Abstract
Healthy habits is a psychoeducational construct that refers to the preventive practice of analyzing and then adapting the sleep, physical, and eating routines of children in ways that enhance health and well-being. This approach is based on evidence that demonstrates the positive therapeutic value of engaging in proactive, healthful behaviors. In addressing healthy habits, occupational therapy practitioners have an opportunity to contribute to the Triple Aim of health care reform while demonstrating the value of occupational therapy in educational, medical, community, and other settings.
In 2009, the Institute of Medicine (IOM) estimated that 45.7 million Americans were living without health insurance. The consequences of being uninsured are significant and include decreased access to immunizations, medications, preventive care, ambulatory care, and dental care (IOM, 2009). Children with special health care needs who do not have health insurance may experience delayed diagnoses, avoidable hospitalizations, and decreased access to specialists and early intervention. Children without insurance are also more likely to miss school secondary to illness (IOM, 2009). A lack of insurance often keeps children and families from seeking appropriate preventive, acute, and long-term care.
The Patient Protection and Affordable Care Act of 2010 (ACA) was passed to extend health care to the many millions of Americans without health insurance. Under the law’s framework, which is based on the Triple Aim (Berwick, Nolan, & Whittington, 2008), the health care system is challenged to achieve outcomes in terms of (1) quality, (2) efficiency, and (3) cost-effectiveness, which have not always been valued as priorities in the U.S. health care system. The concept of the Triple Aim is also reflected in the National Quality Strategy adopted by the U.S. Department of Health and Human Services (2011).
In passing a law as comprehensive as the ACA, Congress did not limit its purview to traditional models of health care. Rather, it recognized the importance of expanded primary care, integrative medicine, community-based health care, and improved access, including access through expanded school-based health centers (SBHCs), to meet the needs of newly insured people as well as the economic need for cost-effectiveness. For example, the ACA includes earmarks for more than $11 billion for community health centers and $200 million for SBHCs (Health Resources and Services Administration, 2015).
As noted by Peterson and Nelson (2003), SBHCs “are federally funded, geographically dispersed . . . programs designed to integrate health services and educational services for children from economically disadvantaged settings” (p. 152). Although they are tailored to meet the specific needs of each community, SBHCs typically provide children with access to immunizations, medications, treatment of acute illness, laboratory services, counseling, and health education (Health Resources and Services Administration, 2015). Many SBHCs provide basic dental care, drug and alcohol counseling, reproductive health services, and management of chronic conditions. For children in rural, urban, or otherwise disadvantaged communities, SBHCs are often the only option for primary care (National Conference of State Legislatures, 2011). Evidence has suggested that when students use SBHCs, they are more likely to receive other care and appropriate preventive care (e.g., vaccinations), and they are less likely to use emergency rooms (Allison et al., 2007). SBHCs appear to augment access to care and quality of care for underserved adolescents compared with traditional outpatient care sites (Allison et al., 2007) and can thus be a critical component of promoting better participation in health by students.
In SBHCs and in other ways, U.S. schools have an important part to play if the Triple Aim of health care reform is to be realized. Fortunately, schools already have a variety of trained health care professionals who provide services in educational settings. The value of occupational therapy in this context extends beyond the usual role of school-based clinicians. Indeed, occupational therapy practitioners provide a readily accessible source of expertise and care and can contribute to the preventive, acute, habilitative, rehabilitative, behavioral, and mental health care needs of children in schools. Although these roles may be unfamiliar or even intimidating to some school-based occupational therapy practitioners, existing evidence-based resources are available to guide expansion of the practice of occupational therapy to improve health and quality of life.
In their column “P4 Medicine and Pediatric Occupational Therapy,” Persch, Braveman, and Metzler (2013) noted that “within psychoeducational psychotherapy, healthy habits refers to structuring a child’s diet, sleep, and physical activity in a way that optimizes health” (p. 385). Occupational therapy practitioners, with their advanced training in activity analysis, have an extraordinary opportunity to deploy healthy habits interventions for children in schools. Approximately 22% of American Occupational Therapy Association (AOTA) members practice in school settings (AOTA, 2010) and thus are ideally situated to deploy preventive practices such as healthy habits. In working to expand their sphere of influence in the schools, clinicians can contribute to overall health, facilitate patient engagement, and reduce the costs of ill health, all of which are key components of the Triple Aim.
The purpose of this article is to provide occupational therapy practitioners with evidence that supports the therapeutic power of healthy habits interventions for children. In doing so, we hope to empower those who seek to demonstrate the value of occupational therapy in “meeting society’s occupational needs” (AOTA, 2007, p. 613) in the schools and elsewhere. We focus on three critical areas of evidence that can be used to support appropriate healthy habits interventions: (1) sleep hygiene, (2) physical activity, and (3) healthy nutrition.
Sleep Hygiene
Sleep is a basic need of all children (Mindell, Meltzer, Carskadon, & Chervin, 2009). Indeed, Maslow (1943) placed sleep at the level of basic physiological needs that motivate human behavior. The time at which typically developing children awake is generally more consistent than their bedtime (Petta, Carskadon, & Dement, 1984), reflecting most children’s dependency on their parents to establish a schedule for waking up, getting dressed, and preparing for the day. In adolescence, children begin to stay up later at night. If their schedule permits, they also begin to wake later in the morning. The effects of this shift in sleep behavior may be profound (Steinberg, 2010). For example, sleep deprivation in adolescence is known to impair school performance and is related to decreased physical and mental health (Danner, 2000; Wolfson & Carskadon, 1998).
Differences in sleep behavior are especially relevant for children with disabilities. Sleep disturbances are commonly observed in children with mental health disorders such as depression (Emslie, Rush, Weinberg, Rintelmann, & Roffwarg, 1990), bipolar spectrum disorders (Lofthouse et al., 2008), and attention deficit hyperactivity disorder (Corkum, Tannock, & Moldofsky, 1998). Impaired sleep can exacerbate behavioral, anxiety, and mood disorders. Similarly, research has indicated that, compared with their typically developing peers, children with autism (Wiggs & Stores, 2004), Down syndrome, Prader-Willi syndrome, intellectual disability (Cotton & Richdale, 2010), and cerebral palsy (Newman, O’Regan, & Hensey, 2006) may experience diminished quantity and quality of sleep. As noted previously, this sleep debt may have negative consequences for health and performance of childhood occupations.
Fortunately, good sleep hygiene is a powerful therapeutic tool. For children, sleep hygiene is defined as “modifiable parent and child practices that promote good sleep quality, allow sufficient sleep duration, and prevent daytime sleepiness” (Mindell et al., 2009, p. 771). Using sleep screening instruments, it is possible to identify patterns of disordered sleep and the consequences of getting too little sleep among children (Owens, Spirito, McGuinn, & Nobile, 2000). When poor sleep routines are noted, an opportunity to intervene arises. Sadeh, Gruber, and Raviv (2003) demonstrated that school-age children respond to modest (i.e., approximately 1 hr) restriction or extension of sleep. Clinically, these results suggest that children may benefit in terms of health, wellness, and performance when sleep is extended in a structured manner. Indeed, it is apparent that efforts to improve the sleep hygiene of children with bipolar spectrum disorders may yield improvements in mood (Fristad, Goldberg Arnold, & Leffler, 2011). Although sleep hygiene is not a usual focus of school-based interventions, these data demonstrate the need to consider sleep in the context of school success.
Empowered with these data and awakened to the opportunity to intervene in sleep hygiene, occupational therapy practitioners have a valued role in helping children and families achieve better health through improved sleep hygiene. First, practitioners must develop an awareness of the signs and symptoms of insufficient sleep and sleep deprivation (Sadeh et al., 2003). These signs and symptoms may include, but are not limited to, fatigue; irritability; decreased stress tolerance; sickness; blurred vision; changes in appetite; and difficulty concentrating, remembering, or learning. When these behaviors are observed in natural settings such as the classroom, occupational therapy practitioners have the opportunity to intervene in simple yet concrete ways.
Occupational therapy practitioners can begin by educating children and families about the importance of sleep. This information provides a good starting point and should be presented in an individualized manner. Next, they can build awareness of sleep patterns, using either formal sleep screening instruments or informal tools. For example, parents can use a rubric designed to record a child’s bedtime, the time the child actually fell asleep, the time the child awoke, nap times, and total sleep time for an entire week (Fristad et al., 2011). Using these data, clinicians may identify opportunities to improve sleep hygiene and suggest feasible behavioral modifications. Such suggestions may be as simple as turning off the television an hour earlier each night, putting pajamas on after dinner, or restricting cell phone usage an hour before bedtime. By considering each person’s individual needs, the child, family, therapist, and others can collaboratively develop a plan for getting healthy sleep that may result in improved school participation and success.
Physical Activity
Like sleep hygiene, patterns of physical activity are strongly linked to childhood health and wellness. Among typically developing children, physical inactivity, especially the amount of television watched per day, is strongly associated with obesity (Burdette & Whitaker, 2005). Patterns of activity and inactivity developed in childhood and adolescence are predictive of adult patterns of behavior (Telama et al., 2005). In this context, female and minority populations experience greater inactivity than do male and nonminority populations (Physical Activity Guidelines Advisory Committee, 2008). Thus, activities must appeal to a wide variety of children.
The physical activity patterns of children with disabilities warrant special consideration. For example, children with mood disorders may experience weight gain because increased appetite is a common symptom of depression. In addition, weight gain is a common side effect of mood-stabilizing medication (Fristad et al., 2011). Physical activity appears to be an especially powerful therapy for this population. Engaging in physical activity results in fewer depressive symptoms and may help to alleviate dysphoria in children with mental health needs (Ströhle, 2009; Strong et al., 2005). Similarly, individualized physical activity programs are health promoting for children with physical disabilities. For example, weight-bearing activities, including standing, are known to have positive effects on bone density and cardiopulmonary and digestive health in children with cerebral palsy (Chad, Bailey, McKay, Zello, & Snyder, 1999). Recent evidence has suggested that physical training delays deterioration of neurological motor function in children who have Duchenne muscular dystrophy (Jansen, van Alfen, Geurts, & de Groot, 2013). However, the benefits of physical activity are not limited to these groups.
Clinicians should emphasize the benefits of physical activity for all children, but especially for minorities, girls, and children with disabilities. When working with families in a school context, occupational therapy practitioners may seek information about the amount of television a child watches each day and the amount of physical activity performed each week (Harris, King, & Gordon-Larsen, 2005). When inactivity or limited activity puts health at risk, practitioners should consider collaborating with students and families to incorporate physical activity routines into their plans of care. When intervention is necessary, home- or school-based exercise programs should be graded to personal needs and capacities, remembering that the just-right challenge looks different for each child, and even minimal amounts of activity may be beneficial for a child with a disability. Incorporating activity trackers, even commercially available health monitors, into daily routines to monitor, measure, and document performance and progress may enhance these practices.
Healthy Nutrition
Nutrition is a key determinant of energy and obesity in children and in adults (Harris et al., 2005). Although a healthy diet is beneficial for all children (Fristad et al., 2011), as many as 31.8% of children and adolescents ages 2–19 are overweight or obese (Ogden, Carroll, Kit, & Flegal, 2012), and many struggle with malnutrition (de Onis, Blössner, & Borghi, 2012). In the United States, the incidence and prevalence of childhood obesity are, and have been, increasing for some time (Ogden et al., 2012). This increase is concerning because children who are overweight or obese have an increased probability of being overweight or obese as adults (Guo, Wu, Chumlea, & Roche, 2002).
Nutrition becomes a particularly important consideration in the context of children with disabilities. For example, changes in appetite related to fluctuations of mood and the side effects of prescription medications put children with mental health disorders at an increased risk for unhealthy eating habits. Children with mood disorders may have unusually strong carbohydrate cravings (Christensen & Pettijohn, 2001) and risk gaining weight. Childhood malnutrition may have a negative impact on intellectual development (Brown & Pollitt, 1996). As Crooks (1995) stated, “Poor health and poor growth are likely to lead to poor school achievement via deficits in cognitive functioning, behavior . . . and increased absenteeism and school failure” (p. 57). The effects of poor nutritional habits or resources may be exaggerated in children with disabilities. For example, children with cerebral palsy often have difficulty maintaining healthy weight (Gisel & Patrick, 1988); children with autism may demonstrate picky eating behaviors and may require nutritional supplements (Lockner, Crowe, & Skipper, 2008); and tactilely defensive children may refuse foods on the basis of smell, temperature, texture, and context (Smith, Roux, Naidoo, & Venter, 2005).
The benefits of a healthy diet are many and may be realized at any point throughout the lifespan. In children, a healthy diet prevents deficiencies (Suskind & Lewinter-Suskind, 1993) and facilitates the development and proper functioning of physiological systems throughout the body. Moreover, proper nutrition enhances cognitive function (Kretchmer, Beard, & Carlson, 1996) and school performance (Meyers, Sampson, & Weitzman, 1991), improves self-esteem and resiliency (American Psychological Association, 2013), and decreases the risk of disease (American Psychological Association, 2013).
Occupational therapy practitioners can help to improve the eating habits of children and families by keeping the following in mind: First, it is best to focus on developing positive eating habits and not on dieting or weight loss. Second, children who eat two or more servings of fruits and vegetables ≥2 times per week are more likely to have a lower body mass index, whereas children who eat fast food ≥2 times per week may experience greater inactivity and a higher body mass index (Harris et al., 2005). Third, some children may not be ready to learn at school until after they have eaten (Crooks, 1995; Rampersaud, Pereira, Girard, Adams, & Metzl, 2005).
When any of these issues are present, an occupational therapist can advocate for an individualized education program modification of the child’s schedule that best positions the child for learning. Occupational therapists can recommend that children participate in the breakfast and snack programs offered though the school. In addition, occupational therapy practitioners could support developing special classes, electives, or extracurricular activities, such as a school garden, around healthy eating and food preparation. Finally, when children are obese and require intensive intervention, an occupational therapy practitioner may collaborate with other health professionals (e.g., physician, registered dietitian) to implement staged interventions such as Prevention Plus and Structured Weight Management strategies (Spear et al., 2007).
Providing nutritional support to children and families does not have to be difficult. Occupational therapy practitioners can begin by educating children and families about the benefits of healthy eating. They can use rubrics and diaries to build awareness of eating patterns, risks, and opportunities to improve health. When appropriate, practitioners can suggest feasible behavioral modifications that are likely to improve nutritional status and overall health, and they can provide support, structure, and routines that facilitate healthy choices and maximize the chances of success (Fristad et al., 2011).
Conclusion
The “powerful, widely recognized, science-driven, and evidence-based” efforts of occupational therapy practitioners (AOTA, 2007, p. 613) can greatly contribute to the United States’ ability to achieve the Triple Aim. By promoting healthy habits in children, occupational therapy practitioners have an opportunity to leverage existing evidence-based practices in ways that support the health and wellness of children, families, and communities. Promoting healthy habits is also aligned with the concept of P4 medicine (Persch et al., 2013) and with AOTA’s (2007) Centennial Vision. Whether it is used in medical, educational, community, or nontraditional settings, a focus on healthy habits provides occupational therapy practitioners with a way to demonstrate the value of their profession, which prevents illness, remediates disability, and restores health by enabling participation in meaningful occupations.