Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review
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Australian Occupational Therapy Journal (2019) 66, 258–273 doi: 10.1111/1440-1630.12573
Review Article
Effectiveness of paediatric occupational therapy for
children with disabilities: A systematic review
Iona Novak and Ingrid Honan
Cerebral Palsy Alliance, Discipline of Child and Adolescent Health, The University of Sydney, Camperdown, North South
Wales, Australia
Introduction: Paediatric occupational therapy seeks to 4% (n = 6/135) ‘don’t do it’ (Red Stop). Green lights were:
improve children’s engagement and participation in life Behavioural Interventions; Bimanual; Coaching; Cognitive
roles. A wide variety of intervention approaches exist. Cog-Fun & CAPS; CO-OP; CIMT; CIMT plus Bimanual;
Our aim was to summarise the best-available intervention Context-Focused; Ditto; Early Intervention (ABA, Develop-
evidence for children with disabilities, to assist families mental Care); Family Centred Care; Feeding interventions;
and therapists choose effective care. Goal Directed Training; Handwriting Task-Specific Prac-
Methods: We conducted a systematic review (SR) using tice; Home Programs; Joint Attention; Mental Health Inter-
the Cochrane methodology, and reported findings accord- ventions; occupational therapy after toxin; Kinesiotape;
ing to PRISMA. CINAHL, Cochrane Library, MEDLINE, Pain Management; Parent Education; PECS; Positioning;
OTSeeker, PEDro, PsycINFO were searched. Two inde- Pressure Care; Social Skills Training; Treadmill Training
pendent reviewers: (i) determined whether studies met and Weight Loss ‘Mighty Moves’.
inclusion: SR or randomised controlled trial (RCT); an Conclusion: Evidence supports 40 intervention indications,
occupational therapy intervention for children with a dis- with the greatest number at the activities-level of the Interna-
ability; (ii) categorised interventions based on name, core tional Classification of Function. Yellow light interventions
components and diagnostic population; (iii) rated quality should be accompanied by a sensitive outcome measure to
of evidence and determined the strength of recommenda- monitor progress and red light interventions could be discon-
tion using GRADE criteria; and (iv) made recommenda- tinued because effective alternatives existed.
tions using the Evidence Alert Traffic Light System.
KEY WORDS disability, intervention and service provi-
Results: 129 articles met inclusion (n = 75 (58%) SRs;
sion, occupational therapy, paediatric, systematic review.
n = 54 (42%)) RCTs, measuring the effectiveness of 52
interventions, across 22 diagnoses, enabling analysis of
135 intervention indications. Thirty percent of the indica-
tions assessed (n = 40/135) were graded ‘do it’ (Green
Go); 56% (75/135) ‘probably do it’ (Yellow Measure); 10%
Introduction
(n = 14/135) ‘probably don’t do it’ (Yellow Measure); and
Occupational therapy intervention for children promotes
engagement and participation in children’s daily life roles
Iona Novak PhD, MSc (Hons), BAppSc; Head of Research. (Mandich & Rodger, 2006). Children’s roles include,
Ingrid Honan PhD, BPysch(Hons); Research Fellow. developing personal independence, becoming productive
Correspondence: Iona Novak, Cerebral Palsy Alliance, Dis- and participating in play or leisure pursuits (Roger et al.).
cipline of Child and Adolescent Health, The University of Inability to participate because of disease, disability or
Sydney, Camperdown, NSW, Australia. skill deficits, can cause marginalisation, social isolation
E-mail: inovak@cerebralpalsy.org.au and lowered self-esteem (Mandich & Rodger, 2006). Occu-
Conflict of interest pational therapists select interventions for children based
The authors have no conflicts of interest to disclose. upon an analysis of the child’s performance of daily life
Accepted for publication 29 January 2019.
roles, how their performance is affected by their disability,
© 2019 The Authors. Australian Occupational Therapy Journal and how their environment supports or constrains their
published by John Wiley & Sons Australia, Ltd on behalf of performance (Mandich & Rodger, 2006).
Occupational TherapyAustralia The practices of paediatric occupational therapists
This is an open access article under the terms of the Creative
have evolved and changed based on research and the-
Commons Attribution License, which permits use,
distribution and reproduction in any medium, provided the ory (Rodger, Brown & Brown, 2005), such as family cen-
original work is properly cited. tred care and the World Health Organisation’s (WHO)
EFFECTIVE PAEDIATRIC OCCUPATIONAL THERAPY 259
International Classification of Functioning, Disability infants OR physical disability OR rheumatoid arthritis
and Health (ICF; World Health Organisation, 2001). OR spina bifida); Intervention = occupational therapy
These frameworks have led many occupational thera- (including all specific named occupational therapy tech-
pists to move away from impairment-based interven- niques); Comparison = none specified; Outcome = all
tions at the body structures and functions level aimed outcomes accepted; and Study Design = SR OR ran-
at remediating the child’s deficits (known as ‘bottom- domised controlled trials (RCTs).
up’ interventions), and instead to focus on improving
functional activity performance and participation (‘top-
down’ interventions) (Weinstock-Zlotnick & Hinojosa, Methods
2004), as well as partnering with parents to deliver ther- Study design
apy embedded within daily life.
Clinicians will always have different expertise and A SR of reviews was conducted, to provide an overview
preferences, but there are financial and ethical ramifica- of the best available evidence. RCTs not included within
tions of delivering interventions. Ensuring the latest the SRs were also appraised.
research findings are easily accessible to families and
clinicians is vital. Occupational therapists positively
Search strategy
embrace evidence-based practice, but on the ground, This review was carried out according to the Cochrane
implementation can lag (Flores-Mateo & Argimon, 2007; Collaboration methodology (Higgins & Green, 2011),
Upton, Stephens, Williams & Scurlock-Evans, 2014). Sys- incorporating the recommended quality features for
tematic reviews (SR) indicate that the translation of the conducting SRs of reviews (Smith, Devane, Begley &
latest evidence into routine clinical care lags 10–20 years Clarke, 2011), and is reported according to the
in all countries and specialities (Flores-Mateo & Argi- PRISMA statement (Moher, Liberati, Tetzlaff & Alt-
mon), which for paediatric patients is an entire child- man, 2010). Relevant articles were identified by search-
hood. Multiple paediatric occupational therapy ing: CINAHL (1983–2016); Cochrane Database of
interventions exist to address children’s specific goals. Systematic Reviews (www.cochrane.org); Database of
In partnership with parents, it is the therapist’s role to Reviews of Effectiveness (DARE); EMBASE (1980–
choose and tailor the intervention choices to match the 2016); ERIC; Google Scholar; MEDLINE (1956–2014);
child and parent’s goals, preferences and potential for OTSeeker (www.otseeker.com); and PsycINFO (1935–
improvement based upon their diagnosis. Staying up- 2016). Searches were supplemented by hand searching
to-date is time-consuming. Furthermore, appraising evi- and retrieval of any additional articles meeting eligibil-
dence and up skilling in new interventions requires ity criteria that were cited in reference lists. The search
reallocation of time and resources. of all published studies was performed in March 2014
The aim of this paper is to systematically describe and updated in August 2018. Interventions and key-
current intervention options available to paediatric words for investigation were identified using the con-
occupational therapists across different child diagnostic tributing authors’ knowledge.
populations, rating the quality and recommendations
for use of each intervention, using the Grading of Rec- Inclusion criteria
ommendations Assessment, Development and Evalua- Published studies fulfilling the following criteria were
tion (GRADE) system (Guyatt et al., 2008) and the included: (i) Type of study: All SRs and RCTs meeting
Evidence Alert Traffic Light System (Novak & McIntyre, inclusion criteria were appraised. SRs were preferen-
2010). The purpose of reviewing and rating the entire tially sought since they provide a summary of large
evidence-base is to provide a ‘one-stop’ access guide for bodies of evidence and help to explain differences
clinicians and policy-makers, allow for the easy compar- amongst studies. Plus, SRs limit bias. We also included
ison of interventions, encourage the uptake of evidence- RCTs not included within the SRs, because they are
based interventions, to confer better outcomes for chil- the gold standard design for measuring the effective-
dren. We sought to answer the following ‘PICOs’ ques- ness of interventions. Lower levels of evidence were
tion: What is the effectiveness of occupational therapy only included if: the SR reviewed lower levels of evi-
intervention for children with disabilities? Popula- dence; (ii) Types of interventions: Studies that involved
tion = children with a disability (including arthrogypo- the provision of any type of occupational therapy
sis OR attention deficit hyperactivity disorder OR intervention; and (iii) Types of participants: Studies
autism spectrum disorder OR behaviour disorders OR that explicitly involved humans in which 100% of the
brachial plexus OR brain injury OR burns OR cerebral participants were children of any childhood disability
palsy OR cancer OR chronic pain OR developmental diagnosis.
coordination disorder OR developmental disability OR
down syndrome OR fetal alcohol spectrum disorder OR Exclusion criteria
learning disability OR mental health OR muscle dis- (i) Studies about typically developing children or adults;
eases; OR intellectual disability OR obesity OR preterm (ii) diagnostic studies OR prognostic studies OR about
© 2019 The Authors. Australian Occupational Therapy Journal published by John Wiley & Sons Australia, Ltd
on behalf of Occupational TherapyAustralia260 I. NOVAK ET AL.
outcome measure psychometrics OR about theoretical effect and is likely to change the estimate’; and very
frameworks NOT intervention; (iii) interventions that low scores indicate ‘any estimate of effect is very
primarily fall under the skillset of another profession, uncertain’ (Guyatt et al.).
for example pharmacotherapies, psychotherapy, speech
therapies, etc. (iv) a second publication of the same Strength of recommendation
study (Note: RCTs that met inclusion criteria but were Unlike SR frameworks, the GRADE framework does not
also cited within included SRs, were treated as dupli- solely examine effect size to determine efficacy of inter-
cates and not reported on twice); (v) studies were vention. Instead, effect size makes up just one compo-
unpublished or non-peer reviewed; and (vi) full-text nent when weighing up the benefits and harms of each
was not available in English. intervention. In line with the GRADE framework, the
following factors were considered by both independent
Data abstraction
raters when evaluating the body of evidence for the
A data abstraction form was devised based on the intervention and arriving at a strength of recommenda-
Cochrane’s recommendations (Higgins & Green, 2011). tion for each diagnostic group: (i) methodological qual-
Abstracts identified from searches were screened by ity regarding likely benefits vs. likely risks; (ii)
two independent raters. Both independent raters inconvenience; (iii) importance of the outcome that the
reviewed full-text versions of the articles and articles intervention prevents; (iv) magnitude of intervention
were retained if they met inclusion criteria. Agree- effect (effect size); (v) precision of estimate of effect; (vi)
ment on inclusion and exclusion assignment was burdens; (vii) costs; and (viii) varying clinician and fam-
unanimous. Data extracted from included studies ily values (Guyatt et al., 2008).
comprised: authors and date of study; type of inter- The Evidence Alert Traffic Light System (Novak &
vention (if named), core components and diagnostic McIntyre, 2010) was then applied based on the
population; who delivered the intervention; location of strength of recommendations by both independent
where the intervention was carried out; intensity of raters. The Evidence Alert Traffic Light System is a
the intervention; study design and original authors’ GRADE-complementary knowledge translation tool
conclusions about efficacy across study outcomes designed to assist clinicians and families to obtain
(Table S1). In addition, based on intervention descrip- easily readable, clinically useful answers within min-
tion and ICF definitions, reviewers assigned an ICF utes (Campbell, Novak, McIntyre & Lord, 2013),
domain to each intervention outcome sought by study because the alert uses a simple, three-level colour cod-
authors (World Health Organisation, 2001). Where ing that recommends a course of action. Green signi-
multiple SRs or RCTs existed, we noted when the fies ‘go’ because high quality evidence indicates
older research was superseded by newer evidence. effectiveness; red signifies ‘stop’ because high quality
Interventions with the same name and/or similar core evidence indicates harm or ineffectiveness; and yellow
components, and that were administered to the same signifies ‘measure’ because insufficient evidence exists
diagnostic populations, were grouped together. All to be certain about whether the child will benefit. Yel-
data required to answer the study questions were low can be assigned in three scenarios: (i) promising
published within the papers, so no contact with evidence (weak positive), (ii) unknown effectiveness
authors was necessary. All the supporting data are because no research exists, or (iii) evidence suggests
included with Table S1. possibly no effect (weak negative).
Quality of the evidence
Ethics and data
Quality ratings were assigned by two independent
The study did not involve contact with humans, so the
raters for each publication using GRADE (Guyatt et al.,
need for ethical approval was waived by the Cerebral
2008), which is endorsed by the World Health Organi-
Palsy Alliance’s National Health and Medical Council
zation. Within GRADE randomised trials are initially
Human Research Ethics Committee. This SR was not
rated high, observational studies low; and other levels
registered.
of evidence very low. However, high quality evidence
is downgraded if methodological flaws exist, and low
quality evidence is upgraded when high rigor and
Results
large effect sizes exist (Guyatt et al. ). Ultimately, a
high score indicates ‘further research is unlikely to 3138 citations were identified using the search strategy,
change our confidence in the estimate of effect’; mod- of which 129 articles met the inclusion criteria for
erate scores indicate ‘further research is likely to have review. Of the 129 included articles, 58% (n = 75/129)
an important impact on our confidence in the estimate were SRs; 42% (n = 54/129) were RCTs. Note, more
of effect and may change the estimate’; low scores than 54 RCTs exist in the paediatric occupational ther-
indicate ‘further research is very likely to have an apy evidence base, but we treated any RCT that was
important impact on our confidence in the estimate of cited within an included SR as a duplicate. Flow of
© 2019 The Authors. Australian Occupational Therapy Journal published by John Wiley & Sons Australia, Ltd
on behalf of Occupational TherapyAustraliaEFFECTIVE PAEDIATRIC OCCUPATIONAL THERAPY 261
outcomes (e.g. an orthotic worn by the child to improve
hand function), whereas the parent was the primary cli-
ent for 13% (n = 7/52) for the interventions (e.g. parent
education, aiming to improve knowledge, skills and
confidence).
Interventions
Included studies, researched the effectiveness of 52
occupational therapy intervention groups: (1) Acupunc-
ture; (2) Assistive Devices; (3) Assistive Technology; (4)
Behavioural Interventions including Applied Beha-
vioural Analysis (ABA) and Positive Parenting Program
(Triple P); (5) Bimanual Training; (6) Biofeedback; (7)
223 full-text Coaching; (8) Cognitive Interventions including CogFun,
records CogMed, (9) Cognitive Orientation to Occupational Per-
excluded
formance (CO-OP); (10) Conductive Education; (11)
Constraint Induced Movement Therapy (CIMT); (12)
CIMT &/or Bimanual; (13) Context Focused; (14) DittoTM
(hand held education & distraction device for burns
patients); (15) Early Intervention, including a Develop-
mental Approach, Neurodevelopmental Therapy (NDT)
and Goals Activity and Motor Enrichment (GAME); (16)
Electrical Stimulation (ES); (17) Family Centred Care;
(18) Feeding Interventions; (19) Goal Directed Training,
including Task Specific Training, Functional Training,
Neuromotor Task Training (NTT) and Motor Imagery;
(20) Handwriting Interventions; (21) Hippotherapy
[Therapeutic Horse Riding]; (22) Home Programs; (23)
FIGURE 1: PRISMA Flow Diagram
Joint Attention; (24) Massage; (25) Meditation and/or
Mindfulness; (26) Mental Health Interventions; (27)
information is presented in the PRISMA diagram Neuro-Developmental Therapy (NDT); (28) Occupa-
(Fig. 1). tional Therapy after BoNT; (29) Orthotics; (30) Pain
The results are now presented using PICO question Management; (31) Parent Counselling; (32) Parent Edu-
format headings. cation/Parent Training; (33) Picture Exchange Commu-
nication System (PECS); (34) Play Therapy; (35)
Population (Participants) Positioning; (36) Pressure Care; (37) School Therapy;
Included studies were across the following childhood (38) Self-Management; (39) Sensation Training; (40) Sen-
disability diagnoses: arthrogyposis; attention deficit sory Approach, including brushing, therapy balls,
hyperactivity disorder (ADHD); autism spectrum dis- weighted vests, warm-ups, sensory stimulation; (41)
order (ASD); behaviour disorders; brachial plexus Sensory Integration, including sensory diets, swinging,
injury; brain injury (BI); burns; cerebral palsy (CP); brushing, therapy balls, weighted vests, body socks; (42)
cancer; chronic pain; developmental coordination dis- Skills Training via Mental Imagery; (43) Sleep Interven-
order (DCD); developmental disability (DD); Down tions; (44) Social Skills Training; (45) Stretching, includ-
syndrome; foetal alcohol spectrum disorder; learning ing passive: self-administered, therapist-administered
disability (LD); mental health; intellectual disability and device-administered; (46) Treatment and Education
(ID); obesity; preterm infants; physical disability; of Autistic and Communication Handicapped Children
rheumatoid arthritis; and spina bifida. Some studies (TEACCH); (47) Therapeutic Listening; (48) Treadmill
included samples from a variety of the aforementioned Training; (49) Visual Motor Interventions; (50) Weight
diagnoses. Consistent with childhood disability popu- Loss; (51) Whole Body Vibration; and (52) Yoga.
lation incidence data, more research existed about ASD
(n = 32/135; 24%), ADHD (n = 8/135; 6%), CP Outcomes
(n = 38/135; 28%) and DCD (n = 9/135; 7%), than Of the 12 included articles, authors measured the effec-
other conditions. tiveness of 52 occupational therapy interventions, across
Paediatric occupational therapy involves working 22 diagnoses. From this, 136 intervention outcome indi-
with the child, the parent and the family unit: The child cators were identified, whereby an intervention, with an
was the primary client for 87% (n = 45/52) of the inter- individual target outcome was administered to specific
ventions, i.e. therapy focussed on improving the child diagnostic groups. Insufficient data was available for
© 2019 The Authors. Australian Occupational Therapy Journal published by John Wiley & Sons Australia, Ltd
on behalf of Occupational TherapyAustralia262 I. NOVAK ET AL. analysis on one of these outcome indicators (number 74 Schaaf, Dumont, Arbesman & May-Benson, 2018; Smith in Table S1, where the SR authors found no publish et al., 2014; Snider, Majnemer & Darsaklis, 2010; Storebø data examining the effectiveness of hand orthotics in et al., 2011; Tatla et al., 2013; Tatla, Sauve, Jarus, Virji- children with brain injury and therefore no recommen- Babul & Holsti, 2014; Vargas & Lucker, 2016; Westen- dations could be made), (Jackman, Novak & Lannin, dorp et al., 2014; Whalen & Case-Smith, 2012; Xu, He, 2014) resulting in 135/136 intervention outcome indica- Mai, Yan & Chen, 2015; Zadnikar & Kastrin, 2011; tors available for analysis. Ziviani, Feeney, Rodger & Watter, 2010; Zwicker & Of the 135 intervention outcome indications: 30% Mayson, 2010); 10% (n = 14/130) were graded ‘probably (n = 40/135) were graded ‘do it’ (Green Go) (Arbesman, don’t do it’ (Yellow Measure) (Wallen & Gillies, 2006; Bazyk & Nochajski, 2013; Bellows et al., 2011; Bleyen- Wells, Marquez & Wakely, 2018); and 4% (n = 6/135) heuft, Arnould, Brandao, Bleyenheuft & Gordon, 2015; were graded ‘don’t do it’ (Red Stop) (Gringras et al., Brown, Kimble, Rodger, Ware & Cuttle, 2014; Chang & 2014; Katalinic et al., 2010). Yu, 2014; Chen, Pope, Tyler & Warren, 2014c; Chen The 40 green light ‘do it’ interventions indications et al., 2014b; Christmas, Sackley, Feltham & Cummins, included: (1) Behavioural Intervention using ABA for 2018; Crompton et al., 2007; Estes et al., 2014; Fehlings children with ASD; (2) Behavioural Intervention using et al., 2010; Frolek Clark & Schlabach, 2013; Hechler Triple P for children behaviour disorders; (3) Beha- et al., 2014; Heinrichs, Kliem & Hahlweg, 2014; Hoare & vioural Intervention using token economy contracts for Imms, 2004; Hoare, Imms, Carey & Wasiak, 2007; Hoare children with a brain injury; (4) Bimanual Training for et al., 2010; Hoy, Egan & Feder, 2011; Huang, Fetters, children with hemiplegic CP; (5) Coaching for parents Hale & McBride, 2009; Inguaggiato, Sgandurra, Perazza, of children at risk of disability to promote development; Guzzetta & Cioni, 2013; Kamps et al., 2015; Kasari et al., (6) Coaching for parents of children with ASD to pro- 2016; Kaya Kara et al., 2015; Kurowski et al., 2014; Lan- mote function and behaviour; (7) CAPS cognitive inter- nin, Scheinberg & Clark, 2006; Lidman, Nachemson, vention for children with brain injury to improve long Peny-Dahlstrand & Himmelmann, 2015; Lin & Wuang, term executive function; (8) Cog-Fun intervention for 2012; Madlinger-Lewis et al., 2014; Maeir et al., 2014; children with attention deficit disorder to improve exec- Novak, 2014a; Park, Maitra, Achon, Loyola & Rinc on, utive function; (9) CO-OP for children with DCD for 2014; Speth et al., 2015; Spittle, Orton, Anderson, Boyd functional motor task performance; (10) CIMT for chil- & Doyle, 2012; Spittle, Orton, Doyle & Boyd, 2007; Stav- dren with CP to improve hand function; (11) CIMT plus ness, 2006; Stickles Goods, Ishijima, Chang & Kasari, Bimanual for children with CP to improve hand func- 2013; Vroland-Nordstrand, Eliasson, Jacobsson, Johans- tion; (12) Context Focused intervention for children with son & Krumlinde-Sundholm, 2016; Zwaigenbaum et al., CP for functional motor task performance; (13) Ditto 2015); 56% (75/135) were graded ‘probably do it’ (Yel- hand held devices for children with burns to provide low Measure) (Armstrong, 2012; Au et al., 2014; Auld, procedural distraction and self-management education; Russo, Moseley & Johnston, 2014; Bialocerkowski, Kur- (14) Early Intervention using ABA for children with lowicz, Vladusic & Grimmer, 2005; Bodison & Parham, ASD; (15) Early Intervention using Developmental Care 2018; Cameron et al., 2017a, 2017b; Chacko et al., 2014; for preterm infants; (16) Family Centred Care for chil- Chantry & Dunford, 2010; Chen, Lee & Howard, 2014a; dren with brain injury or CP, to improve children’s Chiu, Ada & Lee, 2014; Cole, Harris, Eland & Mills, function; (17) Parent education feeding intervention for 1989; Copeland et al., 2014; Dagenais et al., 2009; De children with disability to improve feeding competency Vries, Beck, Stacey, Winslow & Meines, 2015; Duncan and growth; (18) Physiological feeding intervention for et al., 2012; Fedewa, Davis & Ahn, 2015; Grynszpan, children with disability; (19) Goal Directed Training for Weiss, Perez-Diaz & Gal, 2014; Hahn-Markowitz, Ber- children with CP, to improve functional task perfor- ger, Manor & Maeir, 2017; Hammond, Jones, Hill, Green mance; (20) Goal Directed Training for children with & Male, 2014; Huang et al., 2014; Jackman et al., 2018; DCD, to improve functional task performance; (21) James, Ziviani, Ware & Boyd, 2015; Janesl€att, Kottorp & Handwriting Task-Specific Practice for children with Granlund, 2014; Jones et al., 2014; Krisanaprakornkit, DCD; (22) Home Programs for children with CP, to Ngamjarus, Witoonchart & Piyavhatkul, 2010; Lannin, improve functional task performance; (23) Home Pro- Novak & Cusick, 2007; Malow et al., 2014; Maskell, grams for children with ID, to improve functional task Newcombe, Martin & Kimble, 2014; Mast et al., 2014; performance; (24) Joint Attention for children with ASD Matute-Llorente, Gonzalez-Ag€ uero, G omez-Cabello, to improve social interactions; (25) Mental Health inter- Vicente-Rodrıguez & Mallen, 2014; McLean et al., 2017; ventions for children with ASD; (26) Mental Health Meany-Walen, Bratton & Kottman, 2014; Miller-Kuha- interventions for children with developmental delay; neck & Watling, 2018; Montero & G omez-Conesa, 2014; (27) Mental Health interventions for children with men- Morgan, Novak, Dale & Badawi, 2015; Morgan et al., tal health disorders; (28) Occupational therapy after 2016a; Morgan, Novak, Dale, Guzzetta & Badawi, botulinum toxin injections for children with CP to pro- 2016b; Pfeiffer B & Arbesman, 2018; Polatajko & Cantin, mote hand function; (29) Kinesiotape for children with 2010; Reeuwijk, van Schie, Becher & Kwakkel, 2006; CP to improve hand function; (30) Pain Management for © 2019 The Authors. Australian Occupational Therapy Journal published by John Wiley & Sons Australia, Ltd on behalf of Occupational TherapyAustralia
EFFECTIVE PAEDIATRIC OCCUPATIONAL THERAPY 263
FIGURE 2: Occupational Therapy Interventions and the International Classification of Function
children with chronic pain secondary to physical disabil- yellow, which we illustrated by yellow shading in Fig-
ity and or chronic health conditions; (31) Parent Educa- ure 2. All the red lights within the evidence base
tion using mindfulness for parents of children with ASD existed at the body structures and function level. At the
to reduce parental stress; (32) Parent Education using environmental level, the most common traffic code was
problem solving for parents of children with ASD to also yellow, which we illustrated by yellow shading in
reduce parental stress; (33) Parent Education for children Figure 2. Two intervention’s primary ICF code was at
with disabilities to promote parenting confidence; (34) the participation level (Willis et al., 2016) and none at
Parent Education for children with behaviour disorders the personal level, indicating gaps in the occupational
to improve parent well-being; (35) PECS for children therapy evidence base, which we illustrated using grey
with ASD to promote communication; (36) Positioning in shading in Figure 2. The two participation codes were
NICU for preterm infants to promote normal movement weak positive, but these were based on trials that used
development; (37) Pressure Care for children with CP activity-based interventions and assumed an upstream
using mattresses and cushions; (38) Social Skills Training participation gain, which was not well-supported.
mediated by peers for children with ASD; (39) Treadmill
training for children with Down Syndrome to accelerate Comparisons
the onset of independent walking; (40) Weight loss using In the included papers, consistent with conventional
a family education and activity program called ‘Mighty beliefs about it being unethical to withhold early interven-
Moves’ for children with obesity. tion from children, rarely did researchers design studies
We assigned an ICF category to the primary and sec- where the control group received no intervention. In most
ondary intervention outcome of each intervention. studies, the controlled comparison was usual care. Some
Using the primary ICF level code, we mapped the pro- researchers carried out short duration studies using a
file of the paediatric OT evidence base to the ICF frame- wait-list control design, where the control group received
work (Fig. 2). Green light effective interventions existed the experimental intervention after study completion.
at the body structures and function ICF level (n = 14/74 CIMT for children with CP, was the only intervention
indications (19%)), the activity level (n = 14/27 indica- comprehensively and empirically compared to other
tions (52%)) and the environment level (n = 12/34 indi- intervention options, using head-to-head RCT compar-
cations (35%)). When we compared the proportions of isons identified in our search strategy. CIMT was: (i)
green light to yellow light to red light interventions by compared head-to-head with Bimanual Training showing
ICF levels, the activity level contained the largest num- no difference between the approaches (Sakzewski et al.,
ber of green lights. At the activity level where there was 2015; Tervahauta, Girolami & Øberg, 2017); and (ii) com-
27 indications, green lights outweighed the number of bined with Bimanual Training and/or Botulinum toxin
yellow and red lights (Gree n = 14/27; Yellow = 13/27; A, showing no additive benefits occurred from a com-
Red = 0/27), meaning the most common traffic code at bined intervention approach (Hoare et al., 2013). These
the activity level was green, which we illustrated by researcher’s concluded ‘intensity’ of practice was the key
green shading in Figure 2. At the body structures and ingredient of these effective CP approaches (Sakzewski
function ICF level, the most common traffic code was et al.; Tervahauta et al., 2017).
© 2019 The Authors. Australian Occupational Therapy Journal published by John Wiley & Sons Australia, Ltd
on behalf of Occupational TherapyAustralia264 I. NOVAK ET AL.
Motor outcomes Behavioural outcomes Pain Function Self Feeding
manage
Effective Effective
Hand-
EI Pain Effective
CIMT Develop- ABA Manage- Parent
writing mental Family
CP Bimanual Task ASD Triple P ment Education
S+ Do it CP Practice
Approach S+ Do it Behav Dis Mixed S+ Do it Centred Care Mixed
Preterm Bi, CP
OT + DCD
BoNTA Goal-
Goal- Tread- Directed Physio-
CP Home Directed Token DittoTM
Program CO-OP mill Burns Training logical
Training DCD Downs Economies Home CP Mixed
CP CP Synd. BI Program
CP, ID
Orthotics Context
Focused
Positioning Brachial CP
CP Plexus, CP, Visual
Hypermob Motor
Probably Casting DD Probably Assistive Probably
W+ do it CP
EI
GAME CO-OP Assistive W+ do it Tech W+ do it
CP ASD, Tech Smart Self
CP VR Phones Assistive Behavioural
Devices Management
CP, DCD Meditation Behav Dis Interventions
Skills Spina Bifida,
Hippo- CP, Mixed ASD, Mixed
therapy Training ADHD, Mixed
ASD,CP Mental ASD Behavioural
Rehears Triple Interventions
DCD P CP Task
Tread- ADHD Training
mill Mental
CP, Imagery
Mixed Ball
ASD Skills
DCD
Bio- Massage Sensory
Body School Approach SI
Yoga Feed- Vibration CP
ASD back Therapy ASD ASD
CP, Mixed
Worth it line CP DD
Worth it line Worth it line
Orthotics Thera-
Conductive JRA suits
Education ASD
CP
Stretch
Probably Probably Probably
W- don’t do it
CP,
Mixed
W- don’t do it Sensory W- don’t do it
Approach
Sensory ADHD,
Approach ASD
SI CP, DCD,
CP, Mixed
DCD
Hand-
writing Sensory Sensory
S- Don’t do it NDT Sensory S- Don’t do it Integration S- Don’t do it Integration
ASD
CP ASD
Approach
DCD
Ineffective Ineffective Ineffective
ASD=Autism Spectrum Disorder; BoNTA=Botulinum Toxin; CP=Cerebral Palsy; DCD=Developmental Coordination Disorder;
DD=Developmentally Delayed; Downs Synd=Downs Syndrome; Hypermob=Hypermobile; JRA=Juvenile Rheumatoid Arthritis; ABA=Applied Behavioural Analysis; ADHD=Attention Deficit Hyperactivity Disorder; ASD=Autism Spectrum Disorder; Behav ASD=Autism Spectrum Disorder; BI=Brain Injury; CP=Cerebral Palsy; DCD=Developmental Coordination Disorder; ID=
NDT=Neurodevelopmental Therapy; SI=Sensory Integration; VR=Virtual Reality Dis=Behavioural Disorder; BI=Brain Injury; CP=Cerebral Palsy Intellectual Disability; SI=Sensory Integration
Cognitive outcomes Sense Sleep Mental
Parent outcomes Social health
Effective
Effective
Health
EI Develop- Promotion
S+ Do it mental S+ Do it Coaching Mental
Approach ASD, At Risk Joint
Attention Health
Preterm Problem ASD Life
Solving Skills
ASD
Cog-Fun ALERT CAPS Parent PECS Training
ADHD FASD BI Mindful- Education ASD DD
ness Mixed
Social
ASD Peer Skills
Mediated Training
ASD ASD
Probably Probably
W+ do it W+ do it
Parent
TEACCH Education
ASD, Mixed ADHD, ASD,
BI, CP DIR
Play Counselling
Floortime
Therapy CP
DIR Coaching ASD
AdPT Floortime Sleep Sleep
Behav Dis, Social
ASD ASD Assistive Hygiene Hygiene
Proprio- Attach- BI, CP, DD, Skills
Tech VR ASD ment LD ASD
BI, Phys
ceptive Training
Home Hypermob Training ADHD,
Time Dis ASD ASD
Aides Program
ADHD ASD Play Sensation Play
Therapy Training Therapy
CP CP CP
Worth it line Worth it line
Cog-
Med
ADHD
Probably Probably
W- don’t do it W- don’t do it
Sensory Weighted
S- Don’t do it Integration Blankets
ASD
S- Don’t do it
ASD
Ineffective Ineffective
ADHD=Attention Deficit Hyperactivity Disorder; ASD=Autism Spectrum Disorder; BI=Brain Injury; CP=Cerebral Palsy;
DCD=Developmental Coordination Disorder; FASD=Fetal Alcohol Spectrum Disorder; Hypermob=Hypermobile; SI=Sensory ASD=Autism Spectrum Disorder; BI=Brain Injury; CP=Cerebral Palsy; DCD=Developmental Coordination Disorder;
Integration; VR= Virtual Reality DD=Developmentally Delayed; ID=Intellectual Disability; LD=Learning Disability
FIGURE 3: Bubble Charts Comparing the Effectiveness of Different Occupational Therapy Indications for Different Diagnoses
A meta-analysis of intervention options for children more effective than ‘bottom-up’ approaches (effect
with DCD compared the relative effect of DCD motor size = 0.12).
interventions by calculating and comparing effect sizes To assist with comparative clinical decision-making
(Smits-Engelsman et al., 2013). The authors calculated across the paediatric occupational therapy evidence base,
that ‘top-down’ approaches (effect size = 0.89) were we created bubble charts. We mapped the 52 identified
© 2019 The Authors. Australian Occupational Therapy Journal published by John Wiley & Sons Australia, Ltd
on behalf of Occupational TherapyAustraliaEFFECTIVE PAEDIATRIC OCCUPATIONAL THERAPY 265
paediatric occupational therapy interventions, across 22 parenting. Evidence suggests that parent-delivered
diagnoses, spanning 135 intervention indications, which intervention is equally effective to therapist-delivered
sought to provide analogous outcomes, by diagnosis, into intervention (Baker et al., 2012), which is not surprising
separate bubbles. In the bubble charts, the size of the given parent’s knowledge of their children’s preferences
bubble indicated the volume of published evidence, and engagement style, and the volume of caregiving
which was calculated by counting the number of pub- they carryout (Smith, Cheater & Bekker, 2015). In the
lished studies on the topic. The location of the bubble on diagnoses studied (ADHD, ASD, At risk, Behavioural
the y-axis of the graph corresponded to the GRADE sys- Disorders, BI, CP, DD, LD, obesity), it was very clear
tem rating. The colour of the bubble denoted the Traffic that parents respond well to parent education and train-
Light Evidence Alert System rating (Fig. 3). ing (Antonini et al., 2014; Barlow, Smailagic, Huband,
Roloff & Bennett, 2012; Case-Smith & Arbesman, 2008;
Dykens, Fisher, Taylor, Lambert & Miodrag, 2014; Fein-
Discussion berg et al., 2014; Hanna & Rodger, 2002; Howe & Wang,
We set out to systematically summarise the current inter- 2013; Kuhaneck, Madonna, Novak & Pearson, 2015;
vention options available to paediatric occupational ther- Lawler, Taylor & Shields, 2013; Tanner, Hand, O’toole
apists across different childhood disability populations. & Lane, 2015; Zwi, Jones, Thorgaard, York & Dennis,
We found 40 interventions that received a ‘strong’ rec- 2011), consistent with family centred philosophy about
ommendation for use, indicating a high-quality evidence parents’ aspirations of parenting well, to help their chil-
base with more benefits than harms. These ‘green light’ dren (Hanna & Rodger, 2002). Moreover, parents and
interventions included: Behavioural Interventions (in- children carry out intervention effectively at home, and
cluding ABA, Triple P and Token Economies); Bimanual; therefore home programs (Novak & Berry, 2014b;
Coaching; Cognitive Cog-Fun and CAPS; CO-OP; CIMT; Novak et al., 2013; Sakzewski, Ziviani & Boyd, 2013;
CIMT plus Bimanual; Context-Focused; Ditto; Early Inter- Sakzewski et al., 2015; Wuang, Ho & Su, 2013) and self-
vention (including ABA and Developmental Care); Fam- management programs (Lindsay, Kingsnorth, Mcdou-
ily Centred Care; Feeding interventions (including gall & Keating, 2014; Moola, Faulkner, White & Kirsh,
coaching and physiologic); Goal Directed Training; 2014) are an effective method for increasing the inten-
Handwriting Task-Specific Practice; Home Programs; sity of therapy.
Joint Attention; Mental Health Interventions; occupa- When carrying out parent education, literature tells
tional therapy after BoNT; Kinesiotape; Pain Manage- us that parents need and want: knowledge of the condi-
ment; Parent Education; PECS; Positioning in NICU; tion and intervention options; help accessing support
Pressure Care; Social Skills Training Peer Mediated; services; and advice about coping strategies, via a col-
Treadmill training and Weight loss ‘Mighty Moves’. laborative partnership (Smith et al., 2015). Even though
The paediatric occupational therapy evidence base is family centred practice has existed since the 1990s, par-
under immense growth and expansion. The SRs and tri- ents still experience some resistance to their input from
als greater than 10 years old were predominantly about health professionals (Smith et al.). Unclear expectations
CP with one study about Brachial Plexus and DD. about roles further elevate parental stress (Coyne, 2015).
Almost always these older studies showed that the ‘bot- Occupational therapists therefore need to be mindful of
tom-up’ interventions were ineffective with no differ- parent’s experiences and aim to clearly communicate
ence between the experimental and control groups. information and coach parents to guide care, to opti-
mise family outcomes (Coyne).
Clinical Implications
Occupational therapists working with children and their B. Activities-based, ‘top-down’ interventions deliver
parents have several evidence based interventions to bigger gains
choose from. The strength of this paper is that it provides Numerous occupational therapy interventions exist,
a systematic, clear and concise summary of all the avail- aiming to improve motor, behavioural and functional
able interventions by diagnosis with an easy to interpret outcomes (Fig. 3), affording a lot of choice to families
summary of efficacy. There are some important learnings: and clinicians. The greatest number of effective green
light interventions was at the activity level of the ICF,
A. Parent partnership within occupational therapist indicating that daily life skills training using a ‘top-
intervention is effective and worthwhile down’ approach is a strength of the occupational ther-
Occupational Therapists embrace the principles of fam- apy profession. Examples include: Bimanual Training;
ily centred care (Hanna & Rodger, 2002) where the par- CIMT; CO-OP; GAME; Goal-Directed Training; Hand-
ent is the decision-maker and the expert in knowing writing Task Training; Home Programs using Goal-
their child and the therapist is a technical resource to Directed Training; Social Skills Training; and Task
the family. We found that 13% of paediatric occupa- Training. Consistent with current knowledge about the
tional therapy interventions are directed at the parent, conditions for inducing neuroplasticity (Kleim & Jones,
so parents can deliver intervention at home within daily 2008), the green light, ‘top-down’, activity level
© 2019 The Authors. Australian Occupational Therapy Journal published by John Wiley & Sons Australia, Ltd
on behalf of Occupational TherapyAustralia266 I. NOVAK ET AL. interventions all have the following key ingredients in interventions into expanded NDT/Bobath umbrella common: (i) begin with the child’s goal, to optimise terms. motivation and saliency of practice; (ii) practice of real- We analysed the breakdown of the effectiveness of life activities in natural environments to optimise the motor interventions, above and below the worth it line child’s learning and the variability of the practice; (iii) (Fig. 3), in terms of ‘bottom-up’ vs. ‘top-down’, and a intense repetitions to activate plasticity, including trend favouring ‘top-down’ emerged. Of the seven motor home-based practice; and (iv) scaffolded practice to the intervention indications below the ‘worth it line’, coded ‘just right challenge’ to enable success under self-gener- on GRADE as weak negative or strong negative (red), 7/ ated problem-solving conditions, to optimise enjoyment. 7 (100%) were ‘bottom-up’ approaches. Of the 22 motor In contrast, some of the most established paediatric intervention indications above the ‘worth it line’ eight occupational therapy interventions NDT/Bobath and SI were green and 14 were yellow: 8/8 (100%) green indica- were originally developed as ‘bottom-up’ interventions. tions (strong positive) were ‘top-down’. A similar trend NDT/Bobath and SI originated in an era of medicine emerged in the comparative effectiveness analysis of when intervention aimed to remediate the child’s body functional interventions. Of the seven functional inter- structural deficits, thinking function would emerge vention indications above the ‘worth it line’, coded on (Rodger et al., 2005; Rodger et al., 2006). However, over GRADE as strong positive (green), 4/4 (100%) were ‘top- time the NDT/Bobath and SI approaches have been down’. There were a small number of studies using SI broadened to also accommodate use of ‘top-down’ func- and the sensory approach to improve function coded on tional training approaches. Fidelity to the original GRADE as weak positive, but the studies had a high risk NDT/Bobath and SI approach therefore varies greatly of bias and SR authors recommended interpreting the (Mayston, 2016), and as such, a leading Bobath expert positive results with caution (Case-Smith et al., 2014; has recently stated that Bobath ‘no longer stands for a Case-Smith et al., 2015; Watling & Hauer, 2015). valid universal therapy approach’ (Mayston, 2016, p. 994). This means that interpreting the meaning of histor- Research Implications ical NDT/Bobath and SI research evidence about effi- The following areas of the evidence-base would benefit cacy within the context of contemporaneous clinical from more research: (i) Parent Education: None of the practice is challenging. The efficacy of both NDT/ parent education approaches were ineffective. Thus, Bobath and SI have been critiqued within SRs (Boyd & more research is worthwhile exploring parent’s pre- Hays, 2001; Brown & Burns, 2001; Case-Smith & Arbes- ferred learning styles and levels of support required to man, 2008; Case-Smith, Clark & Schlabach, 2013; Case- manage the stress of raising a child with a disability. Smith, Weaver & Fristad, 2015; Lang et al., 2012; May- There are potential financial gains to the health system Benson & Koomar, 2010; Novak et al., 2013; Sakzewski, by thoroughly understanding effective parent interven- Ziviani & Boyd, 2009; Sakzewski et al., 2013; Steultjens tions, because parent-delivered intervention is equally et al., 2004; Watling & Hauer, 2015; Weaver, 2015) and effective and less expensive; (ii) Head-to-head compar- these data mostly relate to older trials. SR authors have isons: Head-to-head comparisons of different interven- concluded that NDT/Bobath and SI rarely confer motor tions aiming to achieve the same outcomes, in well- gains superior to no intervention, but the RCTs contain controlled trials with cost-effectiveness data, would so many methodological flaws that recommendations enable determinations about best practice to be made for use or discontinuation of use within practice cannot from good evidence, and thus inform parent and pol- be made with certainty (Boyd & Hays, 2001; Brown & icy-maker’s decision-making; (iii) ‘Dose’ comparison stud- Burns, 2001; Case-Smith & Arbesman, 2008; Case-Smith ies: ‘Dose’ comparison studies using well controlled et al., 2013; Case-Smith et al., 2014; Lang et al., 2012; intensity trials would enable occupational therapists to May-Benson & Koomar, 2010; Novak et al., 2013; Sak- better inform parents about ‘how much’ intervention is zewski et al., 2009, 2013; Steultjens et al., 2004; Watling enough; and (iv) Participation Interventions: There is a & Hauer, 2015; Weaver, 2015). Some therapists have clear gap in the evidence-base about interventions that interpreted the uncertainty of the NDT/Bobath and SI directly improve a child’s participation in life and systematic evidence as justification of continuance, should be the focus of future RCTs and other rigorous whereas others in the profession recommend discontin- methodologies. CIMT, Bimanual and Home Program uance because of the growing body of ‘top-down’ evi- occupational therapy interventions were measured to dence that offer effective alternatives (Rodger et al., confirm whether or not they conferred participation 2006). A Bobath expert has recommended that the com- gains, and the clinical trials demonstrated no between mon-sense way forward for the profession is to choose group differences (Adair, Ullenhag, Keen, Granlund & interventions that promote activity and participation Imms, 2015). These results indicate that there is a clear outcomes (Mayston, 2016) and to use consistent lan- need to develop interventions that specifically target guage to describe intervention options. For example, participation, rather than anticipating activities-based describing interventions by clear uniform terminology interventions will confer upstream participation gains. (i.e. ‘splitting’) might be more helpful than ‘clumping’ Changes in participation are multifactorial and involve © 2019 The Authors. Australian Occupational Therapy Journal published by John Wiley & Sons Australia, Ltd on behalf of Occupational TherapyAustralia
EFFECTIVE PAEDIATRIC OCCUPATIONAL THERAPY 267
individual factors, contextual factors, the nature of the designed the study, extracted the data, conducted the
participation activity and the environment in which the analyses and wrote the manuscript. Ingrid Honan con-
activity is being performed (Imms et al., 2017). Any new ducted the analyses and wrote the manuscript. All
participation intervention invented, will need to address authors read and approved the final manuscript.
all of these factors to be successful.
Limitations Funding
Our review has several limitations. First, we only included The study was unfunded and there are no competing
SRs and RCTs because we aimed to analyse best-available financial disclosures.
evidence, but means some intervention approaches will
have been excluded and overlooked because no trials or
Conflict of interest
reviews existed. Second, this was an analysis of secondary
data sources and reporting bias and publication bias may The authors have no conflicts of interest to disclose.
be in operation, because positive findings have a higher
chance of being published. This evidence may exist sug- References
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