primary sources published in English

since 1999, selected based on the terminology proposed by Fisher (2013). Nineteen

papers met inclusion criteria. Results: Eight occupation-based, two occupation-focused

and nine occupation-based and occupation-focused interventions were identified.

Outcomes related mainly to occupational and play skill acquisition as well as mastery of

co-occupations. A limited number of occupation-focused outcome measures was

implemented. Conclusions: Several occupation-centred interventions have been

researched. Gaps in knowledge exist regarding measures taking into account (co-

)occupational performance and young children’s perspective. Significance: OTs might

want to expand their scope of practice to include all occupational domains and increase

parent-delivered interventions in natural environments. Measures used should be

relevant to occupational performance and take into account the parent’s and

children’s view. Use of uniform terminology can aid identification of evidence and

clear placement of OT among other professionals.

Keywords: Developmental delay; early childhood; intervention; occupational therapy;

occupation-based; occupation-centred; occupation-focused


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Introduction

Occupational therapists (OTs) play an important role in early childhood interventions

promoting children’s development, occupational performance and participation in domains

such as play, self-care, and social interaction [1-3]. Traditionally, OT services with young

children have been guided by developmental theories focusing on changing performance

components to promote occupational performance [4-7]. Nowadays, early intervention

services are moving towards family-centred care in natural environments and the support of

parent-child interactions [8-11]. The assumption that changing performance components will

automatically result in occupational outcomes has been doubted by several authors [12-16].

Humphry [17] further criticizes that this assumption is not in line with OT’s belief that

occupations arise from person-environment interactions.

In OT, a shift back towards the original focus on occupation has been under way for several

decades [18,19], leading to more occupation-centred interventions, collaborative goal setting

and outcomes focusing on improved activity and participation rather than changes in

performance components [14,20]. In paediatric practice, the interconnectedness of the child’s

occupational performance with the occupations of parents or other family members also needs

to be taken into account [21-23]. Parenting occupations play a central role in providing

children with opportunities to develop and enhance their occupational performance

[21,24,25]. The concept of co-occupation has been introduced to capture the highly interactive

nature of occupations of two or more persons, such as mothers and children [26,27].

Within the profession, a differentiation has been made of occupation as means, i.e. as a

medium of intervention, or as ends, i.e. the ultimate goal being increased quality of

occupational performance [28-30]. Further, the terms occupation-centred, occupation-focused


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and occupation-based are being used, sometimes interchangeably, and no unifying definition

of their core features exists [12,31-33]. Consistent definitions of core concepts are important

both as a prerequisite for a profession’s research and evidence-based practice as well as for

professional identity, reputation and communication with other professions [34-37]. Fisher

[12] suggests the use of uniform terminology with occupation-centred as an overarching

concept and a differentiation between occupation-based practice which uses active

engagement in occupation as the main ingredient of intervention, and occupation-focused

practice which immediately focuses on occupational performance instead of on changing

underlying components or environmental factors in order to improve occupational

performance. Fisher [12] specifically defines occupation as meaningful and purposeful doing

in the way it ordinarily occurs in a person’s daily life.

Several systematic reviews have been conducted investigating the effectiveness of OT in early

childhood interventions [3], but no review of occupation-centred interventions for young

children could be identified in a preliminary search using the databases AMED, CINAHL,

PubMed and PROSPERO with the search words: review, occupation-based, occupation-

centred, occupation-focused, intervention, therapy, treatment, practice and program.

Definition of core concepts used

For the purpose of this review, the concept of occupational performance is defined based on

the Person-Environment-Occupation-Performance (PEOP) model [38]. See Figure 1.

Insert Figure 1

The PEOP model assumes that occupational performance arises from a complex, dynamic

interaction of person, environment and occupation [38]. According to the model, occupational


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performance is influenced by enablers or barriers within the person, environment or

occupation with successful occupational performance promoting participation and well-being

[38,39].

Developmental delay is defined based on Dornelas, Duarte and Magalhães [40] and can occur

along with several childhood conditions including preterm birth, neurological diseases such as

cerebral palsy, genetic aberrations such as down syndrome, mental retardation or autism

which result in delayed acquisition of motor, cognitive, language, and social skills. The delay

can also be transient or without clearly defined underlying pathology [40].

Outcomes measures are tools used to measure change in a person’s occupational performance

or engagement in order to determine the success of an intervention. Features or abilities that

are expected to be influenced by intervention are therefore being quantified and measured at a

minimum at the beginning and end of an intervention. Consistent with client-centred practice,

the focus of an outcome measure should be of importance to the client [41].

Purpose/Aim

The aim of this paper is to (a) identify and describe how occupation-based and occupation-

focused interventions are demonstrated in paediatric occupational therapy for infants and

young children with developmental delay, (b) identify which outcomes these interventions

address and (c) analyse which outcome measures are used.

Material and Methods

A scoping review was chosen since it is appropriate to explore and map available research,

identify gaps in the literature and lay a foundation for future research [42-45]. This scoping


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review was performed based on the Arksey and O’Malley framework [42], informed by

recommendations of Levac et al. [43] as well as guidelines provided by the Jonna Briggs

Institute [45]. Findings are reported using the Preferred Reporting Items for Systematic

Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews [46].

Arksey and O’Malley [42] outline five steps in conducting a scoping review: (1) identifying

the research question, (2) identifying relevant studies, (3) study selection, (4) charting data,

and (5) collating, summarizing, and reporting results. Objectives, inclusion criteria and

methods were specified prior to initiation of the search [45].

Identifying the Research Question

The scoping review question was formulated as “How is occupation-centred practice

demonstrated in paediatric occupational therapy for infants and young children with

developmental delay?"

➢ What occupation-based and occupation-focused interventions are demonstrated?

➢ What are the main outcomes addressed in these interventions?

➢ Which outcome measures are used?

Identifying relevant studies

Search words were derived based on the person, intervention, comparison, outcome (PICO)

framework [47,48] and expanded through synonyms using thesaurus and literature relevant to

the topic to identify concepts relating to occupational performance [49] and alternative terms

for occupation-centred interventions [14]. Using terminology and definitions of occupations

and occupational performance summarised by Reed [50], participation was included as an


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outcome to capture literature involving engagement in play or activities of daily living (ADL)

within the child’s sociocultural context [51].

A three-step search strategy was implemented as recommended by Peters et al. [45]. Firstly,

databases CINAHL and MEDLINE were searched using keywords based on the PICO-model

(Table 1).

Insert Table 1

Text words contained in titles and abstract as well as index terms were screened to identify

additional keywords and the terms ‘neonate, special needs, treatment, rehabilitation and co-

occupation’ were added. Secondly, relevant databases (AMED, CINAHL, ERIC, Medline,

PsychInfo, OTSeeker, Cochrane, Scopus) were searched using all identified keywords and

relevant major headings or MeSH terms. Online issues of 15 OT journals were searched to

identify additional literature and grey literature was searched using ProQuest Dissertation and

Theses. All searches were performed between 05-03-2019 and 13-03-2019. Thirdly, reference

lists of included studies were searched. Included studies were limited to peer-reviewed

literature published in English. Since the last two decades have seen a stronger push towards

implementation of interventions focusing on occupation [34,52,53], only literature published

since 1999 until March-2019 was included. Full search strategy can be found in Appendix 1.

Study Selection

Papers were included in the scoping review if they were peer-reviewed and reported on an OT

intervention for children with developmental delay age 0-5 years. Studies with a broader age

range were included if they provided a separate analysis based on the relevant age group.

Intervention studies were selected if they were consistent with the definitions for occupation-

based (OB) or occupation-focused (OF) practice proposed by Fisher [12], delivered by OTs


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and provided a clear description of the intervention used and information about ethical

procedures, i.e. ethical approval or informed consent.

Definitions proposed by Fisher [12] were chosen since they provide a clear distinction of

concepts. Descriptions of intervention procedures and intended outcomes were read

repeatedly and mapped onto Fisher’s definitions [12] to classify interventions as OB or OF. If

multiple publications were identified referring to the same sample, the publication with the

most comprehensive reporting was chosen for inclusion, but information from background

documents, such as study protocols, were taken into account for qualitative synthesis if

necessary. Ambiguous studies were included as OB if more than 50% of intervention

strategies used occupation as means of intervention and as OF if at least one primary outcome

measure was occupation-focused or the main outcome was occupational, e.g. enjoyment of

mealtimes rather than improvement of oral-motor skills. If ambiguity existed, it was discussed

with the supervisor and in two cases authors were contacted to clarify details regarding study

population and intervention procedures [54,55].

The initial search strategy yielded a total of 678 documents after duplicates were removed

(see Fig. 2 for data selection process).

Insert Figure 2

Of these 413 were excluded because the title indicated that the study did not report on a

paediatric occupation-centred intervention. After screening of 265 abstracts, 90 articles were

eligible for full-text review. Applying inclusion and exclusion criteria, a total of 19 articles

were selected to be included in the review. Thirty-nine of the 90 articles were excluded due to

lack of separate analysis for the age group 0-5 years and 26 for other reasons. Among the


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excluded papers identified as OT interventions within the specified age range, 17 could not be

classified as OB or OF, e.g. interventions at the neurobehavioral level, sensory integration,

training of decontextualized skills or developmental domains. Five studies generally met

inclusion criteria, but did not provide information about ethical procedures and were therefore

excluded. One article describing a relationship-based intervention could not be accessed via

university or author [56].

Charting the Data

A data-charting form was created and applied to all included studies [42,43] recording:

author, year of publication, geographical location, population characteristics and sample size,

short description of intervention, practice setting, research method/study design, intended

outcomes, outcome measures and results (Appendix 2). Based on recommendations of Levac

et al. [43], the data charting form was initially used on five studies to determine whether

extracted data was relevant for answering the research question. As common in scoping

reviews, critical appraisal of included studies was not performed [42].

Collating, Summarizing and Reporting

Numerical analysis was performed based on the extracted data and outcomes were reported

based on occupational domains [49] relevant to the age group.

Additionally, categories of practice were identified using methods of qualitative content

analysis [57,58]. Therefore, extracted data was synthesized into three tables grouped by

intervention features (OB, OF, OB+OF) including authors and year, intervention description

and outcomes. Descriptions of intervention procedures and outcomes were read repeatedly to

identify categories of practice.


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Ethical Considerations

This review followed general ethical considerations based on the ‘Declaration of Helsinki’

[59] and the principles of autonomy, beneficence, justice and non-maleficence to ensure

honesty and integrity in all phases of the review process [60,61]. Since this is a review study

without direct involvement of participants, no ethical approval was obtained [62].

Autonomy: Autonomy includes a client’s ability to make informed choices [61] which is

consistent with client-centred OT. Occupation-centred interventions can help to ensure that

activities and outcomes addressed in OT intervention are meaningful to a client’s life

situation. The use of uniform terminology can aid in positioning occupation-based and

occupation-focused interventions more clearly and help families take informed decisions that

best suit their needs. The concept of autonomy was taken into account by including only

studies in the review which obtained informed consent from participants. Research with

young children requires special ethical considerations and the child’s as well as the parent’s

perspective should be taken into account [63,64].

Beneficence and non-maleficence: The aim of this review is to provide information which can

inform practitioners about how occupation-centred early childhood interventions are

demonstrated in intervention studies. Additionally, the results can provide a basis for further

research. The author set out an objective and transparent process in order to minimize bias

and allow for replication of search process and analysis [65,66].

Justice: This review includes only studies which provided information about ethical

procedures, such as ethical approval or informed consent [67,68] to ensure sampling,

recruitment, intervention and data management were undertaken correctly and fairly [69].


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Results

Results of numerical analysis are presented first, followed by results of thematic analysis

outlining categories of occupation-centred practice as well as outcomes addressed and

outcome measures used.

Most studies were conducted in western countries (n=15) [54,55,70-82], especially the United

States (n=9) [55,71-75,78-80], and used quasi-experimental or descriptive rather than

experimental designs with small sample sizes (Fig 3). A majority of studies were published

during the last 5 years (n=11) [54,55,70,72,74,75,79-81,83,84].

Insert Figure 3

While most identified studies were classified as OB (n=8) [54,55,72-75,79,84] or a

combination of OB and OF (n=9) [70,71,76-78,81-83,85], only two were classified as solely

OF [80,86]. See Table 2 for summary.

Insert Table 2

In some cases, the description of intervention procedures or intended outcomes, did not

provide sufficient information to classify as OF or OB.

Most studies provided direct interventions to children and their families (n=17) [54,55,70-

79,81-85], most often in combination with parent education [54,55,70-72,74-78,81-83,85,86]

and almost half were conducted in a clinic environment (n=9) [70,71,77,78,81-85]. Studies

examined a wide range of populations, including for example children with cerebral palsy

(n=6) [70,71,76,77,81,82], autism (n=4) [55,74,80,83], developmental delays (n=5)

[55,72,75,85,86], or prematurely born infants (n=1) [78].


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Occupation-based Interventions

Promoting Play. The occupation-based interventions focused mainly on play, with five

studies implemented as playgroups in community-settings [55,72,74,75,79]. These included

two community-based playgroups for children with developmental delays [55,75], and one

aquatic playgroup for children with autism [74], focusing on promoting play and parent-child

interaction. Another therapeutic playgroup promoting peer play as well as language and motor

development was implemented in a day-care centre by OTs and speech and language

pathologists (SLPs) [72]. One intervention provided an inclusive playgroup setting with

opportunities for unstructured play and examined effects of a powered ride-on car on play

behaviour and peer interaction for children with mobility-related disabilities [79]. Another

used a non-powered mobility device within individual free play sessions with scaffolded

support to promote engagement in play for children with severe mobility limitations [84].

Motor Skills Training. One OB intervention provided constraint induced movement therapy

(CIMT) in the home environment [73] for a young child with cerebral palsy (CP). The

intervention focused on improving performance skills such as upper extremity reach or

bilateral hand use.

Additionally, one paper was included as questionable. The paper described equine-assisted

therapy for toddlers and their mothers with the intention to provide positive shared

experiences and improve maternal caregiving and attachment [54]. While horse-riding might

not be considered a typical occupation for toddlers in western cultures, in cultures where

equine animals are commonly used in daily life, it could be.


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Occupation-focused Interventions

Promoting Everyday Function. The two OF interventions consisted of coaching for parents of

children with autism within an enriched home environment program [80] or other

developmental delays within a routines-based approach [86]. The focus was on changing

barriers in the environment in combination with modification of tasks or routines to improve

occupational performance.

Interventions both Occupation-based and Occupation-focused

Occupational and Motor Skills Training. Five of the nine interventions identified as OB and

OF were directed towards outcomes relevant to everyday functioning [71,76,77,81,82], often

provided either by OTs or physiotherapists (PTs)[71,77,81,82]. The interventions consisted of

providing intensive structured task practice for children with CP [82] including a study

comparing hand-arm bimanual intensive training (HABIT) and CIMT [71]. Further, two

interventions consisted of modification of task or environment with the goal of promoting

occupational performance in daily occupations, e.g. tying shoe-laces or self-feeding including

family-centred functional therapy [76] and a context-focused intervention [77]. Another study

describing a context-focused intervention for children with CP [81] was added as

inconclusive. Descriptions of activities used during intervention and outcome areas addressed

were insufficient to ensure that the intervention was really OB and OF [81,87].

Experiencing Co-occupation. The other four studies classified as both OB and OF provided

hands-on training of everyday occupations and opportunities for parent and child to

experience these co-occupations in a positive manner. Two interventions focused on feeding

occupations, combining parent coaching and hands-on training during mealtimes, for an infant

[78] and a 16-month old boy [85] with complex medical needs. Further, a relationship-


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focused intervention was implemented with a 20-month old girl with CP and her mother

combining engagement in child-led free play sessions with parent coaching to promote play,

attachment and mother-child interactions [70]. Finally, one intervention for children with

autism combined engagement in free play with sensory strategy use and hands-on training for

parents [83].

Outcomes and Outcome Measures

Most studies focused on outcomes in the areas of ADL or motor skill acquisition, engagement

in play or social interaction with parents or peers. None of the studies focused on outcomes

related to the domains sleep or rest. A variety of different outcome measures were used

(n=30), with the Pediatric Evaluation of Disability Inventory (PEDI; n=6) and the Canadian

Occupational Performance Measure (COPM; n=5) being the most widely used ones. See

Table 2 for summary. Outcome measures identified as occupation-focused included the

COPM, PEDI, Preschool Activity Card Sort (PACS), Assessment of Preschool Children’s

Participation (APCP), Performance Quality Rating Scale (PQRS), and the Routines-based

Interview (RBI). These were implemented in OF and OF+OB interventions and were most

often combined with component-focused measures such as the Assisting Hand Assessment

(AHA), Gross Motor Function Measure (GMFM), Test of Playfulness (ToP) or Child

Behavior Checklist (CBCL). Less than a quarter of papers (n= 4) [71,76,80,83] used only

occupation-focused outcome measures. In OB interventions mainly component-focused

measures were used. Three papers, all OF+OB, reported outcomes only narratively

[70,78,85].


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Discussion

This scoping review provides an overview of occupation-based and occupation-focused

interventions for infants and young children with developmental delay based on the

definitions proposed by Fisher [12] and analysed outcomes and outcome measures applied. A

considerable rise in publications displaying increased attention towards occupation-centred

practice could be identified during the last five years, possibly linked to the publication of the

International Classification of Functioning for Children and Youth (ICF-CY) [88] in 2007.

Nonetheless, the number of intervention studies which could be classified as occupation-

based or occupation-focused was relatively small. Despite the fact that OTs have been

encouraged to implement occupation-centred interventions for several decades [52,53], only

19 studies met inclusion criteria, most of them with small sample sizes. It has been criticized

that translation from theory into practice is slow with practitioners still using “more traditional

approaches directed at remediating impairments” [20,p.47].

Occupation-based and Occupation-focused Early Childhood Interventions

The included papers represent a variety of interventions mainly concerned with promoting

play [55,72,74,75,79,84], ADL skills [71,73,76,77,81,82] and mastery of co-occupations

[70,83,85,89]. Based on Fisher’s [12] definition of occupation which is specific to how

occupations usually occur in a client’s daily life, interventions such as sensory integration

were excluded since they use play, but not in the way it ordinarily unfolds in a child’s life. A

broader definition of occupation such as proposed within the PEOP [38] might have led to the

inclusion of different studies.

One factor complicating clear classifications based on Fisher’s [12] definitions was that

several studies used a mix of intervention strategies and outcome measures focusing on


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occupational performance and performance components likewise. The use of a combination

of approaches rather than a single one seems to represent daily practice of paediatric OTs

[90,91]. Some authors even argue that OT interventions might be most effective if occupation

as the overarching paradigm is combined with approaches addressing performance

components [18,92,93]. However, a recent systematic review of paediatric OT interventions

found activity-based interventions using a top-down approach to be most effective [94].

Further, despite the findings that parent-delivered interventions are as effective as therapist-

delivered ones [94], only two studies described OF parent coaching interventions [80,86]

showing a field of research which can be expanded, especially for this young age group where

occupational performance is so interconnected [21,22]. This is also true for interventions

provided in natural environments which have been found to be most effective [3,94]. Only

about half of the studies in this review were implemented in the home [73,76,80,86],

preschool environment [72] or in community playgroup settings [55,72,74,75,79],

representing a need for more research on how to better implement occupation-centred

interventions in natural settings.

Outcomes and Outcome Measures

Regarding outcomes, the main outcome areas addressed concerned ADL, play and social

participation. The occupational domain of sleep and rest was not covered in the included

studies, despite the fact that sleep problems are common in young children with

developmental delays [95,96] impacting parental stress levels and mental health [97,98]. A

review by Ho and Siu [99] found that sleep interventions provided by OTs for clients of all

ages mainly used assistive devices or cognitive behavioural approaches, only a small number

of interventions adapted activities or habits to improve sleep patterns. During the review


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process, only one sleep intervention was identified using an assistive device for children with

autism [95] which was excluded based on age range. This field of practice would benefit from

more research.

When it comes to measuring outcomes of occupation-centred interventions, measures need to

be compatible with OT values and suit intended outcomes [20,93,100]. Studies have shown

that paediatric OTs frequently use outcome measures that are not conceptually congruent with

the frames of reference or theories used [90,91]. During the review process, some studies

were excluded due to a mismatch of aims and measures applied, e.g. developmental instead of

occupational outcomes measured in a parent coaching intervention with the aim of providing

autistic children with more opportunity to participate in community activities [101]. Although

this review identified occupation-centred interventions, only a limited number of occupational

performance measures were implemented, all of them in interventions with an occupation-

focused component. It can be argued if PEDI and COPM, the most widely used outcome

measures, qualify as occupation-focused measures. PEDI, in this review mainly used in

studies with children with CP, combines items focusing on occupational performance with

items focusing on performance components [102]. COPM, recommended as an appropriate

tool to help parents set activity-based goals [103,104], was used to set occupational

performance goals, e.g. putting on a sweater, as well as goals focusing on performance

components, e.g. bilateral hand use, in the studies included in this review. The same was true

for Goal Attainment Scaling (GAS), which was used in three papers to measure family-

identified outcomes [81,82,86].

Setting clear occupation-based goals is an important prerequisite for measurement of specific

outcomes [105]. In line with family-centred practice which takes into account parent’s


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perspectives and values with regards to goal setting and delivery of intervention [106,107],

most studies incorporated collaborative goal setting [71,72,76-78,80-83,85,86]. None of the

studies however used child-report measures or family goal setting tools which also exist for

younger children with varying psychometric properties [105,108,109]. If activities used in

intervention are to be regarded as occupation they need to be meaningful to the child,

regardless of age [110]. Interventions taking into account a child’s motivation and level of

enjoyment have been found most effective [94,111] and studies with older children have

shown that goals of parents and children can be quite different [112]. In order to acknowledge

the parent’s and the child’s perspective in occupation-centred interventions, practitioners and

researchers should use existing family goal setting tools and child-report measures and ensure

that goals and occupations used in intervention are chosen by the client, not the therapist.

Finally, most of the studies focusing on promoting co-occupations [70,85] used only

observation to measure outcomes. There seems to be a need for occupation-centred outcome

measures for research and practice that capture the impact of OT interventions on

occupational performance taking into account the interconnected nature of young children’s

occupations. Further, DeGrace [113, p.347] has criticized that family-centred OTs should

assist families in “’being’ a family engaged in meaningful occupations” rather than doing

certain occupations which seems to be reflected to a certain extent in these studies with a

focus beyond the child’s functioning on the child-parent dyad as a whole.

Since the studies included in this review were not critically appraised, the level of evidence

for occupation-centred interventions with this age group cannot be determined. Questions

regarding effectiveness could only be thoroughly answered via a systematic review which

might want to include a broader age range to capture more relevant studies with larger sample


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sizes. The small number of studies identified in this review shows the need for more

intervention studies with high-quality designs and rigorous implementation to strengthen the

evidence-base for occupation-centred interventions with young children.

Use of Terminology and Communication about Occupation-centred Interventions

Since the introduction of the ICF [114], the view of disability and health has changed and

functional outcomes are gaining importance among health care professionals [115,116].

Therefore, OTs are not the only profession valuing goals relevant to occupational

performance. Several of the interventions included in this review (n=7) were provided by OTs

and other professionals such as PTs or SLPs [54,71,72,77,81,82,86], two studies did not even

include OT researchers [81,82]. Especially occupational and motor skills training seems to be

an area of practice where OT and PT interventions overlap. This highlights the importance of

clearly communicating the role of OT so we can be differentiated from other professions. Use

of occupation-centred interventions and language representing OT’s core values can be a way

of promoting OT identity and conveying the profession’s unique perspective [12,117-119].

Regarding the use of clear terminology, Rodger and Kennedy-Behr [14] suggest using the

terms ‘occupation-centred’ and ‘performance-component-focused’ to differentiate approaches

used in paediatric OT. Within the included studies, only a limited number of papers used the

terms ‘occupation-based’ [55,78,85] or ‘occupation-centred’ [80], none of them used

‘occupation-focused’. Instead terms such as ‘family-centred functional therapy’ [76],

‘context-focused’ [77,81] or ‘routines-based intervention’ [86] were used. The use of uniform

terminology across intervention studies, can aid in identifying evidence for OB or OF

interventions and facilitate communication within and outside the profession. In order to

classify interventions as OB or OF, procedures used in intervention studies need to be


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thoroughly described, which was not always the case in the included studies. A group of

researchers has created a template for more precise reporting of interventions which might

also be relevant for OT researchers [120].

Conclusion

This scoping review adds to existing knowledge about occupation-centred interventions for

young children by providing an overview of intervention studies performed during the last two

decades. Occupational therapists use a variety of occupation-based and occupation-focused

interventions to promote young children’s occupational performance mainly targeting

outcomes relating to the promotion of play and occupational skills in the domain of ADL as

well as positive mastery of co-occupations. Interventions mainly combined strategies and

outcome measures focusing on occupational performance with those focusing on performance

components. A limited number of occupation-focused outcome measures was implemented,

often not taking into account the interconnectedness of young children’s occupations. This

study indicates the need for measures capturing the impact of occupation-centred interventions

on occupational performance in all occupational domains relevant to young children’s lives,

taking into account the family’s and the children’s perspectives and provides a foundation for

future research, such as a systematic review. Further, results of this review point to the need of

using uniform terminology across intervention studies to aid identification of evidence and help

OTs communicate their unique role and perspective more clearly within and outside the

profession.


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Limitations

Although this scoping review was conducted based on the systematic approach by Arksey and

O’Malley [42] using recommendations by Levac et al. [43] and guidelines provided by the

Jonna Briggs Institute [45], several limitations remain. This review only included articles

published since 1999 in English. Only online issues of OT journals were searched and grey

literature search was limited to one source. Therefore, relevant articles might not have been

identified. Further, several papers relevant to the research question could not be included in

the final analysis due to a lack of information about ethical procedures or a broader age range

without separate analysis for 0-5 year olds, including interventions such as home, summer

camps, cognitive, and handwriting interventions. Studies identified in this review were mainly

limited to western countries and results might therefore not be transferrable to other regions.

Despite the author’s attempts to reduce bias, results should be viewed in the context in which

they were created, i.e. intent, methods and selection of inclusion criteria directly influence

results [66,121]. Since no uniform terminology has been accepted among OT practitioners

and researchers [31,32], using alternative definitions as a basis for study selection might have

affected the results substantially. Furthermore, despite recommendations [43,45], this scoping

review was conducted by only one author during a time frame shorter than the 6 months

recommended by Anderson et al. [44] and the recommended consultation phase [42] was

limited to discussions with colleagues and supervisor regarding importance of the topic and

research methods, increasing the risk of bias and individual errors.

Finally, the author’s limited research experience prior to undertaking the review may have

affected the quality of analysis, e.g. in extracting and interpreting key findings [122].


Evelin Fischer

22

Significance of findings

- OTs use a variety of occupation-centred interventions for infants and young children

with developmental delay, often using a combination of intervention strategies and

outcome measures focusing on occupational performance and performance

components.

- Occupation-centred interventions for young children should be expanded to more

natural environments and address all occupational domains relevant to young

children’s lives as well as include more parent-delivered interventions.

- Measures used in occupation-centred interventions should capture occupational

performance outcomes and take into account the parent’s and children’s view.

Recommendations for future research

- The use of uniform terminology around occupation-centred interventions and a

thorough description of procedures used in intervention studies can aid identification

of evidence and communication with clients and other professionals.

- Occupation-centred outcome measures need to be developed for research and practice

that capture the impact of OT interventions on occupational performance taking into

account the interconnected nature of young children’s occupations.

- Effectiveness of occupation-centred interventions should be analysed via a systematic

review, possibly taking into account a broader age range to capture more relevant

studies with larger sample sizes.

Disclosure of interest

The author reports no conflict of interest.


Evelin Fischer

23

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Figure 1: Core concepts of the PEOP model - adapted from Baum et al. [38]

PA

RT

ICIP

AT

ION

PE

RF

OR

MA

NC

E

WE

LL

-BE

ING

Cognition

Psychological

Physiological

Sensory

Motor

Spirituality

PERSON OCCUPATION

Activities

Tasks

Roles

Assistive

Technology

ENVIRON

MENT

Culture

Social determinants

Social Support

Social Capital

Education and Policy

Physical and

Natural


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Figure 2: PRISMA Flowchart


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Publication Year

1999-2004

2005-2009

2010-2014

2015-2019

n=

1

2

5

11

Age of

participants

0-1;11

2;0-3;11

4;0-5;11

n=

10

16

9

Intervention features

Occupation-based

Occupation-focused

Both OB and OF

n=

8

2

9

Country

Australia

Canada

Germany

Netherlands

Norway

South Africa

South Korea

Taiwan

USA

n=

1

2

1

1

1

1

2

1

9

Sample Sizes

< 10

10-49

50-100

> 100

Participants

across all studies

(age range 0-5)

n=

10

8

1

1

n=

366

Outcomes

ADL

Sleep and Rest

Play

Leisure

Social Participation/

Social Interaction

n=

9

0

12

3

8

Study design

Randomized-Control

trial

Two-group pre/post

One-group pre/post

Single subject

Case study/case report

Qualitative

Mixed methods

n=

5

0

4

7

3

1

2

Practice Setting

Home

Community

Preschool

Clinic

Group

Individual

Mixed

n=

5

6

1

9

5

12

2

Measures used

Standardized measures

PEDI

COPM

GAS

PACS

ACPC

ToP

Observation/Narrative

Task/Performance

analysis

n=

10

6

5

4

1

1

3

3

0

ADL = Activities of daily living; ACPC = Assessment of Preschool Children’s Participation; COPM = Canadian

Occupational Performance Measure; GAS = Goal Attainment Scaling; OB = occupation-based; OF = occupation-focused;

PEDI = Pediatric Evaluation of Disability Inventory; PACS = Preschool Activity Card Sort; ToP = Test of Playfulness

Figure 3: Numerical analysis of included studies


Evelin Fischer

36

Table 1: Search words based on the PICO-model

Population Intervention Control Outcome

Infants and

young children

with

developmental

delay

Occupation-based or

occupation-focused

interventions

Pre-Post Occupational

performance

Pediatric

Paediatric

Child

Toddler

Infant

Neonate

AND

disability

delay

special needs

AND

Occupation-based

Occupation-centred

Occupation-focused

Activity-based

Activity-focused

Task-based

Task-focused

Participation-based

Context-focused

AND

Intervention

Therapy

Practice

Program

Treatment

Early Intervention

Rehabilitation

AND

Occupational

performance

Participation

Activities of daily

living/ADL

Self-care

Sleep

Play

Leisure

Social interaction

Co-occupation


Evelin Fischer

37

Table 2: Thematic synthesis of occupation-based and occupation-focused interventions with

the most widely used outcome measures

Author, year Occupation-based Occupation-focused COPM PEDI

An, 2014 [85]

An, 2017 [83]

Barfoot, Meredith, Ziviani, &

Whittingham, 2015 [70]

Bastable, Dada, & Uys, 2016 [84]

de Brito Brandão, Gordon, &

Cotta Mancini, 2012 [71]

Demchick & Day, 2016 [72]

Dickerson & Brown, 2007 [73]

Fabrizi & Hubbell, 2017 [75]

Fabrizi, Ito, & Winston, 2016

[55]

Fabrizi, 2015 [74]

Hwang, Chao, & Liu, 2013 [86]

Lammi & Law, 2003 [76]

Law et al., 2011 [77]

Price & Miner, 2009 [78]

Ross et al., 2018 [79]

Sood, Szymanski, & Schranz,

2015 [80]

Størvold & Jahnsen, 2010 [82]

Kruijsen-Terpstra et al., 2016*

[81]

Beetz, Winkler, Julius, Unväs-

Moberg, & Kotrschal, 2015**

[54]

* Inconclusive **Questionable

Appendix 1: Full Search Strategy

Date Database Search string Settings/Limitations Hits Relevant

by title

Relevant

by

abstract

Included

05-03-

2019

CINAHL Pediatric OR Paediatric OR Child* OR Toddler

OR Infan* OR Neonat* AND disability OR

delay OR special needs AND Occupation-based

OR Occupation-centred OR Occupation-

focused OR Activity-based OR Activity-

focused OR Task-based OR Task-focused OR

Participation-based OR Context-focused AND

Intervention OR Therapy OR Practice OR

Program OR Treatment OR Early Intervention

OR Service OR Rehabilitation AND

Occupational performance OR Participation OR

Activities of daily living OR ADL OR Self-care

OR Sleep OR Play OR Leisure OR Social

interaction OR co-occupation

English,

Boolean/phrase,

1999-2019,

Research article

28 14 4 Kruijsen-

Terpstra et al.,

2016 [81]

Law et al., 2011

[77]

05-03-

2019

CINAHL (MH "Pediatric Occupational Therapy/MT") English, 1999-2019,

Research article

142 54 25 De Brito

Brandão et al.,

2012 [71]

Dickerson, 2007

[73]

Kruijsen-

Terpstra et al.,

2016 [81]

Law et al., 2011

[77]


Evelin Fischer

39

Størvold and

Jahnsen, 2010

[82]

05-03-

2019

AMED Pediatric OR Paediatric OR Child* OR Toddler













interaction

Boolean/phrase,

search all text,

English, 1999-2019

8 3 1 -

05-03-

2019

ERIC Pediatric OR Paediatric OR Child* OR Toddler














Boolean/phrase,

English, 1999-2019

21 9 1 -

05-03-

2019

ERIC (DE "Occupational Therapy") AND (DE "Early

Intervention" OR DE "Developmental Delays")

English, 1999-2019 53 17 2 Demchick and

Day, 2016 [72]


Evelin Fischer

40

Fabrizi et al.,

2017 [75]

05-03-

2019

MEDLINE Pediatric OR Paediatric OR Child* OR Toddler













interaction

Boolean/phrase,

English, 1999-2019

39 12 7 Kruijsen-

Terpstra et al.,

2016 [81]

Law et al., 2011

[77]

05-03-

2019

MEDLINE (MH "Occupational Therapy/MT") AND (MH

"Pediatrics")

English, 1999-2019 23 3 0 -

05-03-

2019

PsychInfo Pediatric OR Paediatric OR Child* OR Toddler














English, 1999-2019

45 13 3 Kruijsen-

Terpstra et al.,

2016 [81]

Law et al., 2011

[77]


Evelin Fischer

41

05-03-

2019

PsychInfo MAINSUBJECT.EXACT("Pediatrics") AND

MAINSUBJECT.EXACT("Occupational

Therapy")

English, 1999-2019 133 23 8 Dickerson, 2007

[73]

Lammi and Law,

2003 [76]

06-03-

2019

Scopus Pediatric OR Paediatric OR Child* OR Toddler














Search title, abstract,

keywords, 1999-

present

0 - - -

06-03-

2019

Scopus Pediatric OR Paediatric OR Child* OR Toddler














Search all fields,

abstract, keywords,

1999-present

152 16 1 Hwang et al.,

2013 [86]


Evelin Fischer

42

OTSeeker Pediatric OR Paediatric OR Child* OR Toddler














Search any field 9 4 2 Hwang et al.,

2013 [86]

Law et al., 2011

[77]

Cochrane trials Pediatric OR Paediatric OR Child* OR Toddler













interaction

Search all text, 1999-

2019

14 7 3 Hwang et al.,

2013 [86]

667 175 57 9

Grey literature

10-03-

2019

ProQuest

Dissertation &

Theses

Pediatric OR Paediatric OR Child* OR Toddler




Search all text,

1999-2019

0 - - -


Evelin Fischer

43











10-03-

2019

ProQuest

Dissertation &

Theses

Occupation-based OR Occupation-centred OR

Occupation-focused OR Activity-based OR

Activity-focused OR Task-based OR Task-

focused OR Participation-based OR Context-

focused AND Intervention OR Therapy OR

Practice OR Program OR Treatment OR Early

Intervention OR Service OR Rehabilitation

1999-2019 0 - - -

10-03-

2019

ProQuest

Dissertations &

Theses


OR Infan* OR Neonat* AND Occupation-

based OR Occupation-centred OR Occupation-



Participation-based OR Context-focused

1999-2019 0 - - -

0 0 0 0

OT Journals

10-03-

2019

American Journal

of Occupational

Therapy

(via Publisher’s

Website)


OR Infan* OR Neonat* AND Occupation-

based OR Occupation-centred OR Occupation-



Participation-based OR Context-focused

1999-2019 36 5 1 -

10-03-

2019

American Journal

of Occupational

Therapy

Occupation-based OR Occupation-centred OR

Occupation-focused OR Activity-based OR

Activity-focused OR Task-based OR Task-

Research Article

1999-2019

97 9 8 Fabrizi et al.,

2016 [55]


Evelin Fischer

44

(via Publisher’s

Website)

focused OR Participation-based OR Context-

focused AND Intervention OR Therapy OR

Practice OR Program OR Treatment OR Early

Intervention OR Service OR Rehabilitation

Topics: Pediatric

Evaluation and

Intervention

12-03-

2019

Australian Journal

of Occupational

Therapy

(via Wiley)
















2019

222 7 1 -

10-03-

2019

Canadian Journal

of occupational

therapy

(via SAGE

Journals)















Search all text,

Research Article

1999-2019

264 7 3 -


Evelin Fischer

45

12-03-

2019

British Journal of

Occupational

Therapy

(Via SAGE

Journals)










OR Rehabilitation AND Occupational

performance OR Participation OR Activities of

daily living OR ADL OR Self-care OR Sleep

OR Play OR Leisure OR Social interaction OR

co-occupation

Search all text,

Research Article

1999-2019

468 14 4 Barfoot et al.,

2015 [70]

12-03-

2019

Irish Journal of

Occupational

Therapy

(via Emerald OA,

available only

from 2017)















Search all text,

Research paper,

1999-2019

16 1 1 -

12-03-

2019

New Zealand

Journal of

Occupational

Therapy

(via

CINAHL/EBSCO,







Search all text,

Boolean/Phrase,

Research article,

English, 1999-2019

8 1 1 -


Evelin Fischer

46

available only

from 2003)








co-occupation

12-03-

2019

Scandinavian

Journal of

Occupational

Therapy (via

CINAHL/EBSCO)














co-occupation

Search all text,

Boolea/Phrase, 1999-

2019

73 10 4 Price and Miner,

2009 [78]

12-03-

2019

Asian Journal of

Occupational

Therapy

(via Publisher’s

website, available

only from 2001)













English, 1999-2019 0 0 - -


Evelin Fischer

47



12-03-

2019

Indian Journal of

Physiotherapy and

Occupational

Therapy

(via

CINAHL/EBSCO,

available only

from 2011)














co-occupation

English, 1999-2019,

Boolean/Phrase,

Research Article

3 2 0 -

12-03-

2019

South African

Journal of

Occupational

Therapy

(via ProQuest,

available only

from 2013)














co-occupation

Boolean Operators,

English, 1999-2019

22 2 1 -

12-03-

2019

The Open Journal

of Occupational

Therapy (via






2019, Profession:

Occupational

Therapy

119 4 1 -


Evelin Fischer

48

DOAJ, available

only from 2013)










co-occupation

12-03-

2019

OT International

(via ProQuest)














co-occupation

Search all text,

Boolean Operators,

English, 1999-2019

15 2 1 An, 2017 [83]

12-03-

2019

OT and PT in

Pediatrics (via

Taylor & Francis)











Search all text,

1999-2019

248 31 13 Bastable et al.,

2016 [84]


Evelin Fischer

49




co-occupation

13-03-

2019

OTJR –

Occupation,

Participation and

Health

(via SAGE

Journals)














co-occupation

Search all text,

Boolean Operators,

Research Article,

1999-2019

199 6 2 -

13-03-

2019

Journal of

Occupational

Therapy, Schools,

& Early

Intervention

(via Taylor &

Francis, available

only from 2008)














co-occupation


2019

216 31 13 Beetz et al., 2015

[54]

Demchick and

Day, 2016 [72]

Fabrizi, 2015

[74]

Fabrizi and

Hubbell, 2017

[75]

Sood et al., 2015

[80]

2006 132 54


Evelin Fischer

50

Papers identified for full-text review by reference check of papers included in synthesis

Paper Identified paper Included

An, 2017 [83] An, 2014 [85] An, 2014 [85]

Barfoot et al., 2015 [70] Stewart, 2008 [56]

Bulkeley et al., 2016 [123] Magiati et al., 2011 [124]

De Brito Brandao et al., 2012

[71]

Ahl et al., 2005 [125]

Demchick and Day, 2016 [72] Carlson et al., 2010 [126]

Fernell et al., 2011 [127]

Sood et al., 2015 [80]

Fabrizi et al., 2017 [75] Blanche et al., 2016 [128]

Kruijsen-Terpstra et al., 2016

[81]

Darrah et al., 2011 [129]

Lammi and Law [76] Darrah et al., 2001 [130]

Law et al., 2011 Østensjø et al., 2008 [104]

Ross et al., 2018 [79] Casey et al., 2013 [131]

Watling and Dietz, 2007

[132]

Case-Smith and Bryan, 1999 [133]

Linderman and Stewart, 1999 [134]

14


Evelin Fischer

51

Appendix 2: Exemplary Data Charting Form

Database Author,

Year,

(REF#)

Occupation-

based (OB)

or

Occupation-

focused

(OF)

Intervention

description*

Participants/

Sample Size/

Age/ Context/

Country

Method/

Design

Intended

Outcomes

Outcome

Measures

Results

Positive/

negative/

mixed

OT

Journal

search

An, 2017

[83]

OF

OB

Occupation-focused

parent training

combined with direct

intervention with

child-parent dyads

(child – occupational

engagement + sensory

integrative

procedures, parent –

interactive learning +

hands on training)

2 out of 4

children with

autism within

the age range

3-4 years/

clinic-based/

individual/

South Korea

Qualitative &

Quantitative,

One-group

pretest/

posttest

retrospective

design

combined with

interviews

about parent’s

perceptions

and

experiences

Individually

chosen

outcomes

based on

COPM

including

ADL, play

and parent-

child

interactions

COPM Positive

(improvements

in COPM

performance &

satisfaction)

SCOPUS,

OTSeeker,

Cochrane

trials

Hwang

et al.,

2013

[86]

OF* Routines-based early

intervention*

including

collaborative goal

setting and parent

coaching focusing on

performance of daily

routines during bi-

weekly home visits by

38 children

with or at risk

for

developmental

delay (19

intervention,

19 control)/

age range 5-30

months/ home-

Quantitative,

single-blinded

RCT

Participation

in family

routines and

performance

of daily

activities

Primary:

PEDI-C

(Chinese

Version),

GAS,

COPM,

RBI

Secondary:

Positive

(improvements

in GAS &

PEDI self-care

and social

functions, not

in functional

mobility, less

in COPM,


Evelin Fischer

52

a home visitor,

supervised by special

education teachers,

PTs, OTs, doctors &

nurses, vs. child-

focused

developmental home

visit intervention

based/

individual/

Taiwan

CDIIT, The

CCITSN-C

more progress

in the

intervention

group than the

control

developmental

intervention

group)

OT

Journal

search

Ross et

al., 2018

[79]

OB2

Inclusive playgroup

providing

unstructured free play

opportunities

(1hr/week),

introduction of

powered modified

ride-on cars for

children with

disabilities after a

baseline phase

13 children (8

without

disabilities, 5

with mobility

related

disabilities)/

age range 1-3

years/

community-

based/ group/

Oregon, USA

Quantitative,

Single-Subject

design

Play behavior modified

Howes peer

play scale

Negative/

Mixed (some

changes in

peer play and

interaction, but

no significant

changes in

play behaviors

for children

with

disabilities) CCITSN-C = Carolina Curriculum for Infants and Toddlers with Special Needs – Chinese Version; CDIIT = Comprehensive Development Inventory for Infants

and Toddlers; COPM = Canadian Occupational Performance Measure; CP = Cerebral Palsy; GAS = Goal Attainment Scaling; OB = Occupation-based; OF =

Occupation-focused; OT = Occupational Therapy; PEDI (FSS & CAS) = Pediatric Evaluation of Disability Inventory (Functional Skills Scales & Caregiver

Assistance Scales); PT = Physiotherapy; RBI = Routines-based Interview; *relates to intervention group in two-group designs; 1 insufficient information provided

to classify as OB; 2 insufficient information provided to classify as OF

occupation as means and ends in early childhood ...1344445/fulltext01.pdfoccupational therapy,...

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