Occupation- and Activity-Based Interventions to Improve Performance of Activities of Daily Living,Play,and Leisure for Children and Youth Ages 5 to 21: A Systematic Review

Abstract

Importance: The findings support the use of occupation- and activity-based interventions to improve the occupational participation of children and youth with disabilities.

Objective: To examine the effectiveness of occupation- and activity-based interventions to improve participation and performance in activities of daily living (ADLs), play, and leisure in children and youth.

Data Sources: MEDLINE, PsycINFO, CINAHL, ERIC, OTseeker, and Cochrane Database of Systematic Reviews; reference lists of retrieved articles; and tables of contents of selected journals were searched to identify peer-reviewed studies published between 2000 and 2017.

Study Selection and Data Collection: Studies addressing occupation- and activity-based interventions and outcomes for children ages 5 to 21 were selected and appraised using Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines, evaluated for risk of bias, and synthesized to develop practice recommendations.

Findings: Fifteen Level I (meta-analyses, systematic reviews, and randomized controlled trials), 5 Level II (two groups, nonrandomized), and 3 Level III (one group, pretest–posttest, retrospective) studies were examined and categorized by type of intervention and outcome. Each study used occupation- or activity-based interventions and reported ADL, play, or leisure outcomes. Intervention themes identified include supporting engagement in occupations, supporting participation with cognitive supports, and using technology to support occupational participation and performance.

Conclusions and Relevance: Strong evidence indicates that engagement in occupations and activities, practice within and across environments, and coaching and feedback improve participation and performance in ADLs and functional mobility. Moderate evidence supports the use of collaborative goal setting, modeling, and guided participation in play and leisure. Moderate evidence also supports technological interventions for ADL, play, and leisure performance.

What This Article Adds: Engaging children and youth in occupations and activities; providing guidance in goal direction, planning, and feedback to enhance their participation; coaching caregivers in effective carryover; and providing technology-based intervention can improve the occupational participation and performance of children and youth.

Engaging children and youth in occupations and activities; providing guidance in goal direction, planning, and feedback to enhance their participation; coaching caregivers in effective carryover; and providing technology-based intervention were found to improve the occupational participation and performance of children and youth with disabilities.

Participation in meaningful occupations contributes to people’s health and well-being and is essential to the development of identity and perceptions of competence and value (American Occupational Therapy Association [AOTA], 2014). Children and youth and their families report improved health and wellness outcomes and quality of life when they are able to engage in occupations at home and in community environments (Hurn et al., 2006). For children and youth with unique developmental, health, and learning needs, mastering skills that support participation in activities of daily living (ADLs), play, and leisure is influenced by a range of client factors, performance skills and patterns, and factors in contexts and environments (AOTA, 2014). Because occupational engagement provides important opportunities for development of motor, social, cognitive, and vocational skills and can promote positive, healthy engagement in relevant occupations and social communities (Parham & Fazio, 2008), ADL, play, and leisure skills are frequently identified as goal areas of clients and their caregivers (Hurn et al., 2006). Skills that allow children and youth to manage their personal needs are essential for autonomy and are often important prognostic indicators for future employment (Klinger et al., 2015).

Research has shown with increasing frequency that the use of occupations and activities as interventions and outcomes in practice with children and youth (Kreider et al., 2014) contributes to client and provider satisfaction (Estes & Pierce, 2012). Although occupation and activity are often used interchangeably in practice and research, for the purpose of this study, occupation “denotes life engagements that are constructed of multiple activities” (AOTA, 2014, p. S6). Pierce (2001) posited that an occupation is a “subjective event in perceived temporal, spatial, and sociocultural conditions that are unique to that one-time occurrence” (p. 139). An activity, in contrast, is an “idea held in the minds of persons and in their shared cultural language” (Pierce, 2001, p. 139). Despite current emphasis on the provision of occupation- and activity-based intervention, Daud and colleagues (2016) suggested that client factors, practitioner factors, and contextual factors often limit its use in practice. Kreider et al. (2014) found that even when occupation- and activity-based interventions were used, few researchers reported occupation-focused outcomes. Although engagement in ADLs in natural contexts and environments is increasingly supported by high-quality research, outcomes are typically reported as changes in client factors. Likewise, occupational therapy practitioners working with children and adolescents have reported that they often use play and leisure as an intervention, but few focus on play or leisure as outcomes (Kuhaneck et al., 2013).

Effective participation in occupations is key to the development of identity and perceptions of competence and value, and it is an important prognostic indicator for future employment and quality of life (AOTA, 2014). With an array of occupation- and activity-based interventions that are supported by evidence, occupational therapy practitioners are poised to maximize participation and performance and improve quality of life of children and youth.

Objective

The objective of this systematic review was to identify, evaluate, and synthesize the literature related to the effectiveness of occupation- and activity-based interventions to improve participation in ADL, play, and leisure skills in children and youth ages 5 to 21 yr and to contribute to the development of AOTA practice guidelines. This article describes two of the themes that emerged from the full review of the following research question: What is the evidence for the effectiveness of occupation- and activity-based interventions within the scope of occupational therapy practice to improve ADLs, play, and leisure for children and adolescents ages 5 to 21?

Method

The systematic review team used the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) systematic review methodology (Moher et al., 2015) to synthesize the evidence addressing the use and outcome of occupation- and activity-based interventions with children and youth. Search terms were developed iteratively by the AOTA research methodologist with input from AOTA staff, the review authors, and an advisory group of occupational therapy pediatric practitioners, scholars, and leaders. Table 1 includes the list of search terms used to describe the populations, interventions, and outcomes examined and the study designs included in the systematic review.

Table 1.

Key Search Terms

Category	Key Search Terms
Population	adolescence, adolescent, child, infant, infant development, infants, newborn, prematurity, preschool children, school age, teen, teenager, toddlers, young adult, young children, youth
Interventions and outcomes	activities of daily living, adaptive equipment, after school program, anger management, animal assisted therapy, arts program, assistive technology, attachment behavior, attention, auditory processing, balance, bathing, bedtime, bottle feeding, breast feeding, bullying, cognitive development, communication skills training, community integration, community living skills, computer games, computers, conflict resolution, co-occupation, cooking, cooperative behavior, coping skills, developmentally supportive care, diapering, DIR/Floortime, drama, dressing, driving, early childhood transition, early identification, early intervention, early literacy, eating, employment, executive function, exercise, experiential learning, family bonding, family centered care, family engagement, feeding, feeding and eating disorders of childhood, fine motor, food refusal, friendship, games, gross motor, hand skills, handwriting, hobbies, home management, hygiene, imitation skills, inclusion, independent living skills, individualized developmental care, individual placement and support, infant massage, infant mental health, infant nutritional physiological phenomena, instrumental activities of daily living, interest development, interprofessional teaming, job, job coaching, joint attention, kangaroo care, learning environment, leisure, life skills, literacy, manipulation skills, mealtime routines, medication adherence, medication compliance, meditation, memory, mental health, mental health promotion, mindfulness, mother child relations, motor processes, napping, NIDCAP, nonnutritive sucking, nonverbal, nutrition, occupational therapy, oral feeding, oral motor stimulation, oral sensorimotor, parent training, perception training, perceptual learning, perceptual motor, pivot training, play, positive behavior supports, postural control, posture, pre-emergent writing, preliteracy, prevocational, print awareness, problem solving, psychomotor, psychomotor performance, recess, recreation, relationship based interventions, relaxation, religious activities, resiliency, rest, rhythm, routines, routines based interventions, school mental health, seating, secondary, self-advocacy, self-care, self-efficacy, self-regulation, sensorimotor/sensory motor, sensorimotor/sensory motor development, sensory integration, sensory integrative, sign language, sleep, social emotional, social emotional learning, social participation, social skills, sound awareness, space perception, spatial ability, sports, stress management, sucking/swallowing coordination, swallowing, toileting, transition, transportation, tummy time, universal design, virtual reality, visual motor, visual perception, visual perceptual skills, visuospatial, walking, wellness, wheelchair, Wii, work, worker, yoga, youth engagement
Study designs	appraisal, best practices, case control, case report, case series, clinical guidelines, clinical trial, cohort, comparative study, consensus development conferences, controlled clinical trial, critique, cross over, cross-sectional, double-blind, epidemiology, evaluation study, evidence-based, evidence synthesis, feasibility study, follow-up, health technology assessment, intervention, longitudinal, main outcome measure, meta-analysis, multicenter study, observational study, outcome and process assessment, pilot, practice guidelines, prospective, random allocation, randomized controlled trials, retrospective, sampling, scientific integrity review, single subject design, standard of care, systematic literature review, systematic review, treatment outcome, validation study

Note. DIR = Developmental, Individual difference, Relationship-based Model; NIDCAP = Newborn Individualized Developmental Care and Assessment Program.

Inclusion Criteria

MEDLINE, PsycINFO, CINAHL, ERIC, OTseeker, and Cochrane Database of Systematic Reviews were searched by the AOTA medical research librarian for peer-reviewed journal articles published in English that described studies providing Level I, II, and III (AOTA, 2020) evidence addressing occupation- and activity-based interventions and outcomes within the scope of occupational therapy practice (AOTA, 2014). Literature search results were collected by the medical librarian in citation manager software, and exact duplicates were removed by the AOTA research methodologist. The research methodologist conducted the first review of the search results, eliminating articles that did not match the study criteria.

Using the PICO framework (Schardt et al., 2007), the team refined the criteria to address the population of children and youth ages 5 to 21 with disabling developmental, health, and learning conditions that affected participation. The authors examined the citations and abstracts to identify articles for full review. Reference lists of included studies and selected journals were hand searched to identify any additional articles not identified in the literature search. The citations of all articles selected for full review were recorded in a master citation table and annotated and reviewed by the research methodologist and the director of AOTA’s Evidence-Based Practice (EBP) Project. The authors coded all articles and discussed discrepancies until full agreement was achieved on article inclusion.

Data Extraction and Appraisal

Each article chosen for full review was abstracted in an evidence table that included level and type of study, sample description, intervention details, outcome measures, and study results (Table A.1 in the Appendix). The articles on interventions were systematically evaluated for risk of bias, and results were compiled in a risk-of-bias table (Higgins et al., 2011; Table A.2). The risk of bias for included systematic reviews and meta-analyses was evaluated using A MeaSurement Tool to Assess Systematic Reviews (AMSTAR; Shea et al., 2017; Table A.3). The authors coded the articles reviewed, discussing discrepancies until full agreement was obtained, and then synthesized the themes that emerged from the data. The evidence and risk-of-bias tables and the synthesized themes were reviewed by the research methodologist and the EBP Project director. The strength of the evidence was collaboratively examined using the U.S. Preventive Services Task Force (2017) ratings, as follows (AOTA, 2020):

• Strong evidence: Consistent results are reported across at least two randomized controlled trials (RCTs) and other well-conducted studies.

• Moderate evidence: Consistent or slightly inconsistent results are reported in at least one RCT or two or more individual well-conducted studies with lower levels of evidence.

• Mixed evidence: Inconsistent results were reported across a number of studies.

• Insufficient evidence: The number and quality of studies available are insufficient to draw specific conclusions and recommendations.

Table A.1.

Evidence Table for the Systematic Review of the Effectiveness of Occupation- and Activity-Based Interventions to Improve ADLs, Play, and Leisure for Children and Youth Ages 5 to 21

Author/Year	Level of Evidence/Study Design/Participants/Inclusion Criteria	Intervention and Control Groups	Outcome Measures	Results
Activities of Daily Living
Bar-Haim et al. (2010)	Level I Block randomized trial, matched for age and gross motor function N = 78 (age range = 66–146 mo; 65 completed all aspects of the study) Intervention Group 1, n = 31 Intervention Group 2, n = 34 Inclusion Criteria Spastic or mixed type CP, diplegia or quadriplegia, GMFCS Levels II and III, normal cognitive level, no tone reduction treatment, no botulinum toxin, no baclofen pump therapy	Intervention Group 1: NDT—sessions with set order of passive stretching, techniques to reduce spasticity and facilitate normal motor patterns, walking, standing up from sitting, and sitting; 1 hr 3×/wk for 3 mo (36 sessions) Group 2: ML coaching—activity-focused sessions with practice of motor functions in random order in several environments, using augmented feedback that matches the stages of the learner: set goal; do stretching; identify ability level; provide instruction; change features, tasks, and environments; practice chosen tasks and provide feedback; 1 hr 3×/wk for 3 mo (36 sessions) Control No control	• GMFM–66 • Mechanical efficiency during stair climbing • Parent questionnaire on mobility methods	Both intervention groups showed effectiveness at posttest. The NDT group showed some decreases at 9 mo, whereas the ML coaching group remained steady. Retention of gross motor functions and mechanical efficiency were improved by ML coaching, corresponding to an increased transfer of mobility performance in outdoor environments. Significantly increased motor function measures were seen after intensive therapy (1 hr 3×/wk for 3 mo; 36 sessions), and 6-mo retention of gross motor function improvements was maintained only after ML coaching. Children at GMFCS Level II in the ML coaching group benefited more than those in the NDT group in terms of retention and transfer of learned motor functions in the outdoors and community.
Bart et al. (2011)	Level II 2 groups, nonrandomized N = 33 (age range = 6.0–11.4 yr) Intervention group, n = 17 (10 with ABI [2 mild, 3 moderate, 5 severe], 6 with tumors, 1 with an infection; 15 with UE dysfunction [6 in dominant limb, 7 in nondominant limb, 2 in both limbs]) Control group, n = 16 (matched for age, gender, ethnic background, maternal education) Inclusion Criteria Ability to move ≥1 UE against gravity with full or partial ROM, no continuing signs of posttraumatic amnesia, no significant visual impairment, no premorbid psychiatric illness or premorbid progressive neurological impairment or learning disability	Intervention GestureTek’s GX Interactive Rehabilitation and Exercise (IREX) System with 3 virtual environments: birds and balls, soccer, and snowboard. At the start of each trial, the environment was introduced, and participants were trained individually for 1 min. Participants then experienced 3 min of the environment with the difficulty level increasing every minute. For the soccer task, the first 2 min were maintained at Level 1 and the third minute at Level 2. Between each environment, participants had 2 min rest. The total experience time in the 3 environments was about 20 min. Control Same as intervention	• Short feedback questionnaire for children • Test of Everyday Attention for Children • Melbourne Assessment of Unilateral Upper Limb Function • PEDI	Control participants performed better on all measures than the intervention participants with ABI. On selected tasks, the IREX System distinguished between children with and without brain injury. Significant correlations were found between virtual reality performance variables and attention, reaching, and self-care functional abilities. This study highlights the potential of video-capture virtual reality as a tool in the rehabilitation of children with ABI.
Bryant et al. (2013)	Level I Parallel arm RCT N = 35 (age range = 8–17 yr) Intervention Group 1, n = 11 Intervention Group 2, n = 12 Control group, n = 12 Inclusion Criteria Children with CP, GMFCS Level IV or V, able to pedal on adapted static bicycle and walk with partial body weight support on treadmill, no evidence of cognitive or behavioral impairment, no surgery to limbs in past year	Intervention Group 1: Protocol-specific exercise training on a static bike, 3×/wk for 6 wk Group 2: Protocol-specific exercise training on a treadmill, 3×/wk for 6 wk Control Usual physiotherapy activities	Primary • GMFM–66 • GMFM–88 Dimensions D (standing) and E (walking, running, jumping) Secondary • Speed and duration of exercise	Significant improvement in GMFM–88D (standing) scores was found for the static bike group compared with the control group (Mann–Whitney U = 24.5, p = .02) and for the treadmill group compared with the control group (U = 29.5, p = .04). GMFM–88E (walking, running, jumping) scores were higher for both intervention groups compared with the control group but not significantly (p > .05). Similarly, GMFM–66 results showed positive but nonsignificant changes in both intervention groups compared with the control group. Follow-up measures at 2 mo revealed declines.
Drahota et al. (2011)	Level I RCT N = 40 (age range = 7–11 yr) Intervention group, n = 17 Control group, n = 23 Inclusion Criteria Diagnosis of autism, Asperger syndrome, or PDD–NOS; also met research criteria for separation anxiety disorder, social phobia, or obsessive–compulsive disorder; either no medication at baseline or stable dose maintained throughout study; verbal IQ >70; not currently in psychotherapy, social skills training, or applied behavior analysis program; parents able to participate in intervention program	Intervention Building Confidence CBT Program modified for children with ASD, including skills training using CBT followed by practice of adaptive, social, and other skills, as well as an encouraging independence component that focused on parent and child motivation to increase daily living skills; 16 weekly sessions of 90 min each (30 min with child, 60 min with family) Control Wait list	• VABS • Parent–Child Interaction Questionnaire	For the intervention group, the mean standard score on the VABS increased from 50.06 to 60.24 (p < .01) but remained unchanged for the control group (p = .48). Parents in the intervention group (p = .01) also made significantly greater reductions in parental involvement in their child’s self-care tasks than control parents (p = .29). Treatment effects were maintained at 3-mo follow-up.
Grecco et al. (2013)	Level I RCT N = 35 Intervention group, n = 17 (M age = 6.8 yr ± 2.6) Control group, n = 18 (M age = 6.0 yr ± 1.5) Inclusion Criteria Age 3–12 yr, no cognitive or visual impairment that could compromise performance of tasks, GMFCS Levels I–III and functional ambulation for ≥12 mo, no orthopedic deformity indicative of surgery, no surgical procedure or neuromuscular block in 12 mo prior to study	Intervention Treadmill protocol, 30 min 2×/wk for 7 wk Control Overground walking protocol, 30 min 2×/wk for 7 wk	• 6-min walk test • TUG • PEDI • GMFM–88 • BBS	Both groups traveled a longer distance on the 6-min walk test after the interventions (p ≤ .001); the treadmill group achieved greater improvement at postintervention and follow-up (p = .001). Both groups showed gains on the TUG, the Mobility section of the PEDI, Subscales C and E of the GMFM–88, and the BBS. A greater impact was noted with the intervention group via intergroup analysis. Changes in PEDI-measured self-care skills were not significant in either group.
Hong et al. (2016)	Level I Meta-analysis N = 23 studies Inclusion Criteria ≥1 participant had a pervasive developmental disorder including ASD or Asperger syndrome or was reported to have characteristics of ASD, single-subject research design, results reported in a graphic display with individual data points, independent adaptive or functional living skills targeted as outcomes, described participant’s behaviors and not only researchers’ interventions and prompts, published in English	Intervention Point-of-view video modeling (video recorded from the perspective of the viewer) and other video modeling (peer or adult behavior modeling) Control Skills related to accessing the community: employment skills, self-help skills, household chores		Interventions that used some type of video modeling to improve functional living skills of participants with ASD were found to be moderately effective. The strongest effects were for elementary, adolescent, and adult participants; preschool and secondary school participants showed the lowest effects (these 2 age groups were present in only 2 studies, thus leaving doubt). Video-based modeling interventions were similarly effective for participants with autism and intellectual disability, ASD, and Asperger syndrome. The analysis showed strong effects for video modeling when a peer or adult modeled the behavior and moderate effects from the perspective of the viewer. The effects of video-based modeling on functional living skills (accessing the community, employment skills, self-help skills, and house chores) were moderate to strong, with community access the strongest and house chores the weakest.
Hsin et al. (2012)	Level I RCT N = 22 Intervention group, n = 11 (M age = 6.9 yr, SD = 0.6; 5 boys, 6 girls) Control group, n = 11 (M age = 6.9 yr, SD = 0.6; 5 boys, 6 girls) Inclusion Criteria Diagnosis of congenital unilateral spastic CP; considerable nonuse of affected UE; active extension movement of wrist and metacarpophalangeal joint >10°; no excessive muscle tone (Modified Ashworth Scale score ≤2 for any UE joint); no severe cognitive, visual, or auditory disorder or severe concurrent illness or medical condition; no major surgery or nerve blockage within 6 mo of intervention; no poor cooperation during assessments	Intervention Individualized home CIT sessions, 3.5–4.0 hr/day 2×/wk for 4 wk, focused on functional training of the affected arm using shaping and task practice; participants wore a restraint glove and elastic bandage that limited wrist and individual finger movement of the less-affected UE. Participants were encouraged to exercise or perform daily activities at home under parental supervision and to wear the bandage and glove for 3.5–4.0 hr/day while doing exercises or activities. Control Functional bilateral or unilateral arm training using function-oriented activities, NDT techniques, and ML, in individualized home sessions, 3.5–4.0 hr/day 2×/wk for 4 wk. Participants were encouraged to exercise or perform daily activities at home under parental supervision.	• BOTMP • PMAL • CP Quality of Life Questionnaire	Both groups showed improvements on the BOTMP at posttest and 3-mo follow-up. The intervention group improved more with a large effect at posttreatment (p = .001) and 3 mo (p = .001). Both groups also improved on the PMAL at postintervention and 3-mo follow-up. The CIT group improved more on the amount and quality of hand use with a large effect. CP Quality of Life Questionnaire scores improved for both groups. No significant differences were found at postintervention, but the intervention group showed significantly larger improvements at 3-mo follow-up.
James et al. (2015)	Level I Matched pairs wait-list RCT N = 101 Intervention group, n = 51 (M age = 11.8 yr, SD = 2.4; 26 boys, 25 girls) Control group, n = 50 (M age = 11.10, SD = 2.5; 25 boys, 25 girls) Inclusion Criteria Children with spastic-type unilateral CP MACS Levels I –III and GMFCS Level I or II; with sufficient cooperation and cognitive function to perform required tasks and internet access at home	Intervention Use of Mitii, a web-based multimodel home therapy program consisting of upper limb, cognitive, visual–perceptual, and physical activity training, accessed via an internet-connected computer. The system detects movement with a web camera and tracking bands. All equipment was loaned to the participants. Individual programs were devised on the basis of each child’s baseline scores. Mitii was ideally completed for 20–30 min 6 days/wk for 20 wk (maximum potential dose = 60 hr). Therapists remotely monitored and adjusted the modules. Regular contact was provided for feedback, technical support, and to facilitate engagement. Control Standard care, which typically involved consult with medical and allied health professionals	• AMPS • Assisting Hand Assessment • Jebsen–Taylor Test of Hand Function	Groups were similar at baseline. The intervention group completed an average of 32.4 hr of Mitii and was assessed at the 20-wk mark. After intervention, AMPS Motor and Process scale scores were higher in the intervention than in the control group. After adjusting for baseline scores, the differences were close but did not meet statistical significance.
Keenan et al. (2014)	Level III Retrospective N = 50 (M age = 18.1 yr; 22 boys, 28 girls) Inclusion Criteria Youth with a disability (CP, spina bifida, ABI, ASD) who were participants in Skills for Transition, a community-based life skills program	Intervention Six one-to-one coaching sessions in 8-day life skills program; life skills groups (10 youth) with direct instruction, role-play, and peer modeling Control No control	• GAS, 5-item checklist to determine GAS quality • COPM Performance and Satisfaction	GAS goals were categorized into social and interpersonal skills, cognitive skills, and emotional coping skills. Participants made significant improvements on all outcome measures. Both life skills and coaching were effective in improving in goal achievement and satisfaction. Goal domain and content area had no impact on goal achievement; participants were equally likely to achieve their goals, regardless of the type of goal they set.
Law et al. (2011)	Level I RCT N = 128 (age range = 12 mo to 5 yr, 11 mo; M age = 3 yr, 6 mo ± 1 yr, 5 mo; 79 boys, 49 girls) Intervention Group 1, n = 71 Intervention Group 2, n = 57 Inclusion Criteria Diagnosis of CP, GMFCS Levels I–V, no planned surgical or medication changes during intervention period	Intervention Child-focused or context-focused intervention, 18–24 sessions over 6 mo, returning to their regular therapy schedule and approach between 6 and 9 mo. Parents received information about their child’s disability and about strategies they could use at home. Group 1: In the child-focused group, therapists identified the impairments underlying a functional limitation (e.g., tone, posture, ROM) and provided therapy to remediate the impairments (motor, cognitive, or sensory) and practice specific movements and tasks. Group 2: In the context-focused group, treatment focused on changing the identified constraints within the task or environment or both. Whenever feasible, intervention included practice of tasks in natural environments (e.g., home, preschool). Children were encouraged to use compensatory strategies to achieve functional tasks. Therapists were instructed not to include remediation of the children’s impairments. Control Group 1 served as the control group.	• PEDI • GMFM–66 • APCP • FES	Both interventions resulted in equivalent and significant improvements in self-care, mobility, and participation outcomes during the 6-mo intervention period. PEDI scores showed no significant differences between groups except for a small effect (p < .03) on the Caregiver Assistance Mobility subscale between baseline and 9 mo. The mean scores of both groups changed significantly on the PEDI Functional Skills (p < .001) and Caregiver Assistance (p < .02) scales at postintervention. A subgroup effect was found for age (p < .001), with children younger than 3 yr changing significantly more than older children. GMFCS level at baseline did not influence the amount of change on the PEDI scales. There were no significant differences between groups on the GMFM, ROM measures, APCP, or FES. For the GMFM, there was a significant change over time from baseline to 6 mo (p < .001) and no significant change between 6 and 9 mo. For the APCP, significant changes for both groups were found between baseline and 6 mo in play intensity (p < .04), physical activity intensity and diversity (p < .001), and total score intensity (p < .01).
Maeir et al. (2014)	Level II 2 groups, crossover N = 19 (age range = 5–7 yr, M age = 5.6 yr) Inclusion Criteria Medical diagnosis of ADHD confirmed by psychological interview, parent report of executive function difficulties in daily life (BRIEF score >65 on any scale), no other psychiatric or neurological disorder, no specific language disorder, not in a special education setting, no change in medication status in past 6 mo	Intervention Cog–Fun manualized intervention for young children with ADHD administered by 3 trained OTs in 10 1-hr weekly sessions with child and parent in a playful setting. In Cog–Fun, parents identify occupational goals before and during the intervention, goals are introduced gradually with parents attending and engaging in the session, and therapists communicate weekly by phone or email with parents between the sessions. One session is conducted in the home. Sessions target cognitive, emotional, and environmental barriers to participation as they interact in the occupational context. The intervention supports participation via the metacognitive learning of executive strategies (e.g., stop, recruit effort/persist, check, plan) within an enabling context. Control Wait list	• BRIEF • COPM • Videotaped observation	88 occupation-based goals were set on the COPM, with an average of 4.6 per child. The intervention group showed significant gains after treatment on all outcome measures (p < .05) except for the BRIEF Plan scale. Control participants showed no improvement and even demonstrated a trend toward worsening. The results support the assertion that Cog–Fun treatment gains are replicable and not incidental and may be attributed specifically to the treatment and not to maturation.
Miller et al. (2001)	Level I RCT N = 20 (age range = 7–12 yr, 11 mo; M age = 9.05 yr ± 1.23; 14 boys, 6 girls) Intervention Group 1, n = 10 Intervention Group 2, n = 10 Inclusion Criteria Ages 7–12 yr, 11 mo; identified as having movement problems typical of DCD or a diagnosis of DCD; normal intelligence, hearing, and vision; no previous or present exposure to a cognitive-based treatment for motor problems; no medical diagnosis of a specific neurological disorder or physical or sensory deficit causing the motor problem	Intervention Group 1: CO–OP, 10 individual sessions spent learning the Goal-Plan-Do-Check strategy and then applying it in learning to perform targeted tasks determined by children using the COPM Group 2: CTA, 10 individual sessions spent using neuromuscular, multisensory, and biomechanical approaches led by the therapist directed at the target tasks identified using the COPM Control No control	• COPM • VABS • BOTMP • VMI • SPPC (Motor items) • PQRS	At pretest the intervention groups differed only on COPM Satisfaction ratings for their third goal; all other pretest measures were considered equal. Performance and Satisfaction scores for the CO–OP group showed greater improvements than for the CTA group, but both groups demonstrated significant change at posttest (p = .001). The PQRS scores of both groups improved significantly, with the CO–OP group demonstrating greater improvement. VABS composite scores showed a significant effect for time averaged across both treatment groups. Communication, daily living skills, and motor scores were higher for the CO–OP group than the CTA group. Both groups showed significant improvement in the BOTMP and a time effect on the VMI that approached significance. No change was noted on the SPPC self-esteem items for either group. At follow-up (M = 10 mo for the CO–OP group, M = 9 mo for the CTA group), CO–OP parents rated the usefulness of the intervention between 6 and 10 on a 10-point scale (M = 8.69, 8 parents), and the CTA parents rated the usefulness of the intervention between 3 and 10 (M = 7.71, 7 parents).
Park et al. (2014)	Level II 2 groups, nonrandomized N = 55 Intervention group, n = 34 (M age = 6.68 yr ± 2.64; 15 boys, 19 girls) Control group, n = 21 (M age = 7.76 yr ± 3.67; 10 boys, 11 girls) Inclusion Criteria Age 3–12 yr, body weight <40 kg, GMFCS Levels I–IV, no chemodenervation therapy in past 6 mo, no selective dorsal rhizotomy in past year, no moderate to severe intellectual disability, no uncontrolled seizures, no poor visual or hearing acuity, no previous participation in hippotherapy or therapeutic horseback riding	Intervention Hippotherapy conducted by a trained and accredited OT, 45-min sessions 2×/wk for 8 wk Control No intervention	• GMFM–66 • GMFM–88 • PEDI	After the 8-wk intervention, both groups showed significant improvement in GMFM–66 and GMFM–88 scores. GMFM–66 scores were significantly greater in the hippotherapy group, and GMFM–88 scores improved in all dimensions for the hippotherapy group but only in Dimension B (sitting) for the control group. Significant improvements on the total PEDI Functional Skills Scale and subscores on all domains (self-care, mobility, social functioning) were noted in the hippotherapy group but not the control group.
Slaman et al. (2015)	Level I RCT N = 57 (age range = 16–25 yr; 27 boys, 30 girls; 36 completed the study) Inclusion Criteria Unilateral or bilateral spastic CP measured by the Modified Ashworth Scale, ages 16–24 yr, GMFCS Levels I–IV, no disabilities other than CP that affect daily physical activity or cardiopulmonary fitness, no contraindication to maximal exercise, physical activity level at baseline within the mean physical activity level + 2 SD of a CP population, no severe cognitive disorders or insufficient comprehension of the Dutch language	Intervention Active Lifestyle and Sports Participation intervention program consisted of three parts: (1) progressive weekly supervised center- and home-based physical fitness training program, (2) counseling by a personal coach on daily physical activity in which barriers to and facilitators of physical activity in daily life were discussed and increased physical activity was encouraged (6 monthly 30-min sessions), and (3) counseling on sports participation to find suitable sporting activities and facilities for each participant Control Treatment as usual	Physical Activity Scale for Individuals With Physical Disabilities	The intervention did not affect objectively measured physical activity during the intervention (β = 0.34, 95% CI [1.70, 2.37]) or at follow-up (β = 0.30, 95% CI [1.99, 2.59]). Self-reported physical activity improved during the intervention period (β = 7.61, 95% CI [0.17, 15.05]); however, this effect was not present at follow-up (β = 3.65, 95% CI [3.05, 10.36]). This lifestyle intervention was ineffective in eliciting a behavioral change toward more favorable physical behavior in adolescents and young adults with spastic CP.
Song (2014)	Level III 1 group, pretest–posttest N = 12 (age range = 7–12, M age = 9.2; 7 boys, 5 girls) Inclusion Criteria Children with spastic hemiplegia CP, no neurological or musculoskeletal disease except CP, able to understand and follow verbal instructions, no unstable seizures, no treatment for spasticity in past 3 mo, no surgical procedures in past 6 mo	Intervention Task-oriented training consisting of activities similar to the daily tasks performed by children (including play and ADLs), 40 min 5×/wk for 6 wk, in addition to conventional OT (motion exercise and UE stretching) for 30 min to improve function in the affected arm Control No control	• Box and Block Test • MAM–16 • WeeFIM	After the 6-wk training period, a significant increase was observed on the Box and Block Test, MAM–16, and WeeFIM. The results support the efficacy of task-oriented training to improve functional activities and basic ADLs using the affected arm in children with CP.
Tarakci et al. (2016)	Level I RCT N = 30 (19 boys, 11 girls) Intervention group, n = 15 (M age = 10.46 yr ± 2.69) Control group, n = 15 (M age = 10.53 yr ± 2.79) Inclusion Criteria Diagnosis of CP, ages 5–18, GMFCS Levels I–III, no history of epilepsy, no botulinum toxin treatment in past 6 mo, no score >2 on Modified Ashworth Scale, mental capacity to adapt to exercise	Intervention Wii Fit balance-based video game training using an NDT approach, 50 min 2×/wk for 12 wk Control Conventional balance training group using an NDT approach, 50 min 2×/wk for 12 wk	• Functional forward reach test • Functional sideways reach test • TUG • Sit to Stand Test • Wii Fit balance and game scores • 10-mile walk test • 10-step climbing test • WeeFIM (self-care, transfers, locomotion)	Significant improvements in outcome measures, including increases in self-care (p = .02) and locomotion (p = .01), were found in favor of the Wii group, with the exception of transfers, which improved but not significantly.
Tarakci et al. (2012)	Level I RCT, single blind N = 81 (age range = 5–17 yr; 37 boys, 44 girls) Intervention group, n = 43 (M age = 10.02 yr ± 3.44) Control group, n = 38 (M age = 10.82 yr ± 4.00) Inclusion Criteria Diagnosis of juvenile idiopathic arthritis in accordance with International League of Associations for Rheumatology criteria; no active joints in an exacerbation period; no neurological disease, metabolic disorder, decompensated organ failure, intraarticular steroid injection, or surgery on any joint; <2 hr of habitual weekly exercise; able to cooperate with exercise and measurement	Intervention 12-wk individually planned land-based home exercise program that included ROM, strengthening, and stretching activities and functional activities with parent supervision, 3×/wk, with supervision 1×/wk by a PT and progression provided according to each participant’s tolerance and response Control Wait list	• 6-min walk test • Childhood Health Assessment Questionnaire (dressing, grooming, eating, hygiene, and activities) • Pain VAS • Pediatric Quality of Life Inventory Arthritis Module • Participant diary	Significant improvements (p < .001) were found on all outcome measures for the intervention group after 12 wk, with the exception of the pain VAS (p > .05). In the control group, only the pain VAS decreased significantly (p = .01).
Play and Leisure
Cecchini et al. (2014)	Level II 2 groups, nonrandomized N = 447 (M age = 14.34 yr; 57% boys) Intervention group, n = 223 Control group, n = 224 Inclusion Criteria Students in PE class in 8 high schools with consent	Intervention 12-wk program based on Epstein’s TARGET strategies during PE class; included problem-solving and decision-making tasks with rewards and recognition embedded Control PE as usual	5-item scale measuring intention to be physically active	Significant improvements in intention to be active (p = .001) and leisure time physical activity (p = .001) were found in the intervention group and sustained at 3 mo. The intervention and control groups differed significantly on both variables (p = .001).
Chantry & Dunford (2010)	Level I Systematic review N = 27 studies Inclusion Criteria Focus on children with severe and complex neurological disabilities, use of computer assistive technology	Intervention Computer-mediated inclusive educational opportunities; computer access and hardware and software controls; computer-based games; movement to music systems; robotic engineering; computer-augmented communication; environmental control systems Control Noninclusive educational opportunities; typically developing children and youth		Computer-based play increased opportunities for play and increased autonomous free play for children with complex disabilities such as cerebral palsy. The findings of the review were limited by low-quality studies and small samples. A meta-analysis was not conducted for statistical significance, and detailed outcome data were not provided.
Kretzmann et al. (2015)	Level I RCT crossover N = 24 (M age = 8.3 yr; 67% boys) Intervention group, n = 13 (11 boys) Control group, n = 11 (7 boys) Inclusion Criteria Grades 1–5, identified as having ASD on IEP, included in general education ≥80% of day	Intervention Active coaching on the playground, including modeling of starting and maintaining game play, and Remaking Recess training to teach adults how to engage with the children Control Wait list, PE as usual	• Playground Observation of Peer Engagement • Paraprofessional intervention fidelity • Self-reported frequency of leisure physical activity	A significant Treatment × Time effect on active game engagement on the playground was found for the intervention group. A treatment effect size of 1.27 was maintained at 10-wk follow-up. The control group showed no change.
Lang et al. (2011)	Level I Systematic review N = 15 studies Inclusion Criteria ≥1 participant with ASD; ages 3–14; intervention during recess; outcomes related to academics, social skills, play, or communication	Intervention Peer- and adult-mediated or modeled social interventions; explicit instruction in games and social activities; cognitive (coaching) and behavioral (reinforcement or elimination) approaches; use of technological devices Control Typically developing children and youth		Peer-mediated (group play) interventions and structured guidance for use of playground equipment significantly increased appropriate play during recess for children with ASD.
Miltenberger & Charlop (2014)	Level III Multiple baseline across and within participants N = 3 (ages 6.3, 9.1, and 9.2 yr) Inclusion Criteria Independent diagnosis of ASD, in elementary school, attend recess with typically developing peers, demonstrate little athletic group play	Intervention Phase 1: Athletic skills training (4 square and handball) in one-on-one play session with verbal and physical prompts with most to least prompt use; verbal praise and tokens for compliance and success Phase 2: Rules training using prompts for child to play with therapist using established rules; least to most prompting and social praise and tokens used for compliant and appropriate behaviors Control No control	• Social validity • Coding of videotaped sessions for group play, participation, appropriate play, athletic skills, and speech	Significant changes were noted in the children’s group play, athleticism, and speech (p ≤ .05). The 3 children all mastered the targeted athletic skills and increased group play. One child generalized skills to games with other children, but no carryover to school recess was noted.
O’Connor & Stagnitti (2011)	Level II Quasi-experimental, pretest–posttest N = 35 (M age = 5.7 yr; 54% boys) Inclusion Criteria Age 5–8 yr, enrolled in a specialist school	Intervention Learn to Play program involving 4 play stations—doll play, transport, construction, and home corner—with a range of play sequences and therapists guiding play; 1 hr 2×/wk for 6 mo Control Traditional classroom activities	• PIPPS • GAS • Preschool Language Scales 4th Edition • ChIPPA	The control group was older and had higher play abilities at baseline. The intervention group showed significant improvement at postintervention on the ChIPPA, PIPPS, and GAS indicating fewer deficits in play, improved behavior and social interaction, less disruptive behavior, and less socially disconnected behavior. The control group made significant gains in symbolic play and object substitutions and significantly improved their GAS and total language scores. Overall, the children in the intervention group showed greater developmental improvements than the control group when considering the differences at baseline.

Note. ABI = acquired brain injury; ADHD = attention deficit hyperactivity disorder; ADLs = activities of daily living; AMPS = Assessment of Motor and Process Skills; APCP = Assessment of Preschool Children’s Participation; ASD = autism spectrum disorder; BBS = Berg Balance Scale; BOTMP = Bruininks–Oseretsky Test of Motor Proficiency; BRIEF = Behavior Rating Inventory of Executive Function; CBT = cognitive–behavioral therapy; ChIPPA = Child-Initiated Pretend Play Assessment; CI = confidence interval; CIT = constraint-induced therapy; Cog–Fun = Cognitive–Functional; CO–OP = Cognitive Orientation to daily Occupational Performance; COPM = Canadian Occupational Performance Measure; CP = cerebral palsy; CTA = Contemporary Treatment Approach; DCD = developmental coordination disorder; FES = Family Empowerment Scale; GAS = goal attainment scaling; GMFCS = Gross Motor Function Classification System; GMFM = Gross Motor Function Measure; IEP = individualized education program; MACS = Manual Ability Classification System; MAM = Manual Ability Measure; ML = motor learning; NDT = neurodevelopmental treatment; OT = occupational therapy/occupational therapist; PDD–NOS = pervasive developmental disorder–not otherwise specified; PE = physical education; PEDI = Pediatric Evaluation of Disability Inventory; PIPPS = Penn Interactive Peer Play Scale; PMAL = Pediatric Motor Activity Log; PQRS = Performance Quality Rating Scale; PT = physical therapist; RCT = randomized controlled trial; ROM = range of motion; SPPC = Self-Perception Profile for Children; TUG = Timed Up and Go; UE = upper extremity; VABS = Vineland Adaptive Behavior Scales; VAS = visual analog scale; VMI = Beery–Buktenica Developmental Test of Visual–Motor Integration.

Copyright © 2021 by the American Occupational Therapy Association. This table may be freely reproduced for personal use in clinical or educational settings as long as the source is cited. All other uses require written permission from the American Occupational Therapy Association. To apply, visit www.copyright.com.

Suggested citation: Laverdure, P., & Beisbier, S. (2021). Occupation- and activity-based interventions to improve performance of activities of daily living, play, and leisure for children and youth ages 5 to 21: A systematic review (Table A.1). American Journal of Occupational Therapy, 75, 7501205050. https://doi.org/10.5014.ajot.2021.039560

Table A.2.

Risk-of-Bias Table for Included Intervention Studies

Citation	Selection Bias		Performance Bias: Blinding of Participants and Personnel	Detection Bias		Attrition Bias: Incomplete Outcome Data	Reporting Bias: Selective Reporting
Citation	Random Sequence Generation	Allocation Concealment	Performance Bias: Blinding of Participants and Personnel	Blinding of Outcome Assessment: Self-Reported Outcomes	Blinding of Outcome Assessment: Objective Outcomes	Attrition Bias: Incomplete Outcome Data	Reporting Bias: Selective Reporting
Bar-Haim et al. (2010)	+	+	+	–	–	+	+
Bart et al. (2011)	–	–	–	–	+	+	+
Bryant et al. (2013)	+	+	+	+	–	+	+
Cecchini et al. (2014)	–	–	–	–	–	+	+
Drahota et al. (2011)	+	+	?	–	+	+	+
Grecco et al. (2013)	+	+	+	+	+	+	+
Hsin et al. (2012)	+	+	–	–	+	+	+
James et al. (2015)	+	+	–	–	+	+	+
Keenan et al. (2014)	–	–	–	–	–	+	+
Kretzmann et al. (2015)	+	?	–	+	+	+	+
Law et al. (2011)	+	+	+	+	+	+	+
Maeir et al. (2014)	–	–	–	+	+	+	+
Miller et al. (2001)	–	–	–	–	+	+	+
Miltenberger & Charlop (2014)	–	–	–	–	+	+	+
O’Connor & Stagnitti (2011)	–	–	–	–	+	+	+
Park et al. (2014)	–	–	–	+	+	+	+
Slaman et al. (2015)	+	+	+	+	+	+	+
Song (2014)	–	–	–	–	–	+	?
Tarakci et al. (2016)	+	?	–	+	+	+	+
Tarakci et al. (2012)	+	+	?	–	+	+	?

Note. Categories for risk of bias are as follows: + = low risk of bias; − = high risk of bias; ? = unclear risk of bias. Risk of bias table format adapted from “Assessing Risk of Bias in Included Studies,” by J. P. T. Higgins, D. G. Altman, and J. A. C. Sterne, in Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0), by J. P. T. Higgins and S. Green (Eds.), March 2011. https://handbook-5-1.cochrane.org/. Copyright © 2011 by The Cochrane Collaboration.

Suggested citation: Laverdure, P., & Beisbier, S. (2021). Occupation- and activity-based interventions to improve performance of activities of daily living, play, and leisure for children and youth ages 5 to 21: A systematic review (Table A.2). American Journal of Occupational Therapy, 75, 7501205050. https://doi.org/10.5014.ajot.2021.039560

Table A.3.

Risk-of-Bias Table for Included Systematic Reviews

Citation	A Priori Design Included?	Duplicate Study Selection/Data Extraction?	Comprehensive Literature Search Performed?	Status of Publication as Inclusion Criteria?	List of Included/Excluded Studies Provided?	Characteristics of Included Studies Provided?	Quality of Studies Assessed and Documented?	Quality Assessment Used Appropriately?	Methods Used to Combine Results Appropriate?	Likelihood of Publication Bias Assessed?	Conflict of Interest Stated?
Chantry & Dunford (2010)	+	?	+	–	–	+	–	+	–	–	–
Hong et al. (2016)	+	+	+	+	–	–	+	+	+	–	+
Lang et al. (2011)	+	+	+	–	–	–	–	+	+	–	–

Note. Categories for risk of bias are as follows: + = yes; − = no; ? = not sure. Risk-of-bias table format adapted from “AMSTAR 2: A Critical Appraisal Tool for Systematic Reviews That Include Randomised or Non-Randomised Studies of Healthcare Interventions, or Both,” by B. J. Shea, B. C. Reeves, G. Wells, M. Thuku, C. Hamel, J. Moran, . . . D. A. Henry, 2017, BMJ, 358, j4008. https://doi.org/10.1136/bmj.j4008. Copyright © 2017 by the British Medical Association.

Suggested citation: Laverdure, P., & Beisbier, S. (2021). Occupation- and activity-based interventions to improve performance of activities of daily living, play, and leisure for children and youth ages 5 to 21: A systematic review (Table A.3). American Journal of Occupational Therapy, 75, 7501205050. https://doi.org/10.5014.ajot.2021.039560

Using the strength of evidence as a methodological guide, in this article we make policy and education recommendations informed by strong evidence from the systematic review. Practice recommendations are informed by moderate and mixed evidence; recommendations in these categories are supplemented with suggestions to ensure the efficacy of these interventions.

Results

The literature search yielded 89,461 records. After removal of duplicates and screening for titles congruent with the research question, conducted by the research methodologist, 5,312 records remained. The authors reviewed the citations and abstracts of these records and excluded 5,216 articles. After full-text review of the 96 remaining articles, 23 articles were retained for analysis (Figure 1). The most common reasons for exclusion were as follows: The areas of occupation examined were included in another systematic review concurrently conducted (n = 26), the study did not include occupation- or activity-based interventions or the interventions were outside the occupational therapy scope of practice (n = 13), outcome measures evaluated client factors or outcomes but did not address occupational performance or participation (n = 12), or the study did not include children and youth in the designated age range (n = 3).

Figure 1.

Flow diagram for inclusion and exclusion of studies in the systematic review.

Twenty-three studies met the criteria for inclusion in this review. One meta-analysis (Level I), 2 systematic reviews (Level I), 12 RCTs (Level I), 5 two-group nonrandomized studies (Level II), 2 one-group pretest–posttest studies (Level III), and 1 retrospective study (Level III) were examined and categorized by type of intervention and outcome. Each study used occupation- or activity-based interventions and reported ADL (feeding, functional mobility, and self-care [bathing, showering, personal hygiene and grooming, dressing, toileting and toileting hygiene]), play, or leisure outcomes (AOTA, 2014). Three intervention themes emerged from the data: supporting engagement in occupations, supporting participation with cognitive supports, and using technology to support occupational participation and performance.

Supporting Engagement in Occupations

Interventions in the theme of supporting engagement in occupations included active engagement in occupations in home and community settings, home carryover programs, practice within and across environments, and task simulation interventions.

ADL Engagement and Functional Life Skills Training

Strong strength of evidence indicates that interventions promoting engagement in ADLs improve participation and performance in ADL skills for children and youth (6 Level I studies with low risk of bias). Drahota and colleagues (2011) reported that children ages 7 to 11 yr with autism spectrum disorder (ASD) who participated in an adaptive skills training and intervention designed to increase ADL independence showed significantly improved skill performance, and caregivers significantly reduced their involvement in their children’s physical care.

Young children with cerebral palsy (CP; Gross Motor Classification System [GMFCS] Levels I–V) ages 12 mo to 6 yr who practiced ADL tasks in an adapted environment achieved significant improvements in ADL, mobility, and participation outcomes that were equivalent to their age-matched peers who received traditional therapeutic interventions (e.g., therapeutic exercise, coordination tasks; Law et al., 2011). Similarly, youth with CP (GMFCS Levels I–IV) ages 16 to 25 yr who participated in an active lifestyle and sports participation intervention, logged their daily physical activity, and used activity monitors during daily life activities significantly increased their ADL engagement measured using a physical activity self-report measure (Slaman et al., 2015).

In a study of the effectiveness of constraint-induced therapy (CIT), children with CP (M age = 6.9 yr) who used a constraint mitt while engaging in ADLs were compared with a group who did not use a restrictive mitt. Significant improvement in ADL performance was demonstrated in the mitt-wearing group immediately after and 3 mo posttreatment (Hsin et al., 2012). A significant difference was recorded on the Cerebral Palsy Quality of Life Questionnaire at the 3-mo follow-up for the CIT group.

Children with idiopathic arthritis ages 5 to 17 yr who participated in a clinic-based and home program that included range of motion, strengthening, stretching, and engagement in occupational routines showed significant improvement in occupational engagement (dressing, grooming, eating, hygiene), pain management, and quality of life (Tarakci et al., 2012). Participants not only were more actively engaged in ADLs after 12 wk in the program but also reported decreased pain.

Functional Mobility Interventions

Strong strength of evidence was found that engagement in functional mobility activities and structured exercise programs improves functional mobility in children and youth (3 Level I and 1 Level II studies with low risk of bias). Young children with CP (GMFCS Levels I–III; M age = 6.8 yr) who received structured training on a treadmill twice a week for 30 min over 7 wk showed significant increases in the distance they could travel in functional activity (Grecco et al., 2013, Level I). Youth with CP (GMFCS Levels IV and V) ages 8 to 17 who received structured training on a static bike or treadmill showed significant improvement on functional mobility measures (Bryant et al., 2013, Level I). Adolescents and transitioning youth with CP (GMFCS Levels I–IV) ages 16 to 25 who participated in an active lifestyle and sports participation intervention involving progressive supervised center- and home-based physical fitness activities and counseling on increasing daily physical activity significantly increased their ADL and leisure participation as measured by a physical activity self-report measure (Slaman et al., 2015, Level I). Finally, children with CP (GMFCS Levels I–IV; M age = 7.76 yr) who participated in hippotherapy sessions saw significant gains in their functional mobility skills (Park et al., 2014, Level II).

Simulated Training

Low strength of evidence indicates that engagement in simulated training can improve self-feeding performance and mealtime participation in children with spastic CP (1 Level III study with high risk of bias). Children ages 7 to 12 yr engaged in activities that simulated the kinds of activities children typically encounter, such as ball play, play with construction materials, holding a cup, and using a fork, and showed significant improvements in occupational participation outcomes (Song, 2014).

Play and Leisure Interventions

Moderate strength of evidence was found for the use of occupation- and activity-based interventions to improve engagement in play and leisure in children and youth with disabilities (2 Level I studies with low risk of bias and 1 Level II study with high risk of bias). A significant increase in self-directed and symbolic play was found for children with intellectual disabilities (M age = 5.7 yr) after therapist-guided play using Learn to Play stations and structured play sequences (e.g., doll, transport, construction, home corner) compared with children who participated in traditional classroom activities (O’Connor & Stagnitti, 2011, Level II). Active coaching, modeling, and guided play participation in the context of the school playground for children with ASD resulted in significant improvement with a large effect size in active game engagement that was maintained at 10 wk after implementation of the Remaking Recess training (Kretzmann et al., 2015, Level I). Lang et al. (2011, Level I) conducted a systematic review of school recess interventions for children with ASD ages 3 to 12 yr and found 15 single-subject design studies. The studies demonstrated that providing opportunities for children with disabilities to observe typically developing children in play, using peer-mediated (group play) interventions, and providing instruction on game play and the use of playground equipment increased appropriate play behavior during recess for children with ASD.

Supporting Participation With Cognitive Supports

Interventions in the theme of supporting participation with cognitive supports involved collaborative goal setting, activity-based training and education (including motor learning interventions), and coaching and feedback (by, e.g., peer, caregiver, or occupational therapy practitioner).

Functional Mobility and ADL Performance Interventions

Strong strength of evidence was found that supporting participation with cognitive supports improves functional mobility and ADL participation and performance in children and youth (3 Level I studies with low risk of bias). Children with CP (GMFCS Levels II and III) ages 5.5 to 12 yr participated in occupation-based sessions with coaching and feedback (with the child or youth, the caregiver, or both) and home practice, and they showed significant improvement in functional mobility and ADL participation and performance compared with children receiving neurodevelopmental treatment (NDT; Bar-Haim et al., 2010).

Children with idiopathic arthritis ages 5 to 17 yr who participated in an ADL program coupled with caregiver training and home practice showed significant improvement in occupational engagement (dressing, grooming, eating, hygiene; Tarakci et al., 2012). Children with developmental coordination disorder ages 7 to 12 yr who participated in collaborative goal setting, instruction, and feedback (e.g., Cognitive Orientation to daily Occupational Performance [CO–OP]) showed significant improvement in ADL participation, performance, and satisfaction compared with a group who underwent conventional therapy services (e.g., strength training, motor coordination tasks; Miller et al., 2001).

Goal Direction in Occupational Participation

Low strength of evidence was found that goal setting with children ages 5 to 7 yr with attention deficit hyperactivity disorder can improve occupational performance (1 Level II study). Occupational goals were identified by the child’s caregivers, and Cognitive–Functional (Cog–Fun) manualized intervention sessions targeted cognitive, emotional, and environmental barriers to participation; metacognitive learning of executive strategies; and home carryover (Maeir et al., 2014). The intervention group showed significant gains after treatment on all outcome measures. In addition, low strength of evidence (1 Level III study) indicates that engagement in group occupation-based coaching interventions (one-on-one direct instruction, role-playing, and peer modeling) can significantly improve goal-directed occupational performance in youth (M age = 18.1 yr) with a variety of disabilities (CP, spina bifida, acquired brain injury, and ASD; Keenan et al., 2014).

Engagement in Play and Leisure

Low strength of evidence was found for the use of cognitive supports during occupation participation to improve engagement in play and leisure in children and youth with disabilities (1 Level II study and 1 Level III study with high risk of bias). Cecchini and colleagues (2014, Level II) engaged youth with ASD (M age = 14.3 yr) in a program based on using Epstein’s TARGET strategies while playing games in physical education class. Problem-solving and decision-making components with rewards and recognition were embedded into the program. A significant increase in leisure time physical activity was observed immediately and 3 mo after the program. Miltenberger and Charlop (2014, Level III) found that use of praise and tokens in conjunction with athletic skills training resulted in mastery of targeted athletic skill play for children with ASD ages 6 to 9; however, carryover to school recess play was not observed. This study was limited to 3 participants, and statistical significance was not calculated.

Using Technology to Support Occupational Participation and Performance

Interventions in the theme of using technology to support occupational participation and performance involved the use of video modeling, virtual reality, and video games to promote occupational engagement.

ADL Participation and Performance

Moderate strength of evidence indicates that using video modeling can improve ADL participation and performance (1 Level I study with low risk of bias). A meta-analysis of 23 studies examined the effects of video modeling to support occupational participation and performance in people with ASD (Hong et al., 2016). Interventions that used video modeling to improve functional living skills of children and youth with ASD were moderately effective; the strongest effects were for elementary-age children and young adults. Video modeling interventions were similarly effective for participants with ASD and intellectual disability, and effect sizes increased when a peer or adult modeled the behavior.

Strong evidence was found that web-based play improves ADL participation and performance in children and youth with CP (2 Level I studies with low risk of bias). Children and youth with mild CP (GMFCS Levels I–III; M age = 10.5 yr) who participated in Wii Fit balance-based video games saw significant improvement in ADL participation compared with those receiving conventional balance training (Tarakci et al., 2016). Children and youth with spastic CP (Manual Ability Classification System Levels I–III and GMFCS Levels I–II) ages 8 to 18 who used Mitii, a web-based multimodal home program comprising upper limb, cognitive, visual–perceptual, and physical activity games, showed improvement on all ADL outcome measures compared with conventional interventions (e.g., strengthening, balance), although changes did not reach statistical significance (James et al., 2015).

Functional Mobility and ADL Performance Interventions

Low strength of evidence was found that virtual reality play can improve mobility and ADL participation and performance in children and youth with acquired brain injury (Level II study with high risk of bias). Bart and colleagues (2011) introduced children and youth ages 6 to 11.4 yr to three virtual reality environments (Birds and Balls, Soccer, and Snowboard) in Gesture Tek’s GX Interactive Rehabilitation and Exercise System (IREX). Significant correlations were found between virtual reality performance variables (response time and success rates) and ADL performance.

Play and Leisure Interventions

Low strength of evidence indicates that virtual reality interventions and computer-based play increased opportunities for autonomous free play for children with complex disabilities such as CP (Level I study with high risk of bias). The authors of a systematic review examined the impact of computer assistive technologies on participation in childhood occupations for children with multiple and complex disabilities (Chantry & Dunford, 2010). They examined 27 articles and found increased play and leisure opportunities and autonomous play but did not provide a meta-analysis or detailed outcome data.

Discussion

We conducted a systematic review to examine the evidence for the effectiveness of occupation- and activity-based interventions within the scope of occupational therapy practice to improve ADLs, play, and leisure for children and youth ages 5 to 21. Effective participation and performance in ADLs, play, and leisure occupations are key components in the development of identity, perceptions of competence and value, and positive health and wellness outcomes in children and youth (AOTA, 2014). Positive ADL, play, and leisure outcomes are important prognostic indicators for future employment and quality of life (Klinger et al., 2015). The review included studies conducted through 2017 and identified three areas of intervention that can have a positive impact on ADL, play, and leisure outcomes for children and youth: supporting engagement in occupations, supporting participation with cognitive supports, and using technology to support successful occupational participation and performance.

The evidence identified in this review suggests that engagement in ADL, play, and leisure occupations and activities improves participation and performance in these valuable occupations for children and youth. Twelve studies examined the types of interventions that support ADL, play, and leisure outcomes and suggest that occupational participation and performance improves when environments and tasks are adapted to support engagement and when children and youth are provided explicit occupational skills training, engage in structured practice of skills in natural contexts, and are responsible for monitoring their practice and performance (Bryant et al., 2013; Drahota et al., 2011; Grecco et el., 2013; Hsin et al., 2012; Kretzmann et al., 2015; Lang et al., 2011; Law et al., 2011; O’Connor & Stagnitti, 2011; Park et al., 2014; Slaman et al., 2015; Song, 2014; Tarakci et al., 2012).

Seven studies suggest that interventions involving collaborative goal setting, occupation-based training and education (including motor learning interventions when provided in the context of occupation), and coaching and feedback (by, e.g., peer, caregiver, or occupational therapy practitioner) that are embedded in occupational engagement can improve ADL, play, and leisure participation and performance in children and youth (Bar-Haim et al., 2010; Cecchini et al., 2014; Keenan et al., 2014; Maeir et al., 2014; Miller et al., 2001; Miltenberger & Charlop, 2014; Tarakci et al., 2012). Coaching and feedback, with either children and youth or their caregivers, can be a powerful tool for improving participation and performance.

The effectiveness of interventions using video modeling, virtual reality, or video play to improve ADL, play, and leisure outcomes in children and youth was demonstrated in five studies (Bart et al., 2011; Chantry & Dunford, 2010; Hong et al., 2016; James et al., 2015; Tarakci et al., 2016). Technology use had a positive impact on play and leisure participation and expanded play opportunities and autonomy in play and leisure activities. Taken together, the results of this systematic review suggest that supporting engagement in occupations, supporting participation with cognitive supports, and using technology to support successful occupational participation and performance can be effective in improving the ADL, play, and leisure participation and performance of children and youth with disabilities.

Limitations

The methodology of this systematic review was carefully constructed using a published protocol and monitored by the authors, the AOTA research methodologist, and the director of AOTA’s EBP Project. The search was limited to articles published in English, which may influence the findings of this study. In addition, although the search parameters included published studies from 2000 to the present, the bulk of the articles identified, screened, and included in the systematic review were published after 2010. Similarly, most of the studies that examined the influence of occupation- and activity-based interventions on occupational participation and performance were published within the same time frame. This finding suggests that the examination of occupation as means and ends is just beginning to emerge.

Implications for Occupational Therapy Practice

Evidence synthesized in this systematic review suggests that occupation- and activity-based interventions can effectively improve ADL, play, and leisure outcomes in children and youth. The results suggest that occupational therapy practitioners should consider the following intervention components:

• Collaborating with clients and caregivers on the development of goals and intervention plans

• Providing caregiver training in the implementation, carryover, and transfer of occupation- and activity-based interventions in meaningful contexts

• Providing training and feedback to support client initiation of and engagement in occupational tasks and routines

• Embedding occupation- and activity-based interventions in natural routines, contexts, and environments and with naturally occurring social partners (e.g., caregivers, peers)

• Guiding and structuring occupation- and activity-based intervention and considering the use of technology (e.g., video modeling, virtual reality, and video game training interventions) to support and reinforce occupational participation and performance

• Instructing caregivers in the structured practice and provision of coaching and feedback on ADL skills in home and community settings.

Implications for Occupational Therapy Education and Advocacy

The evidence examined in this systematic review indicates that occupational therapy practitioners need specialized preparation to provide occupation- and activity-based interventions for children and youth and to exercise their role in advocating for

• The evaluation and treatment of occupational participation and performance challenges in natural routines and contexts and

• The design of contexts, environments, and tasks that enable children and youth to engage actively in meaningful occupations.

Implications for Occupational Therapy Research

The results of this systematic review have the following implications for occupational therapy research:

• Further high-quality research is needed that examines occupation- and activity-based interventions that have utility within and across specific practice settings and with specific diagnostic groups and populations.

• The development of outcome measures that measure occupational participation and performance are needed for the ongoing validation and valuation of the impact of occupational therapy practice.

Conclusion

In this systematic review, we found that engaging children and youth with disabilities in occupations and activities and providing explicit feedback on their performance, offering caregivers guidance in goal direction and planning and coaching them in effective carryover, and using technology-based intervention can improve occupational participation and performance in ADLs, play, and leisure.

Footnotes

Acknowledgments

Research was conducted at Virginia Commonwealth University. The authors thank Deborah Lieberman, director of the American Occupational Therapy Association’s (AOTA’s) Evidence-Based Practice (EBP) Project, and Marian Arbesman and Elizabeth Hunter, methodology consultants for the EBP Project, for their continued support in the conduct of this review. This systematic review was supported by AOTA. The authors report no conflicts of interest.

*

Indicates studies included in the systematic review.

References

American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. https://doi.org/10.5014/ajot.2014.682006

American Occupational Therapy Association. (2020). Guidelines for systematic reviews. Retrieved from https://ajot.submit2aota.org/journals/ajot/forms/systematic_reviews.pdf

* Bar-Haim

Harries

Nammourah

Oraibi

Malhees

Loeppky

, . . . Lahat

; MERC Project. (2010). Effectiveness of motor learning coaching in children with cerebral palsy: A randomized controlled trial. Clinical Rehabilitation, 24, 1009–1020. https://doi.org/10.1177/0269215510371428

* Bart

Agam

Weiss

P. L.

, & Kizony

(2011). Using video-capture virtual reality for children with acquired brain injury. Disability and Rehabilitation, 33, 1579–1586. https://doi.org/10.3109/09638288.2010.540291

* Bryant

Pountney

Williams

, & Edelman

(2013). Can a six-week exercise intervention improve gross motor function for non-ambulant children with cerebral palsy? A pilot randomized controlled trial. Clinical Rehabilitation, 27, 150–159. https://doi.org/10.1177/0269215512453061

* Cecchini

J. A.

Fernandez-Rio

, & Mendez-Gimenez

(2014). Effects of Epstein’s TARGET on adolescents’ intentions to be physically active and leisure-time physical activity. Health Education Research, 29, 485–490. https://doi.org/10.1093/her/cyu007

* Chantry

, & Dunford

(2010). How do computer assistive technologies enhance participation in childhood occupations for children with multiple and complex disabilities? A review of the current literature. British Journal of Occupational Therapy, 73, 351–365. https://doi.org/10.4276/030802210X12813483277107

Daud

A. Z. C.

Judd

Yau

, & Barnett

(2016). Issue in applying occupation-based intervention in clinical practice: A Delphi study. Procedia: Social and Behavioral Sciences, 222, 272–282. https://doi.org/10.1016/j.sbspro.2016.05.158

* Drahota

Wood

J. J.

Sze

K. M.

, & Van Dyke

(2011). Effects of cognitive behavioral therapy on daily living skills in children with high-functioning autism and concurrent anxiety disorders. Journal of Autism and Developmental Disorders, 41, 257–265. https://doi.org/10.1007/s10803-010-1037-4

10.

Estes

, & Pierce

D. E.

(2012). Pediatric therapists’ perspectives on occupation-based practice. Scandinavian Journal of Occupational Therapy, 19, 17–25. https://doi.org/10.3109/11038128.2010.547598

11.

* Grecco

L. A. C.

Zanon

Sampaio

L. M. M.

, & Oliveira

C. S.

(2013). A comparison of treadmill training and overground walking in ambulant children with cerebral palsy: Randomized controlled clinical trial. Clinical Rehabilitation, 27, 686–696. https://doi.org/10.1177/0269215513476721

12.

Higgins

J. P. T.

Altman

D. G.

, & Sterne

A. C. (2011). Assessing risk of bias in included studies. In Higgins

J. P. T.

& Green

(Eds.), Cochrane handbook for systematic reviews of interventions (Version 5.1.0). https://handbook-5-1.cochrane.org/

13.

* Hong

E. R.

Ganz

J. B.

Mason

Morin

Davis

J. L.

Ninci

, . . . Gilliland

W. D.

(2016). The effects of video modeling in teaching functional living skills to persons with ASD: A meta-analysis of single-case studies. Research in Developmental Disabilities, 57, 158–169. https://doi.org/10.1016/j.ridd.2016.07.001

14.

* Hsin

Y. J.

Chen

F. C.

Lin

K. C.

Kang

L. J.

Chen

C. L.

, & Chen

C. Y.

(2012). Efficacy of constraint-induced therapy on functional performance and health-related quality of life for children with cerebral palsy: A randomized controlled trial. Journal of Child Neurology, 27, 992–999. https://doi.org/10.1177/0883073811431011

15.

Hurn

Kneebone

, & Cropley

(2006). Goal setting as an outcome measure: A systematic review. Clinical Rehabilitation, 20, 756–772. https://doi.org/10.1177/0269215506070793

16.

* James

Ziviani

Ware

R. S.

, & Boyd

R. N.

(2015). Randomized controlled trial of web-based multimodal therapy for unilateral cerebral palsy to improve occupational performance. Developmental Medicine and Child Neurology, 57, 530–538. https://doi.org/10.1111/dmcn.12705

17.

* Keenan

King

Curran

C. J.

, & McPherson

(2014). Effectiveness of experiential life skills coaching for youth with a disability. Physical and Occupational Therapy in Pediatrics, 34, 119–131. https://doi.org/10.3109/01942638.2013.842200

18.

Klinger

L. G.

Klinger

M. R.

Mussey

J. L.

Thomas

S. P.

, & Powell

P. S.

(2015). Correlates of middle adult outcome: A follow-up study of children diagnosed with ASD from 1970–1999. https://imfar.confex.com/imfar/2015/webprogram/Paper20033.html

19.

Kreider

C. M.

Bendixen

R. M.

Huang

Y. Y.

, & Lim

(2014). Centennial Vision—Review of occupational therapy intervention research in the practice area of children and youth 2009–2013. American Journal of Occupational Therapy, 68, e61–e73. https://doi.org/10.5014/ajot.2014.011114

20.

* Kretzmann

Shih

, & Kasari

(2015). Improving peer engagement of children with autism on the school playground: A randomized controlled trial. Behavior Therapy, 46, 20–28. https://doi.org/10.1016/j.beth.2014.03.006

21.

Kuhaneck

H. M.

Tanta

K. J.

Coombs

A. K.

, & Pannone

(2013). A survey of pediatric occupational therapists’ use of play. Journal of Occupational Therapy, Schools and Early Intervention, 6, 213–227. https://doi.org/10.1080/19411243.2013.850940

22.

* Lang

Kuriakose

Lyons

Mulloy

Boutot

Britt

, . . . Lancioni

(2011). Use of school recess time in the education and treatment of children with autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 5, 1296–1305. https://doi.org/10.1016/j.rasd.2011.02.012

23.

* Law

M. C.

Darrah

Pollock

Wilson

Russell

D. J.

Walter

S. D.

, . . . Galuppi

(2011). Focus on function: A cluster, randomized controlled trial comparing child- versus context-focused intervention for young children with cerebral palsy. Developmental Medicine and Child Neurology, 53, 621–629. https://doi.org/10.1111/j.1469-8749.2011.03962.x

24.

* Maeir

Fisher

Bar-Ilan

R. T.

Boas

Berger

, & Landau

Y. E.

(2014). Effectiveness of Cognitive–Functional (Cog–Fun) occupational therapy intervention for young children with attention deficit hyperactivity disorder: A controlled study. American Journal of Occupational Therapy, 68, 260–267. https://doi.org/10.5014/ajot.2014.011700

25.

* Miller

L. T.

Polatajko

H. J.

Missiuna

Mandich

A. D.

, & Macnab

J. J.

(2001). A pilot trial of a cognitive treatment for children with developmental coordination disorder. Human Movement Science, 20, 183–210. https://doi.org/10.1016/S0167-9457(01)00034-3

26.

* Miltenberger

C. A.

, & Charlop

M. H.

(2014). Increasing the athletic group play of children with autism. Journal of Autism and Developmental Disorders, 44, 41–54. https://doi.org/10.1007/s10803-013-1850-7

27.

Moher

Shamseer

Clarke

Ghersi

Liberati

Petticrew

, . . . Stewart

L. A.

; PRISMA-P Group. (2015). Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement. Systematic Reviews, 4, Article 1. https://doi.org/10.1186/2046-4053-4-1

28.

* O’Connor

, & Stagnitti

(2011). Play, behaviour, language, and social skills: The comparison of a play and a non-play intervention within a specialist school setting. Research in Developmental Disabilities, 32, 1205–1211. https://doi.org/10.1016/j.ridd.2010.12.037

29.

Parham

, & Fazio

(2008). Play in occupational therapy for children (2nd ed.). Mosby Elsevier.

30.

* Park

E. S.

Rha

D. W.

Shin

J. S.

Kim

, & Jung

(2014). Effects of hippotherapy on gross motor function and functional performance of children with cerebral palsy. Yonsei Medical Journal, 55, 1736–1742. https://doi.org/10.3349/ymj.2014.55.6.1736

31.

Pierce

(2001). Untangling occupation and activity. American Journal of Occupational Therapy, 55, 138–146. https://doi.org/10.5014/ajot.55.2.138

32.

Schardt

Adams

M. B.

Owens

Keitz

, & Fontelo

(2007). Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Medical Informatics and Decision Making, 7, 16. https://doi.org/10.1186/1472-6947-7-16

33.

Shea

B. J.

Reeves

B. C.

Wells

Thuku

Hamel

Moran

, . . . Henry

D. A.

(2017). AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ, 358, j4008. https://doi.org/10.1136/bmj.j4008

34.

* Slaman

Roebroeck

Dallmijer

Twisk

Stam

, & Van Den Berg-Emons

; Learn 2 Move Research Group. (2015). Can a lifestyle intervention programme improve physical behaviour among adolescents and young adults with spastic cerebral palsy? A randomized controlled trial. Developmental Medicine and Child Neurology, 57, 159–166. https://doi.org/10.1111/dmcn.12602

35.

* Song

C.-S.

(2014). Effects of task-oriented approach on affected arm function in children with spastic hemiplegia due to cerebral palsy. Journal of Physical Therapy Science, 26, 797–800. https://doi.org/10.1589/jpts.26.797

36.

* Tarakci

Huseyinsinoglu

B. E.

Tarakci

, & Ozdincler

A. R.

(2016). Effects of Nintendo Wii-Fit^® video games on balance in children with mild cerebral palsy. Pediatrics International, 58, 1042–1050. https://doi.org/10.1111/ped.12942

37.

* Tarakci

Yeldan

Baydogan

S. N.

Olgar

, & Kasapcopur

(2012). Efficacy of a land-based home exercise programme for patients with juvenile idiopathic arthritis: A randomized, controlled, single-blind study. Journal of Rehabilitation Medicine, 44, 962–967. https://doi.org/10.2340/16501977-1051

38.

U.S. Preventive Services Task Force. (2017). Grade definitions. https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions