Get to Work!Utilizing Jobs for Kids as a Therapeutic ToolLaura Nagel, MS, OTR/L

WOTA Annual ConferenceOctober 11, 2019

INTRODUCTIONS & OBJECTIVES

▸ Students

▸ OTRs

▸ COTAs

▸ Outpatient setting

▸ Schools

▸ Other?

▸ WOTA members

▸ AOTA members

▸ Me!

Who’s Here Today?

1. Examine the value of vocational occupations for

children, such as chores and entrepreneurship.

2. Review current literature on vocational and

pre-vocational skills in children and alignment with the

Occupational Therapy Practice Framework.

3. Utilize activity analysis to apply this area of

intervention to build foundational skills that support

growth in various areas of occupation.

Session Objectives

THE VALUE OF OCCUPATION

Occupational Therapy Practice Framework: Domain and Process - 3rd Edition1

AOTA’s Commission on Practice (COP) is seeking member review

and feedback on the draft revisions of the Occupational Therapy Practice Framework: Domain and Process (OTPF) 4th edition, now

through October 14th .

View the OTPF 4th edition draft and complete the feedback survey.

Occupational Therapy Practice Framework - 4th Edition Feedback Period

“ KIDS NEED JOBS.

-Temple Grandin

CURRENT RESEARCH

▸ (2004) Larson

▸ Describes the nature, form, function, and meaning of children’s work

▸ Provides beginning guidelines for occupation-based work interventions and

typical expectations for nondisabled children that may be applied using clinical

reasoning to populations with disabilities

Children’s Work: The Less-Considered Childhood Occupation4

Health Impact of Participation for Vulnerable

Youth With Disabilities2

▸ (2018) Berg et. al

▸ RESULTS. The probability of reporting clinical depression was 4 times higher

for victimized YWD who reported lower breadth of participation than for

victimized YWD who reported higher breadth of participation (6% vs. 26%; p =

.03).

▸ CONCLUSION. Occupational therapy aimed at increasing opportunities for

engagement in activities may enhance the mental health of the most

vulnerable YWD. Participation in meaningful activities can improve both

overall health and transition to independence for vulnerable YWD.

▸ (2017) Eismann et. al

▸ RESULTS. Autism, cerebral palsy, and intellectual disability were the most

commonly reported disability classifications. Participation in postsecondary

education was significantly associated with functional use of arms and hands.

Postsecondary employment was significantly associated with verbal

comprehension. Participation in community activities was significantly related

to students’ health status, and participation in community service was

significantly related to students’ functional use of arms and hands.

▸ CONCLUSION. Providing transition services to students with disabilities

remains an emerging area of practice. Occupational therapy practitioners may

contribute to transition teams by intervening to improve functional abilities

and health status.

Characteristics of Students Receiving Occupational

Therapy Services in Transition and Factors Related to

Postsecondary Success3

▸ (2019) Rosenberg, Pade, Reizis, & Bar

▸ Results: Children valued their activities, they perceived the challenge as low, they

felt that the time was almost equally distributed between time passing quickly

and passing slowly, and they felt autonomous. The subjective perceived meanings

were moderately correlated with the children’s actual participation.

▸ Conclusions and Relevance: Children are capable of reflecting on the meaning

of their everyday activities. The [Perceived Meaning of Occupation

Questionnaire] may assist occupational therapy practitioners in eliciting their

young clients’ perspectives regarding their everyday occupations.

Associations Between Meaning of Everyday Activities and Participation Among Children5

ACTIVITY ANALYSIS & APPLICATION

▸ Which tools may predict skills needed for vocational

occupations?

▸ Consider use of open ended tools with interview

formats, such as:

▹ Activity Card Sort (various ages)

▹ Canadian Occupational Performance Measure

▹ Casey Life Skills

▹ Joint completion of the PEDI-CAT

Assessment Tools

SMART Goals Are:

SpecificMeasurableAttainableRelevantTime-Bound

The Importance of Solid Goals

EvaluationInformation

● Assessment Results

● Caregiver feedback● Clinical

observations● Developmental

Norms● Activity Analysis

__________● Client factors● Performance

Area(s)● Task Demands● Environmental

Demands

Goal

● How the client will develop their client factors to demonstrate performance area(s) to meet the task demands as determined by the activity analysis to participate in a functional activity in context.

Treatment Activities

● Incorporate occupation as a means and an end and include client interests and occupations

● Are directly related to goals

● Grade up/down to achieve just right fit

Billing

● ICD-10 code should match for scope, setting, interventions

● CPT code should match for diagnosis, interventions, time, therapy discipline, and documentation

Documentation

● Daily session notes include objective data related to goals and document progress

CASE STUDY #1

▸ “Suzy”

▸ 13 y/o female w/autism diagnosis

▸ Have been working together for several years

“Are you excited for your church Sunday School to start up again?”

“I am not going to go to Sunday School this year - I get to be a greeter!”

Ongoing Treatment▸ Suzy will identify 2 things or more things she could change to improve

her performance during functional activities, with use of a visual support to identify activity components, and then implement that change in subsequent opportunities, across 4 or more activities.

▸ Suzy will trial 4 or more note taking strategies (highlighting, guiding questions, bullet points, fillable worksheet, etc.) prior to plan of care revision to support increased ability to utilize written communication as a support for short term recall during functional activities.

Current Goals

▸ Suzy will thoroughly wash her face with use of visual supports as needed, for 3/4 trials.

▸ Suzy will accurately identify appropriate clothing for the weather when looking out a window and having access to the temperature, for 3/4 trials.

▸ Suzy will explore 3 or more home management tasks in the clinical setting (e.g., taking out trash, cleaning bathroom, doing laundry) and identify 1 or more to complete routinely in her home setting, by end of the summer.

Current Goals

▸ Suzy will identify 3 or more novel leisure interests that can be performed

independently to support increased age-appropriate, meaningful use of

down time in her home setting and when spending time with relatives, by

end of plan of care period (6-27-2019).

▸ Per parent report, Suzy will complete her morning routine before school

with minimal verbal cues or use of visual supports for 3/5 days per week or

greater, by the end of the summer.

▸ Upon encountering a known stressor (baby crying, dog, discussion of known

allergens), Suzy will independently take a deep breath and accurately state

the facts of the situation to promote increased independence with

self-regulation, across 4 or more scenarios in the clinical or community

settings.

Current Goals

Current Goals

▸ To support increased comfort and decreased fear of dogs, Suzy will engage in a 5-minute preferred leisure activity (e.g., reading a book aloud) with a service dog in the clinical setting at a distance of 10 feet or less prior to plan of care revision (9-14-2019).

▸ Suzy will place her hair in a ponytail with minimal assistance for 3/4 trials to support increased independence in self-cares and personal fitness.

WORK AT CI STORE AND PRACTICE GREETING CUSTOMERS

TREATMENT ACTIVITY

Occupation as a Means and an End

Means: Serve Real Customers at CI

Store

● Ponytail for hygiene purposes

● Wipe counter● Fill Keurig water● Develop “special”● Greet, small talk● Record or remember

orders● Judgment and safety

with hot drinks● Wipe counter, put cloth

in laundry● Monitor what went well,

make changes for this time or next time

End #1:

Play a [Self-Identified] Valuable Role in Church

Community as Greeter on Sundays

End #2+:

● Ability to self-monitor performance (dressing, homework, completing routines independently)

● Accept feedback while maintaining self-esteem

● Put hair in ponytail for cross country

● Note taking strategies for academics

● Identify chores for home that work toward transition to adulthood

● Decrease/manage anxiety around dogs...?!?

Meet Stella, CI’s Furry Friendship Facilitator!

▸ Suzy will identify 2 things or more things she could change to improve her performance during functional activities, with use of a visual support to identify activity components, and then implement that change in subsequent opportunities, across 4 or more activities.▹ Target through Goal-Plan-Do-Check, activity breakdown, use of

growth mindset approach to assess each interaction with customers

▸ Suzy will trial 4 or more note taking strategies (highlighting, guiding questions, bullet points, fillable worksheet, etc.) prior to plan of care revision to support increased ability to utilize written communication as a support for short term recall during functional activities.▹ Target through recording orders, including details like cup lids,

creamer, etc.

Addressing Current Goals & Documentation Addressing Current Goals & Documentation

▸ Suzy will explore 3 or more home management tasks in the clinical setting (e.g., taking out trash, cleaning bathroom, doing laundry) and identify 1 or more to complete routinely in her home setting, by end of the summer.▹ Target through wiping down counters, washing dishes, doing laundry

from cleaning cloths

▸ Upon encountering a known stressor (baby crying, dog, discussion of known

allergens), Suzy will independently take a deep breath and accurately state

the facts of the situation to promote increased independence with

self-regulation, across 4 or more scenarios in the clinical or community

settings.

▹ Target through use of therapy dog, discussion of nuts as ingredients in drinks, customers with babies

▸ To support increased comfort and decreased fear of dogs, Suzy will engage in a 5-minute preferred leisure activity (e.g., reading a book aloud) with a service dog in the clinical setting at a distance of 10 feet or less prior to plan of care revision (9-14-2019).▹ Target through use of therapy dog

▸ Suzy will place her hair in a ponytail with minimal assistance for 3/4 trials to support increased independence in self-cares and personal fitness.▹ Target through putting hair up prior to serving food/drink

▸ 3 goals not targeted through this activity due to decreased relevance

Addressing Current Goals & Documentation

STRETCH BREAK!

Photo Credit: https://cdn.helix.com/wp-content/uploads/2018/01/giraffes_b.jpg

CASE STUDY #2

▸ “Alex”

▸ 13 y/o male w/autism diagnosis

▸ First time meeting one another

“What do you like to do for fun?”

“Carve walking sticks!”

Session Coverage

▸ Alex will demonstrate improved postural stability to provide him with more stable base of support to produce precise fine motor movements (e.g., shoe tying, food preparation) as evidenced by sustaining an upright posture in a backless chair for at least 2 minutes without seeking out external supports and with minimal cueing from therapist, in 2 out of 3 opportunities or greater.

▸ Alex will demonstrate improved executive functioning skills specific to shifting, as evidenced by his ability to identify a different perspective or way of handling a real situation in 2 out of 3 opportunities, with moderate to maximal verbal cueing from therapist, by the end of this plan of care.

Current Goals Current Goals

▸ Alex will demonstrate the ability to move on from a medium to big disagreement (e.g., disagreeing on an important or meaningful topic, bullying, etc.) for improved age-appropriate emotional processing, with moderate verbal cueing and within at least two minutes without significant increase in arousal level in 2 out of 3 opportunities or greater.

▸ Alex will demonstrate improved executive functioning skills specific to monitoring his emotions and actions related to peer interactions, as evidenced by accurately identifying how his behaviors affect others, provided visual aids and minimal verbal cueing as needed in 4/5 opportunities.

Current Goals

▸ Alex will demonstrate improved fine motor skills related to the functional legibility of his handwriting, as evidenced by writing two sentences with 85% accuracy with letter formation (specifically related to letters a, b, d, j, g) and letter legibility as well as no letter reversals, with minimal verbal cueing from therapist, by the end of this plan of care.

Photo Credits: https://bangordailynews.com/2019/01/30/homestead/maine-veteran-makes-walking-sticks-and-canes-from-an-invasive-plant/ https://www.etsy.com/listing/531848592/walking-stick-with-owl-carving-in-elm?gpla=1&gao=1&utm_campaign=shopping_us_CreationCarvings_sfc_osa&utm_medium=cpc&utm_source=google&utm_custom1=0&utm_content=5396716&gclid=EAIaIQobChMI6JHarNOS5QIVfv7jBx2Y_wb6EAQYAiABEgLy5fD_BwE

CONSIDER TURNING HIS INTEREST INTO A BUSINESS

AND CREATE A FLIER TO ADVERTISE HIS CRAFT

TREATMENT ACTIVITY

Photo Credit: https://www.postermywall.com/index.php/g/lawn-service#1210481dbaea4cbd285c07c154a80047

Occupation as a Means and an End

Means: Create Flier

● Asking clarifying questions

● Following directions● Writing● Perspective taking● Referencing example● Compromising● Receiving feedback● Critical thinking

End #1:

Develop Carving Walking Sticks

Interest into Pre-Vocational/

Vocational Skillset

End #2+:

● Shoe tying● Food preparation● Self-regulation● Perspective

taking/social skills● Letter formation/

handwriting legibility

▸ Alex will demonstrate improved postural stability to provide him with more stable base of support to produce precise fine motor movements (e.g., shoe tying, food preparation) as evidenced by sustaining an upright posture in a backless chair for at least 2 minutes without seeking out external supports and with minimal cueing from therapist, in 2 out of 3 opportunities or greater.▹ Targeted through discussion of project while seated/prone on therapy ball▹ Short sitting on large red therapy ball x5 mins, with 1x LOB while bouncing;

prone over ball x25 mins with VC every ~5 mins to stay on ball (would roll

off during game or slide onto floor to manipulate cards and forget to get

back on)

Addressing Current Goals & Documentation

▸ Alex will demonstrate improved executive functioning skills specific to shifting, as evidenced by his ability to identify a different perspective or way of handling a real situation in 2 out of 3 opportunities, with moderate to maximal verbal cueing from therapist, by the end of this plan of care.▹ Targeted through developing format for flier, determining what to include▹ Flexible w/use of models and consideration of different approaches while

making flier for walking stick carving business, with min VC/guidance to

think through what others would want to know (e.g., listing what his

service/product is, but not listing out what steps he needs to take to achieve

it)

Addressing Current Goals & Documentation

▸ Alex will demonstrate the ability to move on from a medium to big disagreement (e.g., disagreeing on an important or meaningful topic, bullying, etc.) for improved age-appropriate emotional processing, with moderate verbal cueing and within at least two minutes without significant increase in arousal level in 2 out of 3 opportunities or greater▹ Not specifically targeted - no larger disagreements occurred, though

activity provided potential

Addressing Current Goals & Documentation

▸ Alex will demonstrate improved executive functioning skills specific to monitoring his emotions and actions related to peer interactions, as evidenced by accurately identifying how his behaviors affect others, provided visual aids and minimal verbal cueing as needed in 4/5 opportunities▹ Targeted through ▹ Sympathetic to tx's perspectives during project x1; corrected self after

making comment about not wanting to do project (chuckled after

correcting self and said, "Just kidding!")

Addressing Current Goals & Documentation

Addressing Current Goals & Documentation

▸ Alex will demonstrate improved fine motor skills related to the functional legibility of his handwriting, as evidenced by writing two sentences with 85% accuracy with letter formation (specifically related to letters a, b, d, j, g) and letter legibility as well as no letter reversals, with minimal verbal cueing from therapist, by the end of this plan of care.▹ Targeted through writing on flier to make draft▹ On blank paper demo'd difficulty with sizing and spacing between words

▸ Household Chores▹ Laundry, vacuuming, cooking, setting/clearing table, washing dishes,

getting mail, supporting grocery shopping▸ Classroom/School Jobs

▹ Safety Patrol, Line Leader, washing lunch tables▸ Community Roles

▹ Church jobs (acolyte, greeter, coffee hour), scouts, sports team captain/manager

▸ Volunteering▹ Food banks, animal shelters, Habitat for Humanity

▸ Entrepreneurship▹ Mowing lawns, babysitting, pet care/house sitting, painting mailbox

posts, artwork, handicrafts

...what else?

“Job” Examples

What are your clinical examples?

References

1. Occupational Therapy Practice Framework: Domain and Process (3rd Edition). Am J Occup Ther 2017;68(Supplement_1):S1-S48. doi: 10.5014/ajot.2014.682006.

2. Kristin L. Berg, Jonathon Medrano, Kruti Acharya, Amy Lynch, Michael E. Msall; Health Impact of Participation for Vulnerable Youth With Disabilities. Am J Occup Ther 2018;72(5):7205195040p1-7205195040p9. doi: 10.5014/ajot.2018.023622.

3. Maria M. Eismann, Rebecca Weisshaar, Cristina Capretta, Dennis S. Cleary, Anne V. Kirby, Andrew C. Persch; Characteristics of Students Receiving Occupational Therapy Services in Transition and Factors Related to Postsecondary Success. Am J Occup Ther 2017;71(3):7103100010p1-7103100010p8. doi: 10.5014/ajot.2017.024927.

4. Elizabeth A. Larson; Children’s Work: The Less-Considered Childhood Occupation. Am J Occup Ther 2004;58(4):369-379. doi: 10.5014/ajot.58.4.369.

5. Limor Rosenberg, Margalit Pade, Hila Reizis, Michal Avrech Bar; Associations Between Meaning of Everyday Activities and Participation Among Children. Am J Occup Ther 2019;73(6):7306205030p1-7306205030p10. doi: 10.5014/ajot.2019.032508.

Resources

▸ Temple Grandin’s TED Talk:The World Needs All Kinds of Minds

https://www.ted.com/talks/temple_grandin_the_world_needs_all_kinds_of_minds?language=aeb

▸ Autism and Employment Tips from Temple Grandin:https://www.autism.org/jobs-autism-temple-grandin/

▸ LessonPix - to develop tracking charts, visual schedules, etc.https://www.lessonpix.com

▸ CI Scoop: Building Teen Resumeshttps://citherapies.com/blog/building-teen-resumes/

▸ Focus on the Family: Age Appropriate Choreshttps://www.focusonthefamily.com/parenting/age-appropriate-chores/

THANKS!

Any questions?

Contact Information

laura@citherapies.com

www.citherapies.com

608.819.6394

Evaluation Information Treatment Activities BillingGoal Documentation

Example Outcome Measure (Goal)