A model of practice (MOP) helps OT practitioners organize their thinking.¹³ For example, practitioners using the Model of Human Occupation (MOHO) know that they will gather information about volition (e.g., the child’s or parents’ goals and priorities or occupational choices), habituation or routines (e.g., how the child spends the day), performance (e.g., the physical skills and abilities of the child), and environment (e.g., the physical layout of the home). Practitioners using the Person–Environment–Occupational-Performance model will organize their thinking into information about the child (e.g., the child’s physical abilities), the environment (e.g., where the child attends school) and occupational performance (e.g., how the child is performing his or her daily occupations). Other commonly used pediatric MOPs include Occupational Adaptation and the Canadian Occupational Performance Model.

MOPs provide practitioners with a framework for thinking about and arranging their materials. They help practitioners focus on factors that influence functioning. MOPs are developed from OT theory and philosophy. As such, they fit with the Occupational Therapy Practice Framework (OTPF) in their emphasis on occupation. See Table 10-1 for an overview of selected MOPs.

TABLE 10-1

Models of Practice

MODEL	AUTHOR(S)	COMPONENTS	PREMISES
Model of Human Occupation (MOHO)	Kielhofner	Volition Habituation Performance Environment	The human is an open system. Volition drives the system. The clinician’s role is to understand the client in terms of these systems (and subsystems) and intervene to facilitate engagement in occupations.
Canadian Occupational Performance Model	Occupational Therapy Association Townsend, et al.	Spirituality Occupation Context (institutional included)	The worth of the individual is central to this model. Spirituality is the core of a person. Thus, occupational therapy practitioners must understand the client’s spirituality to facilitate engagement in occupations. Performance of occupations takes place within social, physical, and cultural environments.
Person–Environment– Occupation Model	Law, et al.	Person Environment Occupation	Looks at the person in terms of physical, social, and emotional factors. The environment (context) inﬂuences the person and occupations. The environment includes culture. Occupations are the everyday things people do.

Data from Kielhofner G: A model of human occupation: Theory and application, ed 4, Baltimore, MD, 2008, Lippincott, Williams & Wilkins; Law M, Cooper B, Stewart D, et al: The person-environment-occupation model: A transactive approach to occupational performance, Can J Occup Ther 63:9, 1996; Townsend E, Brintnell S, Staisey N: Developing guidelines for client-centered occupational therapy practice, Can J Occup Ther 57:69, 1990.

Referral, screening, and evaluation

The referral, screening, and evaluation aspects of the OT process are concomitantly referred to as the evaluation period. During this period, the OT practitioner meets the child, the family, or other referral sources (e.g., teacher, early interventionist) to collect information that will assist in setting goals and developing an activity configuration for the child.

Referral

Children are usually introduced to OT by means of a referral. The reason for a referral depends on the individual state licensure law or regulations within the area of practice. It is the responsibility of the OT practitioner to know the laws and regulations that govern his or her area of practice setting. Some states require a referral before an OT practitioner can see a client. Other states require a referral only for the intervention process. A physician or a nurse practitioner generally gives the referral, depending on the state’s laws; it is called physician’s referral or doctor’s orders.

According to the Standards of Practice for Occupational Therapy published by the American Occupational Therapy Association (AOTA), only occupational therapists may accept a referral for assessment.¹ The OTA, if given a referral, is responsible for forwarding it to a supervising occupational therapist and educating “current and potential referral sources about the scope of occupational therapy services and the process of initiating occupational therapy referrals.”¹ OTAs may acknowledge requests for services from any source. However, they do not accept and begin working on cases at their own professional discretion without the supervision and collaboration of the occupational therapist.

From American Occupational Therapy Association: Occupational therapy practice framework: Domain and process, 2nd edition, Am J Occup Ther 62:625–683, 2008.

Functional independence refers to the completion of age-appropriate activities with or without the use of assistive devices and without human assistance (e.g., eating independently with an offset spoon).

Assisted performance refers to a child’s participation in a specific age-appropriate task with some assistance from the caregiver (e.g., putting on a shirt and receiving assistance with buttoning).

Dependent performance occurs when a child is unable to perform an age-appropriate task. A caregiver is required to perform the task for the child (e.g., holding a cup for a child with cerebral palsy).

Intervention planning, goal setting, and treatment implementation

Intervention planning

The occupational therapist develops an intervention plan after the evaluation has been completed. The evaluation includes parental concerns, the client’s strengths and weaknesses, a statement of the client’s rehabilitation potential, long-term goals, and short-term objectives. The plan describes the type of media (i.e., specific types of materials) and modalities (i.e., intervention tools) that will be used and the frequency and duration of treatment. The plans for re-evaluation and discharge as well as the level of personnel providing the intervention are also included.¹

The intervention plan is based on a selected MOP or a frame of reference (FOR). The FOR provides guidelines and intervention strategies. The OTA utilizes knowledge of the selected frames of reference, the activity analysis, and the selection, gradation, and adaptation of activities to carry out the intervention plan.

Frames of reference

Once practitioners have gained information by using an MOP, they must decide how to intervene. FORs are used to direct OT intervention. They inform practitioners on what to do and are based on theory, research, and clinical experience.¹³ FORs define the populations for which they are suitable, describe the continuum of function and dysfunction, provide assessment tools, describe treatment modalities and intervention techniques, define the role of the practitioner, and suggest outcome measures. FOR helps the OT practitioner identify problems and develop solutions. Common pediatric FORs in OT are MOHO, developmental, sensory integration, biomechanical, sensorimotor, motor control, and rehabilitation FORs. See Table 10-2 for an overview of FORs. MOHO is both a MOP and a FOR, since this model has numerous assessment tools and intervention strategies. As such, it provides an overall way of thinking and also meets the criteria for a FOR. See Chapter 25 for a description of MOHO.

TABLE 10-2

Pediatric Frames of Reference

FRAME OF REFERENCE	REFERENCE(S)	PRINCIPLES	SAMPLE POPULATIONS	TREATMENT MODALITIES
Developmental	Llorens	Development occurs over time and between skills (e.g., gross and fine motor). Some children experience a gap in their development due to physical, emotional, and/or social trauma. The role of occupational therapy is to bridge this gap.	Down syndrome Intellectual disability Failure to thrive Cerebral palsy Pervasive developmental disorder	Identify current level of functioning. Work on the next step to achieve the skill. Intervention includes practice, repetition, education, and modeling of skills.
Biomechanical	Pedretti and Paszuinielli	Improve strength, endurance, range of motion.	Children with cardiac concerns Brachial plexus Cerebral palsy Juvenile rheumatoid arthritis Down syndrome	Strength: Increase weight of toys or repetitive use of objects. Endurance: Increase time engaged in occupation. Range of motion: Repetitively provide slow, sustained stretch to increase end range.
Sensory integration	Ayres	Children with sensory integration dysfunction have difficulty processing sensory information (vestibular, proprioceptive, tactile). Improvements in sensory processing lead to improved engagement in occupations.	Sensory integrative dysfunction Developmental coordination disorder Sensory modulation disorder Pervasive developmental disorder	Provide controlled sensory input to improve the child’s ability to process sensory stimuli. Use suspension equipment and the “just-right challenge.” Provide activities that are child directed.
Motor control	Shumway-Cook	Acquisition of motor skills is based on dynamic systems theory. (All systems, including sensory, motor, and cognitive, work on each other for movement to occur.)	Cerebral palsy Developmental coordination disorder Down syndrome	Task-oriented approach: Children learn motor skills best by repeating the occupations in the most natural settings, varying the requirements. They learn from their motor mistakes.
Neuro- developmental	Bobath, Schoen, and Anderson	Children learn motor patterns when they “feel” normal.	Cerebral palsy Traumatic brain injury movement patterns	Clinician uses handling techniques and key points of control to inhibit abnormal muscle tone and facilitate normal movement patterns. Children learn through “feeling” normal patterns and thus should not make motor mistakes.
Model of Human Occupation	Kielhofner	Volition Habituation Performance Environment	All diagnoses	The human is an open system. Volition drives the system. The clinician’s role is to understand the client in terms of these systems (and subsystems) and intervene to facilitate engagement in occupations.
Rehabilitation	Early, Pendleton & Schultz-Krohn	Children relearn skills lost; develop compensatory strategies; and develop adaptive techniques.	Acquired brain injury trauma Stroke	Help children regain function for independence in occupations Help children to practice; improve strength, ROM, and endurance.