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Occupational Therapy

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DOI: 10.1007/978-3-319-18096-0_90

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 Occupational Therapy
90
Sharon A. Cermak and Ann E. Borreson

Abstract
Occupational therapists contribute to the care of children and adults with
intellectual and developmental disabilities (IDD) by focusing on activities
and goals that are meaningful to the individuals and their families. Relevant
performance areas include cognitive, sensory, perceptual, motor and psy-
chosocial activities. Goals for intervention can range from self-care to
supporting participation in a work environment. The ultimate goal is to
foster community integration and participation. Occupational therapy
assessment is designed to understand the individual’s strengths and areas
of concern, within the context of the current environment and family/com-
munity culture. In this chapter, the types of interventions for individuals
with IDD at different life stages are discussed, and examples of evidence-
based outcomes are presented.

Introduction engaged in performing work, occupational ther-

The ultimate goal of occupational therapy is “to
facilitate overall well-being and quality of life by
supporting an individual’s ability to engage in
important and meaningful activities” [1].
Originating from the findings that psychiatric
inpatients had better outcomes when they were
apy is based on the belief that participation in
purposeful activities is the basis for a meaningful
life. Since its origin in 1917, occupational ther-
apy has expanded to encompass events of every-
day life, from basic personal hygiene to school
performance to work and leisure. The term
“occupation” refers, not merely to one’s job, but

S.A. Cermak, Ed.D., OTR/L, FAOTA (*)

Ostrow School of Dentistry, Division of Occupational
Science and Occupational Therapy, University of
Southern California, 1540 Alcazar Street CHP 133,
Los Angeles, CA 90033, USA
Department of Pediatrics, University of Southern
California Keck School of Medicine,
Los Angeles, CA 90033, USA
e-mail: cermak@osot.usc.edu
A.E. Borreson, MD
Division of Occupational Science and Occupational
Therapy, University of Southern California, Ostrow
School of Dentistry, 1540 Alcazar Street CHP 133,
Los Angeles, CA 90033, USA
e-mail: annborreson@gmail.com

© Springer International Publishing Switzerland 2016 1053

I.L. Rubin et al. (eds.), Health Care for People with Intellectual and Developmental
Disabilities across the Lifespan, DOI 10.1007/978-3-319-18096-0_90
1054
to any activity in which an individual wants or
needs to participate. For instance, the occupa-
tions of an infant are learning to feed, interact
with caregivers, and begin processing the exter-
nal world.
A person with intellectual and developmental
disabilities (IDD) benefits most from the collab-
orative efforts of a team of professionals made up
of multiple disciplines. The role of the occupa-
tional therapist is to enable the child or adult to
participate as fully as possible in society and to
meet his or her individual and family goals [2–4].
Maximizing skill development and active partici-
pation is achieved through reducing impairments,
modifying activities or environments, and utiliz-
ing assistive technology. Table 90.1 lists the
domains or types of activities that are part of life.
Some or all of these activities may be addressed
by occupational therapists.
Referral for occupational therapy is indicated
whenever there is a reason to suspect delay or
qualitative impairment in the performance of
daily tasks and routines including self-care, play,
leisure, work, social interaction, or performance
of tasks [5]. The goal of evaluation of a child or
adult with IDD is to understand the strengths and
areas of concern, within the context of the current
environment and family/community culture [6].
Table 90.1 Scope of occupational therapy
Activity Examples
Personal care Feeding, dressing, bathing
(ADL)
Community living Care of family and pets,
(IADL) management of finances,
transportation
Rest and sleep Relaxation, sleep hygiene
Education Dance class, extracurricular
activities, learning via internet;
academic class
Work Looking for a job, volunteering,
paid work
Play Playground games, playing
dress up,
Leisure Reading, knitting, watching TV,
internet activities
Social participation Involvement in activities with
others
S.A. Cermak and A.E. Borreson
Family members and other team members, such
as teachers, are integral to the process.
If an individual is unable to perform a desired
activity, the options are improving the capacity of
the individual, modifying the task, or modifying
the environment. In other words, the therapist’s
goal may be to help the individual develop the
deficient skill, to use assistive technology to
make the task easier (e.g. a device that makes it
easier to put on socks), or to modify the environ-
ment, (e.g. altering counter heights to accommo-
date a wheelchair). Environmental adaptations
using both low and high technology are often
crucial to the individual’s performance and full
integration in the community. Assistive technol-
ogy may be as simple as enlarging a spoon handle
to compensate for a weak grasp or teaching a
young child to use a switch to activate a toy to
learn cause and effect. Behavioral approaches
including principles of learning are used to teach
functional skills.
Occupational therapists practice in a wide
variety of settings, including hospitals, rehabili-
tation centers, mental health clinics, home health
care, school systems, early intervention pro-
grams, residential centers, extended care facili-
tates, and community agencies. Utilizing
strengths and resources of the individual and his
or her family and/or caregivers is an important
part of occupational therapy.
Although the ultimate goal of occupational
therapy is to support an individual’s ability to
engage in meaningful activities, the specific roles
of therapists and the types of activities vary as a
function of the developmental age and stage of
the individual.
Infancy and Early Childhood
Children with IDD typically present within the
first 2 years of life. In infancy and early child-
hood, intellectual and developmental disabilities
are most apparent in sensory and motor skills and
most often present with delays in developmental
milestones within the first 2–3 years of life.
Children with autism spectrum disorder represent
an important subgroup in this category.
90 Occupational Therapy
Focus
When working with young children, intervention
is family-focused, with strong emphasis placed
on both supporting child development as well as
building family capacity [7]. Occupational thera-
pists focus on sensory-motor, cognitive, and
communication/interaction skills as well as the
child’s ability to engage in everyday routines by
addressing activities of daily living, including
dressing and feeding, play, social communication
and interaction, and rest and sleep [7].
Goals
In early intervention, an important goal of occu-
pational therapy is to support, encourage, and
enhance the competence of parents in their role as
caregivers. As the child enters the preschool years,
goals include activities of daily living, social
skills, peer interaction and sensory-motor skills.
Assessment
Occupational therapists begin assessment of a
child by gaining an understanding of the child’s
level of participation in daily activities with his or
her family or caregivers. In consultation with the
parent and relevant professionals, therapists iden-
tify what the child/ family unit wants and needs to
do. Childhood activities may encompass sensory-
motor skills, self-care, play and leisure, educa-
tion, learning, and socialization. For the infant
and young child, referral is typically made by the
child’s pediatrician or parent [8]. Referral is indi-
cated whenever a delay is noted, such as a missed
milestone or when a child has difficulty sleeping,
is a poor feeder, or is irritable and startles easily.
Referrals may be made directly to occupational
therapy or to an early intervention program.
Intervention
Developmental, sensorimotor, play-based, and/or
sensory integration approaches are used com-
1055
monly with children with IDD. Application of a
sensory integration approach to children with
IDD has been described by Schaaf and Miller [9].
Parham and Fazio described use of play as both
means and ends in treatment [10]. Early interven-
tion programs, covering ages 0–3 years, exist in
all 50 states and are often run by a state agency.
As the child reaches preschool years, services are
often transferred to preschool programs under the
Department of Education.
Outcomes
Based on evidence of improved outcomes for
earlier intervention, taking a “wait and see”
approach is not recommended [11]. Early inter-
vention and Head Start programs include occupa-
tional therapy, and outcome studies support the
effectiveness of these programs. A recent series
of systematic reviews of outcome research in
children birth through five years has indicated
positive effects for social-emotional develop-
ment, feeding difficulty, motor performance [11–
13] and cognitive development [14]. Programs
with a high level of parental involvement and
which include guidance, support and suggestions
for activities to implement at home were espe-
cially effective [15, 16]. Specific occupational
therapy parent training programs have been
found effective in enhancing parents’ knowledge
and practices about child development, parent
child interactions and children’s play skills [11,
15, 17]. A recent review examining the effective-
ness of different service delivery models in early
intervention indicated that there was no specific
setting or method of service delivery identified as
being the most effective [15] although Part C of
IDEA specifies that services are to be provided in
a child’s natural environment and school-based
services are to be provided in the least restrictive
environment [18] (Picture 90.1).
At 3 years-old, Riley started preschool. His
teacher expressed concern because Riley
became agitated when the class did activities
such as finger painting, gluing, or playing in
the sandbox outside. Riley had difficulty sit-
1056
Picture 90.1 Reilly
ting in circle time and became aggressive
when other children bumped him. When the
noise in the classroom increased, Riley often
hid under the table.
Riley’s mother indicated that Riley had been an
irritable baby who was not cuddly and did not
like to be held. She noted frequent gagging
problems when she introduced textured foods
into Riley’s diet. She reported that Riley now
eats only a very limited variety of foods and
will not eat any food with lumps or grainy tex-
tures. Mealtimes are prolonged, often taking
more than an hour. Evaluation through parent
and teacher interview, administration of the
Sensory Profile [19], and observation of Riley
in his preschool classroom indicated that Riley
perceived sensory input such as light touch or
loud sounds as noxious, and he often acted in
a way to avoid these sensations. This has been
termed sensory over-responsivity [20]. Riley’s
teacher and parents needed to understand that,
S.A. Cermak and A.E. Borreson
rather than simply being difficult, Riley was
reacting to sensory information he perceived
as noxious. By understanding that Riley had
difficulty with loud noises, light touch, and
other sensations, his teacher and parents could
predict situations that would be challenging
and make changes in the environment, such as
modifying seating placement, offering differ-
ent activities, and/or soothing Riley by provid-
ing calming input. Over and under responsivity
to sound, touch and other sensations also are
seen in many individuals with IDD as well as
many children on the autism spectrum [20].
The occupational therapist worked with Riley’s
mother to help develop a program to reduce
oral hypersensitivity and to expand Riley’s
food repertoire. Oral play with rubber toys
was suggested to desensitize the oral area and
promote tongue and jaw movements [2].
Application of deep pressure around the
cheeks and mouth in a game-like fashion was
recommended before mealtimes and before
tooth brushing. Riley’s older sister was
included in the games. Additional approaches
included behavioral strategies including posi-
tive reinforcement, and guided participation
[12]
Riley’s hypersensitivity to touch was also evident
during classroom activities, which helped to
explain why Riley was resistant to activities
such as gluing or finger painting. To mitigate
the irritating sensations, alternate materials to
reduce sensory input were suggested, such as
using a glue stick instead of liquid paste so
Riley would not get his hands messy. Further,
sensory input known to be calming such as
deep massage and heavy work like wall push-
ups were recommended. These types of activi-
ties are referred to as a sensory diet, a
personalized activity plan that provides the
sensory input a person needs to stay focused
and organized throughout the day [21, 22]. In
order to help Riley develop self-regulatory
strategies the Alert Program [23] was incorpo-
rated into Riley’s daily routine. Overall, this
plan helped Riley to participate more fully in
his preschool classroom.
90 Occupational Therapy
School-Aged Child
When a child enters school, delays become more
evident in language and cognitive development.
Such delays may have an influence on all perfor-
mance areas, including activities of daily living
(ADL), play, and participation in educational and
community-based activities. As with younger
children, sensory issues need to be addressed.
Parent-professional partnerships are key to the
quality of intervention. For occupational
therapists working in schools, teacher-therapist
partnerships are equally important.
Focus
With a school-aged child, occupational therapists
focus on school-based function, social interac-
tion, and supporting community participation.
Leisure activities at this age might include hip-
potherapy, karate, and swimming. As the child
reaches the teen years, focus of intervention
includes the development of prevocational and
life skills, and building support networks beyond
the family. Sports and gaming are important
activities for many children at this age.
Goals
In children with IDD, the primary goals of
occupational therapy are to improve perfor-
mance of everyday activities and to enhance
participation in physical and social environ-
ments [24]. Therapeutic intervention focuses
on what is meaningful to the child and his care-
givers. Goals may include enhancing social
skills, literacy, behavior management, recess
and participation in sports, self-help skills, or
prevocational/vocational participation [25].
With older children focus is on adaptive func-
tion and preparation for post-school life includ-
ing community mobility, self-advocacy, and
ongoing social skills [26].
1057
Assessment
Occupational therapists begin by gaining an
understanding of the child’s level of participation
in daily activities with his or her family and in
school with peers and adults. Typically, occupa-
tional therapists are part of the education team
within a school district [25]. A key aspect of
occupational therapy assessment is identification
of supports needed to enhance the child’s adap-
tive function [26].
Intervention
Occupational therapists use several approaches
with school-age children [27]. When therapists
practice within school systems, occupational
therapy is a related service to help the child ben-
efit from and participate in his or her educational
program. As such, skill-based approaches such as
Handwriting Without Tears may be used to pro-
vide children with needed functional skills [28].
Play, another approach, is both a means and an
end in occupational therapy [10]. As a means, the
occupational therapist incorporates playful quali-
ties into the intervention process because play is
an occupation of high relevance and importance
to a child. The child who is playing is active, goal
directed, and intrinsically motivated. In a sensory
integration approach, therapists guide the play
activity to a point where it becomes a challenge
and adapt and modify the activity to present the
“just right challenge” to enable a child to suc-
cessfully respond at the next higher level [24].
Activities are incorporated that have meaning
and purpose for the child and his or her family.
For older children, play can also be a way to
increase competencies in cognition and social
skills. This approach is used in occupational ther-
apy in both private practice and school settings
[29]. In fact, a 2012 Autism Speaks survey indi-
cated that parents reported occupational therapy
as the type of therapy that worked best for their
child [30]. Finally, assistive technology is part of
1058
occupational therapy practice with children [31].
In addition to directly providing services to chil-
dren, therapists play a critical role in training par-
ents, educators and community organizations.
Outcomes
The effectiveness of occupational therapy in a
school context has been found to enhance perfor-
mance in a variety of areas including fine-motor
skills, upper-extremity use, and handwriting [27,
32–35], functional skills [36], attention to task
[37, 38], powered mobility [39], and play and
social interaction [40]. A recent study indicated
that occupational therapy using a sensory
integration approach was effective in reducing
self-stimulating behaviors in school age children
with IDD [41]. This approach also is used with
children with autism to enable them to be more
organized and participate in classroom activities
[29]. In occupational therapy, both consultation
models and direct service models have produced
positive effects [27].
Eight-year old Michael has cerebral palsy with
mild to moderate involvement of upper
extremity function. His teacher reported that
his poor handwriting was interfering with his
performance in school. He was unable to write
legibly and could not complete his work in the
allotted time. Michael fatigued easily; he
failed to stabilize his paper because he used
his non-writing hand to hold his head up.
Michael also demonstrated difficulty figuring out
how to make his body do what he wanted it to
do. He did not have a good awareness of his
body in space. Michael’s increased tone and
decreased strength contributed to poor bal-
ance and poor stability of his shoulders and
arms and to his poor writing skill.
The occupational therapist focused on improving
function by providing strengthening and sta-
bility activities. She also incorporated com-
pensatory strategies by adapting Michael’s
environment (e.g. frequent movement breaks,
arm rests, better positioning of Michael in his
chair). The therapist also provided direct
S.A. Cermak and A.E. Borreson
intervention for Michael’s body awareness
issues by incorporating sensory integration
principles [42, 43]. In addition, the Goal-Plan-
Do-Check [44], cognitive approach helped
Michael learn strategies for handwriting as
well as motor skills. If Michael were an older
child with the same problems, the occupa-
tional therapist might recommend appropriate
school accommodations, such as use of a tape
recorder, a note-taker and/or a keyboard for
writing.
Adolescent/Young Adult
Choice and self-determination, psychosocial
functioning, work, and community participation
are important for adolescents and young adults.
For their parents or caregivers, living arrange-
ments after their child leaves school become of
increasing concern.
Focus
Occupational therapists assist with transition
planning for adolescents taking on adult roles
and responsibilities [16]. Social participation and
prevocational exploration are major themes.
Goals
Therapists working with adolescents and adults
value self-determination and emphasize helping
individuals to identify their interests and needs as
wells as identifying and providing skills and sup-
ports to meet these needs [3, 45]. Common inter-
ests are dating, spectator sports, and internet-based
activities.
Assessment
For adolescents and young adults, assessment
may begin with an exploration of interests and
hobbies. Therapists assess the current abilities of
the individual, e.g. deciding if the individual is
90 Occupational Therapy
able or ready to participate in a work environ-
ment, and helping to choose an appropriate type
of work setting or post-high school vocational
program. In planning for transition to adulthood,
occupational therapy assessment contributes to
characterizing the individuals’ expected level of
independence and where the individual will be
living after graduation [46].
Intervention
Therapists working with people with IDD in
schools, mental health settings and rehabilitation
units help individuals with IDD with life skills,
social skills, and preparation to enter the work-
place. Programs for adolescents and young adults
with disabilities include the development of
vocational interests and skills, focusing on
employment preparation [25, 46]. Adaptive skills
training in areas such as social skills, community
mobility, and leisure are critical for enhancing
independence in the community. Work (compen-
sated or volunteer) is an essential factor in pro-
viding a sense of productivity and meaning, as
well as a sense of competency and the opportu-
nity to interact with others.
Work programs to support individuals with
IDD range from sheltered workshops to competi-
tive employment in a work setting that employs
individuals with and without IDD. Best outcomes
are seen in programs that provide on-the-job
training [47].
Outcomes
Some areas of occupational therapy interventions
for young adults have a strong evidence base. For
instance, several studies have demonstrated that
supported employment improves quality of life
[47–49]. Another study found sensory-motor
benefits from Wii gaming [50]. Many other stud-
ies of intervention efficacy for people with IDD
are descriptive or qualitative in nature.
Bethany is a teenager with Down syndrome who
was in an inclusive vocational program in her
1059
high school. During transition planning,
Bethany identified that her goal post–high
school was “to work” and “to live with friends
in my own house.” An occupational therapist
worked with the team to identify Bethany’s
strengths and the supports needed for her to
obtain and maintain employment and to live
independently or in supported living. Although
Bethany required only minimal supervision in
basic daily living skills (e.g., reminders to
shower), she had never used public transporta-
tion independently, had not prepared meals or
snacks, and had not gone shopping.
Discussion with Bethany’s mother indicated that
Bethany had never been expected to partici-
pate in household chores. A system of assigned
chores was set up at home so that Bethany
could begin to learn to wash her clothes and
cook simple meals, preparing her for assum-
ing an adult role. At school, Bethany began to
work in the school store. Bethany also decided
that she would like to learn to use the bus. She
and her team decided to begin with using pub-
lic transportation, instead of the school bus, to
go to school. The occupational therapist
adapted the Mobility Skills Training Program
[51]. Training took place in phases, progress-
ing from simulated practice to riding the bus,
initially with supervision, and eventually
independently.
Adult
In adulthood, work and community involvement
continue to be major factors, and promoting
healthy living takes on greater importance. When
working with adults with IDD, the therapist
“functions as a facilitator, respecting the person’s
choices and providing the support he or she
requires to work toward personal goals” [46].
Focus
Work, leisure, community and social participa-
tion continue to be the major areas of focus in
adulthood. Examples of leisure activities include
1060
bowling, hiking, or going to the movies. Caregiver
burden is an increasingly important issue, espe-
cially as parents of adults with IDD age.
Therapists and other professionals work with
families to make new living or other arrange-
ments as caregiver abilities change over time.
Goals
Occupational therapists assist adults with IDD to
live “self-determined lives” [3]. Emphasis is on
activities of daily living, work, leisure, and fit-
ness/health promotion.
Assessment
Understanding the individual’s previous history
and experiences, current patterns of daily living,
interests, values, and needs is important in order
to determine appropriate plans [3]. Assessment
and the treatment planning process are collabora-
tive and individualized toward goals that are
meaningful to the individual.
Intervention
Services for adults with IDD are typically pro-
vided in the form of consultation to programs in
which individuals reside and/or work, although
direct occupational therapy may be provided,
especially if a specific medical need exists (e.g.,
injury, stroke) or a change in status occurs (e.g.
transition to work, change in living situation).
Activities may include increasing access to
assistive and universal design technologies, con-
sultation to sponsored employment programs to
enable integration into the workforce, and con-
sultation to community programs to enable indi-
viduals with developmental disabilities to
participate in health promotion activities.
Because work is a major activity in adulthood,
therapists devote a lot of energy to this area.
Intervention in health promotion is another
important function of occupational therapists.
Research indicates that compared to persons
S.A. Cermak and A.E. Borreson
without IDD, individuals with such conditions
are more likely to lead sedentary lives that can
lead to obesity, low cardiac fitness, and increased
risk for osteoporosis [3, 52]. Occupational thera-
pists can develop wellness programs for individ-
uals and provide consultation to industry and
community-based programs to optimize health
and promote fitness of individuals with
IDD. Assistive technology can be used to enhance
function.
Outcomes
Studies examining the effectiveness of occupa-
tional therapy interventions in adults with IDD
have been found, for example, to improve activi-
ties of daily living [53]; to enhance meaningful
occupations using a gardening program [54], to
improve mobility [51], to reduce challenging
behaviors [55], and to enhance self-identified
goals related to transitions to adult roles [56].
Wennberg and Kjellberg [57] reported that when
adults with mild IDD were trained in assistive
technology (smart phones), they reported
improved levels of independent participation in
their daily activities, and they experienced an
increased sense of choice and control
(Picture 90.2).
Julio, a 32-year old man with intellectual dis-
abilities, recently moved into a group home
because his parents were no longer able to
care for him. As a resident of the group home,
Julio was required to help with household
chores, such as setting the table for dinner and
taking out the trash. Julio was cooperative and
pleasant during chore time, but required step-
by-step prompting from a staff member or a
volunteer to complete his chores. The staff
wanted to see Julio do his chores more inde-
pendently, so they contacted their consulting
occupational therapist for suggestions.
The occupational therapist performed an activity
analysis for the task of taking out the trash.
She noted that the steps for the activity could
be performed in a specific, nonvarying order;
that is, taking out the trash involved first get-
90 Occupational Therapy
Picture 90.2 Julio
ting a large garbage bag from the closet, then
emptying all the small wastebaskets into the
bag, tying the bag closed, and placing the bag
into the bin outside. She determined that direct
supervision was not required as a safety pre-
caution for the task; however, due to Julio’s
level of cognitive functioning, he would con-
tinue to need some form of cuing or prompt-
ing to complete each discrete step of the task
in timely manner and to ensure adequate task
performance.
The occupational therapist suggested that Julio
use an auditory prompting system using his
iPod with an audio file for each of his house-
hold tasks. For the task of taking out the trash,
she taped verbal prompts for each step of the
task, leaving time for the completion of one
step before introducing the next. She incorpo-
rated silence, words of encouragement, music,
and cues to check the quality of work as filler
between instructions for each step. In essence,
the occupational therapist “talked” Julio
through the task on the audio file as if she
were there with him.
1061
Once the audio file was recorded, the occupa-
tional therapist walked through the system
with Julio. She also trained the staff how to
use the audio prompting system with Julio,
including how to record instructions appropri-
ately for new tasks and how to determine
when ongoing use of the system may no lon-
ger be necessary. With practice, Julio became
able to take out the trash without staff supervi-
sion after being given his iPod. Julio’s success
in using the auditory prompting system for
this task led staff members to record addi-
tional audio files for other household tasks so
that Julio could function more independently
in the group home.
Older Adult/Aging
Although most older adults with IDD experience
age-related diseases at the same rate as their
counterparts, there are a few diseases that occur
with a higher incidence such as dementia, hypo-
thyroidism, nonischemic heart disease, reflux,
and visual impairments and certain mental disor-
ders [52, 58–60].
Focus
In older adults with IDD, focus is on retirement
planning and prevention of activity limitations
and participation restrictions.
Goals
Successful aging is the goal for older adults with
and without IDD. This includes maintenance of
social and community activities, planning for
retirement, and strategies to promote healthy liv-
ing and prevent social isolation [61].
Assessment
Older adults with IDD may undergo an assess-
ment of current physical and cognitive ability.
1062 S.A. Cermak and A.E. Borreson

Certain tools have been modified for older indi-

viduals with IDD [62]. In addition, in examining
an individual’s hobbies and interests in planning
for retirement, the occupational therapist con-
sults with staff at living facilities to assess indi-
vidual’s interests and choices.

Intervention

Occupational therapists may provide consulta-

tion to or work directly with older adults with
IDD in hospitals, skilled nursing facilities, home
health care settings, community centers and long-
term care facilities [63]. For instance, therapists
may arrange group education about energy man-
agement at community centers. Alternatively,
therapists may serve as consultants at a nursing
home to design programming that will be carried
out by facility staff. For older adults with IDD,
intervention varies from short-term physical
rehabilitation following an acute injury to ongo-
ing social support. For instance, following a
stroke, a therapist may provide assistive devices
such as a shower chair or reacher, and task modi-
fication to conserve energy. On a more long-term
basis, a therapist may work in a community cen-
ter to provide ongoing assistance with low vision
aids, fall prevention, or education about success-
ful aging.
Outcomes
There is a strong evidence base for positive out-
comes from short-term geriatric rehabilitation
[64] as well as for productive aging [65–68],
including systematic reviews of the effectiveness
of occupational therapy-related interventions for
neurodegenerative diseases such as amyotrophic
lateral sclerosis [69], multiple sclerosis [70, 71];
Parkinson’s disease [72] and individuals with
Alzheimer’s disease [73]. However, although
individuals with IDD may have these disorders,
there is limited research specific to this subgroup
of older adults [63] (Picture 90.3).
Picture 90.3 Kendra
Kendra was living in a senior group home when
she sustained a fall, resulting in a broken hip.
Kendra wanted to return home from the hospi-
tal, but she had limited mobility and was
unable to bend toward the ground. Kendra and
the team met to discuss modifications needed
to enable Kendra to return to the group home.
The occupational therapist suggested some prac-
tical techniques to prevent injury to Kendra
and other residents, including removing scat-
ter rugs, and replacing low-wattage bulbs with
high-wattage bulbs to improve lighting. The
occupational therapist pointed out that the
chair on which Kendra sat was too low and
suggested adding a firmer, higher cushion.
Kendra’s shoes were on the floor in her closet,
so a hanging shoe bag was recommended so
that Kendra would not have to bend down to
get her shoes.
Kendra’s dresser was rearranged so that the bot-
tom drawers contained infrequently used and
out-of-season clothes, and she only needed to
90 Occupational Therapy
use the top two drawers. To make it easier for
Kendra to remember the changes, pictures
were placed on the dresser drawers indicating
the clothing items inside. Kendra was shown
how to use a sock aid to help her put her socks
on.
The occupational therapist ordered a combina-
tion raised toilet seat and folding bathtub
bench which could be stored and not interfere
with the routines of the other residents. The
occupational therapist also made several visits
to the residence following Kendra’s return
home to review ADLs to be sure they were
performed safely.
Providing services in Kendra’s home was impor-
tant to assure carryover of learning [74]. The
occupational therapist also met with the staff
of the group home to review precautions and
be sure that all staff used equipment
consistently.
Conclusions
Occupational therapists provide individual inter-
vention as well as consultative services to foster
community participation, prevention, and well-
ness of individuals and groups [75]. Consultation
may be provided to individuals with disabilities
and their families, care providers, teachers, health
professionals, doctors, organizations, communi-
ties, or government policy makers [76].
Intervention focuses on influencing the biolog-
ical, physiological, psychological, or neurological
processes of the infant, child, adolescent, or adult.
Intervention may include teaching new skills, hab-
its, or behaviors to enable the individual’s partici-
pation in different contexts. Occupational
therapists may suggest adapting the task require-
ments, using adaptive equipment or assistive tech-
nology, or modifying the environment. Disability
prevention, education, and health promotion are
designed to help individuals avoid the onset of
unhealthy conditions, diseases, or injuries [1]. For
example, the American Occupational Therapy
Association (AOTA) developed a brochure and
web site on healthy ways to load and wear a back-
pack to prevent back injuries [77].
1063
Occupational therapists embrace a client-
centered, evidence-based practice model and uti-
lize the best evidence available coupled with
clinical reasoning for practice decisions. Overall,
evidence supports the effectiveness of occupa-
tional therapy in enhancing function in individu-
als with IDD.
Access and Legislation
Occupational therapy and physical therapy ser-
vices for children and adults with disabilities
have been influenced by organized advocacy
efforts and resulting federal legislation [78, 79].
Relevant laws include:
• Americans with Disabilities Act, Amendments
Act of 2008: The ADA prohibits discrimina-
tion based on disabilities. The amendments of
2008 clarified “disability”. Broadly as any
impairment that substantially limits one or
more major life activities, including commu-
nicating, walking, bending or reading.
• Individuals with Disabilities Education
Improvement Act of 2004 (IDEA): specifi-
cally includes occupational therapy (OT) as a
related service for eligible students with dis-
abilities, ages 3–21 (part B) and as primary
service for children age 0–3 with developmen-
tal delays (Part C). It also specifies that ser-
vices should be provided in “the least
restrictive environment,” construed to mean
home or nursery school for young children
and schools for older children. The law speci-
fies that each child must have an individual-
ized treatment plan.
• No Child Left Behind amendment to
Elementary and Secondary Education Act of
1964 (ESEA): provides federal funding for
schools. It also establishes Alternative
Achievement Standards for students with the
most significant cognitive disabilities.
• Improving Head Start for School Readiness
Act of 2007: provides comprehensive child
development services for economically disad-
vantaged children 0–5, including children
with disabilities. OT services may be provided
1064
for children less than 4 years old under this act
or under IDEA.
• Section 504 of the Rehabilitation Act of 1973,
as amended: supports reasonable accommoda-
tions for individuals with a disability, a history
or a disability or a perceived disability.
Children and youth who are not eligible for
IDEA may be eligible for services under sec-
tion 504 or the ADA.
• Assistive Technology Act of 2004: promotes
access to assistive technology for persons with
disabilities.
• Rehabilitation Act: provides grant programs
for vocational rehabilitation, supported
employment and independent living. It also
provides for research activities administered
via the National Institute on Disability and
Rehabilitation Research and the National
Council on Disability. Section 501 prohibits
discrimination in hiring individuals with IDD.
• Workforce Investment Act: consolidates fed-
eral job training and employment programs.
Eligible adults are given financial power to
use Individual Training Accounts (ITAs) at
qualified institutions.
• Ticket to Work and Work Incentives
Improvement Act of 1999 (TWIIA) allows
people with disabilities to continue receiving
Medicaid benefits while working.
In summary, in the United States, federal legisla-
tion has greatly influenced the provision of health
care, education and social services for individu-
als of all ages with IDD.
Further Information
The American Occupational Therapy Association
(AOTA), the professional organization of occu-
pational therapy, has published a fact sheet on
utility of occupational therapy practice as it
relates to IDD [80]. A list of resources for profes-
sionals called, “Rehabilitation Disability and
Participation” is available on the AOTA website
at http://www.aota.org/About-Occupational-
Therapy/Professionals/RDP.aspx. Additionally,
S.A. Cermak and A.E. Borreson
fact sheets for lay persons, ranging from “How to
pick a toy” to “Fall prevention” are available on
the AOTA website at http://www.aota.org/en/
About-Occupational-Therapy/Patients-Clients.
aspx.
For information about occupational therapy in
general, a specific guideline, Occupational
Therapy Practice Framework: Domain and
Process (OTPF-3) describes the domain of occu-
pational therapy, emphasizing its unique perspec-
tive on occupation and activities of daily living
and the dynamic evaluation and intervention pro-
cesses that support engagement in occupation.
The most recent version is available on-line at
http://www.aota.org/media/Corporate/Files/
A b o u t AOTA / O f f i c i a l D o c s / G u i d e l i n e s /
Framwork-document-external-review.ashx.
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