Abstract
Through this Practice Guideline, the American Occupational Therapy Association (AOTA) aims to help occupational therapists and occupational therapy assistants, as well as the people who manage, reimburse, or set policy regarding occupational therapy services, understand occupational therapy’s contribution in providing services to children and youth ages 5–21 yr. This guideline can also serve as a reference for health care professionals, health care facility managers, education professionals, education and health care regulators, third-party payers, managed care organizations, and those who conduct research to advance care of children and youth ages 5–21.
This guideline was commissioned, edited, and endorsed by AOTA without external funding being sought or obtained. It was financially supported entirely by AOTA and was developed without any involvement of industry. All authors of the reviews and guidelines completed conflict-of-interest disclosures, with no conflicts noted. AOTA aims to update practice guidelines every 5 yr to keep recommendations on each topic current according to criteria established by ECRI (2020). Guideline topics are evaluated for their currency on a 5-yr basis by a multidisciplinary advisory group consisting of AOTA member and nonmember content experts and external stakeholders. In addition, a preliminary search of the literature is conducted to determine whether an updated systematic review is warranted.
This Practice Guideline reports the findings from published scientific research; interventions that did not emerge from the published literature or did not meet the inclusion criteria are not included. The occupational therapist makes the ultimate clinical judgment regarding the appropriateness of a given intervention in light of a specific client’s or group’s circumstances, needs, and response to intervention, as well as the evidence available to support the intervention. Examples of how this evidence informs practice are provided in case vignettes and examples in this document.
AOTA supported systematic reviews on occupational therapy interventions for children and youth ages 5–21 as part of its Evidence-Based Practice (EBP) Project. AOTA’s EBP Project is based on the principle that the EBP of occupational therapy relies on the integration of information from three sources: (1) clinical experience and reasoning, (2) preferences of clients and their families, and (3) findings from the best available research. The authors of the systematic reviews and this Practice Guideline have signed a conflict of interest statement indicating that they have no conflicts that would bear on this work.
Clinical Recommendations
Table 1 summarizes the clinical recommendations for occupational therapy practice with children and youth ages 5–21. These clinical recommendations were developed after completion of the systematic reviews and full analysis of the data collected and are to be used to guide practice. AOTA uses the July 2012 grading methodology provided by the U.S. Preventive Services Task Force (2018) for clinical recommendations:
Clinical Recommendations for Occupational Therapy Interventions for Children and Youth Ages 5–21 Yr
Note. Criteria for level of evidence and recommendations (A, B, C, I, D) are based on standard language from the U.S. Preventive Services Task Force (2018). Recommendations are based on the available evidence and content experts’ clinical expertise regarding the value of using such evidence. ADHD = attention deficit hyperactivity disorder; ADLs = activities of daily living; ASD = autism spectrum disorder; CO–OP = Cognitive Orientation to daily Occupational Performance; CP = cerebral palsy; DCD = developmental coordination disorder; IADLs = instrumental activities of daily living; ID = intellectual disability.
A: There is strong evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. Good evidence was found that the intervention improves important outcomes and that benefits substantially outweigh harms.
B: There is moderate evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. There is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial.
C: There is weak evidence that the intervention can improve outcomes. It is recommended that the intervention be provided selectively on the basis of professional judgment and client preferences. There is at least moderate certainty that the net benefit is small.
I: There is insufficient evidence to determine whether occupational therapy practitioners should be routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
D: It is recommended that occupational therapy practitioners not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits.
Table 1 provides letter grades for the interventions described in this Practice Guideline. The grades can help practitioners understand at what level they can feel confident to use the interventions. Describing the strength of clinical recommendations is an important part of communicating an intervention’s efficacy to practitioners and other users. As always, research evidence needs to be considered in conjunction with client needs and goals as well as sound clinical reasoning from experience.
Background
AOTA (2019) has identified children and youth as a key practice area for the 21st century. The focus on this population is aligned with the profession’s life course perspective on occupation and speaks to the current state of practice. AOTA’s (2015) Workforce Trends Survey indicated that between 15% and 20% of occupational therapy practitioners surveyed worked directly with children and youth in school settings; beyond schools, practitioners provide services to children in hospitals, outpatient facilities, homes, and community-based programs. Children and youth may present with challenges to occupational participation and performance related to developmental, environmental, medical, psychosocial, and cultural factors that are distinct to that population, thus supporting the AOTA key practice area designation.
The National Survey of Children’s Health, conducted by the Health Resources and Services Administration’s (HRSA’s; 2018) Maternal and Child Health Bureau, found that in 2016–2017, 13.8 million children (or 18.8% of all children) ages 0–17 yr in the United States were reported to have a special health care need. Occupational therapy practitioners support participation in all areas of occupation and recognize unique characteristics of physical and emotional health needs, both of which are represented in the HRSA survey.
Occupational therapy’s reach to children and youth is substantial and ever growing as the profession seeks to expand beyond the provision of traditional services typically provided to children with known medical and developmental concerns and disabilities. Occupational therapy practitioners collaborate with parents, educators, and other providers to offer services to all children and youth, including those who are at risk for learning and social–emotional difficulties (Cahill et al., 2014). Occupational therapy practitioners support the development of the whole child through interventions and habilitative services that support skill acquisition, enhance feelings of subjective well-being, cultivate feelings of competency, and enhance occupational performance and participation (AOTA, 2016).
The World Health Organization (WHO; 2008) defines participation as one’s involvement in daily life situations. This broad definition provides an opportunity for occupational therapy practitioners to support performance and participation across environments and wherever children and youth live, learn, and play. Occupational therapy practitioners consider the myriad factors that influence participation and explore how the use of certain performance patterns and engagement in occupations shape children’s identities and influence their trajectories as they grow into adulthood (Case-Smith & O’Brien, 2015). Participation in activities of daily living (ADLs), academic pursuits, and social participation are both “the process for and the outcome of development” (Humphry, 2002, p. 171).
Play and Leisure
A main occupation of children is play and leisure. Play activities provide a rich environment to develop competency in social, motor, and cognitive skills (Parham & Fazio, 2008). Play behaviors and skills may be negatively affected by disability or deprivation. Occupational therapy practitioners use play as both means and ends to influence motivation, facilitate playfulness, and assist clients in meeting play-based outcomes (Kuhaneck et al., 2013).
Activities of Daily Living, Instrumental Activities of Daily Living, and Rest and Sleep
Participation in meaningful occupations, such as feeding oneself and brushing one’s teeth, contributes to a child’s development, well-being, and identity (AOTA, 2014). Engagement in daily occupations can facilitate the development of client factors (e.g., strength and attention), performance skills (e.g., using and manipulating materials), and efficient and effective habits and routines (AOTA, 2014). ADLs are occupations that begin in early childhood, contribute to a sense of autonomy and independence, and serve as the foundation for more complex instrumental activities of daily living (IADLs).
As adolescents transition from school to postsecondary life, participation in and performance of IADLs (e.g., health management and maintenance, safety, driving) become increasingly relevant. Supporting self-management is within the scope of occupational therapy practice and is recommended for children with conditions that have an impact on social functioning and medical status (Lozano & Houtrow, 2018). One goal of Healthy People 2020 is to “promote quality of life, healthy development, and healthy behaviors across all life stages” (U.S. Department of Health and Human Services, 2010, p. 5). Children and adolescents with health conditions and those at risk for such conditions stand to benefit as health initiatives and evidence-based therapy services that address concerns such as obesity, poor nutrition, fitness, safety, and personal care are made more available.
Sleep deficits have been identified as a public health problem in the United States (Centers for Disease Control and Prevention [CDC], 2017). Occupational therapy practitioners have an opportunity to include sleep hygiene interventions (e.g., visual supports for sleep routines and coaching for relaxation techniques) for pediatric populations at greater risk (e.g., children and youth with autism spectrum disorder [ASD] or developmental coordination disorder [DCD]) and to emphasize sleep as an occupation of interest (Barnett & Wiggs, 2012; Cavalieri, 2016).
Academic Participation
Children in the United States spend, on average, 6.5 hr per day in school (National Center for Education Statistics, 2007). Learning and preparation for the workforce are the primary outcomes of education. The occupation of education includes both academic (e.g., math, reading, writing) and nonacademic (e.g., clubs, drama, sports) occupations and activities, as well as those associated with the development of prevocational and vocational skills. When addressing students’ education, occupational therapy practitioners pay attention to a broad range of occupational performance areas to help children succeed in their student role. Reading and writing are foundational for school success, and impairments associated with literacy and writing have been associated with decreased engagement in and performance of other academic tasks (Grajo et al., 2016; Santangel & Graham, 2016).
Method
A major focus of AOTA’s Evidence-Based Practice (EBP) Program is an ongoing program of systematic reviews of the multidisciplinary scientific literature using focused questions and standardized procedures to identify occupational therapy–relevant evidence and discuss its implications for practice, education, and research. An evidence-based perspective is founded 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 Practice Guideline was developed with input from a wide variety of groups. Content experts; a medical librarian; non–occupational therapy professionals; and AOTA EBP Program staff, including a research methodologist, developed the protocol. A group of internal and external stakeholders comprising multidisciplinary providers, content experts, a research methodologist, professional association representatives, regulatory and policy content experts, and representatives of the target population reviewed the final guideline. The external review process consisted of a full manuscript review with a feedback form containing question prompts for the following information:
Each reviewer’s overall rating of the guideline and suggestions for improvements
Whether any content in the guideline is outdated, irrelevant, or in conflict with the reviewer’s experience and knowledge
Whether the guideline is representative of client-centered care and effectively communicative of best practice and EBP
Whether any topics are missing
Whether the guideline is understandable and accessible
Whether the guideline provides non–occupational therapy practitioners with sufficient information about the role of occupational therapy and the topic.
External reviewers were given the choice to remain anonymous or be identified to the authors, and they were given the option of making additional comments directly on the manuscript.
Evidence Evaluation
AOTA uses standards of evidence modeled on those developed in evidence-based medicine (Sackett, 1989; Sackett et al., 1996). This model standardizes and ranks the value of scientific evidence for biomedical practice as follows:
Level I—Systematic reviews of the literature, meta-analyses, and randomized controlled trials (RCTs). In RCTs, participants are randomly allocated to either an intervention or a control group, and the outcomes for the groups are compared.
Level II—Two-group, nonrandomized studies (e.g., cohort, case-control)
Level III—One-group, nonrandomized studies (e.g., before and after, pretest–posttest)
Level IV—Descriptive studies that include analysis of outcomes (single-subject design, case series)
Level V—Case reports and expert opinion, including narrative literature reviews and consensus statements.
The systematic reviews addressed three focused questions that were developed and reviewed by the review authors; a multidisciplinary guideline development group of experts in the field that included practitioners, academic faculty, researchers, policymakers, and AOTA staff; and the research methodologist for the AOTA EBP Program:
What is the evidence for the effectiveness of activity- and occupation-based interventions within the scope of occupational therapy practice to improve ADLs, IADLs, play and leisure, and rest and sleep for children and adolescents ages 5–21?
What is the evidence for the effectiveness of activity- and occupation-based interventions within the scope of occupational therapy practice to improve mental health, positive behavior, and social participation for children and youth ages 5–21?
What is the evidence for the effectiveness of activity- and occupation-based interventions within the scope of occupational therapy practice to improve learning, academic achievement, and successful participation in school for children and youth ages 5–21?
A previous review of occupational therapy interventions for children and youth ages 5–21 yr was completed covering the time frame of 1990 to October 2008 (Arbesman et al., 2013). For the current systematic reviews, the original focused question (Question 2) was updated, and two new questions (Questions 1 and 3) were added. The literature search for Question 2 covered January 2010–March 2017. For Questions 1 and 3, the literature search covered January 2000–March 2017.
Search Terms and Databases
Search terms for the reviews were developed by the research methodologist for the AOTA EBP Project and AOTA staff, in consultation with the review authors for each question, and by the guideline development group. The search terms were developed both to capture pertinent intervention articles and to ensure that the terms relevant to the specific thesaurus of each database were included. Table 2 lists the search terms related to population, interventions, and study designs included in the systematic reviews.
Search Terms for the Systematic Reviews of Occupational Therapy Interventions for Children and Youth Ages 5–21
Note. DIR = Developmental, Individual differences, Relationship model; NIDCAP = Newborn Individualized Developmental Care and Assessment Program.
A medical research librarian with experience in completing systematic review searches conducted the searches in MEDLINE, PsycINFO, CINAHL, the Cochrane database, and OTseeker and confirmed and improved the search strategies. The librarian exported the search results into EndNote (Version 8; Clarivate Analytics, Philadelphia, PA). The research methodologist did the first review of the search results, eliminating all citations not relevant to the project on the basis of established inclusion and exclusion criteria. The remaining results were then exported to the review authors in EndNote, Microsoft Word (Microsoft Corp., Redmond, WA), and tab-delimited formats. In addition, reference lists from articles included in the systematic reviews were examined for potential articles, and selected journals were hand searched to ensure that all appropriate articles were included.
Inclusion and Exclusion Criteria
Inclusion and exclusion criteria are critical to the systematic review process because they provide the structure for the quality, type, and years of publication of the literature that is incorporated into a review. The reviews were limited to peer-reviewed scientific literature published in English. The intervention approaches examined were within the scope of practice of occupational therapy for children and youth. Participants were children and youth ages 5–21 yr. Studies were excluded if they were dissertations, theses, presentations, or proceedings; were published outside the date range; had a population older than age 21 yr; or were outside the scope of occupational therapy. Studies included in the reviews provide Level I, II, and III evidence.
Overview of Search Results
A total of 89,461 citations and abstracts were located in the searches. The research methodologist completed the first step of eliminating references on the basis of citation and abstract, removing duplicates and studies clearly not within the parameters of the review. This first review reduced the number of citations to 5,312, which were given to the question review teams.
Teams of two or more reviewers with expertise in the content areas carried out the systematic reviews. The review teams completed the next step of eliminating references on the basis of citations and abstracts. The full-text versions of potential articles were retrieved, and the review teams determined final inclusion in the reviews on the basis of the inclusion and exclusion criteria.
A total of 178 studies were included in the final reviews, including 94 Level I, 49 Level II, and 42 Level III studies. Table 3 lists the number of studies included in each review and their levels of evidence. (Note that some articles addressed multiple outcomes of interest and are discussed in more than one section of this guideline.) The teams reviewed the articles for their focused question according to quality (scientific rigor and risk of bias) and level of evidence. They evaluated the articles and summarized the methods and findings in an evidence table. Finally, the review teams synthesized and reported the results of the included articles (see Beisbier & Laverdure, 2020; Cahill et al., 2020; Grajo et al., 2020). All three systematic reviews, with evidence tables and risk-of-bias tables, were published in the March/April 2020 issue of the American Journal of Occupational Therapy:
Beisbier, S., & Laverdure, P. (2020). Occupation- and activity-based interventions to improve performance of instrumental activities of daily living and rest and sleep for children and youth ages 5–21: A systematic review. American Journal of Occupational Therapy, 74, 7402180040. https://doi.org/10.5014/ajot.2020.039636
Cahill, S. M., Egan, B. E., & Seber, J. (2020). Activity- and occupation-based interventions to support mental health, positive behavior, and social participation for children and youth: A systematic review. American Journal of Occupational Therapy, 74, 7402180020. https://doi.org/10.5014/ajot.2020.038687
Grajo, L. C., Candler, C., & Sarafian, A. (2020). Interventions within the scope of occupational therapy to improve children’s academic participation: A systematic review. American Journal of Occupational Therapy, 74, 7402180030. https://doi.org/10.5014/ajot.2020.039016
Number of Articles Included, by Topic
Note. ADLs = activities of daily living; IADLs = instrumental activities of daily living.
Strength of Evidence
For each systematic review, the evidence was grouped into themes, and the strength of the evidence was determined for each theme. Strength-of-evidence designations include a synthesis of level of evidence (I–III), quality of evidence (risk of bias), and findings of the studies (e.g., significance). By synthesizing these three evaluations, the review authors provide important information to practitioners in terms of the level of certainty that the interventions resulted in the outcomes shown. The strength-of-evidence designations are outlined in Table 4 and are based on the guidelines of the U.S. Preventive Services Task Force (2018).
Strength of Evidence (Level of Certainty) Designations
Note. The determination of the strength of evidence is based on the guidelines of the U.S. Preventive Services Task Force (2018).
Benefits and Harms
The studies that met the inclusion criteria for the systematic reviews did not explicitly report potential adverse events associated with the interventions evaluated in these studies. If harms were noted, they would have been explicitly reported in the summary of key findings and would have been taken into account in determining the recommendations. Before implementing any new intervention, it is always prudent for occupational therapy practitioners to be aware of the potential benefits and harms of the intervention.
Clinical Reasoning
Occupational therapy practitioners exercise clinical reasoning on the basis of a sound evaluation of a client’s strengths and limitations, values, preferences, and goals and an understanding of the intervention to determine the potential benefits and harms of that intervention for the individual client. Clinical reasoning is also required to translate the intervention protocols used in the reviewed studies into client-centered, clinically feasible interventions.
Activity- and Occupation-Based Interventions to Improve Activities of Daily Living, Instrumental Activities of Daily Living, Play and Leisure, and Rest and Sleep
Occupational therapy practitioners promote participation for all children and recognize the influence of optimal engagement on development and overall health and well-being. Children with and without identified disabilities have valued roles, occupations, and routines at home, at school, and in the community. Occupational therapy services using activity- and occupation-based interventions aim to maximize motivation and performance outcomes centered on each child’s and family’s individual goals.
This section provides evidence from the systematic review that addressed the question “What is the evidence for the effectiveness of activity- and occupation-based interventions within the scope of occupational therapy practice to improve ADLs, IADLs, play and leisure, and rest and sleep for children and youth ages 5–21?” (Beisbier & Laverdure, 2020; Laverdure & Beisbier, in press). The 52 articles (34 Level I, 8 Level II, 10 Level III; Table 5) included in the review were organized into four themes on the basis of the activity or occupation that was central to the intervention: ADLs, IADLs, play and leisure, and rest and sleep.
Evidence for Activity- and Occupation-Based Interventions to Improve ADLs, IADLs, Play and Leisure, and Rest and Sleep for Children and Youth Ages 5–21
Note. N = 52. RCT = randomized controlled trial; SR = systematic review.
Activities of Daily Living
ADLs such as dressing, eating, and hygiene routines are often identified as goal areas for children receiving occupational therapy services (Hurn et al., 2006). Satisfactory performance of ADLs and management of personal daily needs build autonomy and independence and may have an impact on future performance and participation in more complex occupations. Seventeen studies met the criteria for inclusion in this theme and represented ADL outcomes of feeding, functional mobility, and self-care (e.g., bathing, showering, personal hygiene and grooming, dressing, toileting and toileting hygiene; AOTA, 2014). The ADL theme was organized by type of intervention: task-oriented activities and routines, cognitive-based interventions, and technology-based interventions. One Level I meta-analysis, 11 Level I RCTs, 3 Level II studies (two-group nonrandomized and crossover designs), and 2 Level III studies (1 pretest–posttest, 1 retrospective) were examined.
Task-Oriented Activities and Routines
Self-Care Activities
Five Level I studies with low risk of bias provide strong strength of evidence supporting engagement in self-care activities and routines to improve participation in and performance of functional life skills by children with disabilities (cerebral palsy [CP], ASD, idiopathic arthritis). Law et al. (2011; Level I) studied the effectiveness of child-focused (i.e., remediation of impairment) and context-focused (i.e., task or environment) interventions. Children with CP in both groups showed equivalent and significant improvements in self-care, mobility, and participation outcomes. In a study of the effectiveness of constraint-induced therapy, children with CP who used a constraint mitt while engaging in functional activities were compared with those who did not use a mitt. Although both groups demonstrated improvement in functional activity participation and performance, the group who wore the mitt saw significant changes in motor control immediately after the intervention and 3 mo posttreatment (Hsin et al., 2012; Level I). Children with CP who participated in an active lifestyle and sports participation intervention and logged their daily physical activity and engagement in daily life activities on a self-report measure significantly increased their physical activity (Slaman et al., 2015; Level I). In addition, Drahota et al. (2011; Level I) reported that children with ASD who participated in an adaptive skills training intervention designed to increase independence in self-care significantly improved their skill performance, and their caregivers reduced involvement. Children with idiopathic arthritis who participated in a program focused on musculoskeletal strategies coupled with functional activities showed significant improvement in their occupational engagement (dressing, grooming, eating, hygiene), pain management, and quality of life (Tarakci et al., 2012; Level I).
Functional Physical Activity
Three Level I studies and 1 Level II study with low risk of bias provide strong strength of evidence supporting engagement in functional mobility activities and structured exercise programs to improve functional mobility among children and youth with CP. Children with CP who received structured training on a treadmill showed a significant increase in the distance they could travel during functional activity (Grecco et al., 2013; Level I). A second study’s intervention included weekly center-based and weekly home-based physical fitness activities, as well as counseling focused on increasing daily physical activity. The intervention resulted in a significant increase in participants’ physical activity as reported on a physical activity self-report measure (Slaman et al., 2015; Level I). Bryant et al. (2013; Level I) found that children with CP who received structured training on a static bike or treadmill showed significant improvement on functional mobility measures. Finally, children with CP who participated in a hippotherapy intervention made significant gains in functional mobility skills (Park et al., 2014; Level II).
Task-Oriented Training
Low strength of evidence (1 Level III study with high risk of bias) indicates that engagement in task-oriented training in simulated tasks improved self-feeding performance and mealtime participation among children with spastic CP (Song, 2014; Level III). In this study, all participants received conventional occupational therapy services (motion exercise and stretching of the upper extremity) in addition to a research protocol of task-oriented training that simulated tasks performed by children during ADLs. The results indicated that task-oriented training significantly improved functional skills outcomes among this population.
Cognitive-Based Interventions
Interventions examined in this theme were collaborative goal setting, activity-based training and education (including motor learning interventions), and coaching and feedback (mediated by a peer, caregiver, or occupational therapy practitioner; Goal–Plan–Do–Check from the Cognitive Orientation to daily Occupational Performance [CO–OP™ approach] and Cognitive–Functional [Cog–Fun]). There is strong strength of evidence that cognitive-based interventions can improve functional mobility and self-care performance and participation among children and youth (3 Level I studies with low risk of bias, 1 Level II study with moderate risk of bias, and 1 Level III study with high risk of bias).
Bar-Haim et al. (2010; Level I) conducted a study with children and youth with CP. Participants received activity-focused sessions with coaching and feedback (with the child or youth, caregiver, or both) and home practice addressing functional mobility and self-care performance and participation. Children and youth who received the intervention showed significant improvement compared with children and youth who received a neurodevelopmental treatment approach. In another study, children with idiopathic arthritis who participated in a functional activities program coupled with caregiver training and home practice showed significant improvement in their occupational engagement (dressing, grooming, eating, hygiene; Tarakci et al., 2012; Level I). Children with developmental coordination disorder who participated in collaborative goal setting, instruction, and feedback (e.g., CO–OP) showed significant improvement in self-care participation, performance, and satisfaction in comparison with a group who received conventional therapy services (Miller et al., 2001; Level I).
Two lower level studies that used cognitive interventions were included. Maeir et al. (2014; Level II) used manualized intervention sessions (Cog–Fun) that resulted in significant positive treatment effects on ADL outcomes. Keenan et al. (2014; Level III) used goal attainment scaling and the Canadian Occupational Performance Measure (COPM) and found that engagement in group life skills–based coaching interventions (direct instruction, role-playing, and peer modeling) significantly improved goal-directed performance of functional skills among youths with a variety of disabilities (CP, spina bifida, acquired brain injury [ABI]).
Technology-Based Interventions
Studies in this theme examined video modeling, virtual reality, and video game training interventions. Moderate strength of evidence indicates that video-based modeling interventions improved self-care participation and performance (1 Level I study with low risk of bias). Hong et al. (2016; Level I) conducted a systematic review and meta-analysis of 23 studies that examined the effects of video modeling in teaching functional living skills (e.g., house chores, employment skills, self-help skills) to people with ASD. The authors reported that across all studies, the interventions that used some type of video-based modeling had a large effect size. The results also indicated that video-based modeling interventions were similarly effective for participants with any of three diagnoses (ASD and intellectual disability [ID], ASD alone, and high-functioning ASD).
Moderate strength of evidence was found in support of web-based interventions to improve self-care participation and performance of children and youth with CP (2 Level I studies with low risk of bias and mixed results). Children and youth with mild CP who participated in Wii Fit (Nintendo, Tokyo, Japan) balance-based video game training significantly improved in performance of self-care in comparison with those who received conventional balance training (Tarakci et al., 2016; Level I). In another study (James et al., 2015; Level I), children and youth with spastic CP used Mitii (Mitii, Hørsholm, Denmark), a web-based multimodal home therapy program consisting of upper limb, cognitive, visual–perceptual, and physical activity training, but the findings were not significant.
Low strength of evidence was found supporting virtual reality interventions to improve mobility and self-care participation and performance among children and youth with ABI (1 Level II study with high risk of bias). In a study conducted by Bart et al. (2011; Level II), children were introduced to three virtual reality environments (Birds and Balls, Soccer, Snowboard) in the GX Interactive Rehabilitation and Exercise system (GestureTek; Toronto, Ontario, Canada). The authors found significant correlations between virtual reality performance variables (i.e., response time and success rates) and self-care and functional abilities.
Instrumental Activities of Daily Living
The IADL theme was organized into two main outcome areas: (1) health maintenance and management (i.e., physical activity and fitness, diet and nutrition, and health routines and wellness) and (2) a broader IADL category that included safety, driving, and communication management. Health maintenance and management may be especially important for children with chronic conditions and those who have environmental or developmental barriers to participation. Participation in additional IADL areas such as safety, driving, and communication management has unique implications for children and youth, and targeted interventions to support performance are essential.
Health Maintenance and Management
Sixteen studies met the inclusion criteria for IADLs under the occupation of health maintenance and management. The studies were separated into three specific outcomes: physical activity and fitness, diet and nutrition, and health routines and wellness. Three studies (Hogg et al., 2012; Whittemore et al., 2013; Wong et al., 2016) measured outcomes in more than one of these areas and are summarized in each category with content specific to the intervention.
Physical Activity and Fitness.
Six Level I RCTs with low to moderate risk of bias, along with 1 Level II study and 2 Level III studies with moderate to high risk of bias, measured physical activity outcomes. Of these 9 studies, 6 (5 Level I, 1 Level III) were conducted in school settings, and 3 (1 Level I, 1 Level II, 1 Level III) were conducted outside of the school day or location.
Four Level I studies and 1 Level III study provided strong strength of evidence for occupation- and activity-based interventions in a school setting to increase health outcomes of physical activity and fitness, with statistically significant findings. Beyler et al. (2014; Level I) measured the effect of the Playworks program, which incorporates organized recess and after-school activities, class game time, and coach training. The intervention resulted in significant increases in teacher-reported participation in physical activity during recess as well as significant improvement in vigorous physical activity during recess. Huberty, Siahpush, et al. (2011; Level III) used Ready for Recess programming, which includes activity zones and access to equipment, with children in Grades 3–5. Participation in physical activity was significantly higher at posttest for both recess and school day outcomes. Another intervention that included interactive lessons, use of a pedometer, and facilitation of creative strategies for increasing physical activity was implemented with eighth-grade students (Suchert et al., 2015; Level I). The results of the intervention included significant positive change in days of moderate to vigorous physical activity and an increase in sports in the intervention group; the control group had no or nonsignificant changes.
Three studies with adolescent participants were appraised. Sutherland et al. (2016; Level I) conducted a 24-mo school-based intervention with a focus on physical activity promotion via student physical activity plans, fitness activities and lessons, provision of equipment, and promotion of community activities and parent engagement. The intervention resulted in a statistically significant increase in daily minutes of moderate to vigorous physical activity. Whittemore et al. (2013; Level I) used a web-based program focused on obesity prevention. They found that both in-class and homework versions of the HEALTH[e]TEEN program resulted in significant improvements in physical activity as measured by the Youth Risk Behavior Survey (CDC, 2009). Casey et al. (2014; Level I) investigated the impact of a 12-mo school–community linked program with girls in Grades 7–9. A sport and recreational unit was incorporated into physical education classes. They found no statistically significant changes in self-reported physical activity levels.
Low-strength evidence was found for occupation- and activity-based interventions provided in a nonschool setting to increase health outcomes of physical activity and fitness. Hogg et al. (2012; Level III) evaluated the use of a lifestyle–activity curriculum paired with dance. The participants used diaries to track behaviors after the after-school intervention. Findings revealed an increase in physical activity, but statistical significance was not reached. Maher et al. (2010; Level I) conducted an RCT using eight self-directed interactive web-based modules focused on lifestyle physical activity. Outcome measures showed nonsignificant positive trends for activity behavior and exercise knowledge for children with CP. Wong et al. (2016; Level II) conducted three 6-wk sessions of an after-school program that provided structured physical activity and lessons on nutrition and healthy habits. Activity monitors worn by participants indicated no improvement in physical activity.
Diet and Nutrition.
Six studies met the inclusion criteria and produced evidence of moderate strength to support interventions using a skills-based interactive curriculum and structured physical activity to effect positive change in dietary outcomes for children and youth ages 5–21 yr. Anand et al.’s (2015; Level II) skills-based approach used interactive role-play and homework focused on healthy choices and positive dietary behavior among teenagers. The intervention group completed pre and post questionnaires that indicated statistically significant improvement in dietary knowledge, attitude, and practices. Davis et al. (2016; Level I) provided an after-school program (LA Sprouts) with interactive and activity-based instruction in cooking, nutrition, and gardening to children in Grades 3–5. Significant increases were noted for knowledge of food, nutrition, and gardening and for gardening activity at home. Whittemore et al. (2013; Level I) implemented HEALTH[e]TEEN, a web-based obesity prevention program. The participants engaged in self-directed lessons supported by interaction with a coach and peers that resulted in statistically significant improvements in healthy eating behaviors.
Three studies paired a skills-based curriculum with structured physical activity. Wright et al. (2012; Level I) used a 6-wk family-centered program (Kids Nutrition and Fitness) that focused on nutrition education and physical activity. This RCT, which had low risk of bias, was conducted with children ages 8–12 yr from low-income schools and resulted in statistically significant improvements in dietary behaviors for intervention participants as compared with the control group. Hogg et al. (2012; Level III) used an intervention consisting of a lifestyle and nutrition curriculum paired with a dance activity. Findings revealed positive changes in eating behaviors and food selection; however, statistical significance was not reported. Wong et al.’s (2016; Level II) 6-wk after-school healthy living program featured structured physical activity coupled with nutrition and interactive healthy habits lessons. No improvements in actual dietary habits were detected.
Health Routines and Wellness.
Four Level I studies met the criteria for health routines and wellness. The outcomes included health-related decision making, medication adherence, and management of pain and activity. Two studies had a family or parent component (Letorneau et al., 2013; Palermo et al., 2009) and provided support for family-centered practice with pediatric populations. Overall, moderate strength of evidence supports education and skills-focused interventions using small group activities and activity-based cognitive–behavioral strategies for youth ages 9–18 yr with a health concern.
Letorneau et al. (2013; Level I) studied the effects of a family-centered, home-based interactive cognitive–behavioral approach to address medication adherence among youth with HIV. Statistically significant improvements in medication adherence were found for the intervention group, but not for the control group; however, between-groups differences did not reach significance. Palermo et al. (2009; Level I) measured the impact of a web-based self-guided interactive module program with a sample of youth ages 11–17 yr. Children and parents completed weekly health-focused activities with accompanying homework and received follow-up feedback from a professional with skill in implementing cognitive–behavioral strategies. Findings for the treatment group reached statistical significance for a reduction in activity limitations and pain intensity.
A systematic review of 5 studies examined interventions addressing health-related decision making by youth (Feenstra et al., 2014; Level I). Four of the 5 studies measured the impact of interactive coaching practices and had nonsignificant findings. The fifth study showed that an intervention in the form of an activity-based workshop resulted in significantly increased quality of overall decision making. Although this systematic review featured low risk of bias, the overall quality of the studies was mixed, and the authors reported that studies lacked detail about interventions, outcome measure properties, and effect size. Srof et al. (2012; Level I) evaluated an interactive small-group coping skills training intervention for youth ages 14–18 yr focused on making health-related decisions for asthma self-management. Although the primary outcomes were quality-of-life measures and results for the overall scale did not reach significance, the subscale measuring activity level demonstrated significance in both between-groups (control) and within-group comparisons.
Safety, Driving, and Communication Management
The interventions in this broader outcome area were separated into two categories: technology-based interventions and activity-based coaching or skills training. Three Level I studies (2 RCTs, 1 systematic review with meta-analysis) and 2 Level III studies using technology (simulation, virtual reality, and web-based interactive programs) were included. Two additional studies (1 Level I RCT and 1 Level III study) examined activity-based coaching or skills training interventions. Overall, moderate strength of evidence was found for interventions involving coaching and skills training, and low strength of evidence was found for technology-based interventions. Small sample sizes and moderate to high risk of bias were limiting factors for the majority of studies, which is key when interpreting the true intervention effect and application to practice.
Five studies used technology-based interventions. Schwebel et al. (2014; Level I) conducted an RCT with a large sample (N = 231) of children ages 7 and 8 yr to measure safety outcomes during street crossing. The three intervention groups participated in six training sessions. Group 1 received individualized training in an interactive virtual pedestrian environment with feedback about safety. Group 2 received individual training at street-side locations with instructions and feedback about safety. Group 3 received training through widely available video and internet pedestrian safety programs. Group 4 was the control. Street-side safety training and virtual reality showed the most promise and resulted in statistically significant improvements on three of four safety measures in this high risk-of-bias study.
Two studies measured communication management outcomes after a technology-based intervention. Grynszpan et al. (2014; Level I) conducted a systematic review and meta-analysis of technology-based interventions used specifically with children with ASD. Outcomes included facial affect recognition and communicative behavior (IADL of communication management). Overall, the studies included in this low risk-of-bias study produced a medium effect size (d = 0.45–0.47); however, the authors cautioned that weak designs were a limitation. Ke and Im (2013; Level III) implemented a virtual reality intervention using situational role-play with targeted feedback. Observation and results on the Social Skills Questionnaire provided outcome data showing increased performance, but statistical significance was not reported. The authors indicated that the highly individualized activity, scaffolding, and environmental design were important considerations when implementing the intervention.
Two studies examined driving outcomes resulting from a technology-based intervention. Ekeh et al. (2013; Level I) used a 12-module, web-based interactive program as a driving intervention for new teen drivers. The program addressed safe and skilled driving ability and included a practice drive and an assessment with the Virtual Driver Interactive computerized simulator (Virtual Driver Interactive, Eldorado Hills, CA). Safe driving outcomes, as measured by driving records, did not reach significance. Fabiano et al. (2011; Level III) conducted a study of teens with attention deficit hyperactivity disorder (ADHD) using an 8-wk parent–teen program (Supporting a Teen’s Effective Entry to the Roadway). The activity-based program included driving simulation, behavioral strategies, and teaching and discussion components. A small effect size (d = 0.28) was detected on the outcomes of braking, speed, and overall driving skill.
The remaining studies in this IADL category used activity-based coaching or skills training. A single RCT with moderate risk of bias (Isler et al., 2011; Level I) measuring driving outcomes met the criteria for inclusion. Group 1 received activity-based training aimed at improving skills and insight into driving behavior. Group 2 received training in vehicle handling. Statistically significant findings for Group 1 included improvements in car handling, composite driving skills, and hazard perception. Group 2 had statistically significant improvements in car handling and composite driving skills only. No changes were noted in the control group.
Keenan et al. (2014) implemented a Level III study with high risk of bias that used activity-based training and coaching via a community-based life skills program (Skills for Transition). The coaches supported clients in selecting their own goals using the COPM and then facilitated practice of skills in a natural setting. The most frequently identified goals were in IADL content areas of cooking, money management, and community mobility. For all outcomes, posttest means were greater than pretest means and ratings, with large effect sizes.
Play and Leisure
As a primary occupation of children, play has a significant role in skill acquisition and healthy engagement in childhood roles (Parham & Fazio, 2008). The American Academy of Pediatrics has reported that play and leisure are “essential to the cognitive, physical, emotional, and social well-being of children and youth” (Ginsburg, 2007, p. 183). Lifestyle barriers such as limited time for play exist for many children (Ginsberg, 2007) and may be greater for children with special health care needs.
Six studies met the criteria for inclusion in play and leisure outcomes. Two Level I systematic reviews, 1 Level I RCT, 2 Level II studies, and 1 Level III study were synthesized by type of intervention. All studies included occupation- or activity-based interventions that resulted in a statistically significant positive impact on play and leisure participation and performance; however, the quality of the studies (risk of bias) affected the overall strength of the evidence in each of the intervention categories.
Cognitive–Behavioral Interventions
Low strength of evidence was found for interventions that used cognitive–behavioral strategies with children with ASD. One Level II and 1 Level III study, each with high risk of bias, met the inclusion criteria. Cecchini et al. (2014; Level II) found a statistically significant increase in leisure-time physical activity for children with ASD. The participants received rewards and recognition while engaged in problem solving and decision making during 12 wk of a physical education class. A second study (Miltenberger & Charlop, 2014; Level III) used verbal praise and tokens in conjunction with athletic skills and rules training. The intervention resulted in mastery of targeted athletic skill play for children with ASD, but carryover to school recess play was not observed. This study was limited to 3 participants, and statistical significance was not calculated.
Computer and Technology Interventions
One systematic review (Chantry & Dunford, 2010; Level I) with high risk of bias provided low strength of evidence to support the use of computer and technology interventions for play and leisure outcomes. The authors investigated the use of virtual reality games and computer-based play for children with complex disabilities such as CP. Increased opportunities for play and increased autonomous free play were reported outcomes, but the review lacked detailed outcome data.
Structured and Guided Play Participation
Moderate strength of evidence was found for the effectiveness of structured and guided play participation, with 1 Level I RCT with low risk of bias and 1 Level I systematic review and 1 Level II study, both with high risk of bias. Kretzmann et al. (2015; Level I) studied active coaching, modeling, and guided play participation for children with ASD. This RCT, which was conducted in the context of the school playground, resulted in significant improvement and a large effect size for active game engagement, which was maintained at 10 wk. Lang et al. (2011; Level I) investigated the use of peer-mediated (group play) interventions and structured guidance in the use of school playground equipment. This systematic review, which had moderate risk of bias and included a small sample of lower level studies, provided evidence that such interventions significantly increase appropriate play during recess for children with ASD.
O’Connor and Stagnitti (2011; Level II) found a statistically significant decrease in the number of play deficits for children with ID after therapist-guided play with the Learn to Play program stations (doll, transport, construction, and home corner). However, they found no significant difference between the intervention and comparison groups, resulting in a lower effect size.
Rest and Sleep
Consistent sleeping patterns within the recommended duration ranges are associated with better behavior and emotional, physical, and mental health outcomes in children. The known benefits of sleep coupled with the negative impact of sleeping disturbance on children and their families highlight the need for more goal-directed interventions for sleep (Paruthi et al., 2016).
Three Level I RCTs and 2 Level III studies met the criteria and were included in this theme. Interventions included sleep education (establishing rest and sleep routines, preparing and managing the environment to promote rest and sleep), cognitive-based interventions (coaching, mindfulness, guided imagery), yoga, and relaxation and rigorous exercise activities. Moderate strength of evidence indicates that engagement in sleep preparation activities, including sleep education, coaching, and cognitive strategies for skills in relaxation and sleep hygiene, improves overall sleep outcomes.
Two RCTs were conducted with adolescent participants. De Bruin et al. (2015; Level I) measured the effectiveness of two delivery options (face-to-face group therapy or guided internet therapy) for adolescents with insomnia. Both intervention groups included sleep education, sleep hygiene, and relaxation activities, and both groups showed significant improvements in sleep outcomes compared with the control group. Charette et al. (2015; Level I) used guided imagery interventions with youth who underwent surgery for adolescent idiopathic scoliosis. Participants reported a significant decrease in sleep interference from postsurgical pain.
One study using an aquatic activity program reported significant decreases in sleep onset latency and significant increases in sleep duration for children with ASD (Oriel et al., 2016; Level III). Sciberras et al. (2011; Level I) evaluated a brief and an extended (follow-up) behavioral sleep coaching program for parents of children with ADHD and behavioral sleep disorders. The results of this RCT indicated that children and caregivers experienced significant improvement in healthy sleep routines and sleep hygiene practices, habits and routines, quality of sleep, and daily functioning, with a medium effect size. Although Hooke et al. (2016; Level III) found that participation in 6 wk of yoga involving poses, relaxation, gentle stretching, and breathing, along with a home program, did not change sleep-related symptoms among a small sample of children with a history of cancer, it did result in a significant decrease in anxiety among the participants.
Moving Research Into Practice
Children and youth seek to participate in a wide array of occupations. Each child’s interests and skill set make his or her occupational profile unique. Developmental stages, family preferences, personal characteristics, and context can serve as supports or barriers to a child’s occupational participation and performance. Occupational therapy practitioners using client-centered approaches to assessment and intervention are well poised to serve pediatric clients and their families seeking to improve ADL, IADL, play and leisure, and rest and sleep outcomes. The findings from the systematic review (Beisbier & Laverdure, 2020) are intended to support clinical decision making in an evidence-based model. The included studies were conducted in educational, medical, and community environments and measured the impact of interventions on both typically and nontypically developing children and youth. The scope of the included studies represents many of the populations of children and arenas of practice served by occupational therapy practitioners.
Children and their families report improved health and wellness outcomes and increased quality of life when they can engage in and support ADLs at home, in school, and in the community. The evidence from the systematic review indicates that skills training and active engagement in self-care routines are strong approaches to use with children and caregivers (Beisbier & Laverdure, 2020). It is also important to instruct clients and caregivers in ways to practice and then carry over ADL techniques to other environments. Occupational therapy practitioners can also implement the use of technology as an adjunct to skills training. Video modeling is an evidence-based option, especially for elementary school–age and adolescent populations.
Quality of life and the ease of transition into adulthood may be affected by successful IADL performance because these life skills have a role in preparing youth for independent living and community participation. Occupational therapy practitioners can support skills for health management in the areas of fitness, nutrition, medication adherence, and wellness routines (Case-Smith & O’Brien, 2015). The evidence from the Beisbier and Laverdure (2020) systematic review directs therapists to embed fitness curricula and programs into school environments during recess or physical education classes. To address health management outcomes, practitioners should also consider skills-centered education strategies that include interaction with and feedback from peers, family members, and the occupational therapy practitioner. Occupational therapy practitioners can influence overall IADL participation and performance in children and youth with activity-based skills training in the context of the occupation (driving, cooking). Providing services in the natural environment in which children and youth are expected to perform the IADL is also a key factor. This style of intervention and setting allows the occupational therapy practitioner to promote practice and guide the client in self-evaluation of performance and outcomes. In addition, practitioners should explore the use of interactive technology as an adjunct to skills training, especially for clients with ASD and ADHD.
Play and leisure activities serve to promote overall development and contribute to quality of life for children and youth. Children with special needs, including ASD, ID, and physical disability, may be less engaged or isolated in play situations, may have fewer play opportunities, and may lack skills congruent with play mastery. The evidence supports the use of structured and guided play participation. Incorporating children’s toys, play equipment, and peers or siblings into guided play sessions can be most effective. Interventions should be provided in the environment in which the play outcome is desired to occur, such as the playground.
Children and youth with disabilities such as ASD and DCD are at higher risk for sleep disturbance (Barnett & Wiggs, 2012; Cavalieri, 2016). In addition, inadequate rest and sleep are considered a public health problem (CDC, 2015) that, when addressed, can improve the effectiveness of rehabilitation efforts, improve health and well-being, and increase performance and participation in meaningful occupations (Tester & Foss, 2018). Although practitioners may not frequently consider rest and sleep a priority focus, the evidence supports that carefully planned interventions can affect sleep quality and may contribute to overall health. Strong evidence supports sleep preparation activities, especially those that include sleep education and cognitive-based intervention. When using relaxation, rigorous exercise, or both as components of intervention, occupational therapy practitioners should include coaching and guided practice for the child and caregiver and provide follow-up opportunities to assess effectiveness and modify as needed.
Case Vignette: Adolescent Group
An occupational therapist is working with a small group of adolescents with musculoskeletal pain and related sleep disturbance. The teens share their challenges with the group. They discuss and document the number of hours they are able to achieve quality sleep per night and the strategies they have used in the past. On the basis of this information, the occupational therapist collaborates with the teens to design the following interventions:
The therapist uses coaching techniques to facilitate the teens’ ability to identify potential reasons for lack of success with past strategies.
The teens are provided model goals and encouraged to create achievable and measurable personal goals.
One small group of participants and parents are provided with two face-to-face sessions. The first session consists of education on sleep recommendations and effects and the principles of guided imagery, which is followed by a therapist-led guided imagery experience (Charette et al., 2015; de Bruin et al., 2015).
The second session is structured so that the parents and teens can self-direct the guided imagery experience while supported by the therapist as coach.
The teens continue to document sleep quality, assess progress toward goals, and share the results with the peer group and therapist (Sciberras et al., 2011).
Activity- and Occupation-Based Interventions to Improve Mental Health, Positive Behavior, and Social Participation
Occupational engagement is essential for children and youth with and at risk for mental health conditions. Interventions that prioritize engagement in high-interest, age-appropriate activities and occupations are increasingly recognized as beneficial to the mental health of children and youth (Bazyk & Bazyk, 2009; Petrenchik & King, 2011; Shea & Jackson, 2015). This section provides evidence from the systematic review that answered the question “What is the evidence for the effectiveness of activity- and occupation-based interventions within the scope of occupational therapy practice to improve mental health, positive behavior, and social participation for children and youth ages 5–21?” (Cahill et al., 2020).
The 62 articles (20 Level I, 22 Level II, 20 Level III; Table 6) included in the review were organized into nine themes on the basis of the activity or occupation that was central to the intervention. The themes included in the review are occupations and life skills training, outdoor groups and camps, play, sports activities, video and computer games, yoga, meditation, animal-assisted interventions, and creative arts (see Table 6). The results are reported according to the method of intervention, and some studies address more than one of the three outcomes (i.e., mental health, positive behavior, and social participation).
Evidence for Activity- and Occupation-Based Interventions to Improve Mental Health, Positive Behavior, and Social Participation for Children and Youth Ages 5–21
Note. N = 62. RCT = randomized controlled trial.
Occupations and Life Skills Training
Low to moderate strength of evidence (1 Level I RCT, 2 Level II studies, and 1 Level III study) was found for the use of productive occupations and life skills training activities for children and youth ages 5–21 yr to improve social participation, positive behavior, and mental health. Life skills training interventions involved intentional graded engagement during functional activities, activities that promote the development of work skills and behaviors, and academic work and chores. Occupational therapy practitioners often use life skills interventions to prepare children and youth to transition to postsecondary environments (i.e., college, work, group or independent living situations).
Pfiffner et al. (2014; Level I) used an intervention that combined activities such as organizing a backpack, planning and executing a pizza party, and making reminder checklists to facilitate daily routines at school for children with ADHD ages 7–11 yr. The program included teacher and parent trainings and 10 90-min child-focused group intervention sessions. Children who participated in the intervention showed significantly greater improvements on teacher- and parent-reported measures of organizational skills, social skills, and global psychosocial functioning as measured by the Children’s Organizational Skills Scale, the Social Skills Improvement Scale, and the Impairment Rating Scale than children who did not receive the intervention.
Block et al. (2012; Level II) examined the effectiveness of a farm-to-table intervention that involved gardening and meal preparation for school-age children in Australia. On the basis of scores on locally developed teacher questionnaires, the school-based gardening and cooking group was found to improve children’s cooperative behaviors and positive relationships with peers and adults, although the results were not statistically significant. Kaboski et al. (2015; Level II) studied the impact of a weeklong robotics camp on the social skills of children with ASD ages 12–17 yr. The intervention was presented as a way to prepare youth for a career in science and included instruction in social skills related to success on the job (e.g., how to collaborate with others to achieve a common goal) and opportunities to program an interactive robot. The participants with ASD demonstrated a statistically significant decrease in social anxiety as measured by the Social Anxiety Scale for Children–Revised or the Social Anxiety Scale for Adolescents (depending on age), but no significant differences were found with regard to social skills acquisition.
Tokolahi et al. (2013; Level III) found that weekly 90-min group sessions that included time-use reflections, self-review of participation levels and effects on mental health, and systematic activity scheduling, coupled with occupation-based activities and anxiety management training, resulted in significantly improved parent and clinician ratings of anxiety symptoms and internalizing behaviors on the Child Behavior Checklist and the Children’s Global Assessment Scale for children ages 10–14 yr. Each of the nine weekly sessions included an introduction to a skill and an activity designed to facilitate practice of the skill (e.g., self-awareness, emotional regulation), relaxation techniques, and a plan to practice the new skill before the next session.
Outdoor Groups and Camps
Three Level II and 6 Level III studies provide low strength of evidence for the use of outdoor groups and camps to improve mental health and social participation for children and youth ages 5–21 yr. All of the interventions included a group format. The outdoor activities included in the interventions varied. Adventure therapy and outdoor adventure-based experiences (i.e., rock climbing, canoeing, hiking, and camping) were features in 3 Level II studies (Paquette & Vitaro, 2014; Schell et al., 2012; Scrutton, 2015) and 3 Level III studies (Bowen et al., 2016; Dobud, 2016; Foster et al., 2016). One intervention included camping, outdoor games, swimming, and pool games (Devine & Dawson, 2010; Level III), and another intervention included surfing, sandcastle building, and paddle relay (Cavanaugh & Rademacher, 2014; Level III). One study included daylong outdoor leisure activities (Foster et al., 2016; Level III).
Chance for Change, a residential wilderness therapy program that lasts 10–20 days, was found to significantly reduce levels of antisocial behavior (Paquette & Vitaro, 2014; Level II). An outdoor activity camp lasting 8–10 wk was found to significantly increase self-esteem for adolescents with a diagnosed mental illness, as measured with the Rosenberg Self-Esteem Scale. Another outdoor education camp, lasting just 1 wk, significantly improved social skills for children ages 10–12 yr on the basis of scores on a 30-item questionnaire (Scrutton, 2015; Level II).
Using the Rosenberg Self-Esteem Scale, Schell et al. (2012; Level II) found statistically significant increases in self-esteem for adolescents with a diagnosed mental illness who participated in an outdoor activity camp for 8–10 wk; these increases were greater than for adolescents who participated in a psychosocial recovery group. Increased social connectedness, as measured by the Social Connectedness Scale–Revised, was not statistically significantly different between participants in the outdoor activity group and those in the psychosocial recovery group.
A 10-wk program for adolescents that included outdoor activities (e.g., rock climbing, caving, backpacking, canoeing, and ropes challenge courses) and a 2-day camping trip demonstrated statistically significant improvements in psychological resilience and in depression, according to scores on the Resilience Questionnaire and the Beck Depression Inventory–II (BDI–II), respectively. Improvements on the BDI–II continued at the level of statistical significance at a 3-mo follow-up (Bowen et al., 2016; Level III).
A weeklong residential camp for children at risk for mental health concerns and low self-esteem that included camping, outdoor games, equine therapy, and outdoor adventures resulted in statistically significant changes in self-esteem (Devine & Dawson, 2010; Level III). At a 4-mo follow-up, ON FIRE, an outdoor camp for children and adolescents who have a family member with a mental illness, yielded statistically significant changes in hope, as measured with the Children’s Hope Scale, and perceived social connection outside of the family group, as measured with the Kids Connection Scale (Foster et al., 2016; Level III). Using a pre–post survey, Dobud (2016; Level III) found that a 14-day outdoor adventure program supported improvements in self-esteem, self-concept, overall behavior, and coping skills for adolescents struggling with behavioral and emotional issues. Improvements, however, were not statistically significant for either participant report or parent report. A surf camp for youth with ASD resulted in significant improvements in social skills associated with assertion, responsibility, and engagement, as indicated by scores on the Social Skills Improvement System (Cavanaugh & Rademacher, 2014; Level III).
Play
Strong strength of evidence (2 Level I, 4 Level II, and 1 Level III studies) was found for the use of play-based interventions to improve social participation of children and youth. None of the studies in this subtheme directly measured outcomes specifically related to mental health or behaviors outside of those associated with play, and 4 studies used the Test of Playfulness as an outcome measure.
Frankel et al. (2010; Level I) used a manualized friendship training group intervention for elementary school children with autism and found statistically significant improvements in parent ratings on the Social Skills Rating Scale. Wilkes-Gillan et al. (2016; Level I) found statistically significant improvements in Test of Playfulness scores for children with ADHD who received a clinic-based play intervention that emphasized intrinsic motivation and included regular playmates and parent involvement. Barnes et al. (2017; Level II) examined the longitudinal effects of a play-based intervention that emphasized teaching empathy and included parent involvement as well as regular playmates. Social play gains were measured using the Test of Playfulness 12 mo postintervention. Although gains from the original intervention were maintained, differences between the group receiving the play-based intervention and the group that did not were not significant.
Pop et al. (2014; Level II) examined two play interventions (one that included adults as play partners and one that included robots as play partners) for children with ASD and measured outcomes with locally developed measures that targeted collaborative play and play engagement. Study results suggest that children with ASD in either intervention condition experienced a statistically significant improvement in social participation. Wolfberg et al. (2015; Level II) also examined a play group intervention for children with ASD and found that it led to significant gains in play participation (i.e., symbolic and social play) as measured with a locally developed coding system used to evaluate play observations. Wilkes et al. (2011; Level II) used an intervention that combined video-recorded free-play sessions, feedback from a therapist, and peer modeling and found statistically significant improvements on the Test of Playfulness for children with ADHD and their peers. Cantrill et al. (2015; Level III) examined the results of a parent-delivered play-based intervention at 18-mo follow-up and found that children with ADHD maintained their social play skills as measured by the Test of Playfulness; however, these results were not statistically significant.
Sports Activities
Two Level I and 2 Level II studies supply strong strength of evidence for sports activity interventions, all of which were conducted in a group format, to address social participation, mental health, and positive behavior for children and youth.
Bahrami et al. (2016; Level I) used a 14-wk karate intervention (i.e., warm-up activity, stretching, modified karate instruction, and cooldown) to address the social participation concerns of children and youth with ASD ages 5–16 yr and found significant improvements in scores on the Gilliam Autism Rating Scale–2nd Edition. Participation in sports activities (e.g., shuttle runs, jump rope, and goal-directed exercise) twice weekly for 6 wk resulted in significantly improved scores on the Cooperativeness subscale of the Social Skills Rating System for children with ADHD ages 7–9 yr (Kang et al., 2011; Level I). Haydicky et al. (2012; Level II) provided an intervention consisting of martial arts combined with mindfulness practices over 20 wk to youth ages 12–17 yr over the span of 20 wk and found improvement in parent-rated social functioning. A 10-wk swimming intervention, the Water Exercise Swimming Program, focused on improving the underlying social behaviors associated with participation and was found to significantly decrease the antisocial behaviors of boys with ASD (Pan, 2010; Level II).
Moderate strength of evidence, because of mixed results (1 Level I study and 1 Level II study), was found for sports activity interventions to improve positive (i.e., prosocial) behaviors. Kang et al. (2011; Level I) used aerobic and goal-directed exercise; participants demonstrated a statistically significant improvement in inattention as measured by the Korean version of DuPaul’s ADHD Rating Scale. In the D’Andrea et al. (2013; Level II) study, perseverance and conflict resolution, as measured by a locally developed checklist, were found to improve after a basketball intervention, although not significantly.
Low strength of evidence (3 Level III studies) was found for the use of sports activity interventions to improve mental health among children and youth. D’Andrea et al. (2013; Level III) used a basketball program for adolescents in a residential facility that incorporated trauma-informed principles and found a statistically significant reduction in both internalizing and externalizing behaviors based on scores on the Child Behavior Checklist. Haydicky et al. (2012; Level III) used a martial arts intervention with adolescent boys with ADHD; they demonstrated statistically significant improvements on locally developed self-report questionnaires addressing internalizing and externalizing behaviors. Terry et al. (2014; Level III) examined the impact of a boxing intervention with children ages 11–12 yr during an 8-wk lunchtime intervention and found no significant differences in scores on the Brunel Mood Scale.
Video and Computer Games
Strong strength of evidence (4 Level I and 1 Level III study) was found for the use of computer and video games to support social skills training to enhance the social participation and mental health of children and youth. Bul et al. (2016; Level I) used a computerized serious game (i.e., not designed purely for entertainment) intervention for children with ADHD ages 8–12 yr and found significant improvements related to cooperation skills as measured with the Social Skills Rating Scale. Craig et al. (2016; Level I) used a social skills training game, Zoo U, for elementary school students and found statistically significant improvement in social initiation on the basis of scores on the Social Skills Behavioral Inventory and statistically significant improvements in social self-efficacy, social satisfaction, and overall social literacy on the basis of scores on the Achieved Learning Questionnaire. The game involved children learning to take care of different animals in a virtual classroom, as well as personalized feedback.
Dickinson and Place (2016; Level I) used a school-based Nintendo Wii intervention with children and adolescents with ASD in addition to physical education activities and found significantly improved social functioning for children ages 5–10 yr and for boys ages 11–16 yr as determined by the Staff Questionnaire: Social Behavior at School. Norris et al. (2013; Level I) used an avatar-based, virtual reality role-play game and found statistically significant positive changes in peer resistance self-efficacy postintervention as measured with the Peer Resistance Self-Efficacy Survey. Gal et al. (2016; Level III) used a collaborative technology-based puzzle game with 14 boys with ASD ages 8–12 yr and found statistically significant results on the Friendship Observation for frequency of positive social interactions and collaborative play and lower rates of negative social interactions.
Moderate strength of evidence, because of mixed results (2 Level I studies and 1 Level II study), was found for the use of video and computer games to support improved mental health for children and youth. Hammond et al. (2014; Level I) used a school-based Nintendo Wii Fit intervention to improve the social–emotional well-being of children with DCD as measured by the Strengths and Difficulties Questionnaire; however, the results were not statistically significant. Scholten et al. (2016; Level I) demonstrated statistically significant reductions in anxiety symptoms in children ages 11–15 yr as measured with the Spence Children’s Anxiety Scale. Li et al. (2011; Level II) used a virtual reality intervention game to address depressive symptoms and levels of anxiety among children receiving cancer treatment in a hospital setting. The virtual reality game was found to significantly reduce depressive symptoms, although reductions in overall anxiety were not statistically significant.
Yoga
Moderate strength of evidence, due to mixed results (2 Level I studies, 1 Level II study, and 1 Level III study), was found for the use of yoga to address social participation, mental health, and positive behavior among children and youth. Telles et al. (2013; Level I) compared yoga to engagement in other physical activities (e.g., races and jogging in place) with children ages 8–13 yr and found improvements in social self-esteem (i.e., feelings related to interacting with peers); however, these improvements were not greater than those resulting from physical activity. Conversely, Velásquez et al. (2015; Level I) found statistically significant differences, the basis of peer ratings of social skills, between high school children who received a yoga intervention and peers in a control group.
Koenig et al. (2012; Level II) used Get Ready to Learn (Buckley-Reen, 2009), a classroom-based yoga program (i.e., yoga postures, targeted breathing exercises, relaxation techniques, and chanting) with children with ASD and found increases in social behaviors, although not statistically significant, on the Vineland Adaptive Behavior Scales. Beltran et al. (2016; Level III) studied the use of yoga with boys who had previously experienced trauma and found that parent ratings of family involvement on the Behavioral and Emotional Rating Scale demonstrated statistically significant improvement.
Strong strength of evidence (4 Level I studies, 2 Level II studies, and 2 Level III studies) was found for yoga to improve the mental health of children and youth. Beets and Mitchell (2010; Level I) found that yoga improved symptoms of positive mental health for children ages 12–16 yr, based on the health-related quality-of-life indicators on the Kindl® questionnaire. Carei et al. (2010; Level I) used a yoga intervention and found statistically significant improvements in anxiety for youth with eating disorders ages 11–21 yr as measured with the State–Trait Anxiety Inventory. Khalsa et al. (2012; Level I) used Yoga Ed (https://www.yogaed.com), which includes an emphasis on mindfulness and yoga-based philosophy in addition to yoga postures and games, breathing exercises, and visualization, and found that participants had statistically significant improvements in Profile of Mood States scores. Velásquez et al. (2015; Level I) used a 12-wk school-based yoga intervention and found statistically significant improvements in Strengths and Difficulties Questionnaire scores.
Khalsa et al. (2013; Level II) and Richter et al. (2016; Level II) both found statistically significant improvements in anxiety after yoga interventions as measured by the Music Performance Anxiety Inventory and the Anxiety Questionnaire, respectively. Hall et al. (2016; Level III) used a yoga intervention for children with eating disorders ages 11–16 yr and found statistically significant improvements on mental health indicators of the BDI and the State Anxiety Scale of the Spielberger State–Trait Anxiety Inventory. Thygeson et al. (2010; Level III) also found that participants showed statistically significant improvement in scores on the Spielberger State Anxiety Scale after a yoga intervention that included parent involvement for children with cancer.
Moderate strength of evidence, because of mixed results (1 Level I study and 1 Level II study), was found that yoga improves the behavior of children and youth. Koenig et al. (2012; Level II) found significant improvements in teacher ratings on the Aberrant Behavior Checklist (ABC) after the yoga intervention. Telles et al. (2013; Level I) found that yoga was no more effective than group physical exercise for improving behavior.
Meditation
Low strength of evidence (1 Level II and 4 Level III studies) was found for the use of meditation interventions to improve mental health for children and youth ages 5–21 yr. No studies were found that included outcomes specifically targeted at social participation or behavior. Crescentini et al. (2016; Level II) used a mindfulness meditation program (mindfulness of breathing, body parts, and thoughts) with children for 8 wk. Children demonstrated improvement in attention behaviors and a reduction in internalizing behaviors, as measured with the Child Behavior Checklist, but did not differ significantly from the comparison group, who received a literature-based intervention.
Joyce et al. (2010; Level III) incorporated meditation instruction and regular practice with children ages 10–12 yr in a classroom environment (e.g., 10 min every day after lunch) and found an overall significant improvement on self-reported indicators of mental health based on the Strengths and Difficulties Questionnaire and the Children’s Depression Inventory. Galla et al. (2016; Level III) found that adolescents who developed and followed action plans for meditation in conjunction with a meditation retreat experienced an increase in self-compassion, emotional well-being, and life satisfaction 3 mo postintervention on the basis of scaled scores on questionnaires associated with rumination, self-compassion, depressive symptoms, life satisfaction, and perceived stress. Britton et al. (2014; Level III) used a 10-wk meditation program that included breath awareness, body sweeps, and labeling of feelings and found that incarcerated adolescents who received the intervention demonstrated significantly higher scores on the Healthy Self-Regulation Scale postintervention. Bluth et al. (2015; Level III) studied the impact of a mindfulness curriculum that involved meditations related to breath, body, and feeling awareness and found that participants demonstrated statistically significant improvement as measured with the Self-Compassion Scale.
Animal-Assisted Interventions
Studies in this theme used animal-assisted interventions to address social participation, mental health, and behavior for children and youth. Low strength of evidence (2 Level II studies, 1 Level III study) was found for the use of animal-assisted interventions to improve the social participation of children and youth. Gabriels et al. (2012; Level II) found that therapeutic horseback riding significantly improved the scores of children with ASD on the Social domain of the Vineland Adaptive Behavior Scales. O’Haire et al. (2014; Level II) found statistically significant changes in both parent and teacher ratings on the Social Skills Rating Scale after a guinea pig care intervention for children with ASD. Ghorban et al. (2013; Level III) examined therapeutic horseback riding for children with autism and found significant improvements in affective understanding and perspective taking, as measured by Stone’s Social Skills Scale.
Low strength of evidence (1 Level II study) was found related to animal-assisted interventions for improving the mental health of children and youth. Cuypers et al. (2011; Level II) found that, as measured by the Kindl questionnaire for measuring health-related quality of life, therapeutic horseback riding significantly improved the mental health of children with ADHD.
Moderate strength of evidence (1 Level I study, 3 Level II studies) was found for the use of animal-assisted activities and occupations to improve children’s and youths’ behavior. Cuypers et al. (2011; Level II) examined therapeutic horseback riding and found that children with ADHD ages 5–10 yr had significantly improved scores on the Strengths and Difficulties Questionnaire. Gabriels et al. (2012; Level II) found that children ages 6–16 yr with ASD who participated in therapeutic horseback riding showed significantly positive results on the ABC. Gabriels et al. (2015; Level I) also used therapeutic horseback riding and found that children with ASD demonstrated statistically significant improvements on the ABC Children’s Irritability and Hyperactivity subscales. O’Haire et al. (2014; Level II), whose study was one in this theme that did not include horses, examined an intervention involving the care of a guinea pig with children with ASD and found statistically significant positive changes on behavior ratings on the Pervasive Developmental Delay Behavior Inventory.
Creative Arts
Studies in this theme used creative arts interventions to address social participation, mental health, and positive behavior for children and youth. Two Level III studies provide low strength of evidence for the use of creative arts interventions to address social participation of children and youth. Goldingay et al. (2015) and Lerner et al. (2011) used drama-based creative arts activities designed to increase social participation. However, neither of these studies resulted in statistically significant improved outcomes related to social participation as measured by the Social Skills Improvement System and the Social Skills Rating Scale, respectively.
Moderate strength of evidence (1 Level I study, 1 Level III study) was found for the use of creative arts interventions to address mental health. Boniel-Nissim and Barak (2013; Level I) used creative writing and blogging about social problems and found significant improvements related to youth self-report ratings as measured by the Rosenberg Self-Esteem Scale, Hudson Index of Peer Relations, and Interpersonal Activities Checklist. Wood et al. (2013; Level III) studied the impact of a 10-wk group-based program to teach hand drumming to youth. The hand drumming intervention significantly improved youths’ self-report ratings as measured by the Rosenberg Self-Esteem Scale (Wood et al., 2013).
Low strength of evidence (1 Level III study) was found for the use of a combination of creative arts activities and occupations to address positive behavior. Buskirk-Cohen (2015; Level III) studied a camp-based intervention designed for children with social, emotional, and learning differences that combined movement, art, and music and found improvements, although not significant, in teacher and parent ratings of positive behavior on the Teacher–Child Rating Scale and the Parent–Child Rating Scale, respectively.
Moving Research Into Practice
This review (Cahill et al., 2020) focused on three distinct outcomes: mental health, positive behavior, and social participation. This broad focus resulted in the inclusion of many studies that addressed only one or two of these outcomes. The majority of the interventions included in the review used a group model for service delivery. Nine categories of activity- and occupation-based interventions were identified: occupations and life skills training, outdoor groups and camps, play, sports activities, video and computer games, yoga, meditation, animal-assisted interventions, and creative arts. The studies took place in clinical, community, and educational settings and included children and youth with and at risk for mental health conditions; developmental disabilities, such ASD; other disabilities, such as ADHD; or all of these.
The overall strength of evidence associated with yoga and sports activities is strong, indicating that these interventions are effective in addressing the mental health concerns of children and youth because they reduce symptoms of anxiety and depression and the occurrence of internalizing and externalizing behaviors. Yoga and sports activities were also found to be effective in improving social participation skills (e.g., cooperation). Occupational therapy practitioners should consider how to therapeutically use the social demands associated with yoga and sports activities to foster improved social skills and opportunities for social engagement and participation. These findings suggest that engagement in physical activities, particularly activities that enhance the mind–body connection, improves mental health and that such interventions should be introduced in childhood at the time when children are learning behavioral and emotional regulation skills (Hall et al., 2016).
Animal-assisted interventions should be incorporated into occupational therapy interventions for children and youth with ASD. Animals may provide a sense of support and help to facilitate person-to-person interactions (O’Haire et al., 2014). Animal-assisted interventions, such as therapeutic horseback riding, may encourage children to listen and attend to adult directives (Ghorban et al., 2013), as well as to communicate verbally (Gabriels et al., 2012). Play and creative arts interventions should also be incorporated into occupational therapy interventions for children and youth with and at risk for mental health concerns. Play-based interventions in partner and group contexts, and interventions that include parent involvement, were found to be particularly effective with children with ASD and ADHD. Occupational therapy practitioners should consider including creative writing (e.g., blogging about social problems) or hand drumming in their interventions to address mental health concerns. These interventions prioritize individual expression over group-focused goals. Low-strength evidence was found for the use of outdoor activity groups, productive and life skills groups, and video and computer games with this population.
Occupational therapy practitioners can introduce children and youth to occupation-based interventions and incorporate them into their daily and weekly performance patterns. Interventions that prioritize engagement in activities and occupations are beneficial to children and youth. However, more research is needed to understand the long-term effects of these interventions on the mental health, positive behavior, and social participation of children and youth.
Case Vignette: Middle-School Group
An occupational therapist is working with a group of middle-school students identified as being at risk for mental health concerns by their school’s early intervening services team. The occupational therapist wants to support the students as they develop performance patterns that will help them manage feelings of stress and anxiety. The occupational therapist
Introduces the students to yoga through a series of different yoga postures and games (Khalsa et al., 2012; Richter et al., 2016; Telles et al., 2013).
Teaches the students different breathing exercises and relaxation techniques (Bluth et al., 2015; Joyce et al., 2010; Khalsa et al., 2012).
Encourages students to discuss when and how they can incorporate these strategies throughout the day at school and during evenings and weekends at home.
Collaborates with the school social worker and principal to identify an area in the school that the students can use for yoga breaks.
Works with the students to create an action plan to implement yoga and meditation activities in their typical daily routines.
Encourages the students to keep a log to record their yoga and meditation practices. The log includes a space for reflecting on the experience.
After 6 wk, the students have begun regularly taking yoga and meditation breaks at school. In addition, they have completed their logs and share that they have experienced fewer symptoms of stress and anxiety at school. Their teachers note that they are more engaged in classes.
Activity- and Occupation-Based Interventions to Improve Learning, Academic Achievement, and Successful Participation in School
Education refers to the “activities needed for learning and participating in the educational environment” (AOTA, 2014, p. S20).The student role involves engaging in educational activities and occupations, both academic (e.g., math, reading, writing) and nonacademic (e.g., sports, band, cheerleading, club). This section provides evidence from the systematic review that answered the question “What is the evidence for the effectiveness of activity- and occupation-based interventions within the scope of occupational therapy practice to improve learning, academic achievement, and successful participation in school for children and youths ages 5–21?” (Grajo et al., 2020). The 71 articles (7 Level I systematic reviews, 33 RCTs, 19 Level II studies, and 12 Level III studies; Table 7) included in the review were organized into five themes on the basis of the activity or occupation that was central to the intervention: (1) educational participation, (2) social participation, (3) physical activity, (4) literacy participation, and (5) handwriting.
Evidence for Activity- and Occupation-Based Interventions to Improve Learning, Academic Achievement, and Successful Participation in School
Note. N = 71. RCT = randomized controlled trial; SR = systematic review.
Educational Participation
Indicators of successful educational participation in school include on-task behaviors, compliance with classroom rules, engagement in instructional and social activities, response time, attention, time spent seated, completion of independent and group work, academic performance, and appropriate communication. Eight studies met the criteria and were included in this theme (4 Level I studies, including 2 systematic reviews and 2 RCTs; 1 Level II cohort study; and 3 Level III repeated-measures studies). These studies ranged from low to high risk of bias, with mixed findings regarding significance.
Stability Balls
One Level I study and 2 Level III studies provide moderate strength of evidence supporting the use of stability balls. Fedewa et al. (2015; Level I) conducted an RCT of the use of stability balls versus classroom chairs in a second-grade classroom throughout the day. Children using standard classroom chairs exhibited significantly more time on task working both independently and with peers. Burgoyne and Ketcham (2015; Level III) conducted a repeated-measures comparison of students’ classroom behaviors while using classroom chairs versus stability balls. The percentage of observed behaviors indicated that on-task behaviors, as measured by focused activity and cooperation with classroom rules, significantly increased when second-grade students used stability balls in the classroom. Fedewa and Erwin’s (2011; Level III) single-subject A–B continuous time-series study explored the classroom behaviors of students in Grades 3–5 diagnosed with ADHD while they used stability balls in the classroom. Descriptive results indicated that average time spent seated and average on-task time increased when participants were seated on a stability ball.
Weighted Vests
One Level I and 1 Level II study yielded low strength of evidence for the use of weighted vests because of the limited number of articles and inconsistent results. Taylor et al. (2017; Level I) conducted a systematic review of the use of weighted vests with students with ASD. Thirteen studies with a group or single-case research design met evidence standards, with inconsistent results. The researchers found that the evidence to support the use of weighted vests for children with ASD in the classroom was not significant. Hodgetts et al. (2011; Level II) conducted a single-case withdrawal-design study of classroom behaviors during three phases: not wearing a vest, wearing a weighted vest, and wearing an unweighted vest. Sitting time, attention to task, and seated behavior in the classroom did not significantly improve among children with ASD when they wore weighted vests.
Yoga
Strong strength of evidence exists (2 Level I studies and 1 Level III study) for the use of yoga to improve educational outcomes. A Level I systematic review by Serwacki and Cook-Cottone (2012) explored the effectiveness of yoga programs delivered in school to children with and without disabilities. Results were inconclusive because of the studies’ high risk of bias (N = 12). However, children with learning disabilities and emotional and behavioral problems exhibited significant improvements in communication and classroom contributions compared with control groups. Frank et al. (2017; Level I) conducted an RCT of a manualized yoga-based social–emotional wellness promotion program, Transformative Life Skills, versus no intervention program for sixth- and ninth-grade students. The program consisted of 12 sessions, 15–60 min each, that addressed stress, physical and emotional awareness, self-regulation, and healthy relationships. Students in the intervention group had significantly fewer unexcused absences and significantly higher levels of school engagement. English and math grades were not significantly different. A Level III pretest–posttest study of 10 30-min weekly Yoga 4 classroom sessions yielded significant improvements in social interaction, attention, and on-task academic performance among second-grade students, as reported by teachers (Butzer et al., 2015).
Social Participation
Indicators of successful social participation in school include social awareness, social functioning, initiation of peer interactions, time spent engaging with peers, communication, acceptance by classmates, friendships and relationships, and interaction with teachers. Eight articles (3 Level I RCTs, 2 Level II cohort studies, and 3 Level III repeated-measures studies) met the inclusion criteria and provide evidence related to activity-based interventions addressing social participation in school. These studies’ risk of bias ranged from low to high, with predominantly significant findings.
Peer Mediation
Strong strength of evidence (2 Level I studies and 1 Level III study) was found related to the use of peer-mediated interventions. Kasari et al. (2012; Level I) completed an RCT comparing social skills functioning among children with ASD in general education in response to two 6-wk interventions (peer mediated vs. non–peer mediated or child mediated vs. non–child mediated). Social skills in the classroom significantly improved among children with ASD who received peer-mediated interventions. Students with ASD in the peer-mediated playground intervention group became significantly less isolated on the playground over time.
Kasari et al. (2016; Level I) conducted an RCT that compared two social skills intervention groups that spanned 8 wk and consisted of 16 sessions of either a peer-mediated engagement intervention or a social skills group. Time spent engaging with peers significantly increased in both groups. However, the skills-based intervention was significantly more effective than the peer-mediated engagement intervention in promoting more engagement with peers and less solitary play.
Walberg and Craig-Unkefer’s (2010; Level III) repeated-measures (multiple-baseline) study compared play sessions with planning and review versus baseline sessions of structured play without prompts or prohibiting behaviors. Descriptive results indicated an increase in the mean percentage of peer communication in all dyads from baseline to intervention, and interactive play behaviors did not change across phases.
Manualized Programs
Moderate strength of evidence (1 Level I, 1 Level II, and 2 Level III studies) was found for the use of manualized programs. Kretzmann et al. (2015; Level I) conducted an RCT to evaluate the effectiveness of Remaking Recess, a 16-session psychosocial intervention. This intervention significantly increased peer engagement for children with ASD compared with children with ASD who did not receive the intervention.
Laugeson et al. (2014; Level II) conducted a quasi-experimental (pretest–posttest) study of a 14-wk, 30-min-daily teacher-facilitated, school-based manualized social skills program, Program for the Education and Enrichment of Relational Skills (PEERS). The active-treatment control group received the Super Skills intervention, which was a customary intervention at the school. Social awareness, communication, and motivation significantly improved in the intervention group in comparison with the active-treatment control group. The PEERS program was effective in improving social functioning among middle-school adolescents with ASD and without ID.
Radley et al.’s (2014) Level III single-case-design study (baseline–intervention) evaluated a 30-min manualized Superheroes Social Skills intervention, administered once per week for 8 wk. Time spent engaging with peers significantly improved in response to the intervention. Improvement on the Participation/Avoidance subscale of the Autism Social Skills Profile was not significant.
Stagnitti et al. (2012; Level III) conducted a pre–post comparison of the Learn to Play Program, a child-led, play-based intervention to promote play skills to improve communication and social interaction. Social interaction and communication significantly improved, and children’s social disconnection decreased. The Learn to Play Program was effective in increasing the language and social skills of children with ID and ASD.
Animal-Assisted Activities
One Level II study provides low strength of evidence for the use of animal-assisted activities. O’Haire et al.’s (2014) control-to-intervention-design study explored the effects of 8 wk (16 20-min sessions) of exposure to and handling of guinea pigs on classroom behaviors among children with ASD. Teachers reported significant improvements in socially skilled behaviors and social approach behaviors.
Physical Activity
Physical activity at school is addressed primarily through schoolwide programs for the general population of students. Seventeen studies (5 Level I systematic reviews, 12 Level I RCTs) met the criteria and were included in this theme. The studies include an array of interventions, including those that are activity and interaction based, those that involve context modifications, and virtual interventions (video games).
Activity- and Interaction-Based Programs
Moderate strength of evidence was found for physical activity–based after-school programs, because of mixed results. Three systematic reviews and 8 RCTs (11 Level I studies) examined the effects of school programs that included activity-based programming facilitated by adult interaction. Programs were administered to school populations in natural groupings, either addressing children in the school as a whole or focusing on identified classrooms. Features of these activity-based school programs were varied, but all included time periods of direct instruction or facilitative interaction between staff and students. Physical activity was generally one outcome measure among several for each of the programs.
A Cochrane review conducted by Langford et al. (2015) examined cluster RCTs in 2011–2013 concerning health programs consistent with WHO’s Health Promoting Schools framework. The researchers conducted a meta-analysis of 9 studies concerning physical activity outcomes. They identified small but significant effects for physical activity (standardized mean difference = 0.02–0.17). In 2011, Kriemler et al. conducted a review of 16 RCTs and clinical controlled trials of school-based programs with physical activity as an outcome, all published between 2007 and 2010. Positive significant intervention effects were identified by all 16 studies. Parrish et al. (2013) searched the literature published from 2000 to 2011 concerning recess interventions and identified 9 relevant studies (8 RCTs, 1 clinical controlled trial). Their collective results were judged as inconclusive but promising for effectiveness in increasing physical activity.
Two Level I RCTs demonstrated significant positive outcomes for increased physical activity. Janssen et al. (2015) investigated PLAYgrounds, a multi-intervention approach consisting of active adult encouragement of playground use and monthly themes combined with environmental strategies (i.e., playground markings, fewer children on the playground, provision of equipment). Sacchetti et al. (2013) investigated the effects of an additional 30 min of school time devoted daily to physical activity implemented by the teacher in the classroom and on the playground.
One study demonstrated mixed results. Huberty, Beets, et al. (2011) examined Ready for Recess, a break-time intervention in which trained staff interacted with children at activity zones. Healthy-weight girls were unaffected by the program and showed a significant decrease in physical activity with equipment provision only, as measured by accelerometers. Five studies demonstrated no intervention effect for physical activity outcomes (Bellows et al., 2013; Casey et al., 2014; Eather et al., 2013; Elder et al., 2011; Uys et al., 2016).
Context Modifications
Moderate strength of evidence (5 Level I studies), with mixed results, was found for the effectiveness of context modifications to promote physical activity for children. One systematic review and 4 RCTs examined the effect of contextual modifications on physical activity. Contextual modifications included interventions such as playground markings (i.e., painting playground surfaces for use in games or to create different types of play zones), provision of large and small equipment, and changes to school policy to increase playground access. The literature has not yet established a clear picture of what type or combinations of types of modification are more efficacious.
Escalante et al. (2014) reviewed 8 studies published between 2000 and 2011 (3 RCTs, 5 clinical controlled trials) related to physical activity outcomes for context modifications, including playground markings, game equipment, playground markings and structures, and playground markings and equipment. None of the interventions was effective for preschoolers. Playground markings and equipment were significantly effective for school-age children.
Three studies demonstrated significant positive effects for physical activity outcomes in large samples. Parrish et al. (2016) explored the effects of policy changes that resulted in significantly more time on the playground combined with the provision of equipment in four schools for children ages 4–13 yr (N = 1,582) for 4 mo. Physical activity was measured by observation with SOPLAY, a tool for directly observing physical activity and associated environmental characteristics in free play settings, with significant positive effects. In another study by Ridgers et al. (2007), playground markings using a zonal design, large equipment (e.g., soccer goalposts, basketball hoops), and small equipment were provided to 15 schools; 11 schools served as controls. Student participants (N = 470) provided heart rate telemetry and accelerometer data at baseline, 6 wk, and 6 mo. Significant positive outcomes were found for moderate-to-vigorous and vigorous physical activity on both measures. Blaes et al. (2013) provided playground markings and equipment to two primary schools and used two schools as controls. They collected students’ (N = 420) accelerometer data 1 wk before and 2 wk after the modifications and found a significant increase in the percentage of time spent in moderate-to-vigorous physical activity. One study (Kelly et al., 2012) demonstrated no intervention effect for physical activity outcomes.
Video Games
Low strength of evidence (1 Level I study) was found related to video games. Norris et al. (2016) completed a systematic review and assessed the quality of evidence concerning the effect of active video games on physical activity. This review included 15 studies (3 RCTs, 12 clinical controlled trials) published from 2010 to 2015 that included physical activity outcomes. The results from the systematic review were inconclusive and video games may be no more effective than other methods for improving physical activity.
Literacy Participation
Strong strength of evidence (6 Level I studies, 6 Level II studies, and 1 Level III study) was found for literacy participation interventions. Three types of interventions were found: embedded and supplemental creative literacy activities, parent-mediated interventions (coaching), and peer tutoring.
Embedded and Supplemental Creative Literacy Activities
Moderate strength of evidence (3 Level I studies, 1 Level II study, and 1 Level III study) supports the use of embedded creative and engaging literacy activities in classroom and supplemental intervention sessions. Two Level I studies (Chow et al., 2017; Higgins et al., 2015) found that embedding creative discussions and rotating literacy activities in small groups led to a statistically significant increase in positive attitudes toward reading and improved self-concept as a reader. One Level I study (Saint-Laurent & Giasson, 2005) using nine literacy workshops with an emphasis on successful reading engagement led to statistically significant changes in reading and writing scores but did not lead to significant changes in reading attitudes.
One Level II study (Chong et al., 2014) found that a pullout session that integrated creative reading and writing activities in preschool (mean age = 5.6 yr) to develop early literacy skills led to statistically significant improvements in prosocial behaviors. One Level III study (Grajo & Candler, 2016) integrated choice and creative participation during occupational therapy sessions in an 8-wk program; this program led to statistically significant increases in perceived reading performance and satisfaction.
Parent Coaching
Moderate strength of evidence from 2 Level I studies and 3 Level II studies supports parent-mediated literacy interventions. Kim and Guryan (2010; Level I) found that enhancing parent–child interactions through a family literacy event led to statistically significant changes in frequency of reading and number of books read. Another Level I study (Sylva et al., 2008) found that a 70-hr parent training program resulted in statistically significant changes in children’s single-word reading scores but no changes in print concepts and phonological awareness compared with a control group that had access to a phone help line. Levin and Aram (2012; Level I) used a parent-mediated literacy coaching approach and found statistically significant increases in dyadic reading frequency and increases in mother-initiated dialogues.
Steiner (2014; Level II) provided an 8-wk parent training program and found statistically significant increases in children’s concepts of print. One Level II study (Jordan et al., 2000) found that organized parent training sessions over 5 mo led to statistically significant increases in home literacy activities and home literacy environments, but these effects were not different from changes found in the control group, which received the traditional curriculum.
Peer Tutoring
Moderate strength of evidence (4 Level I studies, 7 Level II studies, 1 Level III study) supports the effectiveness of peer tutoring programs. One meta-analysis (Jun et al., 2010; Level I) of 12 studies found that use of cross-age tutoring, direct reading tutoring, and tutoring with longer durations (≥16 hr) led to the highest effect sizes. One Level II study (Lee, 2014) found that an 8-wk peer tutoring program led to statistically significant increases in attitudes toward recreational reading. All studies used a variety of skill-level outcome measures (i.e., phonological processing, receptive and expressive language tests, reading and writing tests). Five studies used standardized or published assessments of behavior and attitudes toward reading (Chong et al., 2014, Level II; Chow et al., 2017, Level I; Grajo & Candler, 2016, Level III; Higgins et al., 2015, Level I; Lee, 2014, Level II). Four studies used author-developed questionnaires of reading attitudes (Kim & Guryan, 2010, Level I; Saint-Laurent & Giasson, 2005, Level II; Steiner, 2014, Level II; Sylva et al., 2008, Level II). Two studies used standardized literacy environment assessments (Jordan et al., 2000, Level II; Ullery et al., 2014, Level II).
Handwriting
Handwriting is a literacy component frequently addressed by occupational therapy practitioners (Hoy et al., 2011). Impairment in handwriting has been linked to barriers to fluent composition and productive engagement in academic tasks (Santangel & Graham, 2016). The 25 studies in this theme (10 Level I RCTs, 10 Level II studies, and 5 Level III repeated-measures studies) provide evidence for the effectiveness of activity- and occupation-based interventions to improve handwriting performance. The interventions varied across studies and included interventions to address client factors related to handwriting, use of sensorimotor strategies, therapeutic practice, manualized handwriting programs, and combinations of strategies. Study participants were identified as typically developing or as having difficulty with handwriting.
Visual Perception, Kinesthesis, and Motor Skills
Handwriting is a complex occupation involving visual perception, kinesthesis, in-hand manipulation, and visual–motor integration (Denton et al., 2006). Four Level I studies with low risk of bias examined interventions that specifically addressed client factors identified as component skills that affect handwriting proficiency. Although 3 RCTs measured significant gains in handwriting speed after intervention, no evidence from the results of the 4 studies supports the use of isolated activities addressing the components of visual perception, kinesthesis, or motor skills to promote legibility.
Two studies were conducted with Chinese children identified as having handwriting difficulties. Leung et al. (2016; Level I) examined visual–perceptual training with and without an ocular–motor component. Both groups showed significant gains in nonmotor visual perception and handwriting speed, with no improvement in visual–motor skills related to legibility. A second RCT (Poon et al., 2010; Level I) implemented computerized visual perception and visual–motor training as the intervention. Compared with the control group, which received no treatment, the intervention group demonstrated significant gains in nonmotor visual perception and handwriting speed, no gains in visual–motor skills, and a decrease in global legibility.
An RCT completed by Li et al. (2014; Level I) examined a motor training intervention using a nonhandwriting cup-stacking activity compared with no treatment among participants in Grade 2. Between-groups differences were not significant; all participants made gains in handwriting speed, and no significant changes were noted in handwriting accuracy. Sudsawad et al. (2002; Level I) compared kinesthetic training coupled with handwriting practice to no treatment for first-grade children with kinesthetic and handwriting deficits. All groups showed significant improvement on measures of kinesthesis and no improvement on handwriting measures.
Sensorimotor Versus Therapeutic Practice Approaches
Strong strength of evidence (3 Level I studies, 3 Level II studies, and 1 Level III study) was found for therapeutic practice over sensorimotor approaches or usual classroom activities for children with handwriting difficulties, and moderate-strength evidence was found for legibility outcomes for typically developing children.
Four studies included participants identified as having handwriting difficulties. Weintraub et al. (2009; Level I) conducted a three-group RCT comparing a combined sensorimotor approach group (multisensory teaching with therapeutic practice), a pencil-and-paper therapeutic practice group, and a control group engaged in usual classroom activities. Both interventions resulted in statistically significant improvements in overall legibility, with no change in the control group. A second RCT (Denton et al., 2006; Level I) with similar groupings (sensorimotor activities, therapeutic practice, typical classroom activities) resulted in significant gains for the therapeutic practice group, decline for the sensorimotor group, and no gains for the control group on legibility measures. Chang and Yu (2014; Level II) also compared three groups of participants: one using computer-assisted sensorimotor training, a second using pencil-and-paper therapeutic practice for legibility and motor control, and a control group using usual classroom activities. The researchers found a significant positive outcome in near-point copy and in smoothness of writing mechanics for the computer-assisted training. Jongmans et al. (2003; Level II) conducted a case-control comparison between therapeutic practice using a metacognitive self-instruction approach and usual classroom activities for children with identified handwriting difficulties. The authors found significant positive outcomes for the therapeutic practice and self-instruction method.
Three studies comparing sensorimotor and therapeutic practice approaches were conducted with typically developing children. Zwicker and Hadwin’s (2009; Level I) RCT compared use of a multisensory approach with use of a cognitively oriented therapeutic practice method and usual classroom activities for children in Grades 1 and 2. All first graders improved in letter legibility over time. The study yielded significant positive results for therapeutic practice among second graders. Howe et al. (2013; Level II) implemented a handwriting club intervention for children in Grades 1 and 2. Each group participated in the program with either the addition of visual–perceptual–motor activities using copy books or additional therapeutic practice of grade-level writing tasks. The authors found a significant positive outcome on legibility measures for the therapeutic practice group. Finally, Kaiser et al. (2011; Level III) conducted a posttest comparing added therapeutic practice with usual classroom activities for children in Grade 1. The study showed significant positive results in handwriting quality for the added practice.
Combined Sensorimotor and Therapeutic Practice Approaches
Thirteen studies (2 Level I, 8 Level II, and 3 Level III) examined the effectiveness of training programs using a combination of sensorimotor and therapeutic practice approaches. Six of these programs were manualized; two programs were site specific. The manualized programs were Write Start, Handwriting Without Tears, Size Matters, Loops and Other Groups, Peterson Directed Handwriting (a therapeutic practice approach), and Writers Workshop. They were administered primarily to typically developing children, either in addition to or in place of usual classroom activities.
Moderate strength of evidence (2 Level I studies, 2 Level II studies, and 1 Level III study) with mixed results was found for combined programs added to usual classroom activities for typically developing children. Peterson and Nelson’s (2003; Level I) RCT compared a sensorimotor approach combined with therapeutic practice delivered on a 1:1 or 1:2 basis with usual classroom activities for first-grade children. The results showed significantly higher gain scores in legibility for the intervention group. The results of a second Level I RCT (Shimel et al., 2009) yielded no significant between-groups differences (Handwriting Without Tears, Loops and Other Groups, and Zaner–Bloser-based classroom instruction) in cursive writing outcomes for first-grade students.
A nonrandomized comparison of Handwriting Without Tears delivered in small groups to the regular Head Start curriculum for preschool children yielded positive significant results only for the intervention group using prewriting measures (Lust & Donica, 2011; Level II). Hape et al. (2014; Level II) conducted a study with first-grade students. One group received teacher-implemented Handwriting Without Tears and occupational therapy support 20 min per week for 20 sessions. The second group engaged in a school-adopted Writers Workshop curriculum without occupational therapy support. Both groups made significant gains, with no significant between-groups differences. Roberts et al. (2010; Level III) examined the sensorimotor-based Loops and Other Groups cursive writing program for students in Grades 4–6 with identified handwriting difficulties. Participants demonstrated significant positive effects in global legibility, letter legibility, and personal satisfaction.
Moderate strength of evidence (6 Level II studies and 2 Level III studies) was found for the use of combined sensorimotor and therapeutic practice methods in place of classroom activities. Samples in all eight studies consisted of either all or a majority of typically developing children. Case-Smith et al. (2014; Level II) compared the Write Start coteaching program to standard classroom instruction for first-grade students and found a positive and significant advantage for Write Start. Pfeiffer et al. (2015; Level II) compared the Size Matters Handwriting Program implemented by classroom teachers to standard classroom instruction for children in kindergarten–Grade 2. Size Matters gain scores were significant and favorable on 3 of 3 measures for children in kindergarten. First graders who received the intervention outperformed control participants on 6 of 12 measures, and second graders in the intervention group outperformed control participants on 9 of 12 measures; however, both first and second graders demonstrated a decrease in speed.
Donica (2015; Level II) compared a Handwriting Without Tears intervention implemented by teachers, combined to occupational therapy consultation once per week, to a teacher-developed D’Nealian approach for kindergarten students. Results indicated a large effect size for the intervention. Roberts et al. (2014; Level II) compared Handwriting Without Tears with teacher-designed instruction for first-grade students in Canada and reported positive and significant results for the intervention. Salls et al. (2013; Level II) compared classroom teacher–delivered Handwriting Without Tears with the Peterson Directed Handwriting Method. The academic-year-long interventions with first graders resulted in significantly improved handwriting performance under both curricula. Schneck et al. (2012; Level II) investigated classroom teacher–delivered Handwriting Without Tears combined with occupational therapy consultation twice per month to teacher-designed handwriting instruction. The intervention was conducted with first-grade students (general education and special education combined) over an academic year. The authors found positive, significant results for the intervention.
Two Level III studies by Case-Smith et al. (2011, 2012) measured the effectiveness of the Write Start coteaching program with first-grade students. Both repeated-measures studies yielded significant improvement on legibility measures at posttest and 6-mo follow-up. In the 2012 study, the researchers divided the students into high-, average-, and low-performing groups on the basis of pretest legibility scores and found significant improvement on legibility measures at posttest and 6-mo follow-up. The low- and average-performing groups made greater progress than the high-performing group.
Moving Research Into Practice
Interventions to promote participation and engagement in the student role should be based on evidence, the student’s educational goals, and the occupational therapy practitioner’s understanding of the factors that support or limit the student’s performance. Participation in the student role involves engagement in a variety of different activities and occupations. The systematic review findings for activity- and occupation-based interventions to improve learning, academic achievement, and successful participation in school address both academic and nonacademic engagement.
Peer support and involvement, as well as contextual modifications, support increased participation at school. Social awareness, social functioning, initiation of peer interactions, time spent engaging with peers, communication, acceptance by classmates, enhanced friendships and relationships, increased interaction with teachers, and attitudes toward academic tasks are all enhanced through peer interventions. Both manualized and nonmanualized programs are effective.
Intentional and therapeutic practice of certain activities (i.e., handwriting, literacy, yoga) also enhances participation. Therapeutic practice is more effective than sensorimotor approaches or usual classroom activities in increasing handwriting and literacy skills. However, no evidence was found to suggest the need for intervention to address the underlying components related to handwriting and literacy participation, such as the components of visual perception, kinesthesis, or motor skills. Some interventions, such as the use of weighted vests, should be used with caution and close monitoring of behavioral changes.
The scope of occupational therapy in school settings is expanding as a result of multitiered systems of support and services. When possible, occupational therapy practitioners should consider the duration of different interventions and social supports when integrating interventions to enhance participation at school. Occupational therapy practitioners should consider ways to intentionally include parents in the intervention when possible.
Case Vignette: Elementary School Students
A school-based occupational therapist collaborates regularly with the first- through third-grade teachers in an elementary school. Concern with students’ handwriting is a frequent topic of discussion, and the occupational therapist often provides guidance for teacher-directed activities in the classroom. Today, the teachers inquire about new activities to promote their students’ handwriting legibility. They indicate an understanding of some of the performance skills and client factors that may influence handwriting readiness and skill. One second-grade teacher mentions the possibility of using less time for actual handwriting activities and more time for students in the classroom to engage in activities that incorporate visual–motor and visual–perceptual components (puzzles, marble games, painting).
The occupational therapist provides guidance to the classroom teachers that is based on current evidence. She shares that although there is no harm in the activities the teachers have identified and the activities may have an impact on the students’ overall visual–motor skills, a different approach with more actual structured practice would be more beneficial in targeting handwriting. The occupational therapist
Provides suggestions to incorporate therapeutic handwriting practice in the classroom’s typical routines (e.g., writing a heading on each piece of loose-leaf paper used to complete assignments, writing letters to other students or staff)
Models ways in which teachers can provide students with more specific feedback on performance and results
Teaches students methods to self-evaluate and provide peer feedback on handwriting legibility
Meets with teachers on a regular basis to provide additional consultation and support, as needed.
Implications for Occupational Therapy Practice, Education, and Research
Activity- and Occupation-Based Interventions to Support Activities of Daily Living, Instrumental Activities of Daily Living, Play and Leisure, and Rest and Sleep
Implications for Occupational Therapy Practice
Collaboration with clients, parents and caregivers, schools, and communities is essential to serve children and youth in their natural environments and contexts. Providing skilled training, feedback, and follow-up facilitates best outcomes.
Parent, school, and community involvement should be supported throughout the course of intervention, and pediatric services should be provided in the natural context of the child’s or youth’s routine and environments.
Engagement in daily occupations should remain the central focus of goals and intervention. Practitioners should use manualized programs that have clear activity- and occupation-based strategies as opposed to those that are solely focused on performance skills or client factors.
Practitioners should collaborate with clients and caregivers to establish meaningful occupation-based and achievable goals and use intentional strategies to maintain a collaborative relationship throughout the therapy process.
Consistent caregiver training and instruction should be provided to promote carryover, and the power of the caregiver to effect change and support the child should be emphasized.
Practitioners should follow up with children, parents, and teachers and provide ongoing coaching and feedback on performance. They should provide opportunities for collaborative problem solving and model strategies for ongoing problem solving in the home and community as new challenges arise.
Skills-based interventions should incorporate peer, family member, and practitioner interaction.
Small-group service delivery methods provide an opportunity for increased motivation and modeling.
Practitioners should explore interactive technology interventions, especially with clients with ASD and ADHD. The use of technology can be coupled with skills training and other evidence-based interventions.
The evaluation and occupational profile should include consideration of the quality of rest and sleep.
Rest and sleep should be addressed to enhance health and well-being and increase performance and participation in meaningful occupations.
Implications for Occupational Therapy Education
Occupational therapy education programs should emphasize evidence-based practices and occupation-based intervention.
Academic programs should emphasize family-centered care and the provision of services in natural environments so that students are well equipped for evidence-based service delivery models.
Educators should provide opportunities for students to discover the value of occupation as both intervention and outcome while planning for services with children and youth.
Degree programs should focus on all areas of occupation and ensure that rest and sleep are an integral part of educational curricula for occupational therapy practitioners.
Implications for Occupational Therapy Research
A need exists for more research studies with robust methodology and designs that use reliable and sensitive evidence-based outcome measures. In addition, researchers should consider a focus on studies that include both occupation-based interventions and engagement in occupation as a primary outcome.
Activity- and Occupation-Based Interventions to Improve Mental Health, Positive Behavior, and Social Participation
Implications for Occupational Therapy Practice
Activity- and occupation-based interventions should be implemented to address the mental health, positive behavior, and social participation of children and youth with or at risk for mental health concerns.
Practitioners should use group service delivery models when providing intervention to children and youth with or at risk for mental health concerns.
Sports activities should be used to develop social interaction skills.
Practitioners should incorporate meditation practices and blogging when attempting to foster positive feelings about self in children and youth.
Manualized yoga programs or less structured yoga games and poses should be used when addressing the mental health, positive behavior, and social participation of children and youth with or at risk for mental health concerns.
Implications for Occupational Therapy Education
Knowledge of interventions that promote the mental health and wellness of children and youth should be included in educational curricula for occupational therapy practitioners.
Academic programs should emphasize and train students in group facilitation skills specifically for providing occupational therapy services to children and youth.
Degree programs and educators should explore opportunities to provide field experiences at locations that offer camp opportunities for children and youth.
Implications for Occupational Therapy Research
The current scope of the literature implies that more research is needed to understand how to best measure outcomes associated with mental health for children and youth. In addition, research is needed to understand how existing interventions to address mental health, positive behavior, and social participation can best be incorporated into the daily and weekly routines of children and youth.
Activity- and Occupation-Based Interventions to Improve Learning, Academic Achievement, and Successful Participation in School
Implications for Occupational Therapy Practice
Practitioners should incorporate peer support, such as peer tutoring and peer-mediated interventions, into occupational therapy interventions and provide services in typical school environments to promote social participation and academic performance.
Practitioners should emphasize the use of activity- and occupation-based approaches to improve learning, academic achievement, and successful participation in school.
Therapeutic practice should be favored over sensorimotor approaches for the development and remediation of handwriting and literacy skills and performance.
Weighted vests should be used with caution.
Implications for Occupational Therapy Education
Academic programs should provide opportunities for occupational therapy students to develop strategies to increase parent involvement and communication in school systems.
Knowledge related to integrated service delivery and multitiered systems of support should be provided to occupational therapy students.
Implications for Occupational Therapy Research
Research is needed to better understand how occupational therapy practitioners can measure participation in academic tasks and educational environments. Research is also needed to enhance collaboration with teachers to deliver instruction related to literacy and other academic subject areas and to determine which manualized curricula are the most effective.
Conclusion
Occupational therapy practitioners have many resources to draw upon when making clinical decisions. Research on occupational therapy interventions, particularly for children and youth, continues to expand. It is incumbent upon practitioners to stay abreast of the research and incorporate evidence-informed interventions into their practice. The case examples in Tables 8 and 9 illustrate the integration of evidence into practice.
Case Example 1: Kennedy
Note. CP = cerebral palsy; UE = upper extremity.
Case Example 2: Cory
Note. ADLs = activities of daily living; IADLs = instrumental activities of daily living; MTSS = multitiered systems of support.
Footnotes
Acknowledgments
The authors acknowledge and thank the following individuals for their participation in the content review and development of this publication:
Deborah Lieberman, MHSA, OTR/L, FAOTA, Vice President, Practice Improvement, and Staff Liaison to the Commission on Practice, American Occupational Therapy Association, North Bethesda, MD
Elizabeth G. Hunter, PhD, OTR/L, Assistant Professor, Graduate Center for Gerontology, College of Public Health, University of Kentucky, Lexington
Paula J. Costello, OTD, OTR/L; Catherine Cueva, MS, BCBA; Teresa Leibforth Dufeny, PhD, OTR/L; Lenin C. Grajo, PhD, EdM, OTR/L; Patricia Laverdure, OTD, OTR/L, BCP, FAOTA; Amy Plica, MA; Hillary Richardson, MOT, OTR/L; Amanda Sarafian, MS, OTR/L; Michelle Suarez, PhD, OTR/L; Chuck Willmarth, CAE
The authors acknowledge the following individuals for their contributions to the evidence-based systematic review: Catherine Candler, PhD, OTR/L, BCP; Brad Egan, OTD, PhD, CADC, OTR/L; and Joanna Swanton, MS, OTR/L.
*
Indicates studies that were included in the systematic reviews.