Use of the Canadian Occupational

Performance Measure in Client-Centered

Occupational Therapy for Children With

Developmental Disabilities

Daehyuk Kang

The Graduate School

Yonsei University

Department of Rehabilitation Therapy

Use of the Canadian Occupational

Performance Measure in Client-Centered

Occupational Therapy for Children With

Developmental Disabilities

A Dissertation Submitted to the Department of Rehabilitation Therapy

and the Graduate School of Yonsei University in partial fulfillment of the

requirements for the degree of Doctor of Philosophy

Daehyuk Kang

December 2005

This certifies that the dissertation of Daehyuk Kang is approved.

Thesis Supervisor :Eunyoung Yoo

Boin Chung

Minye Jung

Kiyeon Chang

Hyeseon Jeon

The Graduate School

Yonsei University

December 2005

Acknowledgements

I would like to express my gratitude to my advisor, Dr. Eunyoung Yu, for

her professional advice and guidance. Her thorough review and feedback have

shaped the contents of this dissertation. My profound thanks go to Dr. Boin

Chung for her conscientious review of methodological content and quality of

this dissertation. I owe a debt of gratitude to Dr. Minye Jung for her critical

review of this dissertation. I would like to express sincerest thanks to Dr.

Kiyeon Chang for sharing her knowledge and valuable time. I am especially

grateful to Dr. Hyeseon Jeon for her thoughtful and helpful input. I extend a

hearty thanks to the clients and the occupational therapists who participated in

this study for sharing their time and thoughts. They all have my deepest

gratitude.

My work on this dissertation would not have been possible without my

wonderful, supportive family. Seungwon and Joonwon, my sons, have

provided inspiration along the way. And most of all, my wife, Soomi, for more

reasons than I can name.

Finally, I wish to dedicate this dissertation to my parents, who instilled

important values in life.

i

Table of Contents

List of Tables ····························································································· iv

Abstract ····································································································· v

Introduction ······························································································· 1

Methods ····································································································· 6

1. Participants························································································ 6

2. Allocation of Participants to Group A and Group B ······················· 7

3. Intervention ····················································································· 9

4. Instruments ······················································································ 11

4.1. Receptiveness to Client-Centered Approach Survey ············· 11

4.2. Canadian Occupational Performance Measure (COPM) ······ 13

4.3. Assessment of Motor and Process Skills (AMPS) ················ 15

4.4. Functional Independence Measure for Children (WeeFIM) · 17

5. Procedures ······················································································ 19

5.1. Pretest data collection phase ················································· 19

5.2. Intervention phase ································································· 20

5.3. Posttest data collection phase ················································ 20

6. Data Analysis ················································································· 21

ii

Results ······································································································ 22

1. Receptiveness to Client-Centered Approach Survey ····················· 22

2. Pretest Scores of the Occupational Performance Measures ··········· 24

3. Clients’ Perception of Occupational Performance Changes ·········· 25

3.1. Outcomes of Canadian Occupational Performance

Measure ················································································ 25

4. Therapists’ Observation of Occupational Performance Changes ··· 26

4.1. Outcomes of Assessment of Motor and Process Skills ········· 26

4.2. Outcomes of WeeFIM ··························································· 27

5. Correlations Among Occupational Performance Measures ··········· 28

5.1. Correlations in Group A ························································ 28

5.2. Correlations in Group B ························································ 30

Discussion ································································································ 31

1. Clients’ Perspective on Client-Centered Occupational

Therapy ·························································································· 31

2. Therapists’ Perspective on Client-Centered Occupational

Therapy ·························································································· 33

3. Relationship Among COPM, AMPS, and WeeFIM ······················· 35

Conclusion ······························································································· 38

References ································································································ 39

iii

Appendix ·································································································· 49

Abstract in Korean ··················································································· 52

iv

List of Tables

Table 1. Demographics of Between-Group Comparisons ························ 8

Table 2. Most Frequently Identified Goals in COPM ······························ 10

Table 3. Mean Scores of Receptiveness to Client-Centered

Approach Survey ······································································· 23

Table 4. Between-Group Comparisons of Occupational Performance

on Pretest······················································································ 24

Table 5. Within-Group Changes of Occupational Performance

on COPM ··················································································· 25

Table 6. Within-Group Changes of Occupational Performance

on AMPS ···················································································· 26

Table 7. Within-Group Changes of Occupational Performance

on WeeFIM ················································································· 27

Table 8. Spearman Rank Correlation Coefficients on Change Scores

Among COPM, AMPS, & WeeFIM in Group A ······················· 29

Table 9. Spearman Rank Correlation Coefficients on Change Scores

Among COPM, AMPS, & WeeFIM in Group B ······················· 30

v

ABSTRACT

Use of the Canadian Occupational Performance Measure in

Client-Centered Occupational Therapy for Children With

Developmental Disabilities

Daehyuk Kang

Dept. of Rehabilitation Therapy

(Occupational Therapy Major)

The Graduate School

Yonsei University

The aims of this study were to (a) investigate the effectiveness of client-

centered occupational therapy from clients’ perspective using the Canadian

Occupational Performance Measure (COPM), (b) examine the effectiveness of

client-centered occupational therapy from therapists’ perspective using the

Assessment of Motor and Process Skills (AMPS) and the Functional

Independence Measure for Children (WeeFIM), and (c) explore whether the

degree of clients’ receptiveness to client-centered occupational therapy could

influence correlations between clients’ perception and therapists’ observation

vi

of occupational performance changes. Eight girls and twenty-three boys with

developmental disabilities from 3 to 10 years of age participated in this study,

and caregivers of the children completed the Receptiveness to Client-Centered

Approach Survey after finishing initial assessment of the COPM with the

occupational therapists. The higher score of the survey represented the more

positive attitude toward client-centered occupational therapy. The top 15

participants with the score of 30 and higher were assigned to Group A, and the

bottom 16 participants with the score of 29 and lower were assigned to Group

B. During the intervention, each child received client-centered occupational

therapy that concentrated on improvement of occupational performance

identified by the clients (caregivers in this study). The results of the COPM

change scores demonstrated statistically significant improvement (p < .01) of

occupational performance in both Group A and Group B. This finding was

verified by the AMPS and the WeeFIM change scores that also showed

significant improvement (p < .01) of occupational performance. In Group A,

COPM-Satisfaction highly correlated with WeeFIM-Cognitive skills (rs = .78,

p < .01), COPM-Performance moderately correlated with AMPS-Motor skills

(rs = .64, p < .05), and COPM-Satisfaction moderately correlated with AMPS-

Process skills (rs = .62, p < .05). In Group B, no relationship was found among

the sections of the COPM, AMPS, and WeeFIM. The findings of this study

vii

suggested that usefulness of the COPM for children with developmental

disabilities was confirmed by the AMPS and the WeeFIM. Moderate to high

correlations were found in Group A indicating that clients’ perception and

therapists’ observation of occupational performance changes were concurrent.

In order to maximize the usefulness of the COPM for children with

developmental disabilities, the occupational therapists are advised to ensure

that they educate caregivers about the benefits of client-centered occupational

therapy.

Key Words: AMPS, Client-centered approach, COPM, Occupational therapy.

- 1 -

Introduction

The importance of client and family involvement in occupational therapy

has been emphasized from the 1970s (Northen, Rust, Nelson, & Watts,

1995). In treating children with developmental disabilities, the primary

caregivers’ active participation plays vital role for the positive outcome

(Pollock, 1993; VanLeit & Crowe, 2002). One way of facilitating the clients’

active participation is to introduce the client-centered approach. The client-

centered approach is defined as “an approach to service which embraces a

philosophy of respect for, and partnership with, people receiving services”

(Law, Baptiste, & Mills, 1995, p. 253). The goal of client-centered approach

is to have a client identify important tasks for her or him, establish treatment

goals, and design intervention process with the therapist (Simmons, Crepeau,

& White, 2000).

Recently, health care providers have been focusing on evidence-based

practice (EBP) that emphasizes both therapist’s observation and client’s

perception as valuable evidence (Holm, 2000; Lieberman & Scheer, 2002;

Savin-Baden & Taylor, 2001; Tickle-Degnen, 1999, 2002). Tickle-Degnen

and Bedell (2003) further argue that both therapist’s objective assessment

and client’s subjective perception have the same weight in clinical decision

making. In order to provide evidence that an occupational therapy is

- 2 -

effective, it is essential to use proper assessment tools that can detect

changes of occupational performance. However, some investigators dispute

that goals are usually set by therapists in conventional assessment tools, and

this may limit the active participation of clients in treatment (Law et al.,

1998; Pollock, 1993).

For the last decade, client-centered assessment tools such as the

Canadian Occupational Performance Measure (COPM) have been

emphasized in occupational therapy literature (Carpenter, Baker, &

Tyldesley, 2001; Ripat, Etcheverry, Cooper, & Tate, 2001). The COPM

provides an opportunity to establish client-centered goals and evaluate the

success of those goals (Law et al., 1998). This tool has been reported to

supplement conventional assessment tools since client-centered assessments

focus on individual’s unique needs in the areas of self-care, productivity, and

leisure (Law et al., 1994).

Examples of utilizing the COPM have been reported in occupational

therapy literature. Case-Smith (2003) studied occupational therapy outcomes

from 33 clients in hand rehabilitation using the COPM in measuring

functional changes. She identified that clients with upper-extremity injuries

made positive gains following client-centered occupational therapy. VanLeit

and Crowe (2002) evaluated the impact of an 8-week psychosocial

- 3 -

occupational therapy program for 38 mothers who had children with

disabilities. They reported significantly greater score increases on the COPM

satisfaction subscale in the treatment group.

Nevertheless, the authors of the COPM advised that it was not meant to

replace all other assessment tools in measuring effects of occupational

therapy because it only reflects client’s perception of occupational

performance and satisfaction (Law et al., 1998). Simmons and colleagues

(2000) used the COPM and the Functional Independence Measure (FIM) in

predicting outcomes for rehabilitation services in adult physical disabilities

settings. They found that use of the COPM in combination with the FIM

improved accuracy from 29% to 65%. Based on their findings, it was

inferred that other objective assessment tools could be used to supplement

the COPM.

Among objective assessment tools that reflect the therapist’s perspective,

the Assessment of Motor and Process Skills (AMPS) and the Functional

Independence Measure for Children (WeeFIM) have been reported to be

responsive to changes of occupational performance (Chen, Heinemann,

Bode, Granger, & Mallinson, 2004; Darragh, Sample, & Fisher, 1998;

Ottenbacher et al., 2000). Graff, Vernooij-Dassen, Hoefnagels, Dekker, and

de Witte (2003) explored the effects of occupational therapy services on the

- 4 -

performance of daily activities by 12 older adults with cognitive

impairments and on the sense of competence of their primary caregivers.

They used the COPM and the AMPS to measure changes of occupational

performance after 7 weeks of client-centered occupational therapy, and both

tools detected statistically significant changes. Also, the utility of the

WeeFIM has been reported by Ottenbacher and colleagues (2000) who

studied 174 children with developmental disabilities and Chen and

coworkers (2004) who reviewed functional gains of 814 children after

rehabilitation.

Even though the COPM and the AMPS have been widely used as

outcome measure instruments of occupational therapy programs, there is

limited research exploring their effectiveness to detect changes of

occupational performance in children with developmental disabilities. In

addition, while the importance of developing rapport between the clients and

the therapist has been emphasized in occupational therapy literature

(Peloquin, 1998; Tickle-Degnen, 2002), there was paucity of literature about

influence of the client’s receptiveness to client-centered occupational therapy.

In this study, three assessment tools (i.e., COPM, AMPS, and WeeFIM)

were used to measure the outcomes of the client-centered occupational

therapy for children with developmental disabilities. The COPM was

- 5 -

employed in evaluating the changes of occupational performance to reflect

the clients’ perspective. The AMPS and the WeeFIM were used in assessing

the changes of occupational performance to reflect the therapists’

perspective.

The specific purposes of this study were to (a) investigate the

effectiveness of client-centered occupational therapy from clients’

perspective using the COPM, (b) examine the effectiveness of client-

centered occupational therapy from therapists’ perspective using the AMPS

and the WeeFIM, and (c) explore whether the degree of clients’

receptiveness to client-centered occupational therapy could influence

correlations between clients’ perception and therapists’ observation of

occupational performance changes.

- 6 -

Methods

1. Participants

A sample of 60 children with developmental disabilities referred to

community-based occupational therapy programs or rehabilitation hospitals

were recruited from four occupational therapy clinics. The functional levels

of the children eligible to participate in this study were that they had to be

able to follow simple one step directions and initiate two of 83 standardized

AMPS tasks. The reason for choosing these criteria was that the AMPS

could not be used for those who were unwilling to participate in simple daily

tasks.

Among 60 clients, 31 completed the entire procedures. Of the 29 clients

who did not complete, 11 clients sought other occupational therapy clinics,

18 clients were lost because of therapists’ schedule conflict. Of the 31

participants, there were eight girls and twenty-three boys. The diagnoses

were mental retardation (n = 9), cerebral palsy (n = 7), developmental delay

(n = 6), attention deficit hyperactivity disorder (n = 5), and autism (n = 4) in

order. The participants’ ages ranged from 3 to 10 and mean age was 6.1

years old.

- 7 -

2. Allocation of Participants to Group A and Group B

For the purposes of this study, the participants were divided into Group

A and Group B based on the scores of the Receptiveness to Client-Centered

Approach Survey (see Appendix). Eight girls and twenty-three boys

participated in this study, and caregivers of the children completed the

Receptiveness to Client-Centered Approach Survey after initial assessment

of the COPM with the occupational therapists.

The scores of the survey for all participants ranged from 21 to 35, and

median was 29. Of the 31 participants, the top 15 participants with the score

of 30 and higher were assigned to Group A, and the bottom 16 participants

with the score of 29 and lower were assigned to Group B. Therefore, the

participants in Group A showed more positive attitude toward client-

centered occupational therapy than the participants in Group B. All

participants were distributed to two groups somewhat evenly in gender,

diagnoses, and age (Table 1).

- 8 -

Table 1. Demographics of Between-Group Comparisons (N = 31)

Group Aa

M (SD)

Group Bb

M (SD)

Mean

Difference

t p

(2-tailed)

Girls 5 3

Boys 10 13

MR 4 5

CP 4 3

DD 2 4

ADHD 3 2

Autism 2 2

Age 6.80 (2.34) 5.44 (1.55) 1.36 1.93 .06

Note. MR = mental retardation; CP = cerebral palsy; DD = developmental

delay; ADHD = attention deficit hyperactivity disorder. an = 15. bn = 16.

- 9 -

3. Intervention

Caregivers of participating children completed the COPM with their

occupational therapists, identifying and rating performance and satisfaction

in four to five tasks that they wished to improve in therapy sessions. A total

of 145 goals were identified, with an average of 4.7 goals for each individual.

Table 2 shows the most frequently mentioned goals in the areas of

education-related tasks (52%), self-care tasks (34%) and play tasks (14%).

Direct intervention was provided and recorded by the eight collaborating

occupational therapists whose clinical experience ranged from two to five

years. All of the assessment tools used in this study were administered by

occupational therapists who were trained to use respective tools. During the

intervention phase, each child received client-centered occupational therapy

that focused on enhancing occupational performance identified by the clients

(caregivers). The sessions were approximately 30 to 40 minutes per session

and specifically designed to meet the identified goals of the child.

- 10 -

Table 2. Most Frequently Identified Goals in COPM

Education % Self-care % Play %

Communication 24 Dressing 11 Play with peers 7

Listening 10 Eating 9 Block building 3

Reading 7 Toileting 8 Drawing 2

Writing 5 Grooming 3 Other 2

Speaking 3 Mobility 3

Other 3

- 11 -

4. Instruments

4.1. Receptiveness to Client-Centered Approach Survey

The Receptiveness to Client-Centered Approach Survey was developed

by the principal researcher based on the Client-Centered Practice

Questionnaire (Baptiste & Kang, 2002) to assess the degree of client’s

receptiveness to client-centered occupational therapy. The survey consisted

of seven items with 5-point Likert scale (5 = strongly agree, 4 = agree, 3 =

neutral, 2 =disagree, 1 = strongly disagree).

The degree of receptiveness to client-centered occupational therapy was

rated based on the following seven items:

1. I found the COPM easy to understand.

2. I found the COPM helpful.

3. The COPM helped me to identify current worries about my child’s

problems.

4. I felt comfortable helping the therapist plan my child’s treatment.

5. The COPM allowed me to feel respected and valued as an equal

partner in my child’s treatment.

6. I believe that a client is comfortable taking on responsibility for

treatment goals within Korean culture.

- 12 -

7. I believe that the COPM is an appropriate and effective tool in Korean

culture.

The Cronbach’s alpha was found to be .80, and this indicated strong

internal consistency of the survey items according to Portney and Watkins

(2000).

- 13 -

4.2. Canadian Occupational Performance Measure

In this study, the COPM was used as a guide to client-centered

occupational therapy. The therapists discussed about each child’s unique

needs with the caregiver and established treatment priorities and goals. In

addition, the COPM was used as an outcome measure to detect change of

occupational performance from a client’s perspective.

The COPM uses a semi-structured interview to detect what tasks in self-

care, productivity, and leisure a client wants, needs, or is expected to do on a

regular basis (Law et al., 1995, 1998). After all important tasks are identified,

the client (usually caregiver for child) rates each for degree of importance on

a scale of 1 to 10 (10 = most important). The most important tasks are then

the focus of intervention and outcome measurement. The client is then asked

to rate his or her perception of performance and satisfaction with this

performance in the selected tasks. The two scores are separately summed

and divided by the number of tasks, giving the mean for each. The client and

therapist then establish the goal of treatment together. On the completion of

program, possible changes in the client’s perceptions on the previously

identified occupational performance are recorded.

According to Law and colleagues (1998), test-retest reliability was found

to be in the acceptable range for both performance and satisfaction scores in

- 14 -

three different studies (ICC = .63 and .84; .79 and .75; .80 and .89

respectively). The construct and criterion validity has been evaluated for the

COPM and supported by recent studies (McColl, Paterson, Davies, Doubt, &

Law, 2000).

- 15 -

4.3. Assessment of Motor and Process Skills

The AMPS was employed in this study to objectively assess the changes

of occupational performance and reflect the therapist’s expertise. The AMPS

was administered before and after the intervention by trained and calibrated

occupational therapists who had attended 5-day AMPS workshop.

When scoring an AMPS observation, the calibrated rater scores 16

activities of daily living (ADL) motor items and 20 ADL process items with

a 4-point rating scale (4 = competent, 3 = questionable, 2 = ineffective, 1 =

markedly deficient). A Many-Faceted Rasch (MFR) computer program is

used to convert the ordinal data into interval data in the form of ADL ability

measures. The MFR model for the AMPS takes into account the task

challenge, rater severity, and item difficulty when estimating the final client

ADL motor and ADL process abilities (Stauffer, Fisher, & Duran, 2000).

Test-retest reliability coefficients were found to be r = .90 and r = .87 for

the AMPS motor skill scale and process skill scale, respectively. High inter-

and intrarater reliability persisted among 4,322 calibrated raters, and 95% of

the raters demonstrated goodness-of-fit statistics. This indicates acceptable

fit to the measurement model (Fisher, 2003). Concurrent validity with Scales

of Independent Behavior (SIB) was found to be r = .62 to .85 (Fisher, 2003)

and has been supported cross-culturally, across age groups, with a variety of

- 16 -

diagnoses (Darragh et al., 1998; Dickerson & Fisher, 1993). Reliability and

validity estimate have been reported in numerous studies qualifying for use

in this study (Fisher, Liu, Velozo, & Pan, 1992; Merritt & Fisher, 2003;

Nygard, Bernspang, Fisher, & Winblad, 1994).

- 17 -

4.4. Functional Independence Measure for Children

In this study, the WeeFIM was used as an occupation-based assessment

measuring functional improvement in basic activities of daily living. The

pre- and posttest scores were obtained by occupational therapists who

provided the intervention.

The WeeFIM instrument, developed by a multidisciplinary task force in

the early 1990s, was designed to measure functional outcomes of pediatric

clients receiving medical rehabilitation. It is intended for use with children

from six months to seven years of age who have acquired or congenital

disabilities. It may also be used with older children or adolescents who are

delayed in the development of functional abilities (Chen et al., 2004).

The WeeFIM contains 13 motor and 5 cognitive items encompassing

self-care, sphincter control, locomotion, communication, and social

cognition domains. It has a 7-level rating scale that assesses the extent of

assistance needed to perform functional tasks, with 1 indicating total

dependence and 7 indicating complete independence (Uniform Data Set for

Medical Rehabilitation [UDSMR], 1993). The WeeFIM focuses on

evaluating disability and determining levels of functional independence. As

a minimal essential data set, it allows pediatric, educational, and

rehabilitation professionals to describe basic performance in daily routines

- 18 -

(Ottenbacher et al., 1997). The WeeFIM can be administered either through

direct observation, interview, or both methods combined (Sperle,

Ottenbacher, Braun, Lane, & Nochajski, 1997). However, direct observation

on what the subject actually performs is preferred (UDSMR, 1993).

The WeeFIM has been found to be excellent in reliability and validity

(Chen et al., 2004; Ottenbacher et al., 1997, 2000). Ottenbacher, Hsu,

Granger, and Fidler’s study (1996) reported a median inter-rater reliability

for the total FIM of .95 and median test-retest and equivalence reliability

values of .95 and .92, respectively through meta-analysis of 11 studies.

- 19 -

5. Procedures

5.1. Pretest data collection phase

At the beginning of this study, the principal researcher educated eight

collaborating occupational therapists about the purposes of the study and

the key features of client-centered occupational therapy. The education

sessions consisted of orientation to the project, informed consent

procedures, criteria for inclusion of participants, documentation

requirements, measures, reliability in administering the measures, and

recording of data. The occupational therapists were given manuals that

explained details of all the procedures. Prior to the administration of pretest,

they explained the purposes of the study to the participants, and verbal

consent was obtained from them. The COPM and the WeeFIM were

completed by the occupational therapists after interviewing the caregivers

of the children at each clinic. The AMPS was administered by the trained

and calibrated occupational therapists including the principal researcher.

The COPM, the AMPS, and the WeeFIM were administered in the first

week when the client began to participate in client-centered occupational

therapy. After the administration of the COPM with explanation of client-

centered occupational therapy, the Receptiveness to Client-Centered

Approach Survey was completed by the primary caregiver of each child.

- 20 -

5.2. Intervention phase

The process of recruiting final 31 participants occurred four times over

10 months, and data were collected over 13 months between October 2004

and October 2005. Each child participated in 20 to 24 sessions of client-

centered occupational therapy. The site coordinators organized data

collection, selected clients who met the inclusion criteria, and compiled the

data.

5.3. Posttest data collection phase

The posttest scores were obtained in the last week after 20 to 24 sessions

of client-centered occupational therapy. Among 60 children and their

caregivers who participated in the pretest procedures, 31 participants

completed at least 20 sessions of client-centered occupational therapy and

posttest procedures. The posttest procedures of administering the COPM, the

AMPS, and the WeeFIM were the same as the pretest procedures. The

coordinators at each clinic submitted evaluation reports for each participant

to the principal researcher.

- 21 -

6. Data analysis

Data were analyzed using SPSS for Window Version 10.0. Demographic

data and test results were entered into an SPSS file. Unpaired t test was used

to examine the homogeneity between Group A and Group B on pretest of

occupational performance measures. To determine the effectiveness of

client-centered occupational therapy, paired t tests were calculated.

Spearman’s rank correlation coefficients were used to determine the

relationships among the change scores of the COPM, the AMPS, and the

WeeFIM. The alpha level of significance was set at the conventional .05 for

all analysis.

- 22 -

Results

1. Receptiveness to Client-Centered Approach Survey

The survey consisted of seven statements with 5-point Likert scale for

each item. The mean of total scores from 31 clients was 29.55. The mean

scores of the survey items ranged from 3.84 to 4.55. The item scoring the

highest mean was the item number 4. This indicated that the most clients felt

comfortable helping the therapist plan the child’s treatment. The item

scoring the lowest score was the item number 1. This suggested that the

COPM was not that easy for the clients to understand. The mean scores of

each item for Group A and Group B are shown in Table 3.

- 23 -

Table 3. Mean Scores of Receptiveness to Client-Centered Approach Survey

Mean

Items Group

Aa

Group

Bb

Totalc

1. I found the COPM easy to understand. 4.47 3.25 3.84

2. I found the COPM helpful. 4.73 3.93 4.52

3. The COPM helped me to identify current worries about

my child’s problems.

4.60 4.00 4.29

4. I felt comfortable helping the therapist plan my child’s

treatment.

4.80 4.31 4.55

5. The COPM allowed me to feel respected and valued as

an equal partner in my child’s treatment.

4.73 3.94 4.32

6. I believe that a client is comfortable taking on

responsibility for treatment goals within Korean culture.

4.67 3.93 4.29

7. I believe that the COPM is an appropriate and effective

tool in Korean culture.

4.47 3.50 3.97

Totald 32.47 26.81 29.55

Note. Responses were made on 5-point scales (1 = strongly disagree, 5 =

strongly agree). an = 15. bn = 16. cTotal is mean scores of each item for all respondents. dTotal is mean scores of all items for each group.

- 24 -

2. Pretest Scores of Occupational Performance Measures

Table 4 shows the between-group comparisons of occupational

performance on the pretests of the COPM, the AMPS, and the WeeFIM. The

differences of occupational performance between the two groups were not

statistically significant yielding homogeneity assumption.

Table 4. Between-Group Comparisons of Occupational Performance on

Pretest

Outcome

measures

Group Aa

M (SD)

Group Bb

M (SD)

Mean

Difference

t p

(2-tailed)

COPM-P 3.25 (1.34) 3.39 (0.73) - 0.14 - .34 .735

COPM-S 3.33 (1.65) 3.48 (1.27) - 0.15 - .28 .781

AMPS-M 0.36 (1.09) 0.51 (0.69) - 0.15 - .48 .632

AMPS-P - 0.40 (0.76) - 0.57 (0.60) - 0.17 - .70 .489

WeeFIM-M 67.40 (14.79) 62.50 (13.48) - 4.90 - .97 .342

WeeFIM-C 16.07 (8.34) 17.56 (7.49) - 1.49 .53 .603

Note. COPM-P = Canadian Occupational Performance Measure-

Performance; COPM-S = Canadian Occupational Performance Measure-

Satisfaction; AMPS-M = Assessment of Motor and Process Skills-Motor

skills; AMPS-P = Assessment of Motor and Process Skills-Process skills;

WeeFIM-M = WeeFIM-Motor skills; WeeFIM-C = WeeFIM-Cognitive skills. an = 15. bn = 16.

- 25 -

3. Clients’ Perception of Occupational Performance Changes

3.1. Outcomes of Canadian Occupational Performance Measure

Table 5 shows within-group changes of occupational performance on the

COPM. Both Group A and Group B demonstrated statistically significant

improvement of self-perception in the COPM-Performance and the COPM-

Satisfaction.

Table 5. Within-Group Changes of Occupational Performance on COPM

Measure and

Condition

Pretest

M (SD)

Posttest

M (SD)

Change

M (SD)

t P

(2-tailed)

COPM-P

Group Aa 3.25 (1.34) 5.57 (1.70) 2.41 (1.40) - 6.69 .000

Group Bb 3.39 (0.73) 5.39 (1.27) 2.00 (0.95) - 8.43 .000

COPM-S

Group Aa 3.33 (1.65) 5.58 (1.75) 2.24 (1.30) - 6.67 .000

Group Bb 3.48 (1.27) 5.60 (1.12) 2.12 (1.09) - 7.81 .000

Note. COPM-P = Canadian Occupational Performance Measure-

Performance; COPM-S = Canadian Occupational Performance Measure-

Satisfaction. an = 15. bn = 16.

- 26 -

4. Therapists’ Observation of Occupational Performance Changes

4.1. Outcomes of Assessment of Motor and Process Skills

Table 6 shows within-group changes of occupational performance over

time on AMPS. The improvement of motor and process skills was

statistically significant in both Group A and Group B after client-centered

occupational therapy.

Table 6. Within-Group Changes of Occupational Performance on AMPS

Measure and

Condition

Pretest

M (SD)

Posttest

M (SD)

Change

M (SD)

t P

(2-tailed)

AMPS-M

Group Aa 0.36 (1.09) 0.98 (1.10) 0.63 (0.68) - 3.55 .003

Group Bb 0.51 (0.69) 1.32 (0.86) 0.81 (0.58) - 5.57 .000

AMPS-P

Group Aa - 0.40 (0.76) 0.05 (0.69) 0.45 (0.43) - 4.11 .001

Group Bb - 0.57 (0.60) 0.07 (0.89) 0.64 (0.52) - 4.88 .000

Note. AMPS-M = Assessment of Motor and Process Skills-Motor skills;

AMPS-P = Assessment of Motor and Process Skills-Process skills. an = 15. bn = 16.

- 27 -

4.2. Outcomes of WeeFIM

The results of the WeeFIM scores on pre- and posttest are reported in

Table 7. Both Group A and Group B showed statistically significant

improvement of occupational performance after client-centered occupational

therapy.

Table 7. Within-Group Changes of Occupational Performance on WeeFIM

Measure and

Condition

Pretest

M (SD)

Posttest

M (SD)

Change

M (SD)

t P

(2-tailed)

WeeFIM-M

Group Aa 67.40 (14.79) 71.33 (14.70) 3.93 (3.79) - 4.02 .001

Group Bb 62.50 (13.48) 72.13 (9.77) 9.63 (9.11) - 4.23 .001

WeeFIM-C

Group Aa 16.07 (8.34) 18.33 (7.92) 2.27 (1.71) - 5.13 .000

Group Bb 17.56 (7.49) 20.13 (7.68) 2.57 (2.00) - 5.13 .000

Note. WeeFIM-M = WeeFIM-Motor skills; WeeFIM-C = WeeFIM-Cognitive

skills. an = 15. bn = 16.

- 28 -

5. Correlations Among Occupational Performance Measures

The participants in Group A showed more positive attitude toward client-

centered occupational therapy than the participants in Group B based on the

results of the Receptiveness to Client-Centered Approach Survey.

5.1. Correlations in Group A

Correlations among the sections of the COPM, AMPS, and WeeFIM

change scores in Group A are presented in Table 8. In Group A, COPM-

Satisfaction highly correlated with WeeFIM-Cognitive skills (rs = .78, p < .01),

COPM-Performance moderately correlated with AMPS-Motor skills (rs = .64,

p < .05), and COPM-Satisfaction moderately correlated with AMPS-Process

skills (rs = .62, p < .05).

- 29 -

Table 8. Spearman Rank Correlation Coefficients on Change Scores Among

COPM, AMPS, & WeeFIM in Group A (n = 15)

ΔCOPM-P ΔCOPM-S ΔAMPS-M ΔAMPS-P ΔWeeFIM-M

ΔCOPM-S .67**

ΔAMPS-M .64* .47

ΔAMPS-P .43 .62* .16

ΔWeeFIM-M .36 .48 .31 .05

ΔWeeFIM-C .50 .78** .34 .32 .47

Note. ΔCOPM-P = change scores in Canadian Occupational Performance

Measure-Performance; ΔCOPM-S = change scores in Canadian Occupational

Performance Measure-Satisfaction; ΔAMPS-M = change scores in

Assessment of Motor and Process Skills-Motor skills; ΔAMPS-P = change

scores in Assessment of Motor and Process Skills-Process skills; ΔWeeFIM-

M = change scores in WeeFIM-Motor skills; ΔWeeFIM-C = change scores in

WeeFIM-Cognitive skills.

*p < .05. **p < .01.

- 30 -

5.2. Correlations in Group B

Correlations among the sections of the COPM, AMPS, and WeeFIM

change scores in Group B are presented in Table 9. Unlike Group A, in Group

B, no relationship among the sections of the COPM, AMPS, and WeeFIM

change scores was found except between the sections of the same assessment

tools (i.e., COPM and AMPS).

Table 9. Spearman Rank Correlation Coefficients on Change Scores Among

COPM, AMPS, & WeeFIM in Group B (n = 16)

ΔCOPM-P ΔCOPM-S ΔAMPS-M ΔAMPS-P ΔWeeFIM-M

ΔCOPM-S .60*

ΔAMPS-M - .28 .05

ΔAMPS-P - .16 - .05 .62*

ΔWeeFIM-M - .02 - .14 .22 .41

ΔWeeFIM-C .10 - .13 .01 - .08 - .17

Note. ΔCOPM-P = change scores in Canadian Occupational Performance

Measure-Performance; ΔCOPM-S = change scores in Canadian Occupational

Performance Measure-Satisfaction; ΔAMPS-M = change scores in

Assessment of Motor and Process Skills-Motor skills; ΔAMPS-P = change

scores in Assessment of Motor and Process Skills-Process skills; ΔWeeFIM-

M = change scores in WeeFIM-Motor skills; ΔWeeFIM-C = change scores in

WeeFIM-Cognitive skills.

*p < .05.

- 31 -

Discussion

1. Clients’ Perspective on Client-Centered Occupational Therapy

The primary purpose of this study was to investigate the effectiveness of

client-centered occupational therapy for children from clients’ perspective

using the COPM. The focus of client-centered occupational therapy was

identifying occupational performance issues and prioritizing treatment plans

by establishing mutually agreed goals between the therapists and the clients

(caregivers of the children in this study). During the intervention phase, each

child received client-centered occupational therapy that concentrated on

improving occupational performance identified by the clients.

Following client-centered occupational therapy, both Group A and

Group B demonstrated statistically significant improvement of self-

perception in the COPM-Performance and the COPM-Satisfaction.

Explanations for this result can be, first, client-centered occupational therapy

was directed at the improvement of occupational performance skills

necessary for daily activities rather than on the impairment level such as

improving sensory or cognitive functions (Graff et al., 2003). Second, client-

centered occupational therapy program may have been carried over to home

environments through the COPM procedure. The procedure involved

establishing mutually agreed goals and educating caregivers on the focus of

- 32 -

client-centered occupational therapy in the clinics. These results were

concurrent with those reported in other studies (Case-Smith, 2003; Gagne &

Hoppes, 2003; Trombly, Radomski, Trexel, & Burnet-Smith, 2002; VanLeit

& Crowe, 2002).

- 33 -

2. Therapists’ Perspective on Client-Centered Occupational

Therapy

The secondary purpose of this study was to examine the effectiveness of

client-centered occupational therapy from therapists’ perspective using the

AMPS and the WeeFIM. Since the COPM only reflects client’s perspective

on changes of occupational performance, the AMPS and the WeeFIM, that

reflect objective perspective of the therapists, were used to verify the

usefulness of the COPM.

The AMPS is an occupational therapy-specific ADL assessment that can

be administered by calibrated occupational therapists. Its usefulness has

been supported across age groups with a variety of diagnoses (Darragh et al.,

1998; Dickerson & Fisher, 1993; Fingerhut, Madill, Darrah, Hodge, &

Warren, 2002). The WeeFIM measures functional independence in children.

The ratings can be obtained from direct observation by the therapists or from

reports from the caregivers. The responsiveness of the WeeFIM was

demonstrated in Ottenbacher et al.’s research (2000) who studied 174

children with developmental disabilities. After client-centered occupational

therapy, both Group A and Group B demonstrated statistically significant

improvement of occupational performance measured by the AMPS and the

WeeFIM. This finding supported usefulness of the COPM for children with

- 34 -

developmental disabilities. Based on the results from the COPM, the AMPS,

and the WeeFIM, it can be inferred that children with developmental

disabilities (such as mental retardation, attention deficit hyperactivity

disorder, autism, cerebral palsy, developmental delay) had made substantial

progress after client-centered occupational therapy.

Recent health care delivery system urges occupational therapists to provide

the clients with the best occupational therapy services based on the most

credible scientific evidence (Dubouloz, Egan, Vallerand, & von Zweck, 1999).

The definition of evidence-based medicine (EBM) which is a model of

evidence-based practice is “the conscientious, explicit, and judicious use of

current best evidence in making decisions about the care of individual

patients” (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, p.71). In

their revised EBM textbook, patient values were added onto the existing

definition as evidence (Sackett, Strauss, Richardson, Rosenberg, & Haynes,

2000). Therefore, new meaning of evidence-based practice is integrating client

values, clinician’s expertise, and the best available external clinical evidence

from systematic research. In this study, the COPM was used to reflect the

client values, and the AMPS and the WeeFIM were used to reflect clinician’s

expertise. The findings of this study provided external clinical evidence that

client-centered occupational therapy was effective.

- 35 -

3. Relationship Among COPM, AMPS, and WeeFIM

The tertiary purpose of this study was to explore whether the degree of

clients’ receptiveness to client-centered occupational therapy could influence

correlations between clients’ perception and therapists’ observation of

occupational performance changes.

For the purposes of this study, the participants were divided into Group A

and Group B based on the scores of the Receptiveness to Client-Centered

Approach Survey. The scores of the survey for all participants ranged from 21

to 35, and median was 29. Of the 31 participants, the top 15 participants with

the score of 30 and higher were assigned to Group A, and the bottom 16

participants with the score of 29 and lower were assigned to Group B.

Therefore, the participants in Group A showed more positive attitude toward

client-centered occupational therapy than the participants in Group B.

Moderate to good correlations were found among change scores of the

COPM, the AMPS, and the WeeFIM in Group A but not in Group B. This

finding emphasized the importance of developing therapeutic relationship

between clients and therapists (Peloquin, 1998). It further suggested that the

client had to understand and be receptive to the philosophy of the client-

centered occupational therapy in order to have perceptions on the changes of

occupational performance comparable with the occupational therapist. By the

- 36 -

same token, it is the occupational therapist’s responsibility to educate the

client about the benefits of client-centered occupational therapy which is

essential for establishing therapeutic relationship.

It was interesting to note that there was high correlation (rs = .78, p < .01)

between the change scores of the COPM-Satisfaction and those of the

WeeFIM-Cognitive skills in Group A. This correlation coefficient is much

higher than those of Donnelly and colleague’s study (2004) who reported fair

relationship between the FIM-Motor change scores and the COPM-

Performance (r = .35, p < .05) and the COPM-Satisfaction change scores (r

= .50, p < .05). This finding can be explained by the fact that the most

frequently identified clients’ goals and priorities using the COPM were

education-related tasks (52%) sharing some common elements with the

WeeFIM-Cognitive skill items. It should be noted here that while Case-

Smith’s study (2003) found the moderate correlations between the two

assessment tools that reflected the clients’ perception only, this study found

the moderate to good correlations among three assessment tools that reflect

both the clients’ and the therapists’ perspective.

One of the limitations in this study is that there was no mechanism to test

the degree of client’s understanding of the philosophy and concept of client-

centered occupational therapy prior to the intervention. In fact, the results of

- 37 -

Receptiveness to Client-Centered Approach Survey suggested that it was

relatively difficult for the clients to understand the COPM. The item scoring

the lowest score was the item number 1 which was “I found the COPM easy to

understand.” This suggested that it was unclear whether the client fully

understood client-centered occupational therapy or not. Therefore, in the

future study, the degree of understanding client-centered occupational therapy

can be used as one of the inclusion criteria in evaluating the effectiveness of

client-centered occupational therapy. For instance, the participants should be

educated on the philosophy and concept of client-centered occupational

therapy prior to the survey. Since the top 15 participants with the total score of

30 and higher on the survey were assigned to Group A in this study, the

inclusion criterion should also be 30 and higher in the future study.

Other limitation can be the rating process of the WeeFIM scores. Even

though the WeeFIM scores can be obtained through a combination of direct

observation and interview with a family member (Sperle et al., 1997), it is

preferred that the child should be assessed on the basis of what he or she

actually performs according to the WeeFIM guideline (UDSMR, 1993). Since

the most WeeFIM scores were obtained through interviews with the caregivers

in this study, objectivity of the WeeFIM may have been compromised.

- 38 -

Conclusion

The assessment tools used in this study appeared to be responsive to the

clients' progress, and the consistent findings across assessment tools confirmed

the effectiveness of client-centered occupational therapy. The important tasks

identified on the COPM showed statistically significant improvement which

were verified by the AMPS and the WeeFIM. Based on the findings that the

COPM, the AMPS, and the WeeFIM detected changes of occupational

performance in this study, these tools appear to have great promise in

measuring changes of occupational performance in children with

developmental disabilities. Moderate to high correlations were found in Group

A indicating that clients’ perception and therapists’ observation of

occupational performance changes were concurrent. In order to maximize the

usefulness of the COPM for children with developmental disabilities, the

occupational therapists should ensure that they educate the caregivers about

the benefits of client-centered occupational therapy.

- 39 -

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- 49 -

Appendix

The Receptiveness to Client-Centered Approach Survey

Therapist’s Name: Date:

What is Client-Centered Approach?

The client-centered approach is defined as “an approach to service which

embraces a philosophy of respect for, and partnership with, people receiving

services.” The key feature of the Canadian Occupational Performance

Measure is based on the notion that caregiver knows best about the child’s

strength and weakness because she or he spends most of the time with the

child. This assessment tool guides both the therapist and the client to

identify the problems and priorities, and to establish mutually agreed goals.

Through these procedures the client can expect concrete effects of

occupational therapy and evaluate them, and the therapist can prioritize the

target occupational performance for effective and efficient occupational

therapy.

Client Information

Client ID #:

Child’ Age: Child’s Gender:

Diagnosis:

- 50 -

Please respond to Each Statement by Circling the Most Appropriate

Answer

1. I found the COPM easy to understand.

5) Strongly Agree 4) Agree 3) Neutral 2) Disagree 1) Strongly

Disagree

2. I found the COPM helpful.

5) Strongly Agree 4) Agree 3) Neutral 2) Disagree 1) Strongly

Disagree

3. The COPM helped me to identify current worries about my child’s health.

5) Strongly Agree 4) Agree 3) Neutral 2) Disagree 1) Strongly

Disagree

4. I felt comfortable helping the therapist plan my child’s treatment.

5) Strongly Agree 4) Agree 3) Neutral 2) Disagree 1) Strongly

Disagree

- 51 -

5. The COPM allowed me to feel respected and valued as an equal partner in

my child’s treatment.

5) Strongly Agree 4) Agree 3) Neutral 2) Disagree 1) Strongly

Disagree

6. I believe that a client is comfortable taking on responsibility for treatment

goals within Korean culture.

5) Strongly Agree 4) Agree 3) Neutral 2) Disagree 1) Strongly

Disagree

7. I believe that the COPM is an appropriate and effective tool in Korean

culture.

5) Strongly Agree 4) Agree 3) Neutral 2) Disagree 1) Strongly

Disagree

- 52 -

국국국국 문문문문 요요요요 약약약약

발달장애아동을발달장애아동을발달장애아동을발달장애아동을 위한위한위한위한

클라이언트중심의클라이언트중심의클라이언트중심의클라이언트중심의 작업치료프로그램을작업치료프로그램을작업치료프로그램을작업치료프로그램을 실시하는데실시하는데실시하는데실시하는데 있어서있어서있어서있어서

캐나다작업수행측정캐나다작업수행측정캐나다작업수행측정캐나다작업수행측정 (COPM) (COPM) (COPM) (COPM)의의의의 유용성유용성유용성유용성

연세대학교 대학원

재활학과(작업치료학 전공)

강 대 혁

본 연구의 목적은 첫째, 발달장애 아동들을 위한 클라이언트중

심의 작업치료 효과를 캐나다작업수행측정(COPM)을 통해 클라이

언트의 관점에서 측정하고, 둘째, 그 효과를 측정한 캐나다작업수

행측정의 유용성을 운동처리기술평가(AMPS)와 소아일상생활능력

측정(WeeFIM)을 통해 작업치료사의 관점에서 검증하고, 셋째, 클

라이언트중심의 작업치료에 대한 수용도에 따라 작업수행에 대한

클라이언트의 주관적인 평가(COPM)와 작업치료사의 객관적인 평

가(AMPS, WeeFIM)간의 상관관계가 유의한 차이를 보이는지 알

아보고자 하였다. 만 3세에서 10세 사이의 발달장애아동 31명을

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대상으로 재활병원 또는 지역사회 아동발달 센터에서 20-24회에

걸쳐 클라이언트중심의 작업치료 프로그램을 실시하였다. 본 연구

의 목적을 위하여 캐나다작업수행측정의 초기 평가 후 보호자를

대상으로 클라이언트중심의 작업치료에 대한 수용도 설문조사를

실시하였다. 합계 점수 기준으로 상위 15명은 수용도가 높은 그룹

(Group A)으로, 하위 16명은 수용도가 낮은 그룹 (Group B)으로

분류하였다.

짝비교 t-검정(paired t-test)을 통해 클라이언트중심의 작업

치료 전과 후의 세 가지 평가 도구 (COPM, AMPS, WeeFIM) 점

수변화를 비교한 결과, 클라이언트중심의 작업치료에 대한 수용도

가 높은 그룹과 낮은 그룹 모두에서 통계적으로 유의한 작업수행

의 향상을 보였다 (p < .01). 스피어맨 순위상관계수(Spearman

Rank Correlation Coefficient)를 이용하여 상관관계를 알아 본 결

과, 클라이언트중심의 작업치료에 대한 수용도가 높은 그룹에서 캐

나다작업수행측정-만족도(COPM-S)와 소아일상생활능력측정-인

지기술(WeeFIM-C) (rs = .78, p < .01), 캐나다작업수행측정-수

행도(COPM-P)와 운동처리기술평가-운동기술(AMPS-M) (rs

= .64, p < .05), 캐나다작업수행측정-만족도(COPM-S)와 운동

처리기술평가-처리기술(AMPS-P) (rs = .62, p < .05) 영역 사이

에서 양호한 양의 상관관계를 보인 반면, 수용성이 낮은 그룹에서

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는 상관관계가 나타나지 않았다. 본 연구결과를 근거로 다음과 같

은 결론을 내릴 수 있다. 첫째, 발달장애 아동들을 위한 클라이언

트중심의 작업치료프로그램 효과를 COPM을 통해 클라이언트의

관점에서 확인하였고, 둘째, COPM의 유용성이 객관적인 평가도구

인 AMPS와 WeeFIM을 통해 검증되었고, 셋째, 클라이언트중심의

작업치료에 대한 수용도가 높은 그룹에서 작업수행의 변화에 대한

클라이언트의 평가와 작업치료사의 평가가 일치하는 경향을 보였

다. 따라서 발달장애 아동들을 대상으로 COPM의 유용성을 극대화

하기 위해서는 클라이언트중심의 작업치료의 장점에 대한 보다 적

극적인 보호자 교육이 요구된다고 하겠다.

핵심되는 말 : 작업치료, 클라이언트 중심접근, AMPS, COPM.