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OT Models of Practice & Frames of Reference


     Model of Practice vs Frame of Reference (FOR)

Model of Practice
Models of practice refers to the application of theory to occupational therapy practice. They can be thought of as “mental maps” that assist clinicians in understanding their practice. The main purpose is to facilitate the analysis of the occupational profile and to consider potential outcomes with selected interventions. This is achieved by bringing into focus the patient’s needs and abilities, contextual issues, and engagement in occupation. Models are not intervention protocols but instead serve as a means to view occupation through the lens of theory with the focus on the patient’s occupational performance. They aim to guide practice by providing a basis for decision-making. As occupation is the core of occupational therapy, they all deal with occupation in a central way- the commonality seen in each of the models is the focus on occupation. Models should be applicable across various settings and client groups instead of designed primarily for a specific diagnostic group.
Underlying models are 2 key approaches to facilitating occupational performance: Remediation & Compensation.
* In a remediation approach, intervention is targeted towards improving performance components, with the assumption that such improvements will lead to enhanced occupational performance in the performance areas.
* A compensatory approach is used when remediation is not considered achievable or feasible. It focuses on remaining abilities and aims to improve function by adapting or compensating for performance component deficits. Examples of this approach include adapting the methods used to perform tasks, providing assistive devices, or modifying the environment.

Frame of Reference
The purpose of a frame of reference (FOR) is to help the clinician link theory to intervention strategies and to apply clinical reasoning to the chosen intervention methods. It is used to guide the intervention process. A FOR tends to have a narrower view of how to approach occupational performance when compared to models of practice. The intervention strategies described within various FORs are not meant to be used as a protocol but rather offer the clinician a way to structure intervention and think about intervention progressions. The concept of “one size fits all” does not apply to the use of a FOR to guide intervention. That is why there is a need for multiple FORs to meet varied patient goals and outcomes. A clinician may need to blend intervention strategies from several FORs to effectively meet the patient’s needs.

The following charts outline the models of practice and frames of reference commonly used in occupational therapy treatment and provides examples of how they are applied. 

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Compare and Contrast


Models of Practice and Frames of Reference

Frame of Reference/ Model Description Examples of use during OT Intervention Pictures and Video Examples
Allen Cognitive Model

Author/Research Base: Claudia Allen, MA, OT, FAOTA

Model of assessment and treatment that is built around functional cognition, or the interaction between cognitive abilities and the activity setting that results in performance. An occupational therapist administers the Allen Cognitive Levels screening test to determine how much assistance a new patient with mild dementia will need to follow precautions following hip replacement surgery

A cooking activity is structured by the occupational therapist to accommodate the cognitive skills of a patient with schizophrenia, based on the outcome of the Routine Task Inventory (RTI)

An OTA is working with a group of patients who have different stages of dementia. The focus of the group is on basic grooming. Knowing at which ACL each patient is functioning, the clinician provides assistance/supervision, as required .

Behavioral Modification

Author/Research Base: Developed by B.F. Skinner

Based on the principles of operant conditioning.
Relies on the concept of conditioning which is a form of learning. Used to promote healthy behaviors in patients.
The purpose is not to understand why or how a particular behavior started, but rather focuses on changing that behavior.

Positive or negative reinforcement is used to elicit a desired response.
In a public-school setting, an occupational therapist asks a student to write three sentences, after which he may choose an activity that he would like to do.

A head injury patient is required to clean up the occupational therapy treatment area after throwing objects while refusing treatment.

An OT working with a patient who has OCD uses a reward system to encourage the patient to limit the number of times she washes her hands during a craft activity.

Biomechanical Frame of Reference

Author/Research Base:
Unknown – this is the oldest frame of reference used in rehabilitation.


1. Purposeful activities can be used to treat loss of range of motion (ROM), strength, and endurance.

2. After ROM, strength, and endurance are regained, the patient automatically regains function.

3. Rest and stress. First, the body must rest to heal itself. Then, the peripheral structure must be stressed to regain range, strength, and endurance.

4. Best suited for patients with an intact central nervous system. Patients may have limited range, strength, and endurance, but have the ability to perform smooth, isolated movements.

Therapeutic exercise is used to improve range of motion, strength and endurance, which is then thought to lead to improvements in functional abilities.

For an outpatient who has had rotator cuff surgery, an occupational therapist leads active range of motion exercises, and then has the patient reach for plastic glasses in a cupboard.

An occupational therapist has a patient complete upper body strengthening exercises to improve the patient’s ability to push up from a chair during transfers.

Presentation explaining this model

Brunnstrom Movement Therapy Frame of Reference

Author/Research Base: Signe Brunnstrom, PT

Primitive synergistic patterns are used in order to improve motor control through central facilitation.
Based on concept that damaged CNS regressed to older or less mature patterns of movements (limb synergies and primitive reflexes)Synergies, primitive reflexes, and other abnormal movements are considered normal processes of recovery before normal patterns of movements are attained. Patients are taught to use and voluntarily control the motor patterns available to them during their recovery process. These synergies should be facilitated and encouraged during treatment.There are 6 stages of recovery:
1. Flaccidity or no voluntary motion.
2. Developing synergies.
3. Voluntary mvt begins within synergy pathways.
4. Initial movt to deviate from synergy.
5. Independent from basic synergy.
6. Isolated, near normal movt with minimal spasticity.
During occupational therapy treatment for a woman who has hemiplegia following a stroke, the occupational therapist has the woman perform a reaching activity with her unaffected arm while the therapist moves the affected arm in the same manner.

A patient in stage 1 of recovery, post Right CVA is completely flaccid on the left side of her body with no voluntary movement. The OT facilitates movement when none exists by eliciting primitive reflexes e.g. ATNR by rotating the patient’s neck.


Canadian Model of Occupational Performance (CMOP)
The Canadian Model of Occupational Performance and Engagement (CMOP-E)Author/Research Base:Canadian Association of Occupational Therapists
Polatajko, T Townsend & Craik 2007
A framework that illustrates the interaction between people, their environments, and their occupations related to self care, productivity, and leisure.

evolved from the CMOP.
3 main components:
Person – the core is the spirituality of the person. Spirituality is the innate force that drives humans to seek meaning through doing Other components are affective, physical, and cognitive abilities.
Occupation – includes self-care, productivity, and leisure.
Environment – physical, social, cultural, and institutional environment of the person.
Interaction between the person, environment and occupation results in occupational performance. In this version, the concept of the occupational engagement is introduced.
An occupational therapist develops a treatment plan for a woman with rheumatoid arthritis, based on the woman’s desire to resume playing the organ at her church.

An OT treating a patient with a hand injury, administers the Canadian Occupational Performance Measure (COPM) in order to determine the impact the patient’s injury has on her life – the patient identifies performance areas that are difficult for her and rates her current performance in her preferred activities.

Cognitive Behavioral Frame of Reference

Author/Research Base:
Based on the works of several researchers in the area of psychology who developed behavioral therapies in the 1920s and cognitive therapies in the 1960s.

People are taught to replace behaviors that result from abnormal thought processes with more normal or adaptive thought processes and behaviors. An occupational therapist helps a young woman with Down’s Syndrome learn that she does not need to be afraid to use the bathroom by herself.

An OT uses role play to help a patient who has severe anxiety about being in public places, identify her irrational thoughts and to replace those thoughts with more rational thoughts about public places.

Compensatory Frame of Reference

Author/Research Base: Unknown

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.

An educational approach is usually used in conjunction. Patients who will not regain functional skills can compensate by using adaptive equipment or techniques to complete tasks in a different way.
– Assistive device/equipment
– Environmental changes e.g. altering layout of living environment
– Strategies to compensate for poor memory
– Task modifications – to modify the task to compensate for the loss of function in order to increase independence.

A woman with severe osteoporosis uses long handled gardening tools to weed her flowers while standing.

A man with multiple sclerosis who has short term memory problems uses a smart phone to set reminders for appointments.

An OTA teaches a hemi, dressing techniques (dressing affected side of body first, using adaptive dressing aids such as a button hook).

An OT teaches an amputee techniques for completing tasks with the use of one hand.
– Dycem mat – to stabilize a mixing bowl while breaking an egg into the bowl with one hand
– Spike board – secures vegetables or fruit on spikes to enable patient to peel or slice the fruit/vegetable with one hand
– A plate guard – a rim which is clipped onto a plate to prevent food slipping off the plate while eating with one hand

Developmental Frame of Reference

Author/Research Base:
Based on the works of:
Freud, Jung (Psychosocial)
Gessell (Physical and emotional milestones)                – Piaget (Cognitive milestones)
Kohlberg, Wilcox, Gilligan (Moral reasoning)

Development is sequential, and behaviors are primarily influenced by the extent to which an individual has mastered and integrated the previous stages. Each stage of development can only proceed normally if the preceding stages have been completed successfully. Incomplete development in areas of skill will therefore influence subsequent development. Mastery of skills to an age-appropriate level in all areas of development is necessary to achieve satisfactory coping behaviors and adaptive relationships. Occupational therapy aims to prevent the development of maladaptive behavior and skills, and promotes growth and development to close the gap between expectation and ability, through the skilled application of activities.

An OT working with a baby who is developmentally delayed first addresses promoting crawling before focusing on walking. – developmental stages.

A mother’s perspective of the positive outcomes from OT for her daughter who presented with dela
ys in her fine motor development

Dynamic Interactional model of cognitive rehabilitation

– previously called Cognitive Rehabilitation

Author/Research Base: Joan Toglia, PhD, OT

A restorative cognitive rehabilitation approach, used to enhance the functional performance of patients who have a cognitive impairment. e.g. TBI

1. Focus on cognitive processing of patients in multiple situations
2. Emphasis on the patient’s awareness of their own cognitive capacity
3. Training/practice in multiple situations to facilitate generalization and transfer of learning.

Cognition is an on-going product of the dynamic interaction between the individual (person), the task (occupation) and the environment.

Information processing –
1. Input: receiving information from environment. New information is combined with existing information and is made sense of.
2. Throughput /Elaboration: Making sense the information. Judgments and decisions are made.
3. Output: Decisions are acted upon i.e. performance.
4. Feedback about performance – evaluating what you’re doing.

An occupational therapist structures a supported employment job activity for a man who has had a traumatic brain injury to accommodate his current problem solving and decision-making skills.

OT’s teach patients to be self-directed in checking their own performance, shifting emphasis away from actual task outcome, and focusing on their ability to apply cognitive strategies. Optimal performance is observed when there is a match between the three variables (individual, task, and environment).

Ecology of Human Performance

Author/Research Base: Winifred (Winnie) Dunn, PhD, OT, FAOTA

A person’s occupational performance is viewed in relation to the context in which activity occurs. Activity is selected and adapted based on physical, social, temporal and cultural contexts.

Context is described as a lens from which an individual views their world. 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.

An OT works with a patient who recently sustained a SCI on ways he can modify his bathroom and kitchen so that a wheelchair friendly environment can be created for him at home to maximize his independence.

An OT working with a young adult who has been diagnosed with a GAD, discusses the pros of her changing her work schedule, so that she can continue working in a job that she enjoys without having to be in the shop when it is very busy and noisy, which she finds very overwhelming.

An OT working with a student who has DCD and poor self-esteem, adapts the demands of the task during a P.E. class, by using a modified version of basketball.

 Kawa Model

Author/Research Base: Dr Michael Iwama – PhD,MSc, BScOT, BSc

Kawa is the Japanese word for ‘river’. The Kawa Model uses the natural metaphor of a river to depict one’s life journey. The varying and chronological experience of life is like a river, flowing from the high lands down to the ocean. Along its meandering path, the quality and character of its flow will vary from place to place, from instance to instance. OTs try to enable, assist, restore and maximize their clients’ life flow.

There are 5 interrelated constructs:
i. River Flow – life flow and priorities
ii. River Banks – environments / contexts, social and physical
iii. Rocks – obstacles & challenges
iv. Driftwood – influencing factors
v. Spaces – Opportunities for enhancing flow
Like a river where its source represents the beginning of life and its mouth meeting the sea representing the end, the Kawa Model takes into consideration the past, present and future needs of the client.

An OT uses the Kawa Model as a subjective assessment tool to identify what activities, roles, processes are important to the client and what issues they experience in relation to their environments. As a subjective assessment tool, it also allows the OT and client to determine what supports and resources they have internally and externally which can aid or undermine the OT intervention.

Using this model in clinical practice situations:
6 Steps
Step 1 Who is the client? Appreciate the client in context. (Use the Kawa Model to interview the client.)
Step 2 Clarify the context – get your client to elaborate on what information you have just extracted via the interview. “Why is this rock here and why is it so big?”
Step 3 Prioritize issues according to the clients’ perspective.
Step 4 Assess focal points of occupational therapy intervention.
Step 5 Intervention.
Step 6 Evaluation.

A hand therapist uses the Kawa model to work with a student who has been diagnosed with carpal tunnel syndrome.
1. Rocks – Pain & decreased dexterity of hand, difficulty fulfilling his duties as a student when it comes to taking notes, transcribing, writing papers, etc.
2. River Walls & Bottom – Lives in 2-story house with 3 roommates
3. Driftwood – Frustration with his medical condition, perceives injury as a sign of weakness. Very independent. Feels like he “should be able to do everything independently”
4. Water and spaces – The student’s life flow. Water still flows, but to a lesser extent through the gaps.

OT Intervention: The OT provides tips on how to alter body mechanics, fabricates night splints and provides additional assistive stabilizing wrist equipment for use during certain tasks. Brainstorming additional ideas e.g. can someone take notes for him in class?

Lifestyle Performance Model

Author/Research Base: Gail S. Fidler, OT, FAOTA

A person’s total activity repertoire is considered within the context of that person’s world. The framework allows for a holistic approach to treatment. An occupational therapist completes a full occupational profile with a man admitted to inpatient rehabilitation for a spinal cord injury. The profile includes daily routines, living situation, employment, leisure activities, relationships, spiritual views, and priorities for treatment.

A basic principle of the LPM is that a person’s quality of life is the result of interactions between individual and environmental factors. A patient with upper limb weakness has identified that brushing his teeth is important to him and he is not able to complete this task effectively. The OT recommends that the patient uses an electric toothbrush and teaches him compensatory strategies such as resting his arm on a table while brushing his teeth

Presentation explaining this model.

Model of Human Occupation (MOHO)

Author/Research Base: Gary Kielhofner, DrPH, FAOTA

Occupation is assessed based on the three components of volition, habituation, and performance capacity, within the environmental context. Humans are conceptualized as being made up of three interrelated components: volition, habituation, and performance capacity.

Volition refers to the motivation for occupation,

Habituation refers to the process by which occupation is organized into patterns or routines,

Performance capacity refers to the physical and mental abilities that underlie skilled occupational performance.

MOHO is intended to be used for patients experiencing difficulty in their occupational life and is applicable across a lifespan. It can be applied with diverse groups such as adults with chronic pain, children with ADHD, patients with TBI, patients with dementia, patients living with AIDS, and adolescents with mental illness

An occupational therapy assistant helps a 5th grade student with learning disabilities to improve his handwriting. The student has an interest in science, so the OTA has the student hand write and draw his own periodic table of the elements.

Occupational therapy educators document a case study of occupational therapy treatment based on MOHO for a woman with fibromyalgia.

Neurodevelopmental Treatment (NDT)
Previously referred to as the: Bobath ApproachAuthor/Research Base: Berta Bobath, PT and Karel Bobath, MD
NDT is used to analyze and treat posture and movement impairments based on kinesiology and biomechanics.

It assumes that posture and movement impairments are changeable. It is a hands-on treatment approach which is used for rehabilitation for neurological conditions. It focuses on specific handling techniques to facilitate normal posture and movement patterns while inhibiting abnormal patterns.

An occupational therapist physically positions a three-year-old child with cerebral palsy on his hands and knees while the child reaches to play with blocks.

An OT uses specific handling techniques to help a 10 month old baby learn to crawl by using their hips as a key point of control and weight shifting.

Neurofunctional Approach (NFA)

Also known as:
Functional Skills Training Approach

Author/Research Base: Gordon Muir Giles (PhD, Dip COT, OT/L, FAOTAJ) and Clark-Wilson (BA DipCOT MAE)

This approach is used to treat patients with acquired brain injuries, such as TBI.
The NFA is a patient-centered and goal driven approach that targets function, not impairment. It is essentially an occupation-based model which emphasizes “learning by doing” (Bottom Up Approach).
Treatment focuses on learning by participation in tasks.
Theoretical Principles:
– Intervention is targeted towards functional goals for the patient and are adapted to the patient’s level of ability.
– Daily practice and the formation of habits and routines help to develop skills. Automaticity is developed through compensatory strategies.Intervention Principles
– Identify patient goals, motivation, and needs
– Consider patient strengths and neurological impairment when designing intervention.
– Analyze task demands.
– Develop retraining interventions appropriate to patient abilities.
– Use repetition to develop internalized performance & guide future performance.
– Use feedback & reinforcement.
A patient who has an acquired brain injury from a diabetic coma is trained by an Occupational Therapist to accomplish a specific morning routine by repeating the sequence of specific tasks over many days, until it becomes automatic, and part of the patient’s daily routine.

An OTA is working with a patient who has severe cognitive deficits. When teaching the patient independence in self-care tasks, the OTA uses the method of repeated practice with cueing in order to help the patient master a task.

Neurofunctional Approach demonstrated by students. Part 1 & 2

Neurofunctional Approach demonstrated by students. Part 3

Neurofunctional Approach demonstrated by students. Part 4

Neurofunctional Approach demonstrated by students. Part 6

Neurofunctional Approach demonstrated by students. Part 7

Occupational Adaptation
(OA)Author/Research Base: Janette K. Schkade, PhD, OT and Sally Schultz, PhD, OT
The integration of occupation and adaptation is viewed as a single, integrated process. The model focuses on improving adaptability, rather than functional skills.
Based on the belief that humans have an innate drive for mastery. Occupation and adaptation are integrated, with non-hierarchical relationship. As a person becomes more adaptive, they become more functional. The focus of intervention is to facilitate the patient’s adaptiveness /occupational adaptation, in order to improve their functional skills. Intervention therefore focuses on improving adaptiveness, whereas other models focus on improving functional skills.There are 3 elements of occupational adaptation: the person, the environment and their interaction. Each element is fluid and dynamic. Change in one element influences the other elements.
Person – made up of systems that are unique to the individual i.e. sensorimotor, cognitive and psychosocial systems.
Occupational Environment – Types of occupational environment are self-care, leisure/play and work
Interaction – the interplay between the external and the internal factors that continuously interact through occupation.
An occupational therapist teaches a woman with multiple sclerosis how to drive using an adapted van.

An OTA establishes what home modifications and which assistive devices will help her patient who is a paraplegic, be more independent within her home.

A student who has GAD and poor social skills works with different staff members throughout the day instead of staying with only one teacher. This will help the student learn to interact with more than just one person, as well as to adapt more easily when someone new joins that rotation.

Person-Environment-Occupation-Performance Model (PEOP)

Author/Research Base: Charles H. Christiansen, EdD, OT, OT(C), FAOTA and Carolyn Baum, PhD, OT/L, FAOTA

Focuses on occupational performance and participation in daily life.

Highlights the complexity of the interaction between the person and their environment and how this influences their participation and occupational performance. Competence in occupational performance is required to attain occupational participation. .

This interaction between a person’s abilities, environmental factors, and the demands of occupation, influences performance outcomes. The goal of occupational performance is viewed as being an enabler of participation in the cultural, social, financial and political contexts of people and/or organizations.

In a home health setting, an occupational therapist works with a woman with muscular dystrophy to adapt the bathroom in her new home so that she can shower independently.

A patient who is recovering from a CVA is no longer able to drive due to cognitive and motor impairments. Attending church is very important for this patient. In order for the patient to continue participating in his valued role as a church and community member, the OT works with the family to arrange transport to and from church, and arranges the weekly men’s bible study group to be held in the patient’s home.

Proprioceptive Neuromuscular Facilitation (PNF)

Author/Research Base: Herman Kabat, PhD, MD

A treatment model that focuses on motor development through the shift in flexor and extensor muscles, using diagonal movement patterns to facilitate mature motor movements.

Intervention methods
– Diagonal patterns or mass movement patterns are utilized during functional activities.
– All patterns cross midline and encourage rotary components to movement.
– Flexion or extension is the major component.
– For each body segment 2 pairs of diagonals exist.

An occupational therapist works with a woman who has had a stroke on reaching for cones in a diagonal pattern across her upper body, then has the woman apply the movement to combing her hair.

An OTA working with a patient who has spasticity in her hand, repeatedly uses the PNF technique of contract relax agonist, antagonist contract, to maintain ROM and inhibit increased muscle tone. The OTA asks the patient to squeeze her hand closed for 15 seconds (to fatigue the muscles) and then the OTA passively stretches/extends the patient’s fingers and wrist.

Psychoanalytic and psychodynamic theory

Author/Research Base: Dr. Sigmund Freud and others

Personality development is driven by conscious and unconscious factors. The therapy process uses self awareness, emotional expression, social relationships, and defense mechanisms to help patients direct their actions to complete tasks. An occupational therapist teaches a high school student with an anxiety disorder how to use relaxation techniques to help prepare for a test.

An OT and OTA co-lead a social skills group aimed at increasing the group members’ awareness of their behavior. The group members have similar types of diagnoses, such as depression, dependent personality disorder and general anxiety disorder. The purpose of learning about their own dysfunctional patterns is to help them become more self-aware so that they can begin behaving in ways that are healthier.

Psychoeducation, also called Cognitive-Perceptual of Reference

Author/Research Base: Carol Anderson, PhD

A treatment model in which patients and their families are educated about their diseases in order to change their thinking and behavior. An occupational therapist teaches an 8th grade student with a diagnosis of autism about his condition so that he understands why he needs to use noise reducing headphones during assemblies.

A patient who sustained a TBI is adamant that he will drive, even though he has right side weakness, deficits in visual perception, and significantly reduced reaction time. The OTA educates the patient about his condition and current limitations, and makes him aware that his expectations about driving at this stage, are not realistic.

Rehabilitative Frame of Reference

Author/Research Base: Catherine Trombly Latham, SCD, OT, FAOTA

A comprehensive approach to treatment in which the ultimate outcome is for the person to become as independent as possible despite any residual dysfunction. The primary focus of this frame of reference is adaptation to facilitate independence . A man who has suffered a traumatic brain injury as a result of an automobile accident undergoes inpatient and outpatient occupational therapy services to improve physical, psychological and cognitive function. Upon discharge from occupational therapy services, he can live independently using memory aids to compensate for short term memory loss and large handled utensils and devices to compensate for fine motor deficits in his right hand.

An OTA teaches a patient who has COPD energy conservation techniques so that she can continue pursuing her passion for gardening. The patient is thus able to continue to engage in her desired activity even though her condition is chronic.

Rood Frame of Reference

Author/Research Base: Margaret Rood, MA, OT

A neurological treatment approach in which motor patterns are facilitated and normalized through the application of sensory stimulation to specific sensory receptors.

– Heavy/light joint compression
– Manual pressure
– Neutral warmth
– Vibration
– Vestibular stimulation
– Tapping
– Quick stretch

While working with a man who has hemiplegia following a stroke, an occupational therapist performs a quick stretch facilitation technique to the man’s affected triceps, followed by weight bearing on the affect arm.

An OT working with a patient whose arm is flaccid due to a recent CVA, uses the technique of tapping on the muscle belly to facilitate a voluntary contraction of that muscle. In this scenario, the OT supports the patient’s arm and taps 3-5 times over the belly of the Biceps in order to facilitate elbow flexion.

Sensory Integration

Author/Research Base: A. Ayres, PhD, OT

This frame of reference is based on the way the brain receives sensory input from the environment and organizes it so that the body can respond with action. As normal development occurs, the brain’s ability to integrate sensory input matures.

Sensory Integration focuses on how the interaction between the sensory systems including auditory, vestibular, proprioceptive, tactile, and visual systems, provides integrated information that contributes to learning and adaptive behaviors

An occupational therapist helps a child with attention deficit hyperactivity disorder (ADHD) to participate in vestibular swinging to organize and calm his neurological system so that he can sit still in his classroom.

A child who is tactile defensive participates in an activity where he is required to find small plastic animals which have been hidden deep down in a bath filled with beans.

A child who has poor modulation in their proprioception, is given activities that involve jumping and crashing into foam wedges.

Strengths Model

Author/Research Base: Charles A. Rapp, PhD

A mental health frame of reference in which the practitioner views people as individuals, not as patients or clients. A person’s strengths are the focus, not their weaknesses or “disability”. An occupational therapist adapts a social studies lesson for a student with autism so that he can learn by reading and looking at pictures instead of listening to the teacher’s lecture, because visual memory is one of his strengths.

An OTA working with a child who is globally delayed does not focus on what the child cannot do but rather at what the child can do. In this scenario, a student has great difficulty writing, copying letters, etc. The clinician uses what the student can do, which is hold a writing implement and builds on this.

Occupational and physical therapists at a state conference discuss strengths-based practice.


Allen Cognitive Model of assessment and treatment built around cognitive function. Using the ACLS tool, a patient’s abilities are measured, and levels of performance are determined.

Outcome: Functional participation and levels of learning.
Examples of intervention: ADLs/IADLs structured by OT at level of functioning

Behavioral Modification Based on the principles of operant conditioning. The concept of conditioning is a form of learning.

Outcome: Promoting healthy behaviors
Examples of intervention: Positive or negative reinforcement and Positive or negative punishment

Biomechanical Purposeful activities used to treat loss of ROM, strength, and endurance.
After ROM, strength, and endurance are regained, the patient automatically regains function.

Outcome: Regain ROM, strength, and endurance.
Examples of intervention: Purposeful activities used to treat loss of ROM, strength, and endurance.


Person-Environment Occupation (triangle). Spirituality is the center. “Being is doing”.

Outcome: Occupational Performance.
Examples of intervention: Identify performance and satisfaction levels to set goals. Restore Nuclear tasks

Cognitive Behavioral Replacing behaviors that result from abnormal thought processes with more normal or adaptive thought processes and behaviors.

Outcome: Changing thoughts to develop new, healthy behaviors.
Examples of intervention: Talk therapy, coaching, role playing, journaling, home work for generalizing.

Dynamic Interactional Model of Cognitive Rehabilitation
(Toglia’s Dynamic Interaction)
Restorative cognitive rehabilitation approach used to enhance the functional performance of patients who have a cognitive impairment. Restoring orientation, attention, visual processing, motor planning via dynamic engagement

Outcome: Functional performance and task engagement (evaluation and intervention cannot be separated)
Examples of intervention: Self checking, self-evaluation, memory strategies, memory notebook, use of cues during task performance, self-reflection after task

Ecology of Human Performance Views a person’s occupational performance in relation to the context in which the activity occurs. Context is primary focus. Activity is selected and adapted based on physical, social, temporal, or cultural contexts

Outcome: Modify or alter context to optimize performance
Examples of intervention: Home modifications- alter context not the person

MOHO Personal occupational choices and engagement in occupation shape the individual. Humans are conceptualized as being made up of three interrelated components: Volition (thoughts/feelings), habituation, and performance capacity.

Outcome: Occupational-Competence Occupational-Identity
Examples of intervention: Structured and unstructured assessments. Patient’s choice for goals, routines/motivation, not disability focused. Seek new ways to achieve performance.

Occupational Adaptation Involves person, occupational environment, and the interaction process that takes place between the person and environment. Complex series of steps and factors that occur when a person is faced with an occupational challenge within one’s environment and one’s role capacity. Important concepts are: Inner acceptance and recognizing the need for change. Works with a patient who is motivated to explore the world and exhibit mastery in a new environment. Not based on deficits.

Outcome: Improving adaptability through challenge
Examples of intervention: Coaching, minimizing stress, reinforcing flexibility, matching occupation readiness with occupational role

PEOP Examines occupational outcomes of personal skills, occupational demands, and environmental supports or barriers. A person gains self-fulfillment from mastery and self-identity from meaningful participation.

Outcome: Occupation Performance. Mastery. Success is motivating.
Examples of intervention: Looking at the fit of all areas, to impact performance. Alter for safety and performance. Task analysis, identifying barriers to dev plan

Psychodynamic Theory Personality development is driven by conscious and unconscious factors. We are about what may be happening under the surface.

Outcome: Self-awareness, emotional expression, identify defense mechanisms → ultimately to improve self-identity and interpersonal relationships
Examples of intervention: Painting, drawing, using clay, or other artistic therapeutic medium to give the patient a chance to explore what is going on internally

Rehabilitative FOR Patient to be as independent as possible despite any residual dysfunction/residual disability. Primary focus is adaptation to facilitate independence

Outcome: Compensations for limitations
Examples of intervention: Adaptations and modifications

Sensory Integration Interaction between the sensory systems which provides integrated information that contributes to learning and adaptive behaviors. Inner drive to master developmental skills via use and integration of senses.

Outcome: Adaptive responses which results in praxis
Examples of intervention: Somatosensory activities, supporting modulation, follow child’s lead, novel environment

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.
– Assistive device/equipment
– Environmental changes e.g. altering layout of living environment
– Strategies to compensate for poor memory
– Task modifications – to modify the task to compensate for the loss of function in order to increase independence.

Authors &
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:
– Work
– Play /leisure
– Self-maintenance

Occupation is essential to self-organization

Comprised of:
-Motivational factors
-Life patterns
-Performance Capacity
-Environmental factors

Occupational Performance:
– Participation (engagement)
– Performance of occupational form (the actual activities)
– Skills (the breakdown of components of an occupational form)

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)
2. Environment (extrinsic factors)
3. Occupations (activities & tasks)
4. Performance -occupational performance & participation (the act of participating in occupations)
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:
1. Person
2. Task
3. Context
4. Person–Context–Task Interaction. 
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:
1. Occupations
2. Adaptive Capacity – a person’s ability to recognize the need for change
3. Relative Mastery – a person’s self-assessment of their occupational response
4. Occupational Adaptation Process – A complex series of steps and factors that occur when a person is faced with an occupational challenge, that takes place within one’s environment and within one’s role capacity.
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.
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:
1. Use of assistive device/equipment
2. Environmental adaptations
3. Task modifications
4. Compensatory strategies to allow effective participation in desired occupations and to facilitate role performance

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

Intervention Strategies:
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

1.) Evaluate Ability
2.) Assess Occupational Readiness
3.) Assess Occupational Activity

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

Formal assessments:
Assessment of Communication and Interaction Skills (ACIS)
• Assessment of Occupational Functioning (AOF)
• Model of Human Occupation Screening Tool
• Occupational Circumstances Assessment Interview and Rating Scale (OCAIRS)
• Occupational Performance History Interview-II (OPHI-II)
• Occupational Self-Assessment (OSA)
• Worker Role Interview (WRI)

Compensate for dysfunction in desired occupations.
Focus of
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:
1. ACL Screens – The ACLS and the LACLS
2. ADM manual and the related projects from S & S
3. Sensory Stim Kits for low ACLs
4. Safety Series for high ACLs

Biomechanical 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:

1. ROM
• Goniometer measurements
• Jebsen Hand Function Test

2. Muscle Strength
• MMT e.g. Oxford Scale
• Hand-grip dynamometer

3. Endurance
• Metabolic costs of activity- METs
• Borg Rate of Perceived Exertion (RPE Scale for endurance)

Also assess:
i. Edema and Pain as may impact on the capacity for motion
ii. Occupational performance areas: Activities of daily living, Work and Leisure
iii. Coordination/Dexterity

• Circumferential measurement
• Volumetric measurement (water displacement)

• Pain Scale (visual analog and numerical rating scale)

Occupation-based Assessments
• Barthel ADL Index
• Nottingham ADL/Extended ADL
• Klein-Bell Activities of Daily Living Scale (K-B Scale)
• Assessment of motor and process skills (AMPS)
• Functional Independence Measure (FIM)
• Disability of Arm, Shoulder and Hand (DASH)
• Tessa – The Enabling System and Skills Assessment
• Valpar – Component Work Sample Series

• Purdue Pegboard
• Minnesota Manual Dexterity Test
• 9 Hole Peg Test

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:
• Developmental progression
• Gross, fine, and oral motor skills
• Visual perceptual skills
• Cognitive skills
• Sensory skills
• Social skills

Some of the assessment tools that can be used with this model are:
• Gesell’s developmental milestones
• Bayley Scales of Infant Development
• Denver Developmental Screening Test II
• Miller Assessment of The Preschooler
• Hawaii Early Learning Profile
• Sensory profile
• SPM: sensory processing measure
• Developmental Test of Visual Perception-2 (DVPT-2)
• Motor-Free Visual Perception Test (MVPT)
• Peabody Developmental Motor Scales 2nd Edition (PDMS 2)
• Bruininks-Oseretsky Test of Motor Proficiency, Second Edition
• Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI)
• Adolescent Role Assessment
• Lifestyle Performance Profile: An Organizing Frame
• Role Change Assessment
• The Occupational Performance History Interview (OPHI)
• Role Checklist

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:
1. person
2. context
3. tasks
4. performance

The Checklists and worksheets that can be used in the evaluation process:
• Person variables worksheet
• Temporal environment checklist
• Physical environment checklist
• Cultural environment checklist
• Priorities checklist
• Social environment checklist

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)

Neuro FORs

• Brunnstrom

• Neurodevelopmental Treatment Approach

• Proprioceptive Neuromuscular Function

• Rood

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).

Other assessments

• 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)
• Canadian Occupational Performance Measure (COPM)
• Barthel Index of Activities of Daily Living
• The Activity Card Sort (ACS)
• Executive Function Performance Test
• Interest Checklist
• Role Checklist

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