Systematic Review of Occupational Therapy and Mental Health Promotion,Prevention,and Intervention for Children and Youth

Statement of the Problem

Historically, interventions in the area of children’s mental health tended to focus narrowly on services provided to children with diagnosed mental illness provided in psychiatric settings (Bazyk, 2011). More recent efforts have used a public health model to expand the scope of services. According to Bazyk (2011), children’s mental health services using the public health model focus on helping all children develop and maintain mental health, and occupational therapy practitioners provide such services to all children, both with and without identified mental health problems. These services promote occupational performance in areas of occupation, including education, play, leisure, work, social participation, activities of daily living (ADLs), instrumental activities of daily living, and sleep and rest, within a variety of environments, such as school, home, community, and health care settings (American Occupational Therapy Association [AOTA], 2008). Systematic reviews of children’s mental health research strengthen the current knowledge of the efficacy of practices used by occupational therapy practitioners for all children and youth, not just those with diagnosed mental illness.

Background

The mission of public health is to create a society in which people can be healthy (Institute of Medicine, 1988). This mission is accomplished by “creating the expertise, information and tools that people and communities need to protect their health—through health promotion, and prevention of disease, injury and disability” (Centers for Disease Control and Prevention, 2013). The World Health Organization (2001) and national leaders in the field of children’s mental health have advocated for a public health approach to mental health emphasizing the promotion of mental health as well as the prevention of and intervention for mental illness (AOTA, 2010a, 2010b; Bazyk, 2011). The public health model of mental health includes three major levels of service:

Guided by the emerging focus of occupational therapy on wellness and health promotion, the philosophical basis of the profession, and the importance of engagement in meaningful occupations and activities, occupational therapy practitioners can play a vital role in providing services in all three tiers.

Because a public health approach to mental health involves the provision of promotion, prevention, and intensive interventions, it is important to make distinctions among these practices. Mental health promotion interventions focus on competence enhancement—that is, on building strengths and resources in the whole population (Barry & Jenkins, 2007). Prevention interventions have been developed over the past two decades and have traditionally focused on reducing the incidence and seriousness of problem behaviors and mental health disorders (Barry & Jenkins, 2007; Catalano, Hawkins, Berglund, Pollard, & Arthur, 2002). Early prevention programs tended to focus primarily on reducing risk factors (e.g., family history of substance abuse, poverty). Current approaches, however, recognize the importance of minimizing mental health problems by enhancing protective factors as well (e.g., social and emotional competencies, clear standards for behavior; Miles et al., 2010). Intensive individualized interventions are provided to diminish the effects of an identified mental health problem and assist the child in reaching an optimal state of functioning. Intervention at this level is often dependent on the specific mental health problem or formal diagnosis (Miles et al., 2010).

Method

This systematic review examined studies that evaluated the effects of occupation- and activity-based intervention on peer and social interaction, compliance with adult directives and social rules and norms, or productive or task-focused behaviors (including ADLs) for children and youth at the universal, targeted, and intensive tiers. These areas were chosen by a consensus group of occupational therapy practitioners with mental health expertise, who felt that these were the most representative of psychosocial components that predict participation in school and in the home and community. In other words, these mental health experts believed that children who were able to interact in peer and social environments or comply with adult directives and engage in task behavior were more likely to successfully participate in school and in the home and community environments.

An evidence-based perspective is based on the assumption that scientific evidence of the effectiveness of occupational therapy intervention can be judged to be more or less strong and valid according to a hierarchy of research designs, an assessment of the quality of the research, or both. This review used standards of evidence developed in evidence-based medicine that standardize and rank the value of scientific evidence for biomedical practice using the following grading system (Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996):

To conduct the systematic review, reviewers evaluated research studies published in the peer-reviewed scientific literature according to their quality (scientific rigor and lack of bias) and levels of evidence. An initial review conducted in 2003 covered articles published between 1980 and 2002 (Jackson & Arbesman, 2005). An updated review included articles published between 2003 and 2009. In addition, more recent articles were included covering the period 2010–2012 that were recommended by occupational therapy practitioners with mental health expertise. Specific inclusion criteria were as follows:

The following articles were excluded: presentations and conference proceedings, non–peer-reviewed literature, dissertations and theses, articles about participants who were younger than age 3 yr, and articles that provided Level IV and V evidence.

Reviewers, AOTA staff, and the AOTA project methodology consultant first identified search terms, and the advisory group reviewed them. For the updated review, additional search terms were added to reflect changes in terminology that had taken place since the first review. Search terms for the reviews included activities, activities of daily living, bullying, friendship, health, leisure, out-of-school activities, play, promotion/wellness, recreation, resiliency, school mental health, stress, and transition. A medical research librarian with experience in completing systematic review searches conducted all updated searches. Reviewers searched MEDLINE, ERIC, EMBASE, Evidence-Based Medicine Reviews, and PsycINFO; OTseeker was included in the updated review.

The AOTA methodology consultant completed the initial review of the database search results. The updated review was completed in part through an academic partnership with the third author (Susan M. Nochajski) and master’s students in occupational therapy at the University at Buffalo, State University of New York, and in part by the AOTA consultant (Marian Arbesman). The team of reviewers also scanned the bibliographies of articles selected for review. After the literature search, reviewers then evaluated the quality of the studies and ranked them according to level of evidence.

The strength of the evidence is based on the guidelines of the U.S. Preventive Services Task Force (2012). The designation of strong evidence includes consistent results from well-conducted studies, usually at least two randomized controlled trials (RCTs). A designation of moderate evidence is based on one RCT or two or more studies with lower levels of evidence. In addition, some inconsistency of findings across individual studies might preclude a classification of strong evidence. The designation of limited evidence may be based on few studies, flaws in the available studies, and some inconsistency in the findings across individual studies. A designation of mixed evidence may indicate that the findings were inconsistent across studies in a given category. A designation of insufficient evidence may indicate that the number and quality of studies are too limited to make any clear classification.

Only selected articles from the systematic review are mentioned in this article and included in the reference list. Table 1 summarizes the objective, design and participants, interventions and outcome measures, results, and limitations of six articles that helped answer the focused questions and were representative of the results of the systematic reviews.

Results

A total of 124 articles were included in the earlier and updated reviews. Although the reviews included published literature from both occupational therapy and other related fields, all studies provided evidence within the scope of occupational therapy practice. Seventy-seven of the articles (62%) were classified as Level I evidence, 27 (22%) were classified as Level II studies, and 20 (16%) were classified as Level III studies.

Discussion and Implications for Practice, Education, and Research

The results of the systematic review provide a wealth of evidence supporting a strength-based approach for all children and youth, targeted services for at-risk groups and populations, and an individual client impairment–focused model of practice for children and youth with identified mental health challenges. The evidence also provides support for an occupation- and activity-based approach that can be used with children and youth at all three tiers in a wide range of environments (e.g., school, home, community) and contexts.

The results at the Tier 1 universal level provide occupational therapy practitioners with strong evidence to support providing occupation- and activity-based interventions in many areas, such as social–emotional learning programs and schoolwide programming to prevent bullying. Occupational therapy practitioners working in schools and after-school programs should consider incorporating a social skills component because the evidence is strong that activity-based social skills interventions improve social behaviors and reduce problem behaviors. In the area of health promotion, school-based stress management programs have been shown to reduce stress and improve coping skills in children in Grades 3–8 and should be incorporated into school and after-school programs.

At the universal level, occupational therapy practitioners can also play a role in improving participation in activities such as performing arts programs. A recent report by the National Endowment for the Arts (Catterall, Dumais, & Hampden-Thompson, 2012) indicated that children and adolescents from low socioeconomic backgrounds who participate in arts programming either at school or in extracurricular programs achieve better academic success in school.

At the targeted level, the evidence is strong that social and life skills programs are effective for a wide range of at-risk children and youth such as aggressive or rejected youth and teenage mothers. In addition, the evidence is strong that children with intellectual impairments, developmental delays, and learning disabilities benefit from social skills programming and play, leisure, and recreational activities. Occupational therapy practitioners are the ideal professionals to provide these types of programs because they have a wealth of knowledge about the challenges for these children and adolescents and about activity-based programming.

The evidence for the effectiveness of social skills programs is also strong for children requiring services at the intensive level. Occupation- and activity-based social skills programs are effective in helping children with ASD improve social behavior and self-management. In addition, social skills programs are effective in improving social behaviors for children and adolescents with a diagnosed mental illness or serious behavior disorder.

Findings from this systematic review cover many aspects of occupational therapy practice for children’s mental health and demonstrate scientific rigor. The review involved systematic methodologies and incorporated quality control measures. The review included 124 articles, and 84% described Level I and II evidence, indicating that the evidence is of very good to high quality. The articles included in the systematic review, however, have several overarching limitations: small sample sizes; wide variation in interventions, diagnoses, clinical conditions, and outcomes measured; and the use of self-report outcome measures. Depending on the level of evidence, some studies lacked randomization or a control group or provided limited statistical reporting. In addition, a wide range of diagnoses, clinical conditions, and types of interventions may have been included in the meta-analyses and systematic reviews incorporated in this review.

Occupational therapy academic programs have a long history of incorporating mental health practice into curricula. Occupational therapy practitioners are well prepared not only to identify mental health problems but also to understand how to assess and provide interventions to children and youth needing intensive services. The information provided in this systematic review, however, takes a broader approach in emphasizing mental health promotion and prevention interventions for children and youth without diagnosed mental illness. It is important for academic programs to prepare students through coursework and fieldwork experiences to apply a public health model of children’s mental health at the universal, targeted, and intensive levels in both school- and community-based settings. This systematic review shows that occupational therapy practice can expand into a public health model while using occupation- and activity-based approaches.

Although much of the evidence to date, as reported in this systematic review, was published by researchers outside the field of occupational therapy, it is critical for occupational therapy practitioners to use this evidence to support practice and future research in each tier. For example, when developing new programs focusing on social skills; play, leisure, and recreation; or health promotion, practitioners can use summaries of evidence to document the benefits of such programs. In addition, practitioners need to commit to generating evidence-based findings to support services provided at the universal, targeted, and intensive levels. At the universal level, practitioners can collaborate with teachers and administrators in assessing school climate or whole-class social–emotional learning after the implementation of whole-school programming. Collecting pre- and posttest scores on social skills measures when implementing small group intervention to targeted at-risk students is another way to obtain evidence to evaluate intervention outcomes. Finally, clear documentation of student outcomes after individualized services provides evidence regarding the effects of intervention for individual students. Occupational therapy practitioners also can agree to collaborate with colleagues and participate in any large-scale RCTs conducted at their setting.

The findings of this systematic review have the following implications for occupational therapy practice: