Please enable JavaScript.

Coggle requires JavaScript to display documents.

(Week 6) Child and Adolescent Psychiatry, OT Practice Guidelines for…

- - - - (1) Depression
        
        Presentation
        
        Symptoms can sometimes be masked and expressed through development of phobias or delinquent behavior
        
        Low mood and anhedonia
        
        May be secondary to other disorders (e.g conduct disorder and school refusal)
        
        Underlying issues
        
        Suicide
        
        Issue of note, as young people tend to be reactive to environmental stressors such as bullying, family problems and academic pressure
        
        Statistics
        
        Number of suicides in Singapore rose 10% last year, with suicides among boys aged 10 to 19 at a record high, SOS said last week
      - (2) Anxiety
        
        Presentation
        
        Symptoms of anxiety may interfere with the child's ability to function competently in school
        
        e.g Separation anxiety may lead to secondary symptoms such as school refusal
        
        e.g Children may also "somatise" their anxiety. Worries may be expressed as physical compliants such as stomachache, sore throat and headache
        
        Younger children VS Older children
        
        Younger: Social phobia and other simple phobias are more common
        
        Older: Panic disorder, obsessive compulsive disorder and generalised anxiety disorder become more predominant
        
        In a local study (Woo et al. 2007), as many as 12.5% of 6-12 years old school-going children reported internalizing disorders (anxiety and mood disorders)
      - (3) Early Psychosis
        
        Onset usually occurs between the ages of 15 and 24 years old is crucial time in the development of young persons in the following areas:
        
        Self-identity
        
        Forming relationships
        
        Education
        
        Employment
        
        [When psychotic symptoms are first presented, it takes a period of observation before diagnosis is made]
        
        Treatment
        
        Early Psychosis Intervention Programme
        
        Since duration of untreated psychosis is associated with prognostic outcomes
        
        EPIP has been set up to raise awareness of psychosis, monitor those with "high risk" of developing psychosis and provide early treatment to mitigate the effects of psychosis on young people
      - (4) At Risk Mental State
        
        Presentation
        
        "At Risk Mental State" Definition : introduced to describe the prodromal phase whereby an individual is at risk of developing a psychotic disorder
        
        Statistics: 40% transit from ARMS to psychosis within a year of identification
        
        Individuals deem to have ARMS when they meet any of these 3 group criteria
        
        in addition to a decline in functioning over the preceding one year
        
        (1) Vulnerability Group
        
        this includes individuals with a family history of a psychotic disorder in a first degree relative, or the individual has a diagnosis of schizotypal personal disorder
        
        (2) Attenuated Symptom Group
        
        this consists of individuals with attenuated or low grade psychotic symptoms that are deemed to be of sub-threshold frequency or intensity
        
        (3) Brief Limited Intermittent Psychotic Symptoms (BLIPS)
        
        this consists of individuals who have experienced a psychotic episode that resolved spontaneously within a week
    - - Treatment principles
        
        Stress Vulnerability Model
        
        Intrinsic vulnerability
        
        Persons with at risk mental states are said to have intrinsic vulnerability: Abnormal brain function, disorganization
        
        Cognitive problems --> which may affect daily functioning
        
        Cognitive biasness --> affect how these persons pay attention to some elements of information, memories or experiences
        
        Impacts
        
        on how they respond to psychological stressors
        
        Psychosocial Stressors
        
        Definition of psychosocial stressors: Life crises, substance abuse, interpersonal and occupational stressors
        
        Types of Stress
        
        Lifestyle stress: Late night, lack of routine, poor diet, illness
        
        Physical and Social Environmental Stress: Academic pressure, lack of conducive studying environment at home, new environment to adjust to such as moving house or holidays
        
        Emotional Stress: Relationship problems, peer pressure, high expressed emotion within the family, cyber-bullying, anxiety and depression
        
        Stressors may be related to person, environment or occupation factors
        
        Occupational Therapy Interventions targeted to mitigate the intrinsic vulnerability, by facilitating young persons to acquire coping strategies to deal with the above stressors
        
        Intrinsic Vulnerability + Psychosocial Stressors --> Mental illness
      - (1) Group for ARMS and Early Psychosis
        
        Usefulness of this intervention
        
        Equipping adolescents with coping strategies to overcome stressors in the PEO domains
        
        Groups can provide a sense of belonging:
        
        Youths with ARMS and early psychosis commonly experience a loss of social roles, as they are pulled out of their school or work domains --> causing distancing from their networks in school
        
        Allow the group to try out new strategies learned in a safe setting
        
        Examples
        
        Discussion-based groups, physical activities, projective-expressive groups and board games -
        
        mediums that can be used to achieve the aims
        
        Possible themes for adolescents
        
        Making friends with the opposite gender
        
        Assertiveness skill
        
        Dealing with cyber bullies
        
        Building a healthy routine
        
        Keeping fit
        
        Dealing with changes in life
        
        Accessing community resources
        
        Themes can be incorporated into group activities, for adolescents to practice building resiliency in a hands-on or discussion manner
        
        Components of this Intervention
        
        Building Therapeutic relationship with adolescents
        
        OT share your own opinions (values and beliefs)
        
        Many of them are at the stage of shaping their own self-concepts, so they may benefit hearing from the opinions
        
        Role model how to verbalize feelings in an appropriate manner
        
        During groups, can role model e.g. using mature defense mechanisms rather than immature/neurotic ones
        
        Encourage to evaluate own thoughts and help them link thoughts, feelings, behaviors
        
        Help them identify motives for their thoughts, feelings and behaviors using cognitive-behavioral framework
        
        Help them develop higher executive functioning -- may be disrupted during onset of disease process
        
        Encourage to explore and identify own values and beliefs
        
        Use of peer support specialist is also helpful in an early psychosis programme - to promote hope for recovery
        
        General principles of groupwork
        
        Structure and consistency (provide choices within structure)
        
        Setting clear boundaries and limits for behaviour
        
        Avoid power struggles
        
        Communicating acceptance, trust and safety
        
        Goals of group intervention
        
        To enable occupational performance and/or occupational participation in school, vocational and social domains
      - (2) Supported Education
        
        Challenges of returning back to education
        
        Research: Qualitative study of clients with early psychosis
        
        Zafran et al., found that return to school was more difficult than returning to work and functional changes were more problematic in school than work
        
        Main challenges experienced
        
        Side effects of medication
        
        Cognitive difficulties (e.g sustaining attention)
        
        Fear of failure and criticism
        
        However clients still return to school
        Reason; Symbol of normalcy and they wanted to regain productivity and social integration
        
        Components
        
        Involves helping the person to prepare, return to and sustain secondary or post-secondary education and vocational training
        
        Supported education programmes have been conducted by occupational therapists
        
        Typical school preparation programme
        
        Basic academic skills needed to succeed in an educational environment
        
        Social and behavioral skills needed to interact with faculty and fellow students
        
        Exploration of educational interest and identification of available educational opportunities
        
        Financial aid applications
        
        Studying for entrance examinations
        
        Community resources needed to support educational pursuits (e.g library)
        
        Application of materials learned to the person's personal educational goals
        
        Ongoing support group to provide assistance throughout the whole process of reentering student role
        
        During school preparation programmes: Area which are reinforced throughout the topics
        
        Balancing and maintaining healthy lifestyle
        
        Helping persons to understand and reframe previous difficult school experiences when psychosis was emerging
        
        Psychoeducation which went beyond facts to minimize shame and fear of failure and instill hope for recovery
        
        Getting persons to adapt and self manage illness (refer to notes on illness management and recovery) without self-stigmatizing
        
        Coping strategies to compensate/remediate obstacles due to cognitive deficits (refer to cognitive remediation lecture slides)
        
        Forming new social networks and rebuilding old networks
        
        e.g disclosing diagnosis and difficulties to friends
        
        [Useful to involve family in the above process]
        
        [During education phase] Supported education by OT to get through academic demands
        
        Teaching strategies such as time management
        
        Breaking down tasks into smaller chunks
        
        Teaching advocacy skills
        
        Liaising with school representatives to provide classroom accommodations
- - - - Physically hurting the child through hitting, excessive caning, slapping etc
    - - Can have a long lasting effect on abused child
      - Involves lack of physical and medical care
      - Lack of enforced house routines, rules and supervision
      - Lack of emotional closeness: lack of emotional warmth and availability
      - Lack of cognitive stimulation and encouragement in constructive past times
      - Consequences
        
        Lead to delayed language acquisition, short attention span, poor skill acquisition, and poor school functioning
    - - Involves hostility, deprivation of attention
      - Threats to abandon the child
      - Inappropriate demands on the child (such as expecting the child to perform beyond his/her ability or assume adult roles)
    - - Devastatng effect on the child's ability to build trust and establish appropriate and satisfying relationships
      - It may sometimes not be disclosed due to stigma and family's attempts to protect the perpetuator
  - - - Mental Function (Cognitive)
        
        May also be associated with short attention span and development of hyperkinetic behaviour
        
        Victims of abuse may have frequent memories of the event
        
        some young children play in a manner which some or all of the trauma is repeated over and over
        
        Impaired development of executive functioning, due to disruptive effects of toxic stress on the developing architecture of the brain
      - Mental Function (Affective)
        
        Victims may exhibit fear and anxiety
        
        Dissociation
        
        Sense of powerlessness (as they may be overly-compliant or withdrawn)
        
        Blunted or flat affect
        
        Shame and guilt
        
        Poor self-esteem
        
        Impairment of self-identity
        
        Adopting immature defense mechanisms (e,g regressive behaviour such as clingy/whiny behaviour, thumb-sucking)
        
        Sudden and extreme emotional reactions
        
        Behaviours indicative of lack of self-control problems (e.g being sensitive, aggressive and having low frustration tolerance)
      - Sensory Function
        
        Sensory responses: may be hypo- or hyper- responsive to sensory stimuli
        
        A number of them may become hyper-vigilant
        
        Physical somatic symptoms
        
        e.g severe stomach discomort and headaches
        
        Body image may fail to develop or an impaired body image may develop
      - Motor function domain
        
        Deprivation of sensory/movement opportunities: delayed gross and fine motor skills development (developmental milestones affected)
        
        Reflex maturation may be incomplete, with primitive reflexed continuing to be present
        
        If nerve or brain damage has occurred, there might be muscle weakness, or even paralysis
        
        Reduced range of motion may be present, depending on the type of injury
        
        Contractures may be present if condition has existed for some time
    - - Sleep and Leisure
        
        Nightmares or have problems falling asleep
        
        Limited leisure interests
      - Social Participation
        
        Delays in acquiring speech or vocabulary to communicate
        
        Delays in development of social interaction, group interaction and conduct skills
        
        Anger/acting out
        
        Social Isolation
        
        Victims of sexual abuse: may display hypo/hypersexualised behavior or promiscuity
      - Activities of Daily Living
        
        In Self care: may face difficulties such as dressing, tying shoelace or eating with a fork
        
        Due to delayed acquisition of skills due to neglect
      - Play and productivity
        
        Reduced occupational performance may be observed. Some of the performance component issues may be:
        
        Developmental delay in acquiring play skills
        
        Using less imagination in play
        
        Inability to organize play activities
        
        Showing little exploratory behavior in play
        
        Difficulties in handwriting, organizing and completing tasks
        
        Schooling difficulties: delinquency and truancy
    - - Part 1 (interview with abused child)
        
        Beth appeared cold when she described the abuse she went through, even emotionless when she said she was sad/angry
        
        When she was on the route to recovery in a rehabilitation facility - start showing some awareness of how the trauma caused her to hurt other, as well as the effect of her actions on herself
      - Part 2 Agression with rage
        
        How the abuse gave rise to rage and aggression, which she could not control
        
        Even though it is an old vid and rehab facility might not have adopted an evidence-based model of practice, it provides a structured environment with strict boundaries in the beginning
        
        Beth's boundaries were violated and she had no sense of control during the abuse. As a result, she did not understand boundaries and was unable to exercise self-control
        
        Hence centre staff showed her what control and boundaries were so that she could gradually internalize them and exercise appropriate control and choice when she was ready
      - OT intervention: Activities to help children experience control and choice, and success and competence are important
  - - - To communicate and process the trauma through meaningful occupations
      - To improve safety and manage symptoms through engaging in adaptive occupations
      - To use age-appropriate occupations to build self-esteem and reintegrate to new self
- - - - Affective and anxiety disorders, trauma, psychosis or personality disorders
    - - To seek relief from tension or emotional pain
      - To overcome feelings of numbness, emptiness or detatchment
      - To have a sense of control
      - To avoid a perceived difficult situation
      - To communicate distress
      - As revenge towards a significant others
      - As self-punishment
    - - Helping the person to acquire self-soothing strategies
        
        Tips that can be used (ref from picture on slide)
        
        Rub an ice cube on skin instead of cutting it
        
        Wear a rubber band around wrist and snap it gently against skin
        
        Draw on skin with a soft-tipped red pen in place usually cut
        
        Go for a walk or run, ride a bike, dance like crazy or get some form of exercise
        
        Rip up some paper
        
        Write out your hurt, anger or pain using a pen and paper
        
        Scribble on paper using red pen
        
        Squeeze knead or smooth stress ball, handful of clay, or play doh
        
        Benefits of self-sooth strategies
        
        Sensory approach to self-soothing strategies is often helpful to promote healthier way of regulating emotions
        
        To gain more control over their thoughts and feelings, thereby increasing occupational performance
        
        Process of OT Intervention: Self-soothing strategies
        
        OT can engage in these activities together with child.
        
        Child will rate the effectiveness of self soothing after its use
        
        (1) Identify soothing strategies using the Distress Tolerance Checklist
        
        This checklists covers a range of activities that involves 6 sensory systems
        
        Movement: e.g riding a bicycle, aerobics, dancing etc
        
        DIfferent types of touch and temperature e.g blanket wraps, getting a massage etc
        
        After identifying activities or strategies that work, the child/adolescent can create a self-soothing sensory kit - containing items to be used to carry out these activities
      - Healthy ways of expression emotions (can be done using creative media) - e.g narrative writing, art and music
      - Problem solving current difficult situations (can be done using cognitive behavioral strategies or creative media)
      - Crisis management planning (similar to the crisis planning within Wellness Recovery Action Plan)
      - Instilling hope
- - - - Poor self control and sense of self may result in the child being hostile towards teachers and school mates
      - May be inattentive and disruptive in class, making it difficult for him to progress
      - Fights and bullying may occur
      - Even though the child/adolescent may have friends in the form of gang members, he may be incapable of establishing fruitful relationships with peers
    - - Child may refuse to obey parental instructions and may behave in ways that annoy or anger adults
      - Temper tantrums are also common
      - Affects the child/adolescent's ability to establish a healthy routine of productivity, self-care and leisure
  - - - Child and adolescents with ODD and CD may have comorbid affective disorders
        
        He/she may also have experienced abuse and engage in deliberate self-harm
    - - Therapists can help the child/adolescent to label their emotions and learn how to verbalise these emotions, rather than acting them out
      - Work with the child/adolescent to learn how to channel these emotions using appropriate activities (such as heavy work, punching bag), thereby utilizing the mature defense mechanism of sublimation
    - - Set overt and concrete limits/rules, so as to enable to child/adolescent to learn about social behaviours
      - Behaviour modification reward system can be put in place to reward positive social behaviour, but this needs to be carried out consistently
    - - Initial Phase: work with parents on strengthening the parent-child attachment relationship
        
        Can be achieved through engaging in shared meaningful occupations
      - Second Phase: Parents are helped to establish control over disruptive child behaviour by
        
        Learning how to communicate age-appropriate instructions for behaviour in a clear manner
        
        Provide consistent positive and negative consequences for compliance and noncompliance
      - Parents also trained to identify antecedents, resulting behaviours and the associated consequences for the children as well as themselves
      - For Occupational therapy aspects
        
        Focus will be on reinforcing behaviors that promote occupational performance and participation
        
        Problem solving ways to reduce behaviors that interferes with performance and participation
- - - - Spend increasingly more time or money on computer games to feel the same amount of excitement
      - Depressed, restless or irritable when others try to cut down or withdraw computer usage
      - Aggressive or abusive when prevented from playing
    - - Tired and sleep in class
      - Skip lessons and co-curricular activities (CCA) to use the computer
      - Schoolwork with inevitably suffer
    - - Spend long hours at night playing games, so as to compete with players at different time zones --> resulting in sleeping hours to be compromised
      - Little energy for leisure activities and social participation
    - - Ignore activities of daily living such as eating and bathing
      - Spend all money on games
  - - - Establish habits, roles and routines which has been lost due to excessive computer use
    - - OTs starts by engaging in leisure and creative activities that are of interest to the child/adolescent
        
        Activities which elevate mood, give rise to nice end-products or promote self esteem are chosen
      - e.g of Youth-Appropriate Activities
        
        Board Games
        
        Physical Activities eg sports, yoga
        
        Music and Jamming (eg Drumming)
        
        Arts-based activities e.g photography
        
        Drama
        
        Writing: poetry or journaling
        
        Discussion groups
        
        Cooking/Baking
      - During the engagement of such groups, rules about not using internet or mobile devices, as well as no discussions about computer games should apply
      - Establishing Healthy Routines
        
        The Occupational Questionnaire from MOHO can be used to help the adolescent establish balanced time use.
        
        Important to include family members or close friends when engaging in these daily occupation, as there is a high likelihood that the adolescents will not follow the recommended time use schedule
        
        Strategies
        
        Develop an agreement and a way for adolescents to stay away from venues and social circle that may encourage gaming: need to help adolescent establish an alternative network of friends
        
        before this is done OT need to help establish an alternative network of friends (e.g firends who are avid photographers)
        
        Use of community resources will be important
        
        Develop an agreement on internet usage (e.g wireless to be turned off by parent at 10pm)
        
        Managing stressors
        
        Often adolescent turns to internet use as a coping strategy for managing stressors
        
        Hence OT may need to owrk out alternative coping strategies (e.g relaxation therapy to manage test anxiety, assertiveness skills to manage friendship problems)
        
        Potential for relapse
        
        The adolescent may experience a relapse and return to gaming addictive behaviour especially during stressful events
        
        e.g exams, illness in family, relationship breakfup
        
        OT should work withf amily.school to reinstate coping strategies and healthy routine, as well as to work with teh adolescent to see the relapse asa learninge xperience
        
        New coping strategies may need to be learnt
- - - - Partciipation as one's involvement in daily life situations
      - Consider a myriad of factor that influence participation and explore how the use of certain performance patterns and engagement in occupation shape children's identities and influence trajectories as they grow into adulthood
  - - - Play activities provide a rich environment to develop competency in social, motor and cognitive skills
      - Play behavior and skills may be negatively influenced by disability and deprivation
      - OT practitioners use play as both means and ends to influence motivation, facilitate playfulness, and assist clients in meeting play-based outcomes
    - - Participation in meaningful occupations, such as feeding oneself and brushing one's teeth, contributes to child's development, well-ebing and identity
      - Can facilitate development of client factors (e.g strength and attention), performance skills (e.g using and manipulating materials) and effecient and effective habits and routines
      - ADL are occupations beginning in early childhood, contributing to sense of autonomy and independence, serving as foundation for more complex IADLS
      - As adolescents transition from school to post secondary, participation and performance of IADLS (e.g health management and maintenance, safety and driving ) become increasingly relevant
      - Address concerns such as obesity, poor nutrition, fitness, safety and personal care
      - Problems with sleep deficits
        
        OT practitioners have included sleep hygiene interventions
        
        e.g visual supports for skeep routines and coaching for relaxation techniques) for pediatric population at greater risk
        
        e,g children and youth with ASD or developmental coordination disorder (DCD)
    - - Learning and preparation for workforce are primary outcomes of education
      - Occupation of education include
        
        Academic (e.g math, reading, writing)
        
        Nonacademic (e.g clubs, drama, sports) occupations
        
        Those associated with development of prevocational and vocational skills
      - OTs pay attention to a broad range of occupational performance areas to help child succeed in student role
      - Reading and writing are foundation for school success, and impairments associated with literacy and writing associated with decrease engagement and performance in otehr academic tasks
- - - - Task-oriented activities and routines
        
        Supporting engagement in self-care activities and routine to improve participation in and performance of functional life skills
        
        Research: effectiveness of child-focused (e.g remediation of imapirment) and context-focused (e.g task or environment) interventions
        
        Children with CP in both groups showed equivalent and significant improvements in self-care, mobility and participation outcomes
        
        Research: children with CP who participate in active lifestyle and sports participation intervention and logged their daily physical activity and engagement in daily life activities on self report measure increased their physical activity
        
        Research: Children with ASD participated in adaptive skills training intervention designed to increase independence in self care
        
        significant improvement in performance skills and reduced caregiver involvement
        
        Functional physical activities
        
        Three studies provide strong strength evidence supporting engagement in functional mobility activities and structured exercise programmes to improve functional mobility of child and youth with CP
        
        Research: Children with CP who received structured training on a treadmill showed a significant increase in the distance they could travel during functional activity
        
        Task-oriented Training
        
        Low strength evidence indicate engagement in task-oriented training in simulated tasks improved self-feeding performance and mealtime participation among children with spastic CP
      - Cognitive-based interventions
        
        What it consists of
        
        Collaborative goal setting
        
        Activity-based training and education (including motor learning interventions)
        
        Coaching and feedback (mediated by a peer, caregiver, or occupational therapy practitioner);
        
        Goal-Plan-Do-Check from the Cognitive Orientation to Daily occupation [CO-OP approach]
        
        Cognitive-Function {Cog-Fun]
        
        Strong evidence that cognitive-based interventions can improve functional mobility and self-care performance and participation
        
        Research: Participants received activity-focused sessions with coaching and feedback and home practice addressing functional mobility and self-care performance and participation
        
        Research: Children with developmental coordination disorder who participated in collaborative goal setting, instruction, and feedback (e.g CO-OP) showed significant improvement in self-care participation, performance, and satisfaction
        
        Research: Two lower level studies that used cognitive interventions were included
        
        Research: Manualized intervention sessions (Cog-fun) resulted in significant positive treatment effects on ADL outcomes
        
        Research: Used goal attainment scaling and Canadian Occupational Performance Measure (COPM) and found that engagement in group life skills-based coaching interventions (Direct instruction, role-playing and peer modeling)
        
        Significantly improved goal-directed performance of functional skills amongst youth with disabilities
      - Technology-based interventions
        
        What it consists of
        
        Video Modelling
        
        Virtual Reality
        
        Video game training interventions
        
        Evidence
        
        Moderate strength evidence indicating video-based modelling interventions improved self-care participation and performance
        
        Moderate strength of evidence find in support of web-based interventions to improve self-care participation and performance of children and youth with CP
        
        Low strength of evidence supporting virtual reality intervention to improve mobility and self-care participation and performance among children and youth with ABI
  - - - Physical activity and fitness, diet and nutrition, and health routines and wellness
      - Especially important for
        
        Children with chronic conditions and those who have environmental or developmental barriers to participation
      - Three specific outcomes
        
        Physical Activity and fitness
        
        Four Level 1 studies provided strong evidence for occupation- and activity-based interventions in school setting to increase health outcomes of physical activities and fitness
        
        Research interventions include
        
        Playworks programme
        
        Ready for Recess Programming (activity zones and access to equipment)
        
        Conduced a 24-month school-based intervention with a fcus on physical activity promotion via student physical activity plans
        
        Low strength evidence was found for occupation- and activity-based interventions provided in a non-school setting to increase health outcomes of physical activity and fitness
        
        e.g Research: three 6-week session of after-school programme providing structured physical activity and lessons on nutrition and healthy habits. Activity monitors worn by participants indicated no improvement in physical activity
        
        Diet and Nutrition
        
        Six studies met the inclusion criteria and produced evidence of moderate strength to support interventions using a skills-based interactive curriculum and structured physical activity to effect positive change in dietary outcomes
        
        Research approaches
        
        Skills-based approach used interactive role-play and homework focused on healthy choices and positive dietary and behavior among teenagers
        
        After school programme (LA Sprouts) with interactive and activity-based instruction in cooking, nutrition and gardening to children
        
        HEALTH[e]Teen: Web-based obesity prevention programme
        
        Participants engaged in self-directed lessons supported by interaction with a coach and peers resulted in statistically significant improvements in healthy eating behaviours
        
        6 week family-centered programme (Kids Nutrition and FInness) focused on nutrition education and physical activity
        (...)
        
        Health Routines and wellness
        
        Four Level 1 studies met the criteria for health routines and wellness
        
        Outcomes included health related decision making, medication adherence and management of pain and activity
        
        Two studies had a family or parent component
        
        Research:
        
        Family-centered, home-based interactive cognitive-behavioral approach to address medication adherence among youth with HIV
        
        Impact of web-based self-guided interactive module programme with a sample of youth ages 11-17
        
        Systemic review of 5 studies examined interventions addressing health-related decision making by youth
        
        Four of the 5 studies measured the impact of interactive coaching practiced and had nonsignificant findings
    - - Interventions in this broader outcome seperate into two categories
        
        Technology-based interventions
        
        Three level 1 studies and 2 level 3 studies used technology (simulation, virtual reality and web-based interactive programmes)
        
        Overall: low strength of evidence was found for technology-based interventions
        
        Research:
        
        (...)
        
        Page 15
        
        Research:
        
        12 module, web-based interactive programme as a driving intervention for new teen drivers.
        
        Programme addressed safe and skilled driving ability and included a practice drive and an assessment with teh virtual driver interactive computerized simulator
        
        Activity-based coaching or skills training
        
        Two studies examined activity-based coaching or skills training interventions
        
        Overall: Moderate strength of evidence was found for interventions involving coaching or skills training
        
        Research: Used activity-based training and coaching via a community-based life skills programme (Skills for Transition)
        
        Coaches supported clients in selecting their own goals using COPM then facilitated practice of skills in a natural setting
        
        Most frequent identified IADL: Cooking, money management, and community mobility
  - - - Have a significant role in skill acquisition and healthy engagement in childhood roles
        
        Lifestyle barriers such as limited time for play exist for many children and may be greater for children with special healthcare needs
    - - Low strength of evidence was found for intervention that used cognitive-behavioural strategies with children with ASD
      - Research: Participants received rewards and recognition while engaged in problem solving and decision making during 12 week of a physical education class
        
        Verbal praise and tokens in conjection with athletic skills and rules trainin
    - - One review provided low strength of evidence to support computer and tech intervention for play
        
        use of virtual reality games and computer-based play for children with complex disabilities
    - - Moderate strength of evidence found for effectiveness of structured and guided play participation
      - Research:
        
        Active coaching, modeling and guided play participation for children with ASD
        
        Use of peer-mediated (group play) interventions and structured guidance in the use of school playground equipment
        
        Learn to play program stations (doll, transport, construction) : found statistically significant decrease in number of play deficits for children with ID after therapist guided play
  - - - Sleep education (establishing rest and sleep routine, preparing and managing the environment to promote rest and sleep)
        
        Moderate strength of evidence indicates that engagement in sleep preparation activities e.g sleep education, coaching and cognitive strategies for skills in relaxation in sleep hygiene improve sleep outcomes
      - Cognitive based interventions (coaching, mindfulness, guided imagery)
        
        Research: Guided imagery intervention with youth who underwent surgery for adolescent idiopathic scoliosis
        
        significant decrease in sleep interference from postsurgical pain
      - Yoga
        
        Research: Participation in 6 week of yoga involving poses, relaxation, gentle stretching, and breathing, along with a home programme, did not change sleep-related symptoms among a small sample of children with a history of cancer
        
        but it help in signficant decrease in anxiety among participants
      - Relaxation and rigorous exercise activities
- - - - OTs can embed fitness curriculum and programs into school environment during recess or physical education classes
      - Skill-centered education strategies that include interaction with and feedback from peers, family member and OT
      - Implement activity-based skills training in context of occupation (e.g driving, cooking) to improve IADL
      - Providing services in natural environment in which children and youth are expected to perform the IADL is also a key factor
        
        promote practice and guide clients in self-evaluation of performance and outcomes
    - - Promots overall development and contribute to QOL for children and youth
      - Problems children with special needs e.g ASD, ID physical ability face
        
        may be less engaged or isolated in play situations
        
        fewer play opportunities
        
        Lack skills congruent with play mastery
      - Evidence based practices
        
        The use of structured and guided play participation
        
        incorporating children's toys, play equipment, and peers or siblings into guided play sessions
        
        interventions should be provided in the environment in which the play outcome is desired to occur, such as playground
    - - Problems children with ASD and DCD face
        
        Higher risks for sleep disturbances
        
        Inadequate rest ad sleep - considered a public health problem
        
        if addressed can be effective of rehabilitation efforts, improve health and well-being and increase performance and participation in meaningful occupations
      - Carefully planned interventions can affect sleep quality and may contribute to overall health
      - Strong evidence supports sleep preparation activities, especially those that include sleep education and cognitive-based intervention
      - When using relaxation, rigorous exercise, or both as components of intervention, OT practitioners should include coaching and guided practice for the child and caregiver and provide follow-up opportunities to assess effectiveness and modify
  - - - Problems
        
        Teens share challenges with group
        
        Discuss and document the number of hours they are able to achieve quality sleep per night
      - Interventions
        
        therapist uses coaching techniques to facilitate teen's ability to identify potential reasons for lack of success
        
        teens are provided model goals and encouraged to create achievable and measurable personal goals
        
        One small group of participatnts provided with two f2f sessions
        
        1st session: education on skeep recommendation and principles of guided imagery, therapist led guided imagery experience
        
        2nd session: parents and teens self-direct guided imagery experience while supported by therapist
        
        Teen continue to document sleep quality, assess progress and share results
- - - - Life skills training intervention:
        
        intentional graded engagement during functional activities
        
        Activities that promote the development of work skills and behaviours
        
        Academic work and chores
        
        OTs usually use life skills intervention to prepare children and youth to transition to post secondary environment (i.e college, work, group or independent living situations)
    - - e.g Combined activities such as organizing a backpack, planning and executing a pizza party, and making reminder checklists to facilitte daily routines
      - e.g effectiveness of farm-to-table intervention that involved gardening and meal preparation for school-age children in Australia
      - e.g weekly 90 min group sessions included time-use reflections, self-review of participation levels and effects on mental health, and systematic activity scheduling, coupled with occupational-based activities and anxiety management training
        
        significant improved parent and clinican rating of anxiety symptoms and internalizing behaviour on child behaviour checklist and children global assessment scale for children ages 10-14 year
  - - - All of the interventions included a group format
      - Adventure therapy and outdoor adventure based experiences (i.e rock climbing, canoeing, hiking, and camping)
      - e,g Camping, outdoor games, swimming and pool games
      - e.g surfing, sandcastle building and paddle relay
    - - e.g Chance for Change (residential wilderness therapy programme) last for 10-20 days help with antisocial behaviour
      - e.g An outdoor activity camp lasting 8-10 week was found to significantly increase self-esteem for adolescents with a diagnosed mental illness
        
        using the Rosenburg Self-esteem scale
      - E.g 10 week programme for adolescents including outdoor activities (e.g rock climbing, caving, backpacking etc) and 2-day camping trip demonstrate statistically significantly significant improvement in psychological resilience and depression
      - e.g Week long residential camp for children at risk for metal health concerns and low self-esteem that included camping, outdoor games, equine therapy and outdoor adventures resulted in changes in self-esteem
        
        4 month follow up (ON FIRE) -- yield changes in hope
  - - - e.g manualized friendship traning group intervention
        
        improvement in social skills rating scale
      - e.g Clinic-based play interventions emphasized intrinsic motivation and included regular playmates and parent involvement
      - e.g two play interventions
        
        one that included adults as play partners
        
        one taht included robots as play partners
        (Both show positive improvement in social participation)
      - e.g Play group intervention
        
        Significant gains in play participaton (i.e symbolic and social play) measured with locally developed coding system
      - e.g Combined video-recorded free-play sessions, feedback from a therapist and peer modelling
        
        significant improvements on Test of playfulness for chidlren with ADHD
  - - - 14 Week intervention (i.e warm-up activity, stretching, modified karate instruction and cool down)
  - - - e.g found improvements in social self esteem but improvement not as great as those for physical activity
      - e.g yoga intervention improvement in anxiety for youth with eating disorders
  - - - e.g Incorporated meditation instruction and regular practice with children ages 10-12 years in classroom environment
        
        Found overall significant improvement on self-reported indicators of mental health
  - - - e.g therapeutic horseback riding significantly improved scores of children with ASD and Social Domain of the Vineland Adaptive Behaviour Scale
  - - - Indicating that these interventions are effective in
        
        Addressing mental health concerns of children and youth because they reduce symptoms of anxiety and depression and occurence of internalizing and externalizing behaviours
        
        improving social participation skills (e.g cooperation)
      - OTs should consider how to therapeutically use social demands associated with yoga and sports activities
        
        Foster imporved social skills and opp for social engagement and participation
    - - Should be incorporated into OT interventions for children and youth with ASD
      - Animals provide sense of support and help to facilitate person-to-person interactions
      - Animal-assisted interventions e.g therapeutic horseback riding, may encourage children to listen and attend to adult directives as well as to communicate verbally
    - - Should be incorporated into OT interventions for children and youth with and at risk of mental health concerns
      - Play-based interventions in partner and group context
      - Interventions that include parent involvement found to be effective with children with ASD and ADHD
      - OT consider creative writing (e.g blogging about social problems) or hand drumming in interventions to address mental health concerns
      - (these interventions prioritize individual expression over group-focused goals)
    - - Outdoor activity groups
      - Productive and life skills groups
      - Video and computer game groups
    - - Introduce children and youth to occupation-based interventions and incorproate them into daily and weekly performance patterns
      - Interventions prioritizing engagement in activities and occupations are beneficial to children and youth
  - - - Introduce students to yoga through series of different yoga postures and games
      - Teach students different breathing exercises and relaxation techniques
      - Encourage students to discuss when and how they can incorporate these strategies throughout the day at school and during evening and weekends at home
      - Collaborate with school social worker and principal to identify an area in school students can use for yoga breaks
      - Works with students to create action plan to implement yoga and meditation activities in their typical daily routines
      - Encourages students to keep a log to record their yoga and meditation practices. Log includes a space for reflecting on experiences
    - - Students begun regularly taking yoga and mdeitation breaks at school
      - Completed logs and share experiencing fewer symptoms of stress and anxiety at school
- - - - Children using standard classroom chairs exhibited significantly more time on task working both independently and with peers
      - Percentage of observed behaviours indicated that on-task behaviours (measured by focused activity and cooperation with rules_ significantly increased when second-grade students used stability balls in classroom
    - - Yielded low strength of evidence for use of weighted vests
    - - Strong evidence exists for use of yoga to improve educational outcomes
        
        Children with learning disabilities and emotion and behavioral problems exhibited significant improvements in communication
  - - - Strong strength of evidence when using peer mediated interventions
        
        time spent in enagegemnt increase
    - - Moderate strength of evidence found for use of manualized programmes
      - e.g Remaking recess (16 week psychosocial intervention) - intervention significantly increased peer engagement for children with ASD
    - - Low strength of evidence for use of animal-assisted activities
  - - - Moderate strength of evidence found for physical activity-based after-school programmes
      - Programme were administered to school populations in natural groupings, either addressing children in school as a whole or focusing on identified classrooms
    - - Moderate strength of evidence (5 level 1 studies) with mixed results found for effectiveness of context modifications to promote physical activity for children
      - Contextual modifications included interventions such as playground markings (e.g painting playground surfaces for use in games or to create different types of play zones)
        
        Provision of large and small equipment
        Changes to school policy to increase playground access etc
    - - Low strength of evidence
        
        Results from systematic review were inconclusive and video games may be no more effective than other methods
  - - - Moderate strength of evidence supporting the use of embedded creative and engaging literacy activities in classroom and supplemental intervention sessions
    - - Moderate strength of evidence support parents-mediated literacy interventions
    - - Moderate strength of evidence supports effectiveness of peer tutoring programmes
  - - - Handwriting is a complex occupation with visual perception, kinesthesis, in hand manipulation and visual motor integration
    - - Strong strength of evidence found for therapeutic practice over sensorimotor approaches or usual classroom activities for children with handwriting difficulties
  - - - Peer support and involvement
      - Contextual modifications
      - Social awareness, social functioning, initiation of peer interactions, time spend engaging with peers, communication, acceptance by classmates, enhanced friendship and relationships, increased interaction with teachers, attitudes towards academic tasks enhanced through peer interventions
    - - Multitiered systems of support and services
      - Should consider duration of different interventions and social supports when integrating interventions to enhance participation at school
    - - School based OT collaborate with teachers - to improve children's handwriting legibility
      - Provide suggestions to incorporate therapeutic handwriting practices in the classroom's typical routine e.g writing a heading on each piece of loose-leaf paper used to complete assignments, writing letters to other students or staff
      - Model ways in which teachers can provide students with more specific feedback on performance and results
      - Teaches students methods to self-evaluate and provide peer feedback on handwriting legibility
      - Meets with teachers on regular basis to provide additional consultation and support when needed
- - - - Some studies used a specific yoga programme e.g yoga Ed, which emphasizes mindfulness in addition to yoga postures and games, breathing exercises and visualisation
      - Intervention content varied across studies, but all provided yoga in a group format
    - - Intervention components
        
        Life skills module (e.g organization, self-care, daily living skills), vocational skills group and graded occupational engagement
      - Research --> found that avocational skills group for adolescents boy w autism found significant changes in parent ratings of anxiety symptoms and internalizing behaviour
      - Research --> found occupation-based group informed by cognitive-behavioral principles for children with anxiety
        
        found significant changes in parent ratings of anxiety symptoms and internalizing behaviors
    - - Research --> trauma-informed basketball programme for adolescent girls with severe behavioural issues resulted in significantly reduced internalizing and externalizing behaviour
  - - - (..)
    - - Research: found significant reduction in inattention for children with ADHD who participated in 3 hr weekly athletic activities
      - Research: investigated a water exercise swimming programme and found significant decrease in antisocial behaviour
      - Research: found that adolescent girls who participated in a basketball intervention demonstrated increased perseverance, on-task and conflict resolution behaviours, but these changes did not reach statistical significance
    - - Research: explored impact of Child Life and Attention Skills (CLAS) groups on positive behaviour (esp organization behaviour supporting performance at home and school)
        
        significant increase in parent-reported organizational skills found but teacher reports 1 year follow up improvement not maintained
  - - - Research: evidence of 14 week karate intervention for boys with ASD
        
        significant reductions in social skills deficits and communication deficits postintervention and follow-up
      - Research: significant imporvements in cooperativeness after a 6-week sports intervention
      - Research: Another research found improvements thought not significant in parent-reported social problems for adolescent boys who participated in a manualized mindfulness martial arts intervention
    - - Research: found that manualized garden0to-table skills group had signficiant impact on cooperative behaviours
      - Research: impact of CLAS groups on social paricipation
        
        Found significant parent-reported imporvement in social skills
        
        but no reported improvement in teacher-reported outcomes found
- - - - Yoga was the only intervention type that addressed all three outcomes with moderate strength of evidence
      - The evidence supporting yoga and sports interventions is stronger than that for productive and life skills interventions