Occupational Therapy Frames of Reference
A frame of reference is a theoretical basis for a treatment approach. This chart outlines the frames of reference commonly used in occupational therapy treatment and provides examples of how these frames of references are applied. Frames of reference that use more complicated or structured approaches are sometimes called models.
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A Comparison of Occupation Based Frames of Reference
Several occupational therapy frames of reference are based on occupation and the various factors that influence how people engage in occupation. The following chart will compare the similarities and differences of these frames of reference to help clarify the structure of each.
|Person-Environment-Occupation-Performance Model (PEOP)||Ecology of Human Performance||Occupational Adaptation||Model of Human Occupation (MOHO)||The Compensatory Frame of Reference|
|Overall description||Client-centred model organized to improve the everyday performance of necessary and valued occupations of individuals, organizations and populations and their meaningful participation in the world around them.
The complexity of the interaction between the person and their environment and how this influences their participation and occupational performance, is highlighted.
Competence in occupational performance is required to attain occupational participation.
|A person’s occupational performance is viewed in relation to the context in which the activity occurs. Activity is selected and adapted based on physical, social, temporal and cultural contexts.
The interrelationship of person and context determines which tasks fall within the person’s performance range.
Person, occupational performance, and contextual issues are considered as equally important.
|Focuses on the adaptation process when a person encounters occupational challenges. The integration of occupation and adaptation is viewed as a single, integrated process.
The model focuses on improving adaptability, rather than functional skills
|Occupation is assessed based on the three components of volition, habituation, and performance capacity, within the environmental context.||This FOR assumes that dysfunction is irreversible. The goal is to use compensatory techniques to increase occupational performance and enable the patient to regain independence.
Patients who will not regain functional skills can compensate by using adaptive equipment or techniques to complete tasks in a different way.
|Authors: Charles H. Christiansen and Carolyn Baum
Influences: Personality Theorists and Motivational Learning (Maslow). Theoretical foundations include systems theory, environmental theory, neurobehavioral theories, social, behavioral theories and behavioral psychology.
|Authors: Winnie Dunn, Catana Brown, and Mary Jane Yongstrom
Built on Social Science Theory, Environmental Psychology, Csikszentmihalyi’s Flow and the Disability Movement, Transnational Contextualism, Environmental Competence
Influences: Civil Rights Movements.
|Authors: Sally Schultz and Janette Schkade
Developed for a new OT PHD program at Texas Women’s University
Influences: Experimental psychology/counseling and psychosocial aspects
|Authors: Gary Kielhofner and Mary Reilly||Authors: Unknown
|Core component||Occupational performance and participation||The context in which occupation occurs.||The person’s internal ability to master adaptive responses.||Motivation for occupation.||Compensate for dysfunction in desired occupations.|
|Personal factors||Physiological, cognitive, spiritual, neurobehavioral, and psychological factors.||Experiences, sensorimotor skills, cognitive skills, psychosocial skills||Internal occupational adaptation process||Volition, habituation, performance capacity||Compliance and engagement are important in getting successful outcomes.|
|Environmental factors||Social support, social and economic systems, culture and values, built environment and technology, natural environment.||The context in which occupation takes place.||Physical, social, and cultural properties||Objects, spaces, occupational forms, social, cultural and political demands.||The context in which occupation takes place.|
|Occupational Factors||The activities and tasks that the person undertakes in order to manage their daily lives, grouped in some meaningful way so that the person can carry out life-roles.
Occupations of importance to the person’s well-being (activities, tasks and roles).
|Task (occupation) is defined as objective sets of behaviors combined to allow for engagement in performance.
Behaviors are determined by the demand of the task. Combinations of tasks represent responsibilities of roles.
Defined differently and have different meaning by different people.
Task performance is the interaction between the person and the context that dictates the performance range available to the person.
|Activities characterized by the properties, active participation, meaning to the person, and a tangible or intangible product that is the output of a process.
Context in which occupations occur:
|Occupation is essential to self-organization
Occupational behavior is a dynamic process through which we maintain the organization of our bodies and minds. When we work, play, and perform the tasks of daily life, we are not merely engaging in occupational behavior, we are organizing ourselves. Our behavior molds us after our new occupations.
|All occupations that are desired and of importance to the person’s well-being (activities, tasks and roles). Independent functioning is key.
|Main Constructs||4 main constructs:
1. Person (intrinsic factors)
Function occurs when the person demonstrates a level of competency in his/her ability to perform and master meaningful occupations.
Dysfunction is observed when the person’s occupational performance is limited and restricted, and therefore occupational performance is not achieved. Dysfunction is most evident when a person cannot perform roles to a level of personal or social satisfaction.
|4 main constructs:
The main focus is on the interdependent nature of the relationship between the person and the environment; and how this relationship impacts on human performance.
It is impossible to understand the person without also understanding the person’s context.
The OT process begins when the person / family identifies what the person wants/needs.
OT practice includes making changes in systems so that people with disabilities receive the full rights and privileges they are due.
|4 main constructs:
This process depicts how a person can respond adaptively and masterfully when engaged in occupations.
All therapy is directed at improving the person’s adaptiveness;
Adaptiveness = Functional Skills
|Human occupation is described as the act of “Doing”
All behavior is a form of improvisation since no one aspect has control.
Change is expected to be disorderly or chaotic.Change does not simply mean more or less; it means a different organization. Volitional change means finding a new direction in one’s life story or personal narrative.Adaptation.
Changes in skill (as opposed to underlying capacity) should be the primary target of therapy. Change in performance can involve learning to call upon different configurations of skills.Occupations have a powerful influence on changes in skill.
Habits and roles are naturally resistant to change since their basic function is to preserve patterns of behavior. Habituation organizes behavior for specific ecologies; new habits must often be learned in new ecologies. The loss of roles and habits require swift replacement. Acquiring a new role script and related habits is a process of socialization and negotiation. Volitional anticipation, experience, interpretation, and choice are at the core of what is referred to as meaning of therapy.
|The ultimate goal is to use compensatory techniques to increase occupational performance and enable the patient to regain independence, despite irreversible dysfunction. Occupational performance and independence can be facilitated by utilizing compensatory techniques.
An educational approach is usually used in conjunction with this FOR to help the patient understand the purpose and any precautions of the compensatory techniques.
Independent functioning can be achieved by:
|Therapeutic Approaches||Top Down Approach identifies/assesses the person’s perceptions of their problems within occupational performance.
Primary goal: Analyze the person’s strengths and weaknesses in occupational performance.
Application of the PEOP model in practice requires a collaborative relationship between the patient and therapist.
Factors in the personal performance capabilities/constraints and the environmental performance enabler/barriers that are central to the occupational performance, are identified which in turn lead to development of a realistic and sequenced intervention plan
Establish / Restore
-Remediation, done to person
-Change to a different context
-Modify the context or the task
-Work with person, context and/or task to prevent negative outcomes
-Generating circumstances through contexts or tasks. The intervention process is a collaborative one.
|Therapeutic use of self by the OT is imperative to facilitate the person’s internal adaptive process.
The internal adaptation process is the focus for intervention
Facilitate the person’s ability to make their own adaptations to engage in occupational activities
Occupational Adaptation holds a holistic perspective that three elements, person, occupational environment, and the interaction between the two, are involved in every occupational response.
Assessment involves gathering and reasoning with data within MOHO framework
Therapy may be given over a period of time with no apparent result and then a critical level is reached such that new occupational behavior emerges
Therapy should involve experimentation to find the best solutions
|Compensate for dysfunction in desired occupations.|
|Enablers and barriers||Five alternatives: establish or restore, alter, adapt, prevent, create||Narrow the gap between current occupational functioning and performance required by both the patient and the environment.||Volition and habituation.||Independence can be regained by the use of compensatory strategies, environmental and task modifications.|
|Desired Outcome||Occupational participation||Meeting performance needs||Self-initiation, generalization, and relative mastery||Occupational adaptation||Occupational engagement|
|Weakness(es)||No associated assessment tool and therefore no direct outcome measure.
The therapist has a challenge of judging the “weighting” of the different factors, as the model does not make this clear.
|Does not delineate specific assessments or techniques||Impairments in person systems place significant limits on the individual’s ability to effectively use former or existing adaptive responses. Cognitive issues often further limit the ability to adapt.
Practitioners who believe that intervention based on meaning is not practical in everyday practice
Lack of assessment tools
|Diagram of Model|
Commonly used assessment tools for the various FORs
|Frame of Reference||Assessments|
|Allen Cognitive Model (ACL)||The Allen Battery is the combination of all items designed for use with the Allen Cognitive Levels.
The Allen Battery consists of:
|This model is based on the assumption that voluntary movement and control are the result of muscle strength and function, joint integrity and range, and physical endurance/tolerance.
The capacity for motion, therefore, has three main components:
2. Muscle Strength
|COMP_E||The Canadian Occupational Performance Measure (COPM) is the only assessment tool developed along with the CMOP.
It is a semi structured interview based on this model and provides practitioners with the tool to organize their thoughts.
|Developmental||The guiding principle of all developmental theories is that people develop in a predictable sequence from birth to maturity and throughout life. This model is therefore appropriate for all ages. The assessments are selected based on the presenting difficulties.
Areas that can be assessed within this model are:
Some of the assessment tools that can be used with this model are:
|Dynamic Interactional Cognitive Rehab||• Contextual Memory Test (CMT)
• Toglia Category Assessment
• Dynamic Object Search Test (derived from Dynamic Visual Processing Test)
• Assessment of Motor and Process Skills (AMPS)
• Cognitive Performance Test (CPT)
• Executive Function Performance Test (EFPT)
• Arnadottir OT- ADL Neurobehavioral Evaluation (A-ONE)
• Cognitive Assessment of Minnesota (CAM)
• Lowenstein Occupational Therapy Cognitive Assessment (LOTCA)
• Motor Free Visual Perceptual Test (MVPT)
• Test of Everyday Attention (TEA)
|Ecology of Human Performance||There is a worksheet or checklist for each component that makes up the constructs.
The 4 constructs of this model are:
The Checklists and worksheets that can be used in the evaluation process:
|MOHO||The MOHO has over 20 assessments which serve a wide range of purposes
from screening to identifying issues related to specialized areas, such as work rehabilitation.
Some of the assessments are:
• The Assessment of Communication and Interaction Skill (ACIS)
• Assessment of Work Performance (AWP)
• Child Occupational Self-Assessment (COSA)
• The Model of Human Occupation Screening Tool (MOHOST)
• The Occupational Circumstances Assessment Interview and Rating Scale (OCAIRS)
• The Occupational Performance History Interview-II (OPHI-II)
• Occupational Self-Assessment (OSA)
• The Occupational Therapy Psychosocial Assessment of Learning (OTPAL)
• The Pediatric Volitional Questionnaire(PVQ)
• The Short Child Occupational Profile (SCOPE)
• The School Setting Interview (SSI)
• The Volitional Questionnaire (VQ)
• Work Environment Impact Scale (WEIS)
• Worker Role Interview (WRI)
• Residential Environment Impact Scale (REIS)
• Neurodevelopmental Treatment Approach
• Proprioceptive Neuromuscular Function
|• Assessment of Motor and Process Skills (AMPS)
• Functional Independence Measure (FIM)
• Arm Motor Ability Test (AMAT)
• Canadian Occupational Performance Measure (COPM)
• Wolf Motor Function Test (WMFT)
• Fugl-Meyer Assessment (FMA)
• Modified Ashworth Scale
• Motor Assessment Scale (MAS)
• Reflex Testing
• Observe the quality of volitional movement patterns
• Observe reflex patterns, such as equilibrium and righting reactions
|Occupational Adaptation||• Relative Mastery Measurement Scale (RMMS)
– only assessment tool directly related to the occupational adaptation by Schkade and Schultz (1992).
• Occupational Self-Assessment (OSA)
• Occupational Adaptation Interview Guide (OAPG)
• Occupational Case Analysis Interview and Rating Scale (OCAIRS)
• Occupational Performance History Interview (OPHI)
|PEOP||Any assessment assessing the client, environment, and occupation.
• Occupational Self-Assessment (OSA)
|Psychodynamic Theory||• Azima Battery (draw a whole person, finger painting)
• Barbara Hemphill (BH) Battery- (mosaic tile trivet and finger painting)
• Lerner Magazine Picture Collage
|Rehabilitative||• Canadian Occupational Performance Measure (COPM)
• Functional Independence Measure (FIM)
• Klein-Bell Activities of Daily Living Scale
• Kohlman Evaluation of Living Scale (KELS)
• Client Factor Assessments
• Bells Test
• Mini Mental State Exam (MMSE)
• ROM using goniometer
• Semmes-Weinstein for sensation
|Sensory Integration (SI)||• Sensory Integration and Praxis Tests (SIPT)
• The DeGangi–Berk Test of Sensory Integration
• Infant/Toddler Sensory Profile (ITSP)
• Test of Sensory Functions in Infants (TSFI)
• Sensory Processing Measure-Preschool: Home Form
• Sensory Processing Measure-Preschool: Main Classroom and School Environments
• Sensory Processing Measure: Home Form
• Sensory Processing Measure: Main Classroom and School Environments Form
• The Sensory profile 2 includes infant, toddler, child, and school rating forms
• Adolescent/Adult Sensory Profile consists of standardized questionnaires that focus on the student’s sensory processing performance patterns within the natural context
Su Ren Wong & Gail Fisher (2015) Comparing and Using Occupation-Focused Models, Occupational Therapy in Health Care, 29:3, 297-315, DOI: 10.3109/07380577.2015.1010130
Dunn, W., Brown, C., & McGuigan, A. (1994, July 01). The Ecology of Human Performance: A Framework for Considering the Effect of Context. Retrieved March 22, 2018, from https://ajot.aota.org/article.aspx?articleid=1873303
Fidler, G. S. (1996, February 01). Life-Style Performance: From Profile to Conceptual Model. Retrieved March 22, 2018, from https://ajot.aota.org/article.aspx?articleid=1862324
Schultz, S., & Schkade, J. K. (1992, October 01). Occupational Adaptation: Toward a Holistic Approach for Contemporary Practice, Part 2. Retrieved March 22, 2018, from https://ajot.aota.org/article.aspx?articleid=1875299