Abstract
Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association’s (AOTA’s) Evidence-Based Practice Program and illustrate how the research evidence from the reviews can be used to inform and guide clinical decision-making. Each article in this series summarizes evidence from published reviews on a given topic and presents the application of evidence to a related clinical case. In this Evidence Connection article, we describe a case report of a college-age student receiving supported education services and outline the occupational therapy evaluation and intervention that enhanced her academic engagement as well as her health and wellness. The findings from the systematic reviews on this topic were published in the September/October 2018 issue of the American Journal of Occupational Therapy and in AOTA’s Occupational Therapy Practice Guidelines for Adults Living With Serious Mental Illness.
In this Evidence Connection article, the authors describe a case report of a college-age student receiving supported education services and outline the occupational therapy evaluation and intervention that enhanced her academic engagement as well as her health and wellness.
Students at postsecondary institutions are experiencing increasing rates of mental illness, but campus mental health supports remain limited (Oswalt et al., 2020). Occupational therapy practitioners bring expertise to this emerging area of practice, serving students who have psychological, neurodevelopmental, and physical concerns. A scoping review found that occupational therapy in postsecondary settings primarily serves students living with mental health conditions (Keptner & McCarthy, 2020). Occupational therapy interventions prioritize engagement in formal education and related occupations (i.e., health management, social participation, rest and sleep, work, leisure, and instrumental activities of daily living), which enables students’ participation in multiple occupational roles, including student, friend, club participant, home maintainer, and worker (American Occupational Therapy Association [AOTA], 2020).
Occupational therapy practitioners are situated in various settings: supported education programs, college disability centers, assistive technology centers, academic success centers, independent services on college campuses, primary health centers, undergraduate education, and high school transition teams (Keptner & McCarthy, 2020; Spencer et al., 2018). Supported education interventions address goal setting, skill development, cognitive training, and student-directed planning, yielding improved educational attainment, academic skills, self-esteem, self-determination, and quality of life. Through occupational therapy’s mission to enhance occupational performance and health and well-being within activity and contextual influences, higher education interventions for students living with mental health conditions address self-regulated learning and engagement in formal education.
Although occupational therapy practitioners possess needed knowledge and skills, there has been only minimal inclusion of their services in higher education support services. Postsecondary institutions are shifting toward more holistic health and wellness models, such as the Substance Abuse and Mental Health Services Administration’s (n.d.) eight dimensions of wellness (i.e., physical, emotional, social, environmental, spiritual, intellectual, financial, and occupational; Amaya et al., 2019). With academia’s promotion of health and wellness, it is imperative that occupational therapy’s contribution to higher education be recognized. The unique lens of this field enhances students’ occupational engagement through effective occupation-based interventions for multifaceted needs.
When gaps exist in specific practice settings, occupational therapy practitioners must consider the application of related evidence-based interventions. The case we present in this article highlights this process. There is limited evidence addressing higher education performance in regard to students living with mental health conditions; the systematic reviews in AOTA’s Occupational Therapy Practice Guidelines for Adults Living With Serious Mental Illness (Noyes & Lannigan, 2019) offer evidence-based interventions that address education, sleep, social participation, and health and wellness. These intervention applications have yielded interrelated occupational improvement, demonstrating greater academic performance through enhanced learning strategies, self-management routines, and occupational balance.
Case Study: Taylor
Taylor is a 19-yr-old college sophomore at a competitive university. Despite successful performance in high school, she had difficulty transitioning to college because of the heightened academic rigor, unstructured routines, and decreased parental support. In early childhood, Taylor demonstrated symptoms of inattentiveness and hyperactivity–impulsivity and was diagnosed with attention deficit hyperactivity disorder (ADHD), combined type. Taylor’s parents provided daily reminders and regimented routines to help guide her participation in school and extracurricular activities. Throughout school, Taylor exhibited above-average intelligence and effort compared with her peers, and she graduated with honors.
After she started studying at a prestigious out- of-state university, Taylor missed her parents’ assistance. During freshman year, she found emotional and academic support through her honors dorm roommates, who role modeled a healthy life balance of studying, socializing, sleeping, and exercising. Taylor completed most assignments effectively and managed moderate stress levels. As a sophomore, Taylor changed her major to biomedical engineering and struggled with unfamiliar course content and greater academic demands. She withdrew from meaningful activities and became isolated when completing schoolwork. Feeling anxious about succeeding academically, she felt that additional efforts to socialize with friends or exercise were draining and time wasting. Her lifestyle changes and decline in mental health elicited lethargy, disrupted sleeping patterns, and impaired concentration when studying.
Unaware of why these behavioral changes were occurring (i.e., phoning her parents less, socializing less, irregular sleep patterns, and voicing self-loathing comments), Taylor’s parents encouraged her to seek support through the university’s counseling center. There, a psychologist diagnosed Taylor with depression and anxiety and referred her to the campus academic success center for help with educational performance improvement. The center’s multidisciplinary staff, including psychologists, occupational therapists, and graduate students, provided higher education counseling and support. On the basis of her mental health and neurodevelopmental comorbidities, which were affecting her academic performance and general health and wellness, Taylor was paired with Isaac, an occupational therapist.
Occupational Therapy Evaluation and Findings
Isaac administered the Canadian Occupational Performance Measure (COPM; Law et al., 2014) to determine Taylor’s occupational performance strengths and challenges. The results indicated challenges with studying, managing stress, socializing, reading, and self-advocacy (Table 1). Taylor rated her academic performance as poor and expressed a high level of dissatisfaction with managing class readings because of the novel content and unsuccessful reading strategies. Taylor experienced dissatisfaction with her life, missing connections with friends and engineering professors as her anxiety about academics increased.
Taylor’s Assessment Results
Note. COPM = Canadian Occupational Performance Measure; LASSI = Learning and Study Strategies Inventory.
Using a semistructured interview, Isaac completed Taylor’s occupational profile (AOTA, 2021). In her freshman year, Taylor managed stress through routines, weekly intramural sports, meals with friends, and walks. With increasing mental health concerns in her sophomore year, Taylor expressed having decreased energy for meaningful activities. She reported having difficulty remembering concepts from academic readings and completing exams within the allotted times because of test anxiety. With her concentration declining, Taylor felt too overwhelmed to focus and too lethargic to do school work, taking 3-hr naps instead. Although she desired change, she had difficulty seeking campus support.
Isaac administered the Learning and Study Strategies Inventory (LASSI; Weinstein et al., 1996) to understand Taylor’s academic strengths and needs. This 60-item, self-report measure revealed below- average scores on the Anxiety, Attitude, Concentration, Information Processing, Time Management, and Using Academic Resources scales (see Table 1). When asked about her educational performance patterns, Taylor reported underestimating the time required to complete long tasks, multitasking while studying, and working all night on assignments. With limited energy, she submitted assignments late or incomplete. Taylor’s study environment included working on her bed, with dim lighting and loud background noises, which led to high distractibility and emotional dysregulation. Taylor wanted to improve her school performance, regain her life balance, effectively manage her anxiety and depression, and feel like herself again.
Embracing a client-centered approach, Isaac collaboratively developed goals with Taylor, using information from the COPM, occupational profile, and LASSI. Taylor was focused on attaining improvements in her educational occupations, targeting self-reported priorities of time management, stress management, study strategies, and generalized support acquisition. Additional goals were established for health-promoting routines and addressing mental health challenges and life balance. Isaac reviewed evidence from AOTA’s Occupational Therapy Practice Guidelines for Adults Living with Serious Mental Illness (Noyes & Lannigan, 2019) to incorporate evidence-based strategies into Taylor’s intervention plan.
Intervention Implementation
After reviewing the practice guidelines recommendations, Isaac selected evidence-based interventions to address Taylor’s goals. Taylor attended weekly 50-min occupational therapy sessions through the semester. Holistic, client-centered, strengths-based approaches supported her academic engagement through skills training, psychoeducation, and health and wellness promotion. Isaac used the following findings to implement interventions: ▪ moderate evidence for supported education to improve academic skills and functioning (Gutman et al., 2009) ▪ moderate evidence for psychoeducation to promote help-seeking behaviors, self-advocacy, and campus resource use by decreasing self-stigma (Mittal et al., 2012) ▪ strong evidence for relaxation interventions to improve mental health management and stress (Chan et al., 2012; Ly et al., 2014) ▪ strong evidence for managing mental health through exercise interventions to ▫ reduce cognitive errors within depression (Greer et al., 2015) ▫ reduce anxiety symptoms (Jayakody et al., 2014) ▫ reduce depression symptoms (Trivedi et al., 2011) ▫ improve sleep quality (Rethorst et al., 2013).
Intervention 1: Supported Education
Isaac provided academic skills training through brief didactic lessons on time management, studying, reading, and stress management (Gutman et al., 2009). Taylor began using a weekly planner and breaking assignments into smaller parts to improve prioritization and scheduling, reduce procrastination, and cultivate a healthy life balance. To improve reading effectiveness and concentration, she relocated to the library to study to reduce distractions and enhance alerting stimuli (i.e., brighter lighting and sitting upright). By adopting active reading strategies such as creating outlines and writing notes in margins, Taylor enhanced her memory retention and information processing. Isaac taught Taylor to identify stress triggers and symptoms and implement positive coping strategies (i.e., deep breathing, positive self-talk) when feeling overwhelmed. Promoting skill development, Isaac taught Taylor some individualized problem-solving strategies and encouraged her to practice these strategies in sessions and in natural contexts.
Intervention 2: Psychoeducation
Isaac provided Taylor with scaffolded education about her diagnoses and symptoms (Mittal et al., 2012). With increased understanding, Taylor’s help-seeking behavior improved through greater self-awareness of her academic needs. Isaac provided education about campus resources for students with learning differences (i.e., ADHD, mental health conditions). Taylor practiced implementing this acquired knowledge to obtain academic accommodations and advocate for her needs. She gathered relevant documentation and psychoeducational testing from her medical providers and was offered exam accommodations through the university’s academic accessibility center.
Psychoeducation interventions (Mittal et al., 2012) also helped Taylor improve her self-regulation and stress management. Isaac engaged Taylor in role-playing activities to practice discussing her diagnoses, symptoms, and learning needs with others. Mastering the self-advocacy strategies to navigate these conversations reduced Taylor’s feelings of stress in social situations, especially during professors’ office hours, because she felt empowered to share her experiences. Taylor reported greater self-advocacy and self-regulation communicating with professors and peers and navigating support services.
Intervention 3: Health and Wellness Intervention (Relaxation)
Isaac guided Taylor to schedule times during her week to take mindfulness breaks and to set daily alerts to remind her (Chan et al., 2012; Ly et al., 2014). These relaxation strategies enabled greater academic performance through improved symptom management and engagement in meaningful, restorative activities. With practice, Taylor independently engaged in self-guided mindfulness activities (Chan et al., 2012). She improved her concentration; managed her depressive symptoms; and reduced her feelings of anxiety during times of academic stress, such as taking tests and speaking with professors. To enhance her mood and sleep hygiene, she adapted mindfulness strategies when transitioning in between classes and during bedtime routines. By the end of the semester, Taylor reported consistent mindfulness practices, totaling 60 min/wk.
Intervention 4: Health and Wellness Intervention (Exercise)
Isaac provided health-promotion exercise education and helped Taylor develop cardiovascular exercise routines. He included exercise interventions for mental health management to reduce anxiety (Jayakody et al., 2014) and depressive symptoms (Trivedi et al., 2011) while improving sleep quality (Rethorst et al., 2013). Exercise interventions were also used to reduce cognitive errors (Greer et al., 2015). By the end of the semester, Taylor had incorporated daily 30-min brisk walks into her daily routine. On the basis of the effectiveness of her recreational engagement (Battaglia et al., 2013), Isaac encouraged Taylor to participate in sports she had previously enjoyed (e.g., ultimate Frisbee), for 60 min 2×/wk with friends. This added physical activity improved Taylor’s sleep quality from 5 hr/night to 7 hr/night and improved her study concentration, which resulted in reduced cognitive errors on assignments. With these renewed performance patterns, Taylor reported, “I’m starting to feel like myself again now that I can focus on schoolwork and prioritize my health, wellness, and social life.”
Intervention Outcomes
Using evidence-based interventions, Isaac helped Taylor meet her goals by the end of the semester. She studied for 2 hr at a time with minimal distractions, implemented relaxation techniques, and exercised regularly. Feeling well supported, she had a sense of belonging with faculty, classmates, and friends. Upon reevaluation, Taylor improved by more than 2 points on the COPM Performance and Satisfaction scales for studying, managing stress, and self-advocacy (see Table 2). Taylor’s LASSI scores on the Anxiety, Attitude, Concentration, Time Management, Information Processing, and Using Academic Resources scales improved.
Taylor’s Reassessment Results
Note. COPM = Canadian Occupational Performance Measure; LASSI = Learning and Study Strategies Inventory.
Although her semester grades lowered her cumulative grade point average, Taylor expressed gratitude that she had not withdrawn from or failed any classes. At the end of the semester, she and Isaac agreed to discontinue their weekly sessions because of the improvements in implementing academic and health promotion strategies. Taylor agreed to attend drop-in sessions to receive support in subsequent semesters should further problem solving be necessary.
Conclusion
Occupational therapy practitioners in higher education settings have a responsibility to support students living with mental health conditions in attaining role fulfillment and occupational engagement through meaningful activities, routines, and health promotion. Evidence from AOTA’s Occupational Therapy Practice Guidelines for Adults Living With Serious Mental Illness can be applied to support this population. Occupational therapy practitioners should consider how evidence related to supported education, psychoeducation, exercise, and relaxation interventions support improvements in academic skills, self- advocacy, self-regulation, concentration, health- promoting routine development, and overall engagement in meaningful activities. Interventions that take a strengths-based approach have been reported to support individualized problem solving and thereby promote mental health, wellness, and academic functioning. The case we have presented in this article demonstrates occupational therapy’s role in using evidence-based, client-centered approaches to facilitate and enhance participation in higher education.