Theory Final 2015

The Complexity of Occupations August 24

OT was founded on the principles of occupation and participation and now
these have become central in the definition of health. It is what we do that
shapes what we become and who we are; who we are is what we do.
Mary Reilly Focus on humans need for action, action is the concept of
participation. We can influence the state of our health by being engaged, lets
help people do this.
Keilhofner Use it or lose it Restriction from participation causes
physiological deterioration leading to the loss of ability to perform
competently in daily life (this can happen at all stages of life).
Engelhardt It doesnt matter what the diagnosis is, if someone cannot do
the things they need and want to do, their daily life is restricted; we need to
maximize peoples capabilities for doing.
Wilcock We need to help people fulfill their need for engagement, if they
pursue this need they will enhance their health.
Importance of Occupation:
-reduce the risk for disabilities
-are as protective against the risk of mortality as physical activity
-protect against cognitive decline and depressive symptoms
-provide a protective response to cognitive and physical performance
Occupation is a vehicle to acquire, maintain, or redevelop skills necessary to
fulfill occupational roles and provide satisfaction. Because specific actions of
an activity elicit distinguishable and measurable behaviors, they can be used
to learn skills and develop
functional behaviors.
This is the big picture. You
have to have knowledge of
the things in the left box,
but just as important as
these intrinsic factors are
the extrinsic factors in the
right box. Both support
daily life.

Defining Occupation
The ordinary and familiar things that people do every day
Christiansen, Clark, Kielhofner and Rodgers, 1995
Chunks of daily activity that can be named in the lexicon of the
culture [activity that can be described in a cultural context]
Clark, Parham, et al, 1991
Activities or tasks which engage a persons resources of time and
energy; specifically self-care, productivity, and leisure
Canadian OT Association, 1997
Doing culturally meaningful work, play, or daily living tasks in the
stream of time and in a physical and social context
Kielhofner, 1995
Occupations: create identity, establish meaning, are supported by
skills, capacities, interests, and the environment.
Are goal directed and purposeful to the person.
Are performed in situation or contexts that influence how and
with whom they are done.
Have individual meaning or shared meaning with others.
What occupations mean to the person?
Independence, autonomy, identity, accomplishment
Occupations are a PROCESS to support capacity building (activity
analysis) and an OUTCOME (participation in daily life)
Client-Centered Practice
goal is to create a caring, dignified, and empowering environment in
which clients truly direct the course of their care and call upon their
inner resources to speed the healing process 1990
Basic Assumptions:
Clients/families know themselves best
Clients/families are different and unique
Optimal client function occurs within a supportive family and
community context
Expectations of Clients
Lead decision making process in requards to type and amount of
services they receive

Receive info to enable them to make decisions about services

Utilize their own resources
Define priorities and receive services in a timely manner
Maintain their integrity and dignity
Be supported in their decisions and level of participation
Therapist Responsibilities
Encourage client decision-making, inform and advise clients
Respect clients values, visions and priorities, listen to and trust
them
Recognize and build on clients strengths and encourage them to
use community supports
Does client-centered practice make a difference?
Respectful and supportive services yield satisfaction and
adherence
Information exchange yield improved functional outcome and
satisfaction
Partnership yield client participation, self-efficacy and satisfaction
Individualized intervention yields improved functional outcome
and satisfaction
Clients who set goals achieve better outcomes than those who do not.
They are more focused and direct their efforts. Establish realistic but
challenging goals. Goal achievement requires on going feedback that
recognizes the persons progress toward the goal.

Class Evolution of a Profession August 31

OT perspective enabling people to engage in occupation when health
conditions, societal conditions or disabilities impair or threaten their ability to
do that which is important and has meaning for them.
The beginning of OT At the beginning of the 20th century, influenced by
pragmatism, the moral treatment movement, the arts and crafts movement,
the evolving knowledge of the brain, a period of medical reform and the
social activists movement of the period, the leaders of the day recognized
that the activities of everyday life were critical to the individuals health and
well-being.
The interdisciplinary professionals who founded the profession of OT
recognized that occupation was at the heart of therapeutic practice and that
studying this was essential to the advancement of the profession.

Adolph Meyer (1860-1950) We have to consider the persons interests and

fitness, they must gain a sense of satisfaction of completion and
achievement. Our role is in giving opportunities not prescriptions.
Decision to align with medicine (1920) After WWI the gov wanted to define
OT as vocational specialists. The alignment with medicine led to the
development of the profession. OT services were working under physicians
and primarily within hospitals which would dissociate it from vocational
reeducation services.
A historical perspective Eleanor Clarke Slagel (1919-1937) Leaders
believed education and rehabilitation were best accomplished through
engagement in occupation, supported scientific research as a way to develop
sound practice, and agreed that OT faced challenges in establishing itself as
a credible profession.
What is unique about OT? We think of usefulness, productiveness, and
happiness as capabilities that are in the person and can be observed
and responded to with a family that works and lives in the community.
Where should OT work? In the hospital, but not only there because that
would limit OT without giving consideration to community
reintegration.
Establishing standards for OT education (1935) approached the AMA to
build criteria that would bring consistency to OT education; the first allied
profession to establish standards.
After WWII (1944) Huge growth in our workforce, yet more needed. Physical
medicine tried to bring OT under their control, not only to prescribe medical
interventions but to control our educational programs.
Medical advances created demand Development of psychotropic drugs
such as penicillin (1951) allowed people to survive and need rehab services.
Also the advances in the space program spawned assistive technology such
as Velcro and pressure pads.
WFOT (1952) - The World Federation of Occupational Therapists was
constituted in 1952. Helen Willard and Clare Spackman took the leadership
for the United States when 10 countries formed the organization. WFOT is
the official international organization for the promotion of occupational
therapy and it serves to promote international cooperation among
occupational therapy associations, therapists and other allied professional
groups.
De-institutionalization (1955 on) People with mental illness were being
discharged from institutions at the same time we were moving toward
hospital and rehab based practice and mental retardation facilities were
being built. We did not have enough people to serve these needs and we did
not work to get OT services into these community mental health centers

psych, nursing, and social work became the primary mental health
professions.
OTA (1958) Developed to alleviate an acute shortage of OT in mental
health. Expanded to general practice to extend manpower to serve the
growing population of those with disabilities who needed OT services. Vital
role in community health.
Mary Reilly (1962) humans need to produce, create, master and improve
their environment in order to be competent and to achieve in their daily
occupations.
She noted that we were developing fast without a focus to building
knowledge to underpin our work. We were also working with physician
prescription, rather than generating our own approach to care. She felt
we should build to our uniqueness, a profession dedicated to helping
people be active.
Jean Ayres (early 1960s) Brilliant clinician with observations that her
intereventions improved the function of children. Our first well-known
scientist. Her actions helped occupational therapists learn how to engage the
child in experiences that promoted learning and development. Largely as a
result of her work, we now have a substantial body of knowledge that
contributes to our understanding of occupational performance.
Establishment of AOTF (1965) To advance the science of OT. To encourage
the study of OT by provision of scholarships and fellowships. By engaging in
studies, surveys, and research.
Medicare (1965) - When Medicare was enacted, OTs coverage was limited to
Part A in patient services. As you all know we have fought this battle first to
get part B service and we still have work to do to get OT as an independent
service in home health.
Gail Fidler (1972) Was unrelenting in demanding that we use occupation as
our intervention; since doing is at the center of mental and physical
health. She was the first in our profession to coin the term use it or loose
it.
Hand Centers (1974)
Childrens services public law (1975) A federal law requiring states to
provide a free, appropriate public education to children with disabilities so
that they can be educated along with other children (IEP).
ADA (1990) A law to remove barriers to employment, transportation, public
accommodations, services and telecommunications.
(Below:
enabling-disabling process)

International Classification of Functioning and Disability (ICF) WHO 2001

Health A state of complete physical, social, and mental well-being and not
merely the absence of disease or infirmity (WHO 1948)
Policy Orientation Health is a resource for everyday life, not the object of
living. It is a positive concept emphasizing social and personal resources as
well as physical capabilities.
Community programs (1990s)
AOTAs Centennial Vision (2017)
We envision that occupational therapy is a powerful, widely recognized,
science-driven, and evidence-based profession with a globally
connected and diverse workforce meeting societys occupational
needs.

Eight broad imperatives for OT:

Must expand collaboration to achieve success
Must have the power to influence
Association members must be seen as a professional
responsibility
Must have a well-prepared, diverse workforce
Must have a clear, compelling public image
Must deliver services that create customer demand
Must make decisions in practice, education and research that are
based on evidence.
Science fostered innovation in OT practice
We must confront and transcend barriers that impede our success
Occupation: Well-Being and Meaning September 14
Definition of health
Origin whole, sound, uninjured, faring well, a state influenced by the
gods
Health now seen from a systems perspective recognizing social
conditions, attitudes, emotions, habits and activities with genetic and
body function
Your health is a resource for your ability to live- this fits with our OT
lens. Health allows you to participate in what you need and want to do.

The ACS: Assessment of Activity Participation

Designed to record the activity participation of adults in instrumental,

leisure and social activities. The ACS requires the individual to sort
photographic cards depicting typical activities that fit into categories.
By using the pictures of people actually performing the activity, it
prompts the person to recall the level of their engagement with the
activity and provides an occupational profile of the types of activities
the person is engaged in, or given up. Such information is central to
planning the care of a client who needs occupational therapy.
What does ACS tell us about older adults?
55-65 = >85 people become more active after they retire. The
younger group is taking care of kids and or parents
The people that lived alone were more active than the people
who lived with others
More education = more active
We need to make sure to engage them and help them think
about the things they need and want to do. They might not have
the social networks to be able to do these things like more
educated people do.
Health is a resource for living
Well-Being: is achieved by engaging in meaningful activity and reaching ones
potential.
Relationships, autonomy, mastery, purpose

in

life
Meaning in Everyday Occupation
Occupation as doing
Occupation as being
Occupation as becoming
Space and Place (sources of meaning in occupation)
Space container of experiences, no place is a place until things that
happened in it are remembered
How do we use space in OT? Ability to move in space, carry items in
space, assess space for its functionality and safety, identify barriers in
space, modify spaces
Space is embedded with meaning
Links between people and home
Social centered process

Person centered process

Body centered process
Meaning derived from what we do
There is a continuum with self definition of meaning on one end and
social definition of meaning on the other.
OTs are meaning-givers, we help people understand their situations
and the purpose of the therapy all within the context of meaning.

Disability September 21
Gaining an understanding of disability and how occupational therapy
approaches disability to support recovery, adaptation and prevention.
Disability ranks as the nations largest public health problem affecting over
60 million people and their families (20% of population).
Prevalence is a measurement of all individuals affected by the disease at a
particular time, whereas incidence is a measurement of the number of new
individuals who contract a disease during a particular period of time.
Disability only occurs when the environment does not support what people
need and want to do.
People with chronic conditions account for 83% of all healthcare spending.
Older adults are more likely to have multiple chronic conditions. They are the
heaviest users of healthcare services. 2/3 of medicare spending is for people
with 5 or more chronic conditions.
Disability occurs when there is a limitation in activity, the consequences of
disability are understood as an interaction with the social and physical
environment.
The Biomedical Definition disability is identified with illness or impairment
Professional needs to know about the disease because the disability is
part of what is wrong with the person. Disability is a medical
phenomenon residing within the individual
The Philanthropic Definition disability is a human tragedy, person is an
object of sympathy, and is viewed as a victim with little control over the
circumstances of their life.
This approach undermines self-image and the acquisition of skills and
experiences that lead to an independent life.
The Sociological Definition disability is a form of human difference or
deviation
Leads to stigma as abnormal or deviant which implies inferior requiring
privileges.

May act to divide people, communities and society by promoting

division and barriers, emphasizing their differences instead of their
similarities.
The Economic Definition disability is a social cost caused by the extra
resources that people with disabilities require and their limited productivity
(cost more contribute less).
Leads us to devalue the contributions and ignore the basic rights of
people to participate in social life even if it does cost society.
The Sociopolitical Definition locates disability at the interface between the
individual and the physical and social environment
Created by people with disabilities who needed a definition that
removed the disability from residing entirely inside them.
Disability must be seen in the context of health as health is a resource for
living.
Convention on the Rights of Persons with Disabilities (December 13, 2006)
159 nation states have adopted this charter but the US has not
Purpose of the convention (article 1) to promote, protect, and ensure
the full and equal enjoyment of all human rights and fundamental
freedoms by all persons with disabilities and to promote respect for
their inherent dignity.
What is unique about the convention? Both a development and a
human rights instrument, a policy instrument which is cross-disability
and cross-sectoral, legally binding.
Marks a paradigm shift in attitudes and approaches to persons with
disabilities; gives universal recognition to the dignity of persons with
disabilities.
General principles - Non-discrimination and accessibility
Classifying Both Abilities and Disabilities

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Body
functions: the physiological or psychological functions of body systems
Body structures: anatomic parts of the body
Impairments: problems in body function or structure
Activity: the performance of a task or action by an individual
Activity limitations: difficulties an individual may have in the
performance of activities
Participation: an individuals involvement in life situations
Participation Restrictions: problems an individual may have in the
manner or extent of involvement in life situation
Environment factors: make up the physical, social and attitudinal
environment in which people live and conduct their lives
OT and the ICF
To enable people to engage in occupation when health conditions,
societal conditions, or disabilities impair or threaten their ability to do
that which is important and has meaning for them.
Performance results from complex interactions between the person
and the environments in which he or she carries out activities, tasks
and roles that are meaningful or required of them.
What OTs do appears so very simple but it is so very complex.
Occupation factors
Activities, tasks, roles, importance, frequency, meaning,
satisfaction
Person (intrinsic) factors

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Cognition, psychological, physiological, sensory/perceptual,

motor, spirituality
Cognitive Factors
Language comprehension and production, pattern recognition,
reasoning, attention, awareness, executive function, memory
Physiological factors
Physical health and fitness, strength, endurance, flexibility,
inactivity, health
Neurobehavioral factors
Sensory and motor
Psychological and Emotional factors
Personality traits, motivational influences, interpretation of
experience, self-efficacy, theory of mind

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Culture, Occupational Identity, Social Participation and

Community Session I September 28
Culture is an environmental factor that influences each of our clients, our
colleagues, and ourselves in a variety of ways.
What is needed for effective OT practice?
Understand, appreciate and value your cultural background
Reflect how your culture influence your occupational choices and
occupational identity
Develop an informed respect and curiosity about the cultures of others
Is cultures what makes others different from us? Or are there similarities
across cultures?
Cultural awareness competence
This is an ongoing challenge/journey which requires self-assessment,
open-mindedness and curiosity. It helps build understanding of others
occupations and their experience of disability.
Essential elements for cultural competence:
Acknowledge cultural differences and become aware of the impact of
differences on therapeutic processes
Recognize the influence of you culture on your actions, thoughts,
lifestyle, occupations
Realize your efforts at cultural understanding help your work be more
meaningful and productive
Find ways to acquire knowledge and skills for working with people from
other cultures
Culture shapes our occupations
Culture is learned, localized, patterned, evaluative, persistent yet dynamic

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Intercultural effectiveness in OT requires:

Scientific mindedness (hypothesis testing)
Dynamic sizing skills
Some culture-specific expertise
Occupational Identity
Evolving concept
Cultural foundations
Implications for practice and research
World view learned, largely subconscious, expressed in behaviors
Locus of control
Internal fate has little importance, few things cannot be changed, I
am master of my destiny
External fate is my path, many things in life must be accepted as
they are, my destiny is set
Power distance
Low power is shared, potential leaders are nurtured,
debate/disagreement with authority is ok and may be healthy
High power is centralized; followers are managed, open disagreement
with authority can have dire consequences
Concept of self/relational orientation
Collectivist group is focus, protecting others protects ones self,
dependence is taught
Individualist self is focus, protecting self protects others,
independence is taught
Relational values or worldviews for occupations
Lineal - occupations serve group goals, represent ordered positions,
and express continuity of the group over time
Collateral occupations serve goals and welfare of the laterally
extended group such as the family
Individualistic occupations serve individual goals, reflect autonomy,
pursuit of the persons goals
Communication
Direct people mean what they say, words convey information and
carry meaning

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Goal: giving and receiving information

Indirect read between the lines for meaning, words convey power
Goal: create/ preserve/ strengthen relationships
Gender and Age
Fixed m and f have defined roles and responsibilities and are
separated in many ways, age defines or restricts roles and
opportunities
Fluid choices re common but not unlimited, interactions re frequent
and expected, respect is given across the lifespan
Activity for self-expression
Being, becoming, doing
Other cultural variations: view of humans, time orientation/focus, relationship
with nature

Culture II October 5
Families influence our views on independence/dependence
We are all cultural beings and must learn about ourselves so we can work
effectively with others
Cultural assumptions can get overlooked
Culture changes constantly is a dynamic, interactive and developing
psychosocial system, culture shapes identity.
Cultural competency in OT
Health and illness are not just medical, they are social and cultural
Culture specific competency
Intercultural competency
Bridging cultural gaps
Use interpreters for linguistic issues whenever you are not fluent.
Do not use family: bias, lack of interpreting skills, role confusion,
language limits
Limits of tech translation: lack clues to determine context
L.E.A.R.N. for cross-cultural communication
Listen actively to the other persons perceptions
Explain your perception of the concern
Acknowledge and discuss differences and similarities

15

Recommend actions
Negotiate and agreement on a plan
Sources for cultural identity: race, gender, age, religion, social class, health
status
OT intervention
Based on culturally appropriate assessments
Client centered and context driven
Occupation based
Meaningful for clients culture
Worldview and health disparities
The institute of medicine reports that beliefs and values of
clients/patients and health care providers can contribute to health
disparities
Conflicting assumptions misinterpretation misunderstanding, lack
of therapeutic relationship
Understanding ones own worldviews
Cultural humility, self-awareness, respect, appreciation of life
experiences, behaviors and priorities of others, recognition of our
own limitations

Occupations and Roles of Childhood October 6

Constructivism theory/philosophy of learning
Knowledge is self-constructed and our interactions with the world is
based on what we know. People create meaning. The individual has an
active role and there is a dynamic between the individual and their
environment
Developmental Psychology umbrella field of theory to study changes that
occur throughout the lifespan
Encompasses motor, cognitive, psychological, physiological, biological,
personality, language, morality, social learning and essentially
everything construct that pervades our daily life.
Piaget

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New learning: assimilation and accommodation

Schemas internal concept of framework
Equilibrium is achieved via:
Adaptation change in P and/or E factors to better understand
the environment
Assimilation incorporation of new experience into existing
schemas
Accommodation modify existing schemas to fit new experience
Sensorimotor Stage (0-2)
Begin to learn cause and effect and ideas about time and space
Exploration of the world through all of the senses
Children younger than 8 months do not grasp object permanence
Preoperational Stage (2-6/7)
Too young to perform mental operations
Begin to categorize objects and form metal representations of
past
Begin to develop turn-taking and cooperative play

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Egocentric- cannot perceive things from others point of view,

begin forming a theory of mind
Concrete Operational Stage (7-12)
Grasp conservation problems, transform mathematical functions,
decentering
Formal Operational Stage (12+)
Can do abstract thinking, enhanced metacognition
Lev Vygotsky shifted the focus onto social interaction and culture as a
means for cognitive development; focus on the mechanism of development
rather than predefined stages
Zone of Proximal
Development
Meditation: purposeful
interaction with the
environment in order to
modify understanding and
obtain benefits; learning is
interactive
Scaffolding: critical role of a
social partner in the process
of learning, provides
support, is used selectively
when needed

Erik Erikson Emphasized the roles of culture, society and the conflicts that
take place inside a person. Was interested in how children socialize and how
this socialization affects identity or sense of self. Each stage of development
will bring about a deep crisis that needs resolution, this helps develop
identity. Successful completion of each stage results in a healthy personality
and skills to resolve future conflicts. Unsuccessful completion leads to an
unhealthy sense of self and personality.
Identity internal construction
Social identity external construction

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Attachment Theory human biology guarantees that infants become

attached to at least one caregiver, attachment quality and styles contribute
to emotions, behavior, and relationships throughout the life course
Childhood Occupational Development
Daily occupations: taking care of oneself, playing, learning, chores,
resting/sleeping
Facilitators and Barriers to COP
Health conditions
Performance skills (development)
Learning styles, temperament, motivation
Environmental factors: economic, physical, cultural
Expectations
Family and peer influence
Attachment and safety
The occupations of childhood are both the process and product of
development, enabling children to grow physically, intellectually,
emotionally and socially

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Child development is a dynamic and reciprocal process by which the

child interacts with his or her environment and through those
experiences and interactions (physical interactions, social interactions,
etc), physical, emotional, and neuromaturational development is
enhanced so that the child has more capacity to perform occupations.

Occupations of Adults October 19

Competence
Make decisions that reflect their values and goals in order to best
develop and maintain competence.
Drive for competence is a hallmark of adult life and is highly influenced
by opportunities or barriers in the environment. People have a need to
develop competence in their roles and seek our activities and
challenges.
Self-Efficacy
Affects the degree to which the individual perceives that he has the
effectiveness and affordances to successfully address a challenge.
Higher means they are more likely to overcome a challenge and have
higher perseverance.
Occupations
Work is the primary occupation in early and middle adulthood. Trends
are that people are more likely to change jobs or have multiple jobs.
Occupational deprivation when people are willing and able to
work but cannot find adequate or sustainable employment
Employment disparities where work participation is different
among groups because of differences which create greater
barriers to participation
Occupational imbalance when demands of work impinge on
enjoyment of other parts of life such s family time and recreation
Unemployment reflects the health of the general economy but
certain demographics are more at risk. Higher for those less
educated, African Americans and those with mental health
problems
Underemployment may be working but at jobs that are below
their capability, at lower rates of pay, or for less hours
Influence of caregiving on work most of the time this is
informal, associated with high cost related to time lost
Parenting learn by doing and memory of own childhood, most have
little prior knowledge

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Caregiving of Elderly Parents More than half of adults 85 and over

need help to perform ADLs. Distance is an issue which adds to stress
and strain
Sandwich generation reduction in work and leisure,
occupational imbalance
Leisure Typically occurs during discretionary time, are activities
chosen and inherently satisfying. Play is to children as leisure is to
adults. Work influences leisure. Work/leisure balance seems to predict
health.
Disruption to Occupations Life imbalance, insomnia and sleep
disorders, obesity and inactivity, poverty,
Stages of Adulthood
Adulthood occupational performance demands are most challenging,
requires personal and environmental supports to be successful
Young Adults Often involved in education, career training, decisions
about life roles and establishing social and intimate relationships.
Middle Age Adults Adjustments made based on past experiences.
Parental responsibilities for children may decrease while
responsibilities for adult parents may be increasing. Career
responsibilities may change.
Dimensions or Domains of Occupational Development
Physical motor, sensory and body systems
Cognitive awareness, thinking, communication abilities
Emotional feelings, temperament, motivation
Social roles, relationships and moral awareness
LLorens (1970) Suggests that development occurs horizontally through the
growth of physical, cognitive, linguistic and psychosocial skills and
longitudinally through the maturation and extension of these skills, abilities,
and behaviors. Addresses environmental influences.
Havighurst Developmental Tasks
Early Adulthood 18-30 Individual is selecting and learning to live with
mate and beginning a family. Emotional independence from parents
begins.
Middle Age 30-60 Individual achieves social responsibility and
satisfactory career performance. Commitment to a relationship.
Individual begins to adjust to gradual physiologic changes.
Erikson Psychosocial Development Crises

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Intimacy vs Isolation (16-29)

Generativity vs Stagnation (30-60)
Young adults must develop intimate relationships and middle adults
must contribute to society or risk isolation and self-absorption.
Levinson
Early adulthood demands development of mature behaviors in family
and career
Middle adulthood involves reassessing meaning, direction and value
of life. New life structure is formed when choices and commitments are
made.
Emphasize importance of transitioning from one phase to the next
Lifespan Development Theory Growth, stability, and change in behavior
occur throughout life. There is a continuous interplay between growth and
decline. Selection, optimization and compensations constitute fundamental
elements of development. There is age associated change in adaptive
potential.
Theory of Selective Optimization and Compensation (SOC) Integrates the
work of child-adolescent researchers with the work of scientists studying
aging and midlife development. Successful development results from the
simultaneous maximization of gains and minimization of losses. The goals,
strategies to achieve goals and behavioral context change over time.
Individuals maintain competence by choosing activities (selection), modifying
the task related demands (compensation) that increase or sustain feelings of
well being and preserve skills (optimization).
Self-Determination Theory (SDT) Theory of motivation that addresses
personality development and function within social contexts. Growth,
integrity and well being occur through engagement in activities that support
competence and autonomy.
Summary: OT Role Working with Adults
Examine roles, routines, habits. Consider culture and individual beliefs.
Work with clients to achieve and maintain balance. Understand
developmental theories and stages to assist with finding ways to
motivate adults. Dont forget to address leisure. Wellness programs,
advocacy, coaching.

Occupations and Theory Supporting Older Adults

October 26

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How is Aging Defined?

Chronological aging the passing of calendar time
Biological aging Internal and external changes in the structure and
function of the organism that influence behavior and longevity. These
changes influence social and psychological process. Lifestyle stress or
depression can retard or accelerate the biological process.
Psychological/Behavioral aging changes in personality, cognition,
emotions, learning, memory, motivation and creativity.
Role of society in defining aging could be linked to retirement age,
loss of roles accompanying physical decline, point when active
contribution is no longer possible.
Role of Occupation in Successful Aging occupation plays a central role as a
person ages
Older adults may experience a decline in health, activity level and
social support BUT later life can provide opportunity for growth new
hobbies, deepen relationships, time for spiritual growth.
Successful aging includes low probability of disease, high cognitive
and physical functioning, engagement in productive activity and
interpersonal relations, attainment of personal goals. These can all be
enhanced through engagement in occupation.
What do older adults do?
IADLs, reading, resting and TV are most common. Most activities are
done alone and at home, half of waking hours are spent doing
sedentary leisure activities. Age had greatest effect on activity
duration, frequency and variety. Residential status also plays a role.
Impact of Aging on Person Factors Supporting Occupation
Cognitive decreased executive function, encoding information
becomes more difficult and slow, anxiety and depression increases,
medication side effects may exacerbate problems
Physiological and motor decline in coordination and reaction time,
postural changes, gait speed slows, energy levels decrease
Sensory decreased vision, hearing loss, smell and taste, tactile
Psychological variety of stressors increase risk of depression which
can be expressed as fatigue, reduced concentration, insomnia,
negative attitudes
Spiritual majority believe in higher power and that prayer can lead to
healing
Impact of Aging on Environment Factors Supporting Occupation

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Physical/Built home modifications can lead to reduced falls and

increased occupational performance
Social social support may be a key link to activity participation
Impact of Chronic Disease on Occupation in Older Adults
Medical conditions that: last more than one year, require ongoing
medical care, limit ability to engage in activities
Often: have no cure, are medically complex, require significant medical
coordination
Leading causes: heart disease (leading cause of death), cancer,
arthritis (leading cause of disability), stroke, diabetes, lung disease,
hearing loss
Baltes Theory of Selection, Optimization with Compensation
Older adults maximize positive and minimize negative experiences and
activities by selection, optimization and compensation
They choose the most rewarding activities, select fewer and more
meaningful goals and activities as they age to optimize their
experiences; they also compensate for losses by finding other ways
to accomplish tasks and activities.
*this is why we deliver client-centered care
Bronfenbrenners Ecological Systems Theory
Gaining understanding of human development requires examination of
multi-person systems of interaction
Lifelong course of development of older adults and their environments
must be fully considered.
Microsystem: as older adults experience loss of spouses and
friends their children become their caregivers and activity
patterns change due to loss of community mobility and social
roles
Mesosystem: older adults may have difficulty accessing settings
relevant to their needs and interests
Exosystem: community agencies used by older adults may not
exist or be easy to access
Lawton and Nahemows Ecological (Competence Press) Model

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Stress and adaptation depend on the fit between

the demands of the environment and an
individuals competence to meet these demands.
OTs need to identify the fit of the older adults
environment and adapt the environment to create
just right challenge.
Social Support Theories
Key because social support is often an important
link to community participation
Social Network Typology important for older adults to engage in a
variety of relationships and develop diverse social network
Social Emotional Exchange Theory identifies a conscious narrowing of
social circles of adults 80+; allows them to focus on remaining close
family members and friends
Convoy Model of Social Engagement respective roles of those in the
network changes over time; first the older adult is providing more
assistance to younger adults but it shifts to the younger member
providing support for the elder
Support Bank Theory social support given is analogous to a bank
deposit and support received is like a withdrawal

Theories and the Brain November 2

What is the Brain for? The brain is for movement.
Emerges from interaction between individual, task, and environment
(parallels with PEOP model.
Useful context (theory) to understand brain evolved to let humans
influence their environment
Brain disorders produce unique occupational challenges
Examples: Parkinsons disease, cerebellar ataxia, Huntingtons
chorea, proprioceptive disorders, aphasia
Why care about theory?
We use theory when we dont have enough information we never
have enough information. Understanding is theory all the way down.
Everyday life and experience are full of prediction and inference, your
brain fills in the blanks.
Filling in the Blanks continuous awareness as a constructed
phenomenon

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saccadic suppression (no vision during saccades)

stopped-clock illusion
theory of consciousness a story we tell ourselves (split-brain
patients)
left hemisphere has interpreter and invents reasons using
the info available to it
We need theory because we cannot just rely on evidence from our
senses.
Theory hypothesis
Theories of the Brain
Brain as computer: information processing
Advantages: intuitive, fruitful
The brain doesnt work that way! Unrelated processes can
happen together and single processes can be distributed.

Technology as Theory brain as pneumatic device brain as todays

complex machine
Affordance Competition
Affordance the action possibilities provided by an object
Whole brain involved in figuring out how to interact with the
world
Fits our current understanding of neuroscience, same neurons
involved in planning, selecting, acting.

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Conclusions
Theory is necessary to help you understand what you see
Movement is the brains purpose
Affordance competition
Embodied cognition
Neuroscience is only just beginning to turn these principles into
therapies

Theories of Learning and Motor Control November 9

Affordance Competition Hypothesis the whole brain works to plan and
choose actions
Embodied Cognition
Cognition is defined and restrained by action, cognitive processes
are an outgrowth of action
Action simulation theory of mind
Relating others actions to your own, understanding others
mental states
Prediction and testing hypothetical situations, movement models in
the cerebellum
Brain Lateralization
Crossed fibers in brainstem: opposite side of body
Lateralized tasks involve more activity in one hemisphere, you use
your whole brain for everything!
Split Brain Patients
Brain-Computer Interfaces (BCI)
What is Learning? Acquiring knowledge about the world.
Consolidation: process of forming persistent physical representation
in the brain
Retrieval: accessing stored memories
Types of memory
Declarative memory (explicit) facts, people, events, spatial
Non-declarative memory (implicit) procedures, skills, emotional,
conditioning
Fluidity of memory

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Memory is distributed across the brain. Every time you retrieve a

memory, you have to remember/ consolidate it anew. Declarative
memory is constructive.
False memories: partly/wholly inaccurate memories, accepted as
real. Social context increases agreement with false and planted
memories
Behavioral vs Cognitive Learning
Learning to vs learning that
Behaviorism: operant conditioning
Work with behaviors not cognition
Behavioral and cognitive are complimentary
Types of learning
Behavioral/cognitive is how you learn
Motor learning is (an example of) what you learn
Theory of Motor Learning
Closed-loop theory and forward models in closed-loop sensory
feedback drives learning. You detect errors by comparing feedback
with intended movement and outcome.

Forward model: brains prediction of the body

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Schema theory abstract representation of a broad class

Generalized motor program rules needed to produce muscle
activity
Effector the acting organ
True predictions variable practice
Multi-stage models
Cognitive, associative, autonomous
Novice, advanced, expert
Degrees of freedom
Ecological theory
Motor control evolved to allow animals to explore and manipulate
the environment. Not just sensory and motor, but perception of
important environmental factors.
Motor Learning
Consolidation: off-line learning
Goal based learning consolidate in sleep
Movement based learning consolidated in wake
More practice: movement > goal
Motor Practice
Amount of training: power law of practice
Knowledge of results: goal-related feedback
Massed vs distributed practice
Constant vs variable practice
Generalization and transfer
Mental practice, not as good as real practice but helps
Guidance vs discovery learning (guidance is basically never better)
Challenge point - just the right amount of information
Barriers to learning
Personal: cognitive, physiological, psychological, motivational
Environment: critical for behavioral training, social/physical
environment
Conclusions
Caught up on theories of the brain

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The nature of (motor) learning

Practice and application

Emotion and Affective Theories November 16

The arousal and cognition chicken and egg debates
Which happens first, the body changes that go with an emotion, or the
thoughts, or do they happen together?
James-Lange Theory body (physiological arousal) before thoughts (emotion)
Experience of emotion is awareness of physiological responses to
emotion-arousing stimuli.
Evidence: Soldiers that are paralyzed report that emotions dont
have the same intensity as they used to. Merely smiling leads to
greater reported happiness.
Cannon-Bard Theory body with thoughts simultaneously
Evidence: Physiological experience does not have to precede
emotions. There is more to our emotion than merely reading
physiology, there is cognition. Some emotions require thought in
order to be elicited such as pride, patience, caution.
Singer-Schachters Two-factor Theory body plus thoughts/label
Suggests that emotions do not exist until we add a label to whatever
body sensations we are feeling. Emotions = Body plus a cognitive
label.
To experience emotion must: be physically aroused and cognitively
label the arousal.
Zajonc, LeDoux, Lazarus Theory body/brain without conscious thoughts
Some emotional reactions, especially fears, likes, and dislikes, develop
in a low road through the brain, skipping conscious thought.
Two halves of a whole
Cognition (cortical regions) thinking and acting objective, able to
measure, easy to correlate with brain regions, core processes are
generally agreed upon
Emotion (subcortical) feeling and being subjective, difficult to
operationalize in experiments, must dissent about core process or
role in human experience
Emotive Cognitive Models
Emotions result from our cognitive evaluations of situations
Cultures can strongly affect appraisal of situations

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Cultures moderate the amount of emotional expressions

Emotion regulation depends on norms and social context
Explicating Emotion Science
Emotion brief episode triggered by event or object that triggers
global change in the brain, body and behavior
Mood general state of lesser intensity and prolonged duration that
caused by emotion
Feeling internal, subjective, mental representation of an emotion
Attitude pervasive, affective characteristic about a belief or
preference
Affective style biased but stable disposition or perception and
reaction to an event
Temperament affective style that might be present form an early
age and carried throughout life
Emotion and Culture
Facial expression and posturing indicate presence of emotion.
Basic emotions (biologically driven): anger, fear, sadness,
enjoyment, disgust, surprise
Characteristics: distinctive universal signals, automatic appraisal, etc

Introduction to Two Environmental Theories:

Bronfenbrenner November 23
Occupational Performance: results from the person interacting with his
environment, environments can promote and enhance or hinder and
undercut OP
Ecology of human development Progressive accommodation, throughout
the life span, between the growing human organism and changing
environments in which it actually lives and grows.
B pushed beyond prior emphasis of separate lenses
Child psychologists children
Anthropologists society/culture
Economists sources and uses of funds
Political scientists governments
Systems perspective each system or level influences and is influenced by
every other system (reciprocal effects, bidirectional)

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Center microsystem mesosystem exosystem macrosystem

outer ring
Microsystem: the developing person and his very close environment.
Immediate settings home, school, or playground
Key Roles family, teachers, staff with direct contact
Mesosystem: relationships/interconnectedness between microsystem
players
Exosystem: larger social systems with indirect but significant
influence
Neighborhood characteristics, media/communications, economic
climate
Macrosystem: overarching societal values and shared belief patterns
Culture, religion, politics, educational systems (worldview)
Chronosystem the influences of time
Proximal Processes Progressively more complex reciprocal interaction of
human and surrounding environments. Primary engine for development and
actualization of genetic potential.
Progressive interaction includes symbolic environments that invite:
exploration, manipulation, elaboration, imagination.
Interactions help develop capacity for emotional control AND ability to defer
immediate gratification as one pursues progressively longer range goals.
Ecological Niche particular regions in the environment that are especially
favorable or unfavorable to the development of individuals with particular
characterizes B
Ecological Validity the extent to which the environment experienced by the
subjects in a scientific investigation has the properties it is supposed or
assumed to have by the investigator-B
Community health challenges: the epidemic of obesity, bullying in schools,
aging in place
Nature or nurture? Bs work shows that BOTH are important influences.

Introduction to Two Environmental Theories: Lawton

November 23
Lawtons Environmental Press Model leading researcher on aging and the
physical, social and psychological needs of the elderly. Much of his research
focused on individuals with Alzheimers. Realized that living spaces should be
designed to accommodate the elderly.

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Why consider environment? Environment is the context in which activity

occurs and disability occurs when the environment does not allow for
activity, changes in the environment can impact participation.

Competence
The ability that enables an individual to function
Intrinsic performance potential
Maximum performance across domains: biological, perceptual,
sensorimotor, cognitive
We need to look at the persons experience in the environment not just at
the environment.
Environmental Press Aspects of the environment that act in concert with a
personal need to evoke behavior by an individual. Stimuli in the environment
that will produce a response in all people. Whether or not a response occurs
is based upon individual competence.
Adaptation (P-E Fit)
Adaptive/Maladaptive or negative behaviors are a result of lower
cognition with high environmental challenge or high intelligence and

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low environmental challenge falls, additional injuries, decreased

occupational performance.
Environmental Docility Hypothesis The environment places a greater
demand as an individuals competence decreases
Less competence greater environmental determination
Environmental Proactivity Hypothesis When an individual is more
competent, he is able to use environmental resources to achieve a desired
outcome. The more competent you are, the greater the degree of
environmental change you are able to handle.
Lawton and Occupational Performance
Outcomes depend on the match between environmental press and
competence. A small mismatch may result in positive outcomes. A
large mismatch is associated with negative outcomes such as
decreased safety and independence aka lower occupational
performance.

Biomechanical Framework November 30

Physical Stress Theory Stress leads to a predictable response in body
tissues. Stress is needed to maintain tissue variability. Tissues demonstrate
decreased tolerance if physical stress levels on the tissue are too low. Tissues
will demonstrate increased tolerance with an overload of physical stress.
Excessive physical stress damages tissues. There is an ideal level of stress
necessary to promote tissue healing.
Biomechanical Framework Explains function utilizing biomechanical
concepts, anatomy, exercise physiology, kinetics, and kinematics as the
theoretical base. Applies principles of physics to human movement and
posture with respect to the forces of gravity. Evaluation and intervention
focuses on ROM, strength, endurance, and preventing contractures and
deformities; used primarily with orthopedic disorders.
Assumptions of the BF
Anatomy/physiology determine normal function.
Physiological tolerances of anatomical structures can be improved
with progressive overloading.
If the body functions are remediated, the client will use these skills to
regain functional skills.
Limitation of sustained stability or movement produces an incapacity
to perform occupations.
Evidence for using the BF to:

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Increase strength, improve joint mobility, increase cardiorespiratory

endurance, increase ability to lift, improve body mechanics, improve
health
Evidence that the BF:
Increases quality of life, improves participation, increases well-being,
enhances occupational performance
Performance skills the clients demonstrated/observable abilities that are
learned and develop over time.
OTPF classifies as motor, process, and social interaction skills.
Many body functions underlie each performance skill.
Performance skills are closely linked with each other and can affect
each other.
Performance skills are key aspects of successful occupational
participation.
Body Functions joint stability, joint mobility, body flexibility, muscle
strength, muscle endurance, muscle length, ligament length, skin mobility,
posture
Performance skills/activities walk, climb, lift, carry, manipulate, write, sit,
stand, stoop, bend, reach, jump, chores, hobbies
Relationship within the OTPF
Client factors are affected by the presence or absence of illness,
disease, deprivation, disability, and life experiences.
Client factors are affected by performance skills, performance patterns,
contexts and environments, and performance and participation in
occupations.
Through this cyclical relationship preparatory methods, activities, and
occupation can be used to affect client factors and vice versa.
Intervention Approach Create
Does not assume a disability is present or that any factors would
interfere with performance. This approach is designed to provide
enriched contextual and activity experiences that will enhance
performance for all persons in the natural contexts of life.
Intervention Approach Establish
Designed to change client variables to establish a skill or ability that
has not yet developed or to restore a skill or ability that has been
impaired.
Intervention Approach Maintain

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Designed to provide the supports that will allow clients to preserve the
performance capabilities they have regained, that continue to meet
their occupational needs, or both. Assumption that without continued
maintenance intervention, performance would decrease, occupational
needs would not be met, or both, thereby affecting health and quality
of life.
Intervention Approach Modify
Directed at finding ways to revise the current context or activity
demands to support performance in the natural setting, including
compensatory techniques, such as enhancing some features to provide
cues or reducing other features to reduce distractibility.
Intervention Approach Prevent
Designed to address clients with or without a disability who are at risk
for occupational performance problems. Designed to prevent the
occurrence or evolution of barriers to performance in context.
Interventions may be directed at client, context, or activity variables.
Types of OT interventions
1) Therapeutic Use of Occupations and Activities
2) Preparatory methods and tasks that prepare the client for
occupational performance
a. Preparatory methods modalities, devices, and techniques
b. Preparatory tasks client performs to target skills
3) Education and training
4) Advocacy
5) Groups
Body Functions
Decrease with inadequate load, stretch, repetition, duration
Increase with adequate load, stretch, repetition, duration
Can fail with excessive load, stretch, repetition, duration
Limitations Cannot assume that these outcomes will negatively impact
health, wellbeing or participation. Cannot assume that increased flexibility,
strength, and endurance will decrease functional limitation. Reduced
impairment does not necessarily result in improved occupational
performance. Must be used with other approaches to fully address clients
issues.
BF was not originally developed by OTs we should translate it to the OT
perspective to avoid the risk of movement or exercise becoming the main
focus.
ROM needs to be restored to motion required for normal daily tasks,
other meaningful tasks

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BF can be used to: create, restore/establish, maintain,

modify/compensate/adapt
Preparatory Biomechanical Treatment Principles Tied to Functional Outcome
Maintaining length of the collateral ligaments will allow for full joint
mobility increasing ability to manipulate tools for cooking.
Improved shoulder flexibility will result in ability to perform overhead
work tasks.
Biomechanical approach can be:
Preparatory performed prior to purposeful activities, helps to
prepare the client for activity or occupational performance
Purposeful goal-directed behavior in therapeutic context that leads
to occupation
Occupation clients engage in actual occupation
Overload Principle:
Increases occur only if the load/range is greater than what the tissue
is accustomed to and is applied to the point of fatigue
Appropriate overload will cause adaptation
Is achieved by varying frequency, intensity, and time of the stress
Muscle Tension
Active tension tension developed by contractile elements
Passive tension tension developed in non-contractile components
when muscle is lengthened
Total muscle tension = active + passive
Greatest tension is when contracting maximally in a lengthened
position.
You need to know more before using the biomechanical approach.

Models to Guide My Practice

Principles supporting the use of occupations
Humans have a drive to engage in occupation
Occupation is complex and multidimensional
Occupation must be considered within an environmental context
Experienced within the context of time
Occupations hold meaning for the person
Occupations influence health and well-being

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Common Characteristics of OT Models

All models have person, environment, and occupation as key
elements.
All are ecological models that recognize the importance of stages of
development as they influence motivation, skills and roles.
All emphasize complex interactions of biological, psychological and
social phenomena
All recognize the importance of the match between person, task and
the situation for performance to be supported.
What is different?
The degree to which the constructs are explicated.
Different language
All were developing concurrently

38

What supports
in Daily Life?

participation

Models of Occupational Performance

Canadian Model Enabling Occupation: A person centered model of
occupational performance
Occupational performance refers to the ability to choose,
organize and satisfactorily perform meaningful occupations that
are culturally defined and age appropriate for looking after ones
self, enjoying life, and contributing to the social and economic
fabric of a community
Not as focused on what they can recover; dont treat as much in
order to recover; more looking at how to modify for
environmental support.
Model of Human Occupation Kielhofner

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Occupational performance consists of meaningful sequences of

action in which a person completes an occupational form.
(Occupational form = the element of the doing that gives it
meaning and purpose.

The Kawa River Model

Collectivistic view of reality. Reflects an eastern relativistic
ontology. Regards life and occupation as elements/dynamic of
nature. Focuses on the here and now. Tool to elicit the clients
view of reality.
Occupational performance is depicted metaphorically- the
location, volume, rate and clarity of multiple water channels
(occupations) that form the clients river or life flow. Enhanced
occupational performance is depicted by the increased quality of
flow in the river, which increases the quality of the life flow.
Occupational Therapy: Helps to identify spaces, where water (life
force) can still flow; focuses water (life flow/occupation) through
the spaces, over rocks (problems/obstacles), driftwood
(resources; liabilities and assets) and walls/sides (environmental
context), eroding the surfaces and thus increasing life flow.
Christiansen and Baum
Performance results from complex interactions between the
person and the environments in which he carries out actions,
tasks, and roles that are meaningful or required of them. (PEOP)
Person centered interventions, Organization centered interventions,
Population centered interventions the narrative and outcome measures are
what change between them.
A changing health system

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41