Theory Final 2015

The Complexity of Occupations – August 24OT 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 doesn’t 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

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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 client’s values, visions and priorities, listen to and trust them

Recognize and build on client’s 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 person’s progress toward the goal.

Class Evolution of a Profession – August 31OT 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.

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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.

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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, OT’s 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)

Children’s 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)

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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)

AOTA’s 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 society’s 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

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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.

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‘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 21Gaining 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.

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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.

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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

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 individual’s 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.

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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

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

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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

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

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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 one’s 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 person’s goals

Communication

Direct – people mean what they say, words convey information and carry meaning

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 5Families influence our views on independence/dependence

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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 person’s perceptions

Explain your perception of the concern

Acknowledge and discuss differences and similarities

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 client’s 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

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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 6Constructivism – 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

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

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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

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

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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

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

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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

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 19Competence

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

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Parenting – learn by doing and memory of own childhood, most have little prior knowledge

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

Intimacy vs Isolation (16-29)

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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. Don’t forget to address leisure. Wellness programs, advocacy, coaching.

Occupations and Theory Supporting Older Adults – October 26How 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.

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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

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

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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

Bronfenbrenner’s 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 Nahemow’s Ecological (Competence Press) Model

Stress and adaptation depend on the fit between the demands of the environment and an individual’s competence to meet these demands.

OTs need to identify the fit of the older adult’s 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

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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 2What 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: Parkinson’s disease, cerebellar ataxia, Huntington’s chorea, proprioceptive disorders, aphasia

Why care about theory?

We use theory when we don’t 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

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 doesn’t work that way! Unrelated processes can happen together and single processes can be distributed.

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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.

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 9Affordance 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

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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

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

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outcome.

Forward model: brains prediction of the body

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

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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

The nature of (motor) learning

Practice and application

Emotion and Affective Theories – November 16The 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 don’t 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-Schachter’s Two-factor Theory – body plus thoughts/label

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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

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

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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)

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

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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? B’s work shows that BOTH are important influences.

Introduction to Two Environmental Theories: Lawton – November 23Lawton’s 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 Alzheimer’s. Realized that living spaces should be designed to accommodate the elderly.

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

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Maximum performance across domains: biological, perceptual, sensorimotor, cognitive

We need to look at the person’s 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 low environmental challenge falls, additional injuries, decreased occupational performance.

Environmental Docility Hypothesis – The environment places a greater demand as an individual’s 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 30Physical 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.

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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:

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 client’s 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.

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Intervention Approach – Maintain

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 Activities2) Preparatory – methods and tasks that prepare the client for occupational

performancea. Preparatory methods – modalities, devices, and techniquesb. Preparatory tasks – client performs to target skills

3) Education and training4) Advocacy5) 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 client’s 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 PracticePrinciples 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

Common Characteristics of OT Models

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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

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What supports participation in Daily Life?

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 one’s self, enjoying life, and contributing to the social and economic fabric of a community

Not as focused on what they can recover; don’t treat as much in order to recover; more looking at how to modify for environmental support.

Model of Human Occupation – Kielhofner

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.

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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 client’s view of reality.

Occupational performance is depicted metaphorically- the location, volume, rate and clarity of multiple water channels (occupations) that form the client’s 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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