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Practice Framework 2nd Edition 8/22/08 1:32 PM Page 625

OCCUPATIONAL THERAPY PRACTICE

FRAMEWORK:
Domain &2nd
Process
Edition

Contents INTRODUCTION
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .625

Domain of Occupational Therapy . . . . . . . . . . . . . . . . . . . .626


The Occupational Therapy Practice Framework: Domain and Process, 2nd
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .626

Supporting Health and Participation in Life


Edition (FrameworkII) is an ofcial document of the American
Through Engagement in Occupation . . . . . . . . . . .628

Areas of Occupation . . . . . . . . . . . . . . . . . . . . . . . . . .630


Occupational Therapy Association (AOTA). Intended for internal and
Client Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .630

Activity Demands . . . . . . . . . . . . . . . . . . . . . . . . . . . .634

external audiences, it presents a summary of interrelated constructs that


Performance Skills . . . . . . . . . . . . . . . . . . . . . . . . . . .639

Performance Patterns . . . . . . . . . . . . . . . . . . . . . . . . .641

dene and guide occupational therapy1 practice. The Framework was


Context and Environment . . . . . . . . . . . . . . . . . . . . . .642
developed to articulate occupational therapys contribution to promot
Process of Occupational Therapy . . . . . . . . . . . . . . . . . . . .646

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .646
ing the health and participation of people, organizations, and popula
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .649

Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .652
tions through engagement in occupation. It is not a taxonomy,
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .660

Historical and Future Perspectives on the Occupational theory, or model of occupational therapy and therefore must be used in
Therapy Practice Framework . . . . . . . . . . . . . . . . . . .664

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .667

conjunction with the knowledge and evidence relevant to occupation


Tables and Figures

Table 1. Areas of Occupation . . . . . . . . . . . . . . . . . . .631

and occupational therapy. The revisions included in this second edition


Table 2. Client Factors . . . . . . . . . . . . . . . . . . . . . . . .634
are intended to rene the document and include language and concepts
Table 3. Activity Demands . . . . . . . . . . . . . . . . . . . . .638

Table 4. Performance Skills . . . . . . . . . . . . . . . . . . . .640


relevant to current and emerging occupational therapy practice.
Table 5A. Performance PatternsPerson . . . . . . . . .643

Table 5B. Performnance PatternsOrganization . . . .643


Implicit within this summary are the professions core beliefs in the pos
Table 5C. Performance PatternsPopulation . . . . . .644

Table 6. Contexts and Environments . . . . . . . . . . . . .645


itive relationship between occupation and health and its view of people as
Table 7. Operationalizing the Occupational Therapy

Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .648

occupational beings. All people need to be able or enabled to engage in the


Table 8. Types of Occupational Therapy

Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .653

occupations of their need and choice, to grow through what they do, and
Table 9. Occupational Therapy Intervention
to experience independence or interdependence, equality, participation,
Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .657

Table 10. Types of Outcomes . . . . . . . . . . . . . . . . . . .662


security, health, and well-being (Wilcock & Townsend, 2008, p. 198).
Table 11. Summary of Signicant Framework

Revisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .665
With this aim, occupational therapy is provided to clients, the entity that
Figure 1. Occupational Therapys Domain . . . . . . . . .627

Figure 2. Occupational Therapys Process . . . . . . . . .627


receives occupational therapy services. Clients may be categorized as
Figure 3. Occupational Therapy . . . . . . . . . . . . . . . . .627

Figure 4. Aspects of Occupational Therapys

Persons, including families, caregivers, teachers, employers, and


Domain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .628

Figure 5. Process of Service Delivery . . . . . . . . . . . .646

relevant others;
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .669
Organizations, such as businesses, industries, or agencies; and
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .676

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .681
Populations within a community, such as refugees, veterans who
Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .683

are homeless, and people with chronic health disabling condi


Copyright 2008, by the American Occupational Therapy
tions (Moyers & Dale, 2007).
Association. When citing this document the preferred reference

is: American Occupational Therapy Association. (2008).


The Framework is divided into two major sections: (1) the domain,
Occupational therapy practice framework: Domain and process

(2nd ed.). American Journal of Occupational Therapy, 62,

which outlines the professions purview and the areas in which its mem
625683.

Many of the terms that appear in bold are dened in the glossary.
1

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Practice Framework 2nd Edition 8/22/08 1:32 PM Page 626

of the denitions of these terms discussed in the


The Framework was literature.
developed to articulate
occupational therapys Domain of Occupational Therapy
Overview
contribution to This edition of the Framework begins with a
promoting the health description of the occupational therapy professions
domain. The overarching statementsupporting
and participation of health and participation in life through engage
ment in occupationdescribes the domain in its
people, organizations, fullest sense. Within this diverse profession, the
and populations dening contribution of occupational therapy is
the application of core values, knowledge, and
through engagement skills to assist clients (people, organizations, and
in occupation. populations) to engage in everyday activities or
occupations that they want and need to do in a
manner that supports health and participation.
bers have an established body of knowledge and Figure 4 identies the aspects of the domain and
expertise (see Figure 1), and (2) the dynamic occu illustrates the dynamic interrelatedness among
pation and client-centered process used in the them. All aspects of the domain are of equal value,
delivery of occupational therapy services (see and together they interact to inuence the clients
Figure 2). The domain and process of occupation engagement in occupations, participation, and
al therapy direct occupational therapy practition health.
ers2 to focus on performance of occupations Occupational therapists are educated to evalu
that results from the dynamic intersection of the ate aspects of the occupational therapy domain and
client, the context and environment, and the their transactional relationships. Occupational
clients occupations (Christiansen & Baum, 1997; therapists and occupational therapy assistants are
Christiansen, Baum, & Bass-Hagen, 2005; Law, educated about the aspects of the occupational
Baum, & Dunn, 2005). Although the domain and therapy domain and apply this knowledge to the
process are described separately, in actuality, they intervention process as they work to support the
are inextricably linked in a transactional relation health and participation of their clients.
ship (see Figure 3). Occupational therapists are responsible for all
Numerous resource materials, including an aspects of occupational therapy service delivery and
appendix, a glossary, references, and a bibliogra are accountable for the safety and effectiveness of
phy, are supplied at the end of the document. that service delivery process. Occupational therapy
Although the Framework includes a glossary of assistants deliver occupational therapy service
dened terms, it does not contain an exhaustive or under the supervision of and in collaboration with
uniform list of terms used in the profession nor all an occupational therapist (AOTA, 2004b).

2When the term occupational therapy practitioner is used in this document, it refers to occupational therapists and occupa
tional therapy assistants (AOTA, 2006).
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CONTEXT ENVIRONMENT


E
MA Y

ILL NC
S
DE TIVIT
ND

SK RMA

N
S

INTE
TIO
AC

Occupational Intervention

FO
Plan

LUA

RVE
Prole
R
PE

EVA
Intervention

NTIO
Analysis of
Implementation

PE PATT
Occupational

N
RF ER
Performance


Collaboration Intervention

OR NS


Between Review

MA
Practitioner

NC
and Client

E
CONTEXT AND
CL TORS
FA

ENVIRONMENT
IEN
C
T

Supporting Health and


Participation in Life
Through Engagement in
Occupation
AREAS OF


OCCUPATION
OUTCOMES
ENVIRONMENT CONTEXT

Figure 1. Occupational Therapys Domain. Figure 2. Occupational Therapys Process.


Supporting health and participation in life through engagement in Collaboration between the practitioner and the client is central to the
occupation. interactive nature of service delivery.

Collaboration
Between
Practitioner
and Client

Supporting

Health and
Participation in Life
Through Engagement in
Occupation

Figure 3. Occupational Therapy.


The domain and process are inextricably linked.

Note: Mobius in gures 1 and 3 originally designed by Mark Dow. Used with permission.

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AREAS OF CLIENT PERFORMANCE PERFORMANCE CONTEXT AND ACTIVITY

OCCUPATION FACTORS SKILLS PATTERNS ENVIRONMENT DEMANDS

Activities of Daily Living (ADL)* Values, Beliefs, Sensory Perceptual Habits Cultural Objects Used and
Instrumental Activities of Daily and Spirituality Skills Routines Personal Their Properties
Living (IADL) Body Functions Motor and Praxis Skills Roles Physical Space Demands
Rest and Sleep Body Structures Emotional Regulation Rituals Social Social Demands
Education Skills Temporal Sequencing and
Work Cognitive Skills Virtual Timing
Play Communication and Required Actions
Leisure Social Skills Required Body
Social Participation Functions

*Also referred to as basic activities of Required Body

daily living (BADL) or personal Structures

activities of daily living (PADL).

Figure 4. Aspects of Occupational Therapys Domain.


All aspects of the domain transact to support engagement, participation, and health. This gure does not imply a hierarchy.

The discussion that follows provides a brief


explanation of each aspect identied in Figure 4.
All aspects of the
Tables included throughout provide full lists and domain are of equal
denitions of terms.
value, and together
Supporting Health and Participation in Life they interact to
Through Engagement in Occupation
The profession of occupational therapy uses the
inuence the clients
term occupation to capture the breadth and mean engagement in
ing of everyday activity. Occupational therapy
is founded on an understanding that engaging in occupations,
occupations structures everyday life and con
tributes to health and well-being. Occupational
participation,
therapy practitioners believe that occupations are and health.
multidimensional and complex. Engagement in
occupation as the focus of occupational therapy
intervention involves addressing both subjective ulation) identity and sense of competence and have
(emotional and psychological) and objective particular meaning and value to the client. They
(physically observable) aspects of performance. inuence how clients spend time making decisions.
Occupational therapy practitioners understand Several denitions of occupation can be found in the
engagement from this dual and holistic perspec literature that adds to an understanding of this core
tive and address all aspects of performance when concept. Occupation has been dened as
providing interventions. Goal-directed pursuits that typically extend
Occupational science, a discipline devoted to over time, have meaning to the performance,
the study of occupation, informs occupational ther and involve multiple tasks (Christiansen et
apy practice by expanding the understanding of al., 2005, p. 548).
occupation (Zemke & Clark, 1996). Occupations Daily activities that reect cultural values,
are central to a clients (person, organization, or pop provide structure to living, and meaning to

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individuals; these activities meet human dence, occupational therapy practitioners consid
needs for self-care, enjoyment, and partici er a client as independent whether the client sole
pation in society (Crepeau, Cohn, & ly performs the activities, performs the activities
Schell, 2003, p. 1031). in an adapted or modied environment, makes
Activities that people engage in throughout use of various devices or alternative strategies, or
their daily lives to fulll their time and give oversees activity completion by others (AOTA,
life meaning. Occupations involve mental 2002a). For example, people with a spinal cord
abilities and skills and may or may not have injury can direct a personal care assistant to assist
an observable physical dimension (Hinojosa them with their activities of daily living (ADLs),
& Kramer, 1997, p. 865). demonstrating independence in this essential
[A]ctivitiesof everyday life, named, orga aspect of their lives.
nized, and given value and meaning by indi Occupations often are shared. Those that
viduals and a culture. Occupation is everything implicitly involve two or more individuals may be
people do to occupy themselves, including termed co-occupations (Zemke & Clark, 1996).
looking after themselvesenjoying lifeand Care giving is a co-occupation that involves active
contributing to the social and economic participation on the part of the caregiver and the
fabric of their communities (Law, Polatajko, recipient of care. For example, the co-occupations
Baptiste, & Townsend, 1997, p. 32). required during mothering, such as the socially
A dynamic relationship among an occupa interactive routines of eating, feeding, and com
tional form, a person with a unique devel forting, may involve the parent, a partner, the
opmental structure, subjective meanings child, and signicant others (Olsen, 2004). The
and purpose, and the resulting occupational activities intrinsic to this social interaction are
performance (Nelson & Jepson-Thomas, reciprocal, interactive, and nested co-occupa
2003, p. 90). tions (Dunlea, 1996; Esdaile & Olson, 2004).
[C]hunks of daily activity that can be Clients also may perform several occupations
named in the lexicon of the culture (Zemke simultaneously, enfolding them into one another
& Clark, 1996, p. vii). such as when a caregiver concurrently helps with
Sometimes occupational therapy practitioners homework, pays the bills, and makes dinner.
use the terms occupation and activity interchange Consideration of co-occupation supports an inte
ably to describe participation in daily life pursuits. grated view of the clients engagement in relation
Some scholars have proposed that the two terms ship to signicant others within context.
are different (Christiansen & Townsend, 2004; Occupational therapy practitioners recognize
Hinojosa & Kramer, 1997; Pierce, 2001; Reed, that health is supported and maintained when
2005). In the Framework, the term occupation clients are able to engage in occupations and activi
encompasses activity. ties that allow desired or needed participation in
Occupational engagement occurs individually home, school, workplace, and community life.
or with others. A client may be considered inde Thus, occupational therapy practitioners are con
pendent when the client performs or directs the cerned not only with occupations but also the com
actions necessary to participate regardless of the plexity of factors that empower and make
amount or kind of assistance desired or required. possible clients engagement and participation in
In contrast with narrower denitions of indepen positive health-promoting occupations (Wilcock &

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Townsend, 2008). In 2003, Townsend applied the Individual differences in the way in which
concept of social justice to occupational therapys clients view their occupations reect the com
focus and coined the term occupational justice to plexity and multidimensionality of each occupa
describe the professions concern with ethical, moral, tion. The clients perspective of how an occupa
and civic factors that can support or hinder health- tion is categorized varies depending on that
promoting engagement in occupations and partici clients needs and interests. For example, one per
pation in home and community life. Occupational son may perceive doing laundry as work, while
justice ensures that clients are afforded the opportu another may consider it an instrumental activity
nity for full participation in those occupations in of daily living (IADL). One population may
which they choose to engage (Christiansen & engage in a quiz game and view their participa
Townsend, 2004, p. 278). Occupational therapy tion as play, while another population may engage
practitioners interested in occupational justice recog in the same quiz game and view it as an educa
nize and work to support social policies, actions, and tional occupation.
laws that allow people to engage in occupations that The way in which clients prioritize engagement
provide purpose and meaning in their lives. in areas of occupation may vary at different times.
Occupational therapys focus on engaging in For example, a community psychiatric rehabilita
occupations and occupational justice comple tion organization may prioritize member voter reg
ments the World Health Organizations (WHO) istration during a presidential campaign and cele
perspective of health. WHO, in its effort to bration preparations during holiday periods. The
broaden the understanding of the effects of dis extent and nature of the engagement is as impor
ease and disability on health, has recognized that tant as the engagement itself; for example, excessive
health can be affected by the inability to carry out work without sufcient regard to other aspects of
activities and participate in life situations caused life such as sleep or relationships places clients at
by environmental barriers, as well as by problems risk for health problems (Hakansson, Dahlin-
that exist with body structures and body func Ivanoff, & Sonn, 2006).
tions (WHO, 2001). As members of a global
Client Factors
community, occupational therapy practitioners
advocate for the well-being of all persons, groups, Client factors are specic abilities, characteristics,
and populations with a commitment to inclusion or beliefs that reside within the client and may
and nondiscrimination (AOTA, 2004c). affect performance in areas of occupation. Because
occupational therapy practitioners view clients
holistically, they consider client factors that involve
Areas of Occupation
the values, beliefs, and spirituality; body functions;
When occupational therapy practitioners work and body structures. These underlying client fac
with clients, they consider the many types of occu tors are affected by the presence or absence of ill
pations in which clients might engage. The broad ness, disease, deprivation, and disability. They
range of activities or occupations are sorted into cat affect and are affected by performance skills, per
egories called areas of occupationactivities of formance patterns, activity demands, and contex
daily living, instrumental activities of daily liv tual and environmental factors.
ing, rest and sleep, education, work, play, leisure, Despite their importance, the presence or
and social participation (see Table 1). absence of specic body functions and body

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TABLE 1. AREAS OF OCCUPATION

Various kinds of life activities in which people, populations, or organizations engage, including ADL, IADL, rest and sleep, education, work, play,
leisure, and social participation.
ACTIVITIES OF DAILY LIVING orthotics, prosthetics, adaptive equipment, Community mobilityMoving around
(ADLs) and contraceptive and sexual devices. in the community and using public or pri
Activities that are oriented toward taking Personal hygiene and grooming vate transportation, such as driving, walk
care of ones own body (adapted from Obtaining and using supplies; removing body ing, bicycling, or accessing and riding in
Rogers & Holm, 1994, pp. 181202). ADL hair (e.g., use of razors, tweezers, lotions); buses, taxi cabs, or other transportation
also is referred to as basic activities of daily applying and removing cosmetics; washing, systems.
living (BADLs) and personal activities of drying, combing, styling, brushing, and trim Financial managementUsing scal
daily living (PADLs). These activities are ming hair; caring for nails (hands and feet); resources, including alternate methods of
fundamental to living in a social world; caring for skin, ears, eyes, and nose; applying nancial transaction and planning and
they enable basic survival and well-being deodorant; cleaning mouth; brushing and using nances with long-term and short-
(Christiansen & Hammecker, 2001, p, 156). ossing teeth; or removing, cleaning, and term goals.
Bathing, showeringObtaining and reinserting dental orthotics and prosthetics. Health management and mainte
using supplies; soaping, rinsing, and dry Sexual activityEngaging in activities nanceDeveloping, managing, and main
ing body parts; maintaining bathing posi that result in sexual satisfaction. taining routines for health and wellness
tion; and transferring to and from bathing Toilet hygieneObtaining and using promotion, such as physical tness, nutri
positions. supplies; clothing management; maintain tion, decreasing health risk behaviors, and
Bowel and bladder management ing toileting position; transferring to and medication routines.
Includes completing intentional control of from toileting position; cleaning body; and Home establishment and manage
bowel movements and urinary bladder and, caring for menstrual and continence needs mentObtaining and maintaining person
if necessary, using equipment or agents for (including catheters, colostomies, and sup al and household possessions and environ
bladder control (Uniform Data System for pository management). ment (e.g., home, yard, garden, appliances,
Medical Rehabilitation, 1996, pp. III20, vehicles), including maintaining and repair
INSTRUMENTAL ACTIVITIES
III24). ing personal possessions (clothing and
DressingSelecting clothing and acces household items) and knowing how to seek
OF DAILY LIVING (IADLs)
sories appropriate to time of day, weather, help or whom to contact.
Activities to support daily life within the
and occasion; obtaining clothing from Meal preparation and cleanupPlan
home and community that often require
storage area; dressing and undressing in a ning, preparing, and serving well-balanced,
more complex interactions than self-care
sequential fashion; fastening and adjusting nutritional meals and cleaning up food and
used in ADL.
clothing and shoes; and applying and remov utensils after meals.
ing personal devices, prostheses, or orthoses. Care of others (including selecting
Religious observanceParticipating in
and supervising caregivers)Arranging,
EatingThe ability to keep and manipu religion, an organized system of beliefs,
supervising, or providing the care for others.
late food or uid in the mouth and swallow practices, rituals, and symbols designed to
it; eating and swallowing are often used Care of petsArranging, supervising, facilitate closeness to the sacred or transcen
interchangeably (AOTA, 2007b). or providing the care for pets and service dent (Moreira-Almeida & Koenig, 2006,
animals. p. 844).
FeedingThe process of setting up,
arranging, and bringing food [or uid] from Child rearingProviding the care and Safety and emergency mainte
the plate or cup to the mouth; sometimes supervision to support the developmental nanceKnowing and performing preven
called self-feeding (AOTA, 2007b). needs of a child. tive procedures to maintain a safe environ
Functional mobilityMoving from one Communication managementSend ment as well as recognizing sudden,
position or place to another (during perfor ing, receiving, and interpreting information unexpected hazardous situations and initiat
mance of everyday activities), such as in-bed using a variety of systems and equipment, ing emergency action to reduce the threat to
mobility, wheelchair mobility, and transfers including writing tools, telephones, type health and safety.
(e.g., wheelchair, bed, car, tub, toilet, writers, audiovisual recorders, computers, ShoppingPreparing shopping lists
tub/shower, chair, oor). Includes functional communication boards, call lights, emer (grocery and other); selecting, purchasing,
ambulation and transporting objects. gency systems, Braille writers, telecommu and transporting items; selecting method of
nication devices for the deaf, augmentative payment; and completing money
Personal device careUsing, cleaning,
communication systems, and personal transactions.
and maintaining personal care items, such
digital assistants.
as hearing aids, contact lenses, glasses,
(Continued)

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TABLE 1. AREAS OF OCCUPATION

(Continued)

REST AND SLEEP fort and safety of others such as the family Retirement preparation and adjust
Includes activities related to obtaining while sleeping. mentDetermining aptitudes, developing
restorative rest and sleep that supports interests and skills, and selecting appropri
EDUCATION
healthy active engagement in other areas of ate avocational pursuits.
occupation. Volunteer explorationDetermining
Includes activities needed for learning and
RestQuiet and effortless actions that community causes, organizations, or
participating in the environment.
interrupt physical and mental activity result opportunities for unpaid work in relation
Formal educational participation ship to personal skills, interests, location,
ing in a relaxed state (Nurit & Michel, 2003,
Including the categories of academic (e.g., and time available.
p. 227). Includes identifying the need to
math, reading, working on a degree),
relax; reducing involvement in taxing physi Volunteer participationPerforming
nonacademic (e.g., recess, lunchroom, hall
cal, mental, or social activities; and engag unpaid work activities for the benet of
way), extracurricular (e.g., sports, band,
ing in relaxation or other endeavors that identied selected causes, organizations, or
cheerleading, dances), and vocational (pre
restore energy, calm, and renewed interest facilities.
vocational and vocational) participation.
in engagement.
PLAY
Informal personal educational needs
SleepA series of activities resulting in
or interests exploration (beyond for
going to sleep, staying asleep, and ensur
mal education)Identifying topics and Any spontaneous or organized activity that
ing health and safety through participation
methods for obtaining topic-related infor provides enjoyment, entertainment, amuse
in sleep involving engagement with the
mation or skills. ment, or diversion (Parham & Fazio, 1997,
physical and social environments.
Informal personal education participa p. 252).
Sleep preparation(1) Engaging in
tionParticipating in classes, programs, Play explorationIdentifying appropri
routines that prepare the self for a comfort
and activities that provide instruction/training ate play activities, which can include explo
able rest, such as grooming and undress
in identied areas of interest. ration play, practice play, pretend play,
ing, reading or listening to music to fall
games with rules, constructive play, and
asleep, saying goodnight to others, and
WORK
symbolic play (adapted from Bergen,1988,
meditation or prayers; determining the time
pp. 6465).
of day and length of time desired for sleep Includes activities needed for engaging in
ing or the time needed to wake; and estab Play participationParticipating in play;
remunerative employment or volunteer
lishing sleep patterns that support growth maintaining a balance of play with other
activities (Mosey, 1996, p. 341).
and health (patterns are often personally areas of occupation; and obtaining, using,
Employment interests and pursuits and maintaining toys, equipment, and sup
and culturally determined). Identifying and selecting work opportunities plies appropriately.
(2) Preparing the physical environment for based on assets, limitations, likes, and dis
periods of unconsciousness, such as mak
LEISURE
likes relative to work (adapted from Mosey,
ing the bed or space on which to sleep; 1996, p. 342).
ensuring warmth/coolness and protection; Employment seeking and acquisition A nonobligatory activity that is intrinsically
setting an alarm clock; securing the home, Identifying and recruiting for job opportuni motivated and engaged in during discre
such as locking doors or closing windows ties; completing, submitting, and reviewing tionary time, that is, time not committed
or curtains; and turning off electronics or appropriate application materials; preparing to obligatory occupations such as work,
lights. for interviews; participating in interviews and self-care, or sleep (Parham & Fazio, 1997,
Sleep participationTaking care of per following up afterward; discussing job bene p. 250).
sonal need for sleep such as cessation of ts; and nalizing negotiations. Leisure explorationIdentifying inter
activities to ensure onset of sleep, napping, Job performanceJob performance ests, skills, opportunities, and appropriate
dreaming, sustaining a sleep state without including work skills and patterns; time leisure activities.
disruption, and nighttime care of toileting management; relationships with co-work Leisure participationPlanning and
needs or hydration. Negotiating the needs ers, managers, and customers; creation, participating in appropriate leisure activities;
and requirements of others within the social production, and distribution of products maintaining a balance of leisure activities
environment. Interacting with those sharing and services; initiation, sustainment, and with other areas of occupation; and obtain
the sleeping space such as children or part completion of work; and compliance with ing, using, and maintaining equipment and
ners, providing nighttime care giving such work norms and procedures. supplies as appropriate.
as breastfeeding, and monitoring the com

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TABLE 1. AREAS OF OCCUPATION

(Continued)

(Mosey, 1996, p. 340). FamilyEngaging in [activities that


SOCIAL PARTICIPATION CommunityEngaging in activities that result in] successful interaction in specic
result in successful interaction at the com required and/or desired familial roles
Organized patterns of behavior that are
munity level (i.e., neighborhood, organiza (Mosey, 1996, p. 340).
characteristic and expected of an individual
or a given position within a social system tions, work, school). Peer, friendEngaging in activities at
different levels of intimacy, including

Note. Some of the terms used in this table are from, or adapted from, the rescinded Uniform Terminology for Occupational TherapyThird Edition (AOTA, 1994,
pp. 10471054).

structures do not necessarily ensure a clients suc Body functions refer to the physiological func
cess or difculty with daily life occupations. tion of body systems (including psychological
Factors that inuence performance such as sup functions) (WHO, 2001, p. 10). Examples
ports in the physical or social environment may include sensory, mental (affective, cognitive,
allow a client to manifest skills in a given area perceptual), cardiovascular, respiratory, and
even when body functions or structure are absent endocrine functions (see Table 2 for complete
or decient. It is in the process of observing a list).
client engaging in occupations and activities that Body structures are the anatomical parts of the
the occupational therapy practitioner is able to body such as organs, limbs, and their compo
determine the transaction between client factors nents (WHO, 2001, p. 10). Body structures
and performance. and body functions are interrelated (e.g., the
Client factors are substantively different at the heart and blood vessels are body structures that
person, organization, and population levels. support cardiovascular function; see Table 2).
Following are descriptions of client factors for The categorization of body function and body
each level. structure client factors outlined in Table 2 is based
on the International Classication of Functioning,
Person
Disability, and Health proposed by the WHO
Values, beliefs, and spirituality inuence a (2001). The classication was selected because it
clients motivation to engage in occupations and has received wide exposure and presents a language
give his or her life meaning. Values are princi that is understood by external audiences.
ples, standards, or qualities considered worth
Organization
while by the client who holds them. Beliefs are
cognitive content held as true (Moyers & Dale, Values and beliefs include the vision statement,
2007, p. 28). Spirituality is the personal quest code of ethics, value statements, and esprit de
for understanding answers to ultimate questions corps.
about life, about meaning and about relation Functions include planning, organizing, coordi
ship with the sacred or transcendent, which may nating, and operationalizing the mission, prod
(or may not) lead to or arise from the develop ucts or services, and productivity.
ment of religious rituals and the formation of Structures include departments and departmen
community (Moreira-Almeida & Koenig, tal relationships, leadership and management,
2006, p. 844). performance measures, and job titles.
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Population Activity Demands


Values and beliefs can be viewed as including Activity demands refer to the specic features of an
emotional, purposive, and traditional perspec activity that inuence the type and amount of effort
tives (Foucault, 1973). required to perform the activity. Occupational ther
Functions include economic, political, social, apy practitioners analyze activities to understand
and cultural capital (Weber, 1978). what is required of the client and determine the rela
Structure may include constituents such as those tionship of the activitys requirements to engage
with similar genetics, sexual orientation, and ment in occupation. Activity demands include the
health-related conditions (Baum, Bass-Haugen, specic objects and their properties used in the activ
& Christiansen, 2005, p. 381). ity, the physical space requirements of the activity,

TABLE 2. CLIENT FACTORS

Client factors include (1) values, beliefs, and spirituality; (2) body functions; and (3) body structures that reside within the client and may affect
performance in areas of occupation.
VALUES, BELIEFS, AND SPIRITUALITY

Category and Denition Examples

Values: Principles, standards, or qualities considered worthwhile Person


or desirable by the client who holds them. 1. Honesty with self and with others
2. Personal religious convictions
3. Commitment to family.
Organization
1. Obligation to serve the community
2. Fairness.
Population
1. Freedom of speech
2. Equal opportunities for all
3. Tolerance toward others.

Beliefs: Cognitive content held as true. Person


1. He or she is powerless to inuence others
2. Hard work pays off.
Organization
1. Prots are more important than people
2. Achieving the mission of providing service can effect positive
change in the world.
Population
1. People can inuence government by voting
2. Accessibility is a right, not a privilege.

Spirituality: The personal quest for understanding answers to Person


ultimate questions about life, about meaning, and the sacred 1. Daily search for purpose and meaning in ones life
(Moyers & Dale, 2007, p. 28). 2. Guiding actions from a sense of value beyond the personal
acquisition of wealth or fame.
Organization and Population
(see Person examples related to individuals within an
organization and population).

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TABLE 2. CLIENT FACTORS

(Continued)

BODY FUNCTIONS: [T]he physiological functions of body systems (including psychological functions) (WHO, 2001, p. 10).
The Body Functions section of the table below is organized according to the classications of the International Classication of
Functioning, Disability, and Health (ICF) classications. For fuller descriptions and denitions, refer to WHO (2001).

Categories Body Functions Commonly Considered


by Occupational Therapy Practitioners
(Not intended to be all-inclusive list)

Mental functions (affective, cognitive, perceptual)


Specic mental functions Specic mental functions
Higher-level cognitive Judgment, concept formation, metacognition, cognitive exibility,
insight, attention, awareness
Attention Sustained, selective, and divided attention
Memory Short-term, long-term, and working memory
Perception Discrimination of sensations (e.g., auditory, tactile, visual,
olfactory, gustatory, vestibularproprioception), including
multi-sensory processing, sensory memory, spatial, and tempo
ral relationships (Calvert, Spence, & Stein, 2004)
Thought Recognition, categorization, generalization, awareness of reality,
logical/coherent thought, and appropriate thought content
Mental functions of sequencing complex movement Execution of learned movement patterns
Emotional Coping and behavioral regulation (Schell, Cohn, & Crepeau, 2008)
Experience of self and time Body image, self-concept, self-esteem

Global mental functions Global mental functions


Consciousness Level of arousal, level of consciousness

Orientation Orientation to person, place, time, self, and others

Temperament and personality Emotional stability

Energy and drive Motivation, impulse control, and appetite

Sleep (physiological process)

Sensory functions and pain Sensory functions and pain


Seeing and related functions, including visual acuity, visual Detection/registration, modulation, and integration of sensa
stability, visual eld functions tions from the body and environment
Visual awareness of environment at various distances
Hearing functions Tolerance of ambient sounds; awareness of location and dis
tance of sounds such as an approaching car
Vestibular functions Sensation of securely moving against gravity
Taste functions Association of taste
Smell functions Association of smell
Proprioceptive functions Awareness of body position and space
Touch functions Comfort with the feeling of being touched by others or touching
various textures such as food

Pain (e.g., diffuse, dull, sharp, phantom) Localizing pain

Temperature and pressure Thermal awareness

(continued)

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TABLE 2. CLIENT FACTORS


(Continued)

BODY FUNCTIONS: (Continued)

Categories Body Functions Commonly Considered


by Occupational Therapy Practitioners
(Not intended to be all-inclusive list)

Neuromusculoskeletal and movement-related functions Neuromusculoskeletal and movement-related functions


Functions of joints and bones
Joint mobility Joint range of motion
Joint stability Postural alignment (this refers to the physiological stability of the
joint related to its structural integrity as compared to the motor
skill of aligning the body while moving in relation to task objects)
Muscle power Strength
Muscle tone Degree of muscle tone (e.g., accidity, spasticity, uctuating)
Muscle endurance Endurance
Motor reexes Stretch, asymmetrical tonic neck, symmetrical tonic neck
Involuntary movement reactions Righting and supporting
Control of voluntary movement Eyehand/foot coordination, bilateral integration, crossing the
midline, ne- and gross-motor control, and oculomotor (e.g.,
saccades, pursuits, accommodation, binocularity)
Gait patterns Walking patterns and impairments such as asymmetric gait, stiff
gait. (Note: Gait patterns are considered in relation to how they
affect ability to engage in occupations in daily life activities.)
Cardiovascular, hematological, immunological, Cardiovascular, hematological, immunological,
and respiratory system function and respiratory system function
Cardiovascular system function Blood pressure functions (hypertension, hypotension, postural
Hematological and immunological system function hypotension), and heart rate
Respiratory system function (Note: Occupational therapy practitioners have knowledge of these
body functions and understand broadly the interaction that occurs
between these functions to support health and participation in life
through engagement in occupation. Some therapists may special
ize in evaluating and intervening with a specic function as it is
related to supporting performance and engagement in occupations
and activities targeted for intervention.)
Additional functions and sensations of the cardiovascular and Rate, rhythm, and depth of respiration
respiratory systems
Physical endurance, aerobic capacity, stamina, and fatigability

Voice and speech functions (Note: Occupational therapy practitioners have knowledge of
Voice functions these body functions and understand broadly the interaction
Fluency and rhythm that occurs between these functions to support health and par
ticipation in life through engagement in occupation. Some ther
Alternative vocalization functions apists may specialize in evaluating and intervening with a spe
Digestive, metabolic, and endocrine system function cic function, such as incontinence and pelvic oor disorders,
Digestive system function as it is related to supporting performance and engagement in
occupations and activities targeted for intervention.)
Metabolic system and endocrine system function
Genitourinary and reproductive functions
Urinary functions
Genital and reproductive functions

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TABLE 2. CLIENT FACTORS


(Continued)

BODY FUNCTIONS: (Continued)

Categories Body Functions Commonly Considered


by Occupational Therapy Practitioners
(Not intended to be all-inclusive list)

Skin and related-structure functions Skin and related-structure functions


Skin functions Protective functions of the skinpresence or absence of

Hair and nail functions wounds, cuts, or abrasions

Repair function of the skinwound healing


(Note: Occupational therapy practitioners have knowledge of these
body functions and understand broadly the interaction that occurs
between these functions to support health and participation in life
through engagement in occupation. Some therapists may special
ize in evaluating and intervening with a specic function as it is
related to supporting performance and engagement in occupations
and activities targeted for intervention.)

BODY STRUCTURES: Body structures are anatomical parts of the body, such as organs, limbs, and their components [that
support body function] (WHO, 2001, p. 10). The Body Structures section of the table below is organized according to the ICF
classications. For fuller descriptions and denitions, refer to WHO (2001).

Categories Examples are not delineated in the


Body Structure section of this table.

Structure of the nervous system (Note: Occupational therapy practitioners have knowledge of
Eyes, ear, and related structures body structures and understand broadly the interaction that
occurs between these structures to support health and partici
Structures involved in voice and speech
pation in life through engagement in occupation. Some thera
Structures of the cardiovascular, immunological, and pists may specialize in evaluating and intervening with a specic
respiratory systems structure as it is related to supporting performance and engage
Structures related to the digestive, metabolic, and ment in occupations and activities targeted for intervention.)
endocrine systems
Structure related to the genitourinary and reproductive
systems
Structures related to movement
Skin and related structures

Note. Some data adapted from the ICF (WHO, 2001).

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TABLE 3. ACTIVITY DEMANDS


The aspects of an activity, which include the objects and their properties, space, social demands, sequencing or timing, required actions and skills,
and required underlying body functions and body structure needed to carry out the activity.

Activity Demand Aspects Denition Examples


Objects and their properties Tools, materials, and equipment used in the pro Tools (e.g., scissors, dishes, shoes, volleyball)
cess of carrying out the activity Materials (e.g., paints, milk, lipstick)
Equipment (e.g., workbench, stove, basketball
hoop)
Inherent properties (e.g., heavy, rough, sharp,
colorful, loud, bitter tasting)

Space demands (relates Physical environmental requirements of the activi Large, open space outdoors required for a
to physical context) ty (e.g., size, arrangement, surface, lighting, tem baseball game
perature, noise, humidity, ventilation) Bathroom door and stall width to accommodate
wheelchair
Noise, lighting, and temperature controls for a
library

Social demands (relates Social environment and cultural contexts that may Rules of game
to social environment and be required by the activity Expectations of other participants in activity
cultural contexts) (e.g., sharing supplies, using language appro
priate for the meeting)

Sequence and timing Process used to carry out the activity (e.g., specic Steps to make tea: Gather cup and tea bag, heat
steps, sequence, timing requirements) water, pour water into cup, and so forth.
Sequence: Heat water before placing tea bag
in water.
Timing: Leave tea bag to steep for 2 minutes.
Steps to conduct a meeting: Establish goals for
meeting, arrange time and location for meeting,
prepare meeting agenda, call meeting to order.
Sequence: Have people introduce them
selves before beginning discussion of topic.
Timing: Allot sufcient time for discussion
of topic and determination of action items.

Required actions and The usual skills that would be required by any Feeling the heat of the stove
performance skills performer to carry out the activity. Sensory, per Gripping handlebar
ceptual, motor, praxis, emotional, cognitive, Choosing the ceremonial clothes
communication, and social performance skills Determining how to move limbs to control
should each be considered. The performance the car
skills demanded by an activity will be correlated Adjusting the tone of voice
with the demands of the other activity aspects Answering a question
(e.g., objects, space)

Required body functions [P]hysiological functions of body systems Mobility of joints


(including psychological functions) (WHO, 2001, Level of consciousness
p. 10) that are required to support the actions
used to perform the activity

Required body structures Anatomical parts of the body such as organs, Number of hands
limbs, and their components [that support body Number of eyes
function] (WHO, 2001, p. 10) that are required to
perform the activity

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the social demands, sequence and timing, the Emotional regulation skills
required actions or skills needed to perform the Cognitive skills
activity, and the required body functions and struc Communication and social skills.
tures used during the performance of the activity Numerous body functions and structures
(see Table 3 for denitions and examples.) underlie and enable performance (Rogers &
Activity demands are specic to each activity. Holm, 2008). Whereas body functions such as
A change in one feature of an activity may change mental (affective, cognitive, perceptual), sensory,
the extent of the demand in another feature. For neuromuscular, and movement-related body
example, an increase in the number of the steps or functions (WHO, 2001) reect the capacities
sequence of steps in an activity increases the that reside within the body, performance skills are
demand on attention skills. the clients demonstrated abilities. For example,
praxis skills can be observed through client
Performance Skills actions such as imitating, sequencing, and con
Various approaches have been used to describe structing; cognitive skills can be observed as the
and categorize performance skills. The occupation client demonstrates organization, time manage
al therapy literature from research and practice ment, and safety; and emotional regulation skills
offers multiple perspectives on the complexity can be observed through the behaviors the client
and types of skills used during performance. displays to express emotion appropriately.
According to Fisher (2006), performance skills Numerous body functions underlie each perfor
are observable, concrete, goal-directed actions mance skill.
clients use to engage in daily life occupations. Multiple factors, such as the context in which
Fisher further denes these skills as small, measur the occupation is performed, the specic demands
able units in a chain of actions that are observed as of the activity being attempted, and the clients
a person performs meaningful tasks. They are body functions and structures, affect the clients
learned and developed over time and are situated in ability to acquire or demonstrate performance
specic contexts and environments. Fisher catego skills. Performance skills are closely linked and are
rized performance skills as follows: Motor Skills, used in combination with one another to allow the
Process Skills, and Communication/Interaction client to perform an occupation. A change in one
Skills. Rogers and Holm (2008) have proposed performance skill can affect other performance
that during task-specic performance skills, various skills. In practice and in some literature, perfor
body functions and structures coalesce into unique mance skills often are labeled in various combina
combinations and emerge to affect performance in tions such as perceptualmotor skills and
real life. socialemotional skills. Table 4 provides deni
Given that performance skills are described tions and selected examples under each category.
and categorized in multiple ways, within the Occupational therapy practitioners observe
Occupational Therapy Practice Framework they are and analyze performance skills in order to under
dened as the abilities clients demonstrate in the stand the transactions among underlying factors
actions they perform. The categories of a persons that support or hinder engagement in occupa
performance skills are interrelated and include tions and occupational performance. For exam
Motor and praxis skills ple, when observing a person writing a check, the
Sensoryperceptual skills occupational therapy practitioner observes the

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TABLE 4. PERFORMANCE SKILLS


Performance skills are the abilities clients demonstrate in the actions they perform.

Skill Denition Examples


Motor and Motor: Actions or behaviors a client uses to move and Bending and reaching for a toy or tool in a storage bin
praxis skills physically interact with tasks, objects, contexts, and Pacing tempo of movements to clean the room
environments (adapted from Fisher, 2006). Includes Coordinating body movements to complete a job task
planning, sequencing, and executing new and novel Maintaining balance while walking on an uneven surface
movements. or while showering
Anticipating or adjusting posture and body position in
Praxis: Skilled purposeful movements (Heilman & Rothi, response to environmental circumstances, such as obstacles
1993). Ability to carry out sequential motor acts as part Manipulating keys or lock to open the door
of an overall plan rather than individual acts (Liepmann,
1920). Ability to carry out learned motor activity, includ
ing following through on a verbal command,
visualspatial construction, ocular and oralmotor
skills, imitation of a person or an object, and sequenc
ing actions (Ayres, 1985; Filley, 2001). Organization of
temporal sequences of actions within the spatial context,
which form meaningful occupations (Blanche & Parham,
2002).

Sensory Actions or behaviors a client uses to locate, identify, and Positioning the body in the exact location for a safe jump
perceptual skills respond to sensations and to select, interpret, associate, Hearing and locating the voice of your child in a crowd
organize, and remember sensory events based on dis Visually determining the correct size of a storage container
criminating experiences through a variety of sensations for leftover soup
that include visual, auditory, proprioceptive, tactile, Locating keys by touch from many objects in a pocket or
olfactory, gustatory, and vestibular. purse (i.e., stereognosis)
Timing the appropriate moment to cross the street safely
by determining ones own position and speed relative to
the speed of trafc
Discerning distinct avors within foods or beverages

Emotional Actions or behaviors a client uses to identify, manage, Responding to the feelings of others by acknowledgment
regulation skills and express feelings while engaging in activities or or showing support
interacting with others Persisting in a task despite frustrations
Controlling anger toward others and reducing aggressive acts
Recovering from a hurt or disappointment without lashing
out at others
Displaying the emotions that are appropriate for the situation
Utilizing relaxation strategies to cope with stressful events

Cognitive skills Actions or behaviors a client uses to plan and manage Judging the importance or appropriateness of clothes for
the performance of an activity the circumstance
Selecting tools and supplies needed to clean the bathroom
Sequencing tasks needed for a school project
Organizing activities within the time required to meet a
deadline
Prioritizing steps and identifying solutions to access trans
portation
Creating different activities with friends that are fun, novel,
and enjoyable
Multitaskingdoing more than one thing at a time, necessary
for tasks such as work, driving, and household management

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TABLE 4. PERFORMANCE SKILLS


(Continued)

Skill Denition Examples


Communication Actions or behaviors a person uses to communicate and Looking where someone else is pointing or gazing
and social skills interact with others in an interactive environment (Fisher, Gesturing to emphasize intentions
2006) Maintaining acceptable physical space during conversation
Initiating and answering questions with relevant information
Taking turns during an interchange with another person
verbally and physically
Acknowledging another persons perspective during an
interchange

motor skills of gripping and manipulating objects health promoting or damaging (Fiese et al., 2002;
and the cognitive skills of initiating and sequenc Segal, 2004). Roles are sets of behaviors expected
ing the steps of the activity. The observed skills are by society, shaped by culture, and may be further
supported by underlying body functions related conceptualized and dened by the client. Roles
to movement and cognition and by the environ can provide guidance in selecting occupations or
mental context of the bank. Procient occupa can lead to stereotyping and restricted engage
tional performance observed in playing a game of ment patterns. Jackson (1998a, 1998b) cautioned
tennis or playing the piano requires multiple sets that describing people by their roles can be limit
of performance skills. ing and can promote segmented rather than
Further resources informing occupational
therapy practice related to performance skills
include Fisher (2006); Bloom, Krathwohl, and ...only occupational
Masia (1984); Harrow (1972); and Chapparo and
Ranka (1997). Detailed information about the
therapy practitioners
way that skills are used in occupational therapy focus this process
practice also may be found in the literature on
specic theories such as sensory integration theo toward the end-goal of
ry (Ayres, 1972, 2005) and motor learning and
motor control theory (Shumway-Cook &
supporting health and
Wollacott, 2007). participation in life
Performance Patterns through engagement
Performance patterns refer to habits, routines,
roles, and rituals used in the process of engaging
in occupations.
in occupations or activities. Habits refer to specif
ic, automatic behaviors that can be useful, domi enfolded occupations. When considering roles
nating, or impoverished (Clark, 2000; Neistadt & within occupational therapy, occupational thera
Crepeau, 1998), whereas routines are established py practitioners are concerned with the way
sequences of occupations or activities that provide clients construct their occupations to fulll their
a structure for daily life. Routines also can be perceived roles and identity and reinforce their

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routine, may struggle with poor nutrition and


Occupational social isolation. Tables 5a, 5b, and 5c provide
examples of performance patterns for persons,
therapy practitioners organizations, and populations.
apply theory, evidence, Context and Environment
knowledge, and A clients engagement in occupation takes place
within a social and physical environment situated
skills regarding the within context. In the literature, the terms environ
therapeutic use ment and context often are used interchangeably. In
the Framework, both terms are used to reect the
of occupations to importance of considering the wide variety of
interrelated conditions both internal and external
positively affect to the client that inuence performance.
the clients health, The term environment refers to the external
physical and social environments that surround
well-being, and life the client and in which the clients daily life occu
satisfaction. pations occur. Physical environment refers to the
natural and built nonhuman environment and
the objects in them. The social environment is
values and beliefs. Rituals are symbolic actions constructed by the presence, relationships, and
with spiritual, cultural, or social meaning that expectations of persons, groups, and organiza
contribute to the clients identity and reinforce tions with whom the client has contact.
the clients values and beliefs (Fiese et al., 2002; The term context refers to a variety of interre
Segal, 2004). Habits, routines, roles, and rituals lated conditions that are within and surrounding
can support or hinder occupational performance. the client. These interrelated contexts often are
People, organizations, and populations demon less tangible than physical and social environ
strate performance patterns in daily life. They ments but nonetheless exert a strong inuence on
develop over time and are inuenced by all other performance. Contexts, as described in the
aspects of the domain. When practitioners consid Framework, are cultural, personal, temporal,
er the clients patterns of performance, they are bet and virtual. Cultural context includes customs,
ter able to understand the frequency and manner in beliefs, activity patterns, behavior standards, and
which performance skills and occupations are inte expectations accepted by the society of which the
grated into the clients life. While a client may have client is a member. Personal context refers to
the ability or capacity for skilled performance, if he demographic features of the individual such as
or she does not embed those skills in a productive age, gender, socioeconomic status, and education
set of engagement patterns, health and participa al level that are not part of a health condition
tion may be negatively affected. For example, a (WHO, 2001). Temporal context includes stages
client who has the skills and resources to engage in of life, time of day or year, duration, rhythm of
appropriate grooming, bathing, and meal prepara activity, or history. Virtual context refers to inter
tion but does not embed them into a consistent actions in simulated, real-time, or near-time situ-

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TABLE 5A. PERFORMANCE PATTERNSPERSON


Patterns of behavior related to an individuals or signicant others daily life activities that are habitual or routine.

Examples

HABITSAutomatic behavior that is integrated into more com Automatically puts car keys in the same place.
plex patterns that enable people to function on a day-to-day basis Spontaneously looks both ways before crossing the street
(Neistadt & Crepeau, 1998, p. 869). Habits can be useful, dominat
Repeatedly rocks back and forth when asked to initiate a task
ing, or impoverished and either support or interfere with perfor
mance in areas of occupation. Repeatedly activates and deactivates the alarm system before
entering the home
Maintains the exact distance between all hangers when hanging
clothes in a closet

ROUTINESPatterns of behavior that are observable, regular, Follows the morning sequence to complete toileting, bathing,
repetitive, and that provide structure for daily life. They can be sat- hygiene, and dressing
isfying, promoting, or damaging. Routines require momentary time Follows the sequence of steps involved in meal preparation
commitment and are embedded in cultural and ecological contexts
(Fiese et al., 2002; Segal, 2004).

RITUALSSymbolic actions with spiritual, cultural, or social Uses the inherited antique hairbrush and brushes her hair
meaning, contributing to the clients identity and reinforcing values with 100 strokes nightly as her mother had done
and beliefs. Rituals have a strong affective component and repre- Prepares the holiday meals with favorite or traditional
sent a collection of events (Fiese et al., 2002; Segal, 2004). accoutrements, using designated dishware
Kisses a sacred book before opening the pages to read

ROLESA set of behaviors expected by society, shaped by cul- Mother of an adolescent with developmental disabilities
ture, and may be further conceptualized and dened by the client. Student with learning disability studying computer technology
Corporate executive returning to work after experiencing a stroke

Note. Information for Habits section of this table adapted from Dunn (2000b).

TABLE 5B. PERFORMANCE PATTERNSORGANIZATION

Patterns of behavior related to the daily functioning of an organization.

Examples

ROUTINESPatterns of behavior that are observable, regular, Holds regularly scheduled meetings for staff, directors, execu
repetitive, and that provide structure for daily life. They can be sat tive boards
isfying, promoting, or damaging. Routines require momentary time Follows documentation practices for annual reports, timecards,
commitment and are embedded in cultural and ecological contexts and strategic plans
(Fiese et al., 2002; Segal, 2004). Turns in documentation on a scheduled basis
Follows the chain of command
Follows safety and security routines (e.g., signing in/out, using
pass codes)
Maintains dress codes (e.g., casual Fridays)
Socializes during breaks, lunch, at the water cooler
Follows beginning or ending routines (e.g., opening/closing the
facility)
Offers activities to meet performance expectations or standards

(Continued)

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TABLE 5B. PERFORMANCE PATTERNSORGANIZATION


(Continued)

Examples

RITUALSSymbolic actions that have meaning, contributing to Holds holiday parties, company picnics
the organizations identity and reinforcing values and beliefs Conducts induction, recognition, and retirement ceremonies
(adapted from Fiese et al., 2002; Segal, 2004).
Organizes annual retreats or conferences
Maintains fundraising activities for organization to support local
charities

ROLESA set of behaviors by the organization expected by soci- Nonprot organization provides housing for persons living with
ety, shaped by culture, and may be further conceptualized and mental illness
dened by the client. Humanitarian organization distributes food and clothing dona
tions to refugees
University educates and provides service to the surrounding
community

Note. In this document, habits are addressed only in Table 5A (Person).

TABLE 5C. PERFORMANCE PATTERNSPOPULATION

Patterns of behavior related to a population.

Examples

ROUTINESPatterns of behavior that are observable, regular, Follows health practices, such as scheduled immunizations for
repetitive, and that provide structure for daily life. They can be sat- children and yearly health screenings for adults
isfying, promoting, or damaging. Routines require momentary time Follows business practices, such as provision of services for
commitment and are embedded in cultural and ecological contexts the disadvantaged populations (e.g., loans to underrepresented
(Fiese et al., 2002; Segal, 2004). groups)
Follows legislative procedures, such as those associated with
IDEA and Medicare
Follows social customs for greeting

RITUALSRituals are shared social actions with traditional, Holds cultural celebrations
emotional, purposive, and technological meaning, contributing to Has parades or demonstrations
values and beliefs within the population.
Shows national afliations/allegiances
Follows religious, spiritual, and cultural practices, such as
touching the mezuzah or using holy water when leaving/enter
ing, praying to Mecca

ROLES SEE DESCRIPTION OF THESE AREAS FOR INDIVIDUALS WITHIN


THE POPULATION

Note. In this document, habits are addressed only in Table 5A (Person).

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TABLE 6. CONTEXTS AND ENVIRONMENTS

Context and environment (including cultural, personal, temporal, virtual, physical, and social) refers to a variety of interrelated conditions within and
surrounding the client that inuence performance.
The term context refers to a variety of interrelated conditions that are within and surrounding the client. Contexts include cultural, personal, temporal,
and virtual.The term environment refers to the external physical and social environments that surround the client and in which the clients daily life
occupations occur.

Context and
Environment Denition Examples
Cultural Customs, beliefs, activity patterns, behavior standards, and Person: Shaking hands when being introduced

expectations accepted by the society of which the client is Organization: Employees marking the end of the work week

a member. Includes ethnicity and values as well as political with casual dress on Friday

aspects, such as laws that affect access to resources and


Population: Celebrating Independence Day

afrm personal rights. Also includes opportunities for edu


cation, employment, and economic support.

Personal [F]eatures of the individual that are not part of a health Person: Twenty-ve-year-old unemployed man with a high

condition or health status (WHO, 2001, p. 17). Personal school diploma

context includes age, gender, socioeconomic status, and Organization: Volunteers working in a homeless shelter

educational status. Can also include organizational lev


Population: Teenage women who are pregnant or new mothers

els (e.g., volunteers and employees) and population lev


els (e.g., members of society).

Temporal Location of occupational performance in time (Neistadt Person: A person retired from work for 10 years

& Crepeau, 1998, p. 292). The experience of time as Organization: Annual fundraising campaign

shaped by engagement in occupations. The temporal


Population: Engaging in siestas or high teas

aspects of occupation which contribute to the patterns


of daily occupations are the rhythmtemposyn
chronizationdurationand sequence (Larson &
Zemke, 2004, p. 82; Zemke, 2004, p. 610). Includes
stages of life, time of day or year, duration, rhythm of
activity, or history.

Virtual Environment in which communication occurs by means Person: Text message to a friend

of airways or computers and an absence of physical Organization: Video conference, telephone conference call,

contact. Includes simulated or real-time or near-time instant message, interactive white boards among all the

existence of an environment via chat rooms, email, members

video-conferencing, radio transmissions.


Population: Virtual community of gamers

Physical Natural and built nonhuman environment and the Person: Individuals house, apartment

objects in them: Organization: Ofce building, factory

Natural environment includes geographic terrain, Population: Transportation system

sensory qualities of environment, plants and animals


Built environment and objects includes buildings,
furniture, tools or devices.

Social Is constructed by presence, relationships, and expecta Person: Friends, colleagues

tions of persons, organizations, populations. Organization: Advisory board

Availability and expectations of signicant individuals, Population: City government

such as spouse, friends, and caregivers


Relationships with individuals, groups, or organizations
Relationships with systems (e.g., political, legal, eco
nomic, institutional) that are inuential in establishing
norms, role expectations, and social routines.

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EVALUATION
Occupational proleThe initial step in the evaluation process that provides an understanding of the clients occupational history and experiences, patterns of daily
living, interests, values, and needs. The clients problems and concerns about performing occupations and daily life activities are identied, and the clients priorities
are determined.
Analysis of occupational performanceThe step in the evaluation process during which the clients assets, problems, or potential problems are more specically
identied. Actual performance is often observed in context to identify what supports performance and what hinders performance. Performance skills, performance
patterns, context or contexts, activity demands, and client factors are all considered, but only selected aspects may be specically assessed. Targeted outcomes are
identied.
INTERVENTION
Intervention planA plan that will guide actions taken and that is developed in collaboration with the client. It is based on selected theories, frames of reference,
and evidence. Outcomes to be targeted are conrmed.
Intervention implementationOngoing actions taken to inuence and support improved client performance. Interventions are directed at identied outcomes.
Clients response is monitored and documented.
Intervention reviewA review of the implementation plan and process as well as its progress toward targeted outcomes.

OUTCOMES (Supporting Health and Participation in Life Through Engagement in Occupation)


OutcomesDetermination of success in reaching desired targeted outcomes. Outcome assessment information is used to plan future actions with the client and to
evaluate the service program (i.e., program evaluation).

Figure 5. Process of Service Delivery.


The process of service delivery is applied within the professions domain to support the clients health and participation.

ations absent of physical contact. Some contexts Process of Occupational Therapy


are external to the client (e.g., virtual), some are
internal to the client (e.g., personal), and some Overview
may have both external features and internalized This second section of the Occupational Therapy
beliefs and values (e.g., cultural). Practice Framework describes the process that out
Clients engagement in occupations evolves lines the way in which occupational therapy prac
within their social and physical environments and titioners operationalize their expertise to provide
reects their interdependence with these environ services to clients (see Figure 5). This process
ments. Cultural contexts often inuence how includes evaluation, intervention, and outcome
occupations are chosen, prioritized, and orga monitoring; occurs within the purview of the
nized. Contexts and environments affect a clients domain; and involves collaboration among the
accessibility to occupations and inuence the occupational therapist, occupational therapy
quality of performance and satisfaction with per assistant, and the client. Occupational therapy
formance. A client who has difculty performing practitioners are required to maintain appropriate
effectively in one environment or context may be credentials and abide by ethical standards, exist
successful when the environment or context is ing laws, and regulatory requirements for each
changed. The context within which the engage step of the occupational therapy process.
ment in occupations occurs is unique for each Many professions use the process of evaluating,
client. Contexts and environments are interrelat intervening, and targeting intervention outcomes.
ed both with each other and all other aspects of However, only occupational therapy practitioners
the domain (see Table 6 for a description of the focus this process toward the end-goal of support
different kinds of contexts and environments). ing health and participation in life through engage-

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ment in occupations. Occupational therapy practi Occupational therapy practitioners develop a


tioners also use occupations as a method of inter collaborative relationship with clients in order to
vention implementation by engaging clients understand their experiences and desires for inter
throughout the process in occupations that are vention, as noted in Figure 2. The collaborative
therapeutically selected. The professions use of approach, which is used throughout the process,
occupation as both means and end is a unique honors the contributions of the client and the
application of the process (Trombly, 1995). occupational therapy practitioner. Clients bring
Although for the purpose of organization the knowledge about their life experiences and their
Framework describes the process in a linear man hopes and dreams for the future. They identify
ner, in reality, the process does not occur in a and share their needs and priorities. Occupational
sequenced, step-by-step fashion (see Table 7). therapy practitioners bring their knowledge about
Instead, it is uid and dynamic, allowing occupa how engagement in occupation affects health and
tional therapy practitioners to operate with an performance. This information is coupled with
ongoing focus on outcomes while continually the practitioners clinical reasoning and theoreti
reecting on and changing an overall plan to cal perspectives to critically observe, analyze,
accommodate new developments and insights describe, and interpret human performance.
along the way. Occupational therapy practitioners also apply
Occupational therapy involves facilitating knowledge and skills to reduce the effects of dis
interactions among the client, the environments ease, disability, and deprivation and to promote
or contexts, and the activities or occupations in health and well-being. Together, practitioners and
order to help the client reach the desired out clients identify and prioritize the focus of the
comes that support health and participation in intervention plan. This collaboration may include
life. Occupational therapy practitioners apply family, signicant others, community members,
theory, evidence, knowledge, and skills regarding and stakeholders who affect or are affected by the
the therapeutic use of occupations to positively clients engagement in occupation, health, and
affect the clients health, well-being, and life satis participation.
faction. Rarely is an individual the exclusive focus of
The broader denition of client included in the intervention. For example, the needs of an at-
this document is indicative of the professions risk infant may be the initial impetus for inter
increasing involvement in providing services not vention, but the concerns and priorities of the
only to a person but also to organizations and parent, the extended family, and funding agencies
populations. Regardless of whether the client is a also are considered. Similarly, services addressing
person, organization, or population, the clients independent-living skills for adults coping with
wants, needs, occupational risks, and problems serious and persistent mental illness may involve
are evaluated, and information is gathered, syn the needs and expectations of state and local ser
thesized, and framed from an occupational per vices agencies as well as business groups.
spective. This perspective is based on the theories, Throughout the process, the occupational
knowledge, and skills generated and used by the therapy practitioner is engaged continually in
profession and informed by available evidence. clinical reasoning about the clients engagement
Client concerns are viewed relative to problems or in occupation. Clinical reasoning enables the
risks in occupational performance. occupational therapy practitioner to (1) identify

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TABLE 7. OPERATIONALIZING THE OCCUPATIONAL THERAPY PROCESS

Evaluation Intervention Outcomes


Supporting Health and
Analysis of Participation in Life
Occupational Occupational Intervention Intervention through Engagement in
Prole Performance Intervention Plan Implementation Review Occupation

Identify Synthesize Develop plan that Determine types of Reevaluate plan Focus on outcomes
information from the includes occupational therapy relative to achieving as they relate to
Who is the client? occupational prole.
Objective and interventions to be targeted outcomes. supporting health
Why is the client Observe clients measurable goals used and carry them Modify plan as and participation in
seeking services? performance in with time frame, out. needed. life through
What occupations desired occupation/ engagement in
Occupational Monitor clients Determine need for
and activities are activity. occupation.
therapy response according continuation,
successful or are Note the intervention to ongoing discontinuation, or Select outcome
causing problems? effectiveness of approach based assessment and referral. measures.
What contexts and performance skills reassessment.
on theory and Measure and use
environments and patterns and evidence, and outcomes.
support or inhibit select assessments

desired outcomes? to identify factors Mechanisms for

(context or contexts, service delivery.


What is the clients
occupational activity demands, Consider discharge
history? client factors) that needs and plan.

What are the clients may be inuencing Select outcome

priorities and performance skills measures.


targeted outcomes? and patterns. Make
Interpret recommendation or
assessment data to referral to others as

identify facilitators needed.

and barriers to

performance.

Develop and rene

hypotheses about

clients occupational

performance

strengths and

weaknesses.

Collaborate with

client to create

goals that address

targeted outcomes.

Delineate areas for

intervention based

on best practice
Continue to renegotiate intervention plans and targeted outcomes.
and evidence.

Ongoing interaction among evaluation, intervention, and outcomes occurs throughout the process.

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the multiple demands, skills, and potential mean knowledge and skills in these areas inuence the
ings of the activity and (2) gain a deeper under information that is collected during the evaluation.
standing of the interrelationships between aspects Knowledge and evidence about occupational per
of the domain that affect performance and those formance problems and diagnostic conditions are
that will support client-centered interventions used to guide information gathering and synthesis
and outcomes. of information for interpretation and intervention
planning. The occupational therapists skilled inter
Evaluation pretation of assessment results relative to the whole
The evaluation process begins with an evaluation evaluation leads to a clear delineation of the
conducted by the occupational therapist and is strengths and limitations affecting the clients occu
focused on nding out what the client wants and pational performance. The occupational therapy
needs to do, determining what the client can do assistant contributes to the evaluation process based
and has done, and identifying those factors that act on established competencies and under the supervi
as supports or barriers to health and participation. sion of an occupational therapist.
Evaluation often occurs both formally and infor
Occupational Prole
mally during all interactions with the client. The
type and focus of the evaluation differs depending An occupational prole is dened as a summary of
on the practice setting. information that describes the clients occupational
The evaluation consists of the occupational history and experiences, patterns of daily living,
prole and analysis of occupational perfor interests, values, and needs. Because the prole is
mance. The occupational prole includes informa designed to gain an understanding of the clients
tion about the client and the clients needs, prob perspective and background, its format varies
lems, and concerns about performance in areas of depending on whether the client is a person, orga
occupation. The analysis of occupational perfor nization, or population. Using a client-centered
mance focuses on collecting and interpreting approach, the occupational therapy practitioner
information using assessment tools designed to gathers information to understand what is current
observe, measure, and inquire about factors that ly important and meaningful to the client. The
support or hinder occupational performance. prole includes inquiry related to what the client
Although the ways occupational therapists collect wants and needs to do in the present or future
client information are described separately and as well as past experiences and interests that may
sequentially in the Framework, the exact manner assist in identifying strengths and limitations.
is inuenced by the client needs and the practice Renement of the information collected during
setting. Information related to the occupational the occupational prole subsequently renes the
prole is gathered throughout the occupational intervention plan and identied outcomes.
therapy process. During the process of collecting this informa
The occupational therapists knowledge and tion, the clients priorities and desired outcomes
skills, as well as theoretical principles and available that will lead to engagement in occupation for
evidence, guide his or her clinical reasoning for the improved health are identied. Clients identify
selection and application of various theories and occupations that give meaning to their lives and
frames of reference throughout the evaluation pro select the goals and priorities important to them.
cess. Concurrently, the occupational therapists Valuing and respecting the clients collaboration in

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the therapeutic process helps foster client involve sis regarding possible reasons for identied prob
ment and more efciently guide interventions. lems and concerns. The occupational therapy assis
The process and timing of completing the tant contributes to this process. The information
occupational prole varies depending on the cir from the occupational therapy prole often guides
cumstances. Occupational therapy practitioners the selection of outcome measures. If an organiza
may gather information formally and informally tion or population is the identied client, the
in one session or over a longer period while work strengths and needs are those that affect the collec
ing with the client. Obtaining information tive entity rather than the individual.
through both formal interview and casual conver
sation helps establish a therapeutic relationship Analysis of Occupational Performance
with the client. Ideally, the information obtained Occupational performance is the accomplish
during the development of the occupational pro ment of the selected occupation resulting from
le leads to a more client-centered approach in the dynamic transaction among the client, the
the evaluation, intervention planning, and inter context and environment, and the activity.
vention implementation stages. Evaluation of occupational performance involves
Specically, the information collected answers one or more of the following:
the following questions: Synthesizing information from the occupa
Who is the client (person, including family, tional prole to focus on specic areas of occu
caregivers, and signicant others; popula pation and contexts that need to be addressed;
tion; or organization)? Observing the clients performance during
Why is the client seeking services, and what activities relevant to desired occupations,
are the clients current concerns relative to noting effectiveness of the performance
engaging in occupations and in daily life skills and performance patterns;
activities? Selecting and using specic assessments to
What areas of occupation are successful, and measure performance skills and perfor
what areas are causing problems or risks (see mance patterns, as appropriate;
Table 1)? Selecting assessments, as needed, to identify
What contexts and environments support or and measure more specically contexts or
inhibit participation and engagement in environments, activity demands, and client
desired occupations? factors inuencing performance skills and
What is the clients occupational history performance patterns;
(i.e., life experiences, values, interests, previ Interpreting the assessment data to identify
ous patterns of engagement in occupations what supports performance and what hin
and in daily life activities, the meanings ders performance;
associated with them)? Developing and rening hypotheses about the
What are the clients priorities and desired clients occupational performance strengths
outcomes? and limitations;
Once the prole data are collected and docu Creating goals in collaboration with the
mented, the occupational therapist reviews the client that address the desired outcomes;
information; identies the clients strengths, limita Determining procedures to measure the out
tions, and needs; and develops a working hypothe comes of intervention; and

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Delineating a potential intervention approach Examining the environments and contexts in


or approaches based on best practices and which occupational performance can or does
available evidence. occur provides insights into overarching, underly
Multiple methods often are used during the ing, and embedded inuences on engagement.
evaluation process to assess the client, the context, The external environments and context (e.g.,
the occupation or activity, and the occupational physical and social environment, virtual context)
performance. Methods may include an interview provide resources that support or inhibit the
with the client and signicant others, observation of clients performance (e.g., doorway widths as part
performance and context, record review, and direct of the physical environment that allow for
assessment of specic aspects of performance. wheelchair passage, presence or absence of a care
Formal and informal, structured and unstructured, giver as part of the social environment, access to a
and standardized criterion or norm-referenced computer to communicate with others as part of
assessment tools can be used. Standardized assess the virtual context). Different environments (e.g.,
ments are preferred, when appropriate, to provide community, institution, home) provide different
objective data about the various aspects of the supports and resources for service delivery (e.g.,
domain inuencing engagement and performance. assessment of an infant or toddler in the hospital
Obtaining reliable and valid information [through without the primary caregivers present yields dif
the use of standard assessments] provides a high ferent results than while at home with a parent).
level of support that can justify the need for occu The clients personal context affects service deliv
pational therapy services (Gutman, Mortera, ery by inuencing personal beliefs, perceptions, and
Hinojosa, & Kramer, 2007, p. 121). expectations. The cultural context exists within small
Activity analysis is an important process used groups of related individuals, such as a nuclear fam
by occupational therapy practitioners to understand ily, and within larger groups of people, such as pop
the demands that a specic desired activity places ulations of a country or ethnic group. The expecta
on a client. Activity analysis addresses the typical tions, beliefs, and customs of various cultures can
demands of an activity, the range of skills involved affect a clients identity and activity choices and
in its performance, and the various cultural mean need to be considered when determining how and
ings that might be ascribed to it (Crepeau, 2003, when services may be delivered. Note that in Figure
p. 192). When activity analysis is completed and 2, context and environment are depicted as sur
the demands of a specic activity that the client rounding and underlying the process.
wants and needs to do are understood, the clients Analyzing occupational performance requires an
specic skills and abilities are then compared with understanding of the complex and dynamic interac
the selected activitys demands. tion among performance skills, performance pat
Occupation-based activity analysis places the terns, contexts and environments, activity demands,
person [client] in the foreground. It takes into and client factors. Occupational therapy practition
account the particular persons [clients] interests,
ers attend to each aspect and gauge the inuence of
goals, abilities, and contexts, as well as the
each aspect on the othersindividually and collec
demands of the activity itself. These considera
tions shape the practitioners efforts to help tively. By understanding how these aspects dynami
theperson [client] reach his/her goals through cally inuence each other, occupational therapists
carefully designed evaluation and intervention. can better evaluate how they contribute to the
(Crepeau, 2003, p. 193) clients performance-related concerns, and how they

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Supporting health [F]ollowing an occupation-focused health pro


motion approach to well-being embraces a belief
and participation that the potential range of what people can do,
be, and strive to become is the primary concern
in life through and that health is a by-product. A varied and full
occupational lifestyle will coincidentally main
engagement in tain and improve health and well-being if it
enables people to be creative and adventurous
occupation is the physically, mentally, and socially. (p. 315)
broad, overarching Interventions vary depending on the client
person, organization, or populationand the con
outcome of the text of service delivery (Moyers & Dale, 2007). The
actual term used for clients receiving occupational
occupational therapy therapy varies among practice settings and delivery
intervention process. models. For example, when working in a hospital,
the person might be referred to as a patient, and in a
school, the client might be a student, teacher, parent,
potentially contribute to interventions that support or administrator. When providing services to an
occupational performance. When working with an organization, the client may be called the consumer.
organization or population, occupational therapy When serving a population, the client may be spe
practitioners consider the collective occupational cic entities, such as disability groups, veterans who
performance abilities of the respective members. are homeless, or refugees.
The term person includes others who also may
Intervention help or be served indirectly, such as caregiver,
The intervention process consists of the skilled teacher, parent, employer, or spouse. When
actions taken by occupational therapy practition addressing the person or a small group of persons
ers in collaboration with the client to facilitate who support or care for the client in need of ser
engagement in occupation related to health and vices (e.g., caregiver, teacher, partner, employer,
participation. Occupational therapy practitioners spouse), the practitioners address the interaction
use the information about the client gathered among client factors, performance skills, perfor
during the evaluation and from theoretical princi mance patterns, contexts and environments, and
ples to direct occupation-centered interventions. activity demands that inuence occupational per
Intervention is provided then to assist the client formance within those occupations the person
in reaching a state of physical, mental, and social needs and wants to do. The intervention focus is
well-being; to identify and realize aspirations; to on modifying the environment/contexts and
satisfy needs; and to change or cope with the envi activity demands or patterns, promoting health,
ronment. A variety of types of occupational ther establishing or restoring and maintaining occupa
apy interventions are discussed in Table 8. tional performance, and preventing further dis
Intervention is intended to be health-promoting. ability and occupational performance problems.
Health promotion is the process of enabling people to Interventions provided to organizations are
increase control over, and to improve, their health designed to affect the organization to more efcient
(WHO, 1986). Wilcock (2006) states ly and effectively meet the needs of the clients or

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TABLE 8. TYPES OF OCCUPATIONAL THERAPY INTERVENTIONS

THERAPEUTIC USE OF SELFAn occupational therapy practitioners planned use of his or her personality, insights, perceptions, and judgments
as part of the therapeutic process (adapted from Punwar & Peloquin, 2000, p. 285).
THERAPEUTIC USE OF OCCUPATIONS AND ACTIVITIESaOccupations and activities selected for specic clients that meet therapeutic
goals. To use occupations/activities therapeutically, context or contexts, activity demands, and client factors all should be considered in relation to
the clients therapeutic goals. Use of assistive technologies, application of universal-design principles, and environmental modications support the
ability of clients to engage in their occupations.

Occupation-based intervention Purpose: Client engages in client-directed occupations that match identied goals.
Examples:
Completes morning dressing and hygiene using adaptive devices
Purchases groceries and prepares a meal
Utilizes the transportation system
Applies for a job
.Plays on playground and community recreation equipment
Participates in a community festival
Establishes a pattern of self-care and relaxation activities in preparation for sleep

Purposeful activity Purpose: Client engages in specically selected activities that allow the client to develop skills that enhance
occupational engagement.
Examples:
Practices how to select clothing and manipulate clothing fasteners
Practices safe ways to get in and out of a bathtub
Practices how to prepare a food list and rehearses how to use cooking appliances
Practices how to use a map and transportation schedule
Rehearses how to write answers on an application form
.Practices how to get on and off playground and recreation equipment
Role plays when to greet people and initiates conversation
Practices how to use adaptive switches to operate home environmental control system

Preparatory methods Purpose: Practitioner selects directed methods and techniques that prepare the client for occupational
performance. Used in preparation for or concurrently with purposeful and occupation-based activities.
Examples:
Provides sensory enrichment to promote alertness
Administers physical agent modalities to prepare muscles for movement
Provides instruction in visual imagery and rhythmic breathing to promote rest and relaxation
Issues orthotics/splints to provide support and facilitate movement
Suggests a home-based conditioning regimen using Pilates and yoga
Provides hand-strengthening exercises using therapy putty and theraband
Provides instruction in assertiveness to prepare for self-advocacy

(Continued)

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TABLE 8. TYPES OF OCCUPATIONAL THERAPY INTERVENTIONS

(Continued)
CONSULTATION PROCESSA type of intervention in which occupational therapy practitioners use their knowledge and expertise to collaborate
with the client. The collaborative process involves identifying the problem, creating possible solutions, trying solutions, and altering them as neces
sary for greater effectiveness. When providing consultation, the practitioner is not directly responsible for the outcome of the intervention (Dunn,
2000a, p. 113).

Person Advises a family about architectural options


Advises family how to create pre-sleep nighttime routines for their children

Organization Recommends work pattern modications and ergonomically designed workstations for a company
Recommends disaster evacuation strategies for a residential community related to accessibility and
reduced environmental barriers

Population Advises senior citizens on older driver initiatives

EDUCATION PROCESSAn intervention process that involves imparting knowledge and information about occupation, health, and participation
and that does not result in the actual performance of the occupation/activity.

Person Instructs a classroom teacher on sensory regulation strategies

Organization Teaches staff at a homeless shelter how to structure daily living, play, and leisure activities for shelter
members

Population Instructs town ofcials about the value of and strategies for making walking and biking paths accessible
for all community members

ADVOCACYEfforts directed toward promoting occupational justice and empowering clients to seek and obtain resources to fully participate in
their daily life occupations.

Person Collaborates with a person to procure reasonable accommodations at worksite

Organization Serves on policy board of an organization to procure supportive housing accommodations for persons
with disabilities

Population Collaborates with adults with serious mental illness to raise public awareness of the impact of this stigma
Collaborates with and educates federal funding sources for the disabled population to include cancer
patients prior to their full remission

aInformation adapted from Pedretti and Early (2001).

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consumers and stakeholders. Practitioners address tional therapist and the occupational therapy assis
features of the organization or agency such as its mis tant in the development, implementation, and
sion, values, organizational culture and structure, review of the intervention plan.
policies and procedures, and built and natural envi
ronments. Practitioners evaluate how each of these Intervention Plan
features either supports or inhibits the overall per The intervention plan directs the actions of the
formance of individuals within the organization. For occupational therapist and occupational therapy
example, to enable the staff at a skilled-nursing facil assistant. It describes the selected occupational
ity to provide better services, an occupational thera therapy approaches and types of interventions for
py practitioner may recommend the walls in each reaching the clients identied outcomes. The
hallway be painted a different color, enabling resi intervention plan is developed collaboratively with
dents to more easily locate their rooms. the client and is based on the clients goals and pri
Interventions provided to populations are orities. Depending on whether the client is a per
directed to all the members of the group collec son, organization, or population, others such as
tively rather than individualized to specic people family members, signicant others, board mem
within the group. Practitioners direct their inter bers, service providers, and community groups
ventions toward current or potential health prob also may collaborate in the development of the
lems and disabling conditions within the popula plan.
tion and community. Their goal is to enhance the The design of the intervention plan is directed
health of all people within the population by by the
addressing services and supports within the com Clients goals, values, beliefs, and occupa
munity that can be implemented to improve the tional needs;
populations performance. The intervention focus Clients health and well-being;
often is on health promotion activities, self-man Clients performance skills and performance
agement educational services, and environmental patterns;
modication. For instance, the occupational ther Collective inuence of the context, environ
apy practitioner may design developmentally ment, activity demands, and client factors
based day care programs run by college student on the client;
volunteers for homeless shelters catering to fami Context of service delivery in which the
lies in a large metropolitan area. Practitioners may intervention is provided (e.g., caregiver
work with a wide variety of populations experi expectations, organizations purpose, payers
encing difculty in accessing and engaging in requirements, applicable regulations); and
health occupations due to conditions such as Best available evidence.
poverty, homelessness, and discrimination. The selection and design of the intervention
The intervention process is divided into three plan and goals are directed toward addressing the
steps: (1) intervention plan, (2) intervention imple clients current and potential problems related to
mentation, and (3) intervention review. During the engagement in occupations or activities.
intervention process, information from the evalua Intervention planning includes the following
tion is integrated with theory, practice models, steps:
frames of reference, and evidence. This informa 1. Developing the plan. The occupational thera
tion guides the clinical reasoning of the occupa pist develops the plan with the client, and the

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occupational therapy assistant contributes to 1. Determining and carrying out the type of
the plans development. The plan includes occupational therapy intervention or inter
Objective and measurable goals with a time- ventions to be used (see Table 8)
frame Therapeutic use of self
Occupational therapy intervention approach Therapeutic use of occupations or activities
or approaches (see Table 9) Occupation-based interventions
Create or promote Purposeful activity
Establish or restore Preparatory methods.
Maintain Consultation process
Modify Education process
Prevent. Advocacy.
Mechanisms for service delivery
2. Monitoring the clients response to interven
People providing the intervention
tions based on ongoing assessment and reassess
Types of interventions
ment of the clients progress toward goals.
Frequency and duration of service.

2. Considering potential discharge needs and plans Intervention Review


3. Selecting outcome measures Intervention review is the continuous process of
4. Making recommendation or referral to others as reevaluating and reviewing the intervention plan,
needed. the effectiveness of its delivery, and the progress
toward outcomes. As during intervention planning,
Intervention Implementation this process includes collaboration with the client
Intervention implementation is the process of based on his or her goals. Depending on whether
putting the plan into action. It involves the the client is a person, organization, or population,
skilled process of altering factors in the client, various stakeholders, such as family members, sig
activity, and context and environment for the nicant others, board members, other service
purpose of effecting positive change in the providers, and community groups, also may collab
clients desired engagement in occupation, orate in the intervention review. Re-evaluation and
health, and participation. review may lead to change in the intervention plan.
Interventions may focus on a single aspect of The intervention review includes the follow
the domain, such as a specic performance pat ing steps:
tern, or several aspects of the domain, such as per 1. Re-evaluating the plan and how it is imple
formance patterns, performance skills, and con mented relative to achieving outcomes
text. Given that the factors are interrelated and 2. Modifying the plan as needed
inuence one another in a continuous, dynamic 3. Determining the need for continuation or dis
process, occupational therapy practitioners expect continuation of occupational therapy services
that the clients ability to adapt, change, and and for referral to other services.
develop in one area will affect other areas. Because The intervention review may include program
of this dynamic interrelationship, assessment and evaluations that critique the way that occupational
intervention planning continue throughout the therapy services are provided. This may include a
implementation process. Intervention implemen review of client satisfaction and the client's percep
tation includes the following steps: tion of the benets of receiving occupational ther-

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TABLE 9. OCCUPATIONAL THERAPY INTERVENTION APPROACHES


Specic strategies selected to direct the process of intervention that are based on the clients desired outcome, evaluation data, and evidence.

Approach Focus of Intervention Examples


Create, promote (health Performance skills Create a parenting class to help rst-time
promotion)aAn intervention parents engage their children in developmentally
approach that does not assume a appropriate play
disability is present or that any Performance patterns Promote effective handling of stress by creating
factors would interfere with perfor time use routines with healthy clients
mance. This approach is designed
Context or contexts or physical environments Promote a diversity of sensory play experiences
to provide enriched contextual
by recommending a variety of equipment for
and activity experiences that will
playgrounds and other play areas
enhance performance for all persons
in the natural contexts of life (adapt Activity demands Serve food family style in the congregate dining
ed from Dunn, McClain, Brown, & area to increase the opportunities for socialization
Youngstrom, 1998, p. 534). Client factors Promote increased endurance by recommending
(body functions, body structures) year-round daily outdoor recess for all school
children
Design a dance program for senior citizens that
will enhance strength and exibility

Establish, restore (remediation, Performance skills Provide adjustable desk chairs to improve client
restoration)aAn intervention sitting posture
approach designed to change client Work with senior community centers to offer
variables to establish a skill or ability driving educational programs targeted at
that has not yet developed or to improving driving skills for persons ages 65
restore a skill or ability that has been or older
impaired (adapted from Dunn et al.,
Performance patterns Collaborate with clients to help them establish
1998, p. 533).
morning routines needed to arrive at school or
work on time
Provide classes in fatigue management for
cancer patients and their families
Collaborate with clients to help them establish
healthy sleepwake patterns
Develop walking programs at the local mall for
employees and community members
Client factors
Support daily physical education classes for
(body functions, body structures)
entire population of children in a school aimed
at improving physical strength and endurance
Collaborate with schools and businesses to
establish universal-design models in their
buildings, classrooms, and so forth
Gradually increase time required to complete
a computer game to increase clients attention
span

(Continued)

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TABLE 9. OCCUPATIONAL THERAPY INTERVENTION APPROACHES


(Continued)

Approach Focus of Intervention Examples


MaintainAn intervention Performance skills Maintain the ability of the client to organize
approach designed to provide the tools by providing a tool outline painted on a
supports that will allow clients to pegboard
preserve the performance capabili Develop a refresher safety program for industri
ties they have regained, that contin al organizations to remind workers of need to
ue to meet their occupational needs, continue to use safety skills on the job
or both. The assumption is that,
Provide a program for community-dwelling
without continued maintenance
older adults to maintain motor and praxis skills
intervention, performance would
decrease, occupational needs would Performance patterns Enable client to maintain appropriate medica
not be met, or both, thereby affect tion schedule by providing a timer to aid with
ing health and quality of life. memory
Establish occupational performance patterns to
maintain a healthy lifestyle after signicant
weight loss
Context or contexts or physical environments Maintain safe and independent access for per
sons with low vision by recommending
increased hallway lighting
During a natural disaster, work with facilities
identied as shelters to provide play and
leisure activities for displaced people to allow a
constructive outlet and semblance of normalcy
Incorporate principles of universal design in
homes to allow people to age in place
Activity demands Maintain independent gardening for persons
with arthritic hands by recommending tools
with modied grips, long-handled tools, seating
alternatives, raised gardens, and so forth
Client factors Provide multisensory activities in which nurs
(body functions, body structures) ing-home residents may participate to maintain
alertness
Provide hand-based thumb splint for client use
during periods of stressful or prolonged inten
sive activity to maintain pain-free joints

Modify (compensation, adapta Performance patterns Provide a visual schedule to help a student
tion)aAn intervention approach follow routines and transition easily between
directed at nding ways to revise activities at home and school
the current context or activity Simplify task sequence to help a person with
demands to support performance cognitive issues complete a morning self-care
in the natural setting, [including] routine
compensatory techniques, [such
Context or contexts or physical environments Assist a family in determining requirements for
as]...enhancing some features to
building a ramp at home for a family member who
provide cues or reducing other
is returning home after physical rehabilitation
features to reduce distractibility
(Dunn et al., 1998, p. 533). Consult with builders in designing homes that
will allow families the ability to provide living
space for aging parents (e.g., bedroom and full
bath on the main oor of a multilevel dwelling)
Modify the number of people in a room to
decrease clients distractibility

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TABLE 9. OCCUPATIONAL THERAPY INTERVENTION APPROACHES


(Continued)

Approach Focus of Intervention Examples


Activity demands Adapt writing surface used in classroom by fourth
grader by adding adjustable incline board
Assist a patient with a terminal illness and his
or her family in modifying tasks to maintain
engagement
Consult with school teams on placement of
switches to increase students access to com
puters, augmentative communication devices,
environmental devices, and so forth
Provide a seat at the assembly station to allow a
client with decreased standing tolerance to be
able to continue to perform

Prevent (disability Performance skills Prevent poor posture when sitting for prolonged
prevention)aAn intervention periods by providing a chair with proper back
approach designed to address support
clients with or without a disability Performance patterns Aid in the prevention of illicit chemical sub
who are at risk for occupational stance use by introducing self-initiated routine
performance problems. This strategies that support drug-free behavior
approach is designed to prevent
Context or contexts or physical environments Prevent social isolation of employees by promot
the occurrence or evolution of
ing participation in after-work group activities
barriers to performance in context.
Interventions may be directed at Reduce risk of falls by modifying the environ
client, context, or activity variables ment and removing known hazards in the home
(adapted from Dunn et al., 1998, (e.g., throw rugs)
p. 534). Activity demands Prevent back injury by providing instruction in
proper lifting techniques
Client factors Prevent repetitive stress injury by suggesting
(body functions, body structures) that clients wear a wrist support splint when
typing
Consultation with hotel chain to provide an
ergonomics educational program designed to
prevent back injuries in housekeepers

a
Parallel language used in Moyers and Dale (2007, p. 34).

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apy services (adapted from Maciejewski, Kawiecki, result of choice, motivation, and meaning and
& Rockwood, 1997). Examples may include (1) a includes objective and subjective aspects of
letter of thanks from the family of a child with carrying out activities meaningful and pur
spinal bida (person); (2) a request for additional poseful to the individual person, organization,
occupational therapy services at a homeless shelter or population. Occupational therapy inter
for their clients (organizations); and (3) procure vention focuses on creating or facilitating
ment of funds to implement support groups for opportunities to engage in these occupations.
caregivers of people with Alzheimers disease To determine the clients success in achieving
throughout the United States (populations). health and participation in life through engage
ment in occupation, occupational therapy practi
Outcomes tioners assess observable outcomes. This assess
Supporting health and participation in life through ment takes into consideration the hypothesized
engagement in occupation is the broad, overarching relationships among various aspects of occupa
outcome of the occupational therapy intervention tional performance. For example, a clients
process. This outcome statement acknowledges the improved ability to embed performance skills into
professions belief that active engagement in occu a routine (performance pattern) and improved
pation promotes, facilitates, and maintains health strength or range of motion (body functions)
and participation. Outcomes are dened as impor enables engagement in managing a home (IADL).
tant dimensions of health, attributed to interven Implicit in any outcome assessment used by
tions, and include the ability to function, health occupational therapy practitioners are the clients
perceptions, and satisfaction with care (adapted beliefs systems and underlying assumptions regarding
from Request for Planning Ideas, 2001). Outcomes their desired occupational performance. The assess
are the end-result of the occupational therapy pro ment tools and the variables measured often become
cess and describe what occupational therapy inter the operational denition for the outcome.
vention can achieve with clients. Therefore, occupational therapy practitioners select
The three interrelated concepts included in the outcome assessments pertinent to the needs and
professions overarching outcome are dened as desires of clients, congruent with the practitioners
1. Health[A] positive concept emphasizing theoretical model of practice, based on knowledge of
social and personal resources, as well as physi the psychometric properties of standardized measures
cal capacities (WHO, 1986). or the rationale and protocols of non-standardized
2. ParticipationThat is, involvement in a life measures and the available evidence. In addition, the
situation (WHO, 2001, p. 10). Participation clients perception of success in engaging in desired
naturally occurs when clients are actively occupations is vital to any outcomes assessment. As a
involved in carrying out occupations or daily point of comparison and in collaboration with the
life activities they nd purposeful and mean client, the occupational therapist may revisit the
ingful in desired contexts. More specic out occupational prole to assess change.
comes of occupational therapy intervention The benets of occupational therapy are multi
(see Table 10) are multidimensional and sup faceted and may occur in all aspects of the domain
port the end-result of participation. of concern. Supporting health and participation in
3. Engagement in occupationThe commitment life through engagement in occupation is the broad
made to performance in occupations as the outcome of intervention. Clients improved perfor-

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mance of occupations, perceived happiness, self- evaluation to identify the clients initial desired out
efcacy, and hopefulness about their life and abili comes related to engagement in valued occupations
ties are valuable outcomes. For example, parents or daily life activities. During intervention imple
whose children received occupational therapy val mentation and re-evaluation, the client and thera
ued understanding their childs behaviors in new pist and, when appropriate, the occupational thera
ways and had greater perceived efcacy about their py assistant, may modify desired outcomes to
parenting (Cohn, 2001; Cohn, Miller, & Tickle- accommodate changing needs, contexts, and per
Degnan, 2000). Interventions designed for care formance abilities. As further analysis of occupa
givers who provide care for people with dementia tional performance and the development of the
improve the quality of life for both the care recipi intervention plan occur, the occupational therapist
ent and the caregiver. Caregivers who received inter and client may redene the desired outcomes.
vention reported fewer declines in the occupational Implementation of the outcomes process
performance of care recipients and less need for help includes the following steps:
and enhanced mastery and skill, self-efcacy, and 1. Selecting types of outcomes and measures,
well-being for themselves (Gitlin & Corcoran, including but not limited to occupational per
2005; Gitlin, Corcoran, Winter, Boyce, & Hauck, formance, adaptation, health and wellness,
2001; Gitlin et al., 2003). participation, prevention, self-advocacy,
Outcomes for people may include subjective quality of life, and occupational justice (see
impressions related to goals such as an improved Table 10).
outlook, condence, hope, playfulness, self-efcacy, Selecting outcome measures early in the
sustainability of valued occupations, resilience, or intervention process (see Evaluation above)
perceived well-being. Outcomes also may include Selecting outcome measures that are valid,
measurable increments of progress in factors related reliable, and appropriately sensitive to
to occupational performance such as skin integrity, change in the clients occupational perfor
amount of sleep, endurance, desire, initiation, bal mance and are consistent with the outcomes
ance, visualmotor skills, and at the participation Selecting outcome measures or instruments
level, activity participation and community re-inte for a particular client that are congruent
gration. Outcomes for organizations may include with client goals
increased workplace morale, productivity, reduced Selecting outcome measures that are based
injuries, and improved worker satisfaction. on their actual or purported ability to pre
Outcomes for populations may include health pro dict future outcomes.
motion, social justice, and access to services. The 2. Using outcomes to measure progress and
denitions and connotations of outcomes are specif adjust goals and interventions
ic to clients, groups, and organizations as well as to Comparing progress toward goal achieve
payers and regulators. Specic outcomes as well as ment to outcomes throughout the interven
documentation of those outcomes vary by practice tion process
setting and are inuenced by the particular stake Assessing outcome use and results to make
holders in each setting. decisions about the future direction of inter
The focus on outcomes is interwoven through vention (e.g., continue intervention, modify
out the process of occupational therapy. The occu intervention, discontinue intervention, pro
pational therapist and client collaborate during the vide follow-up, refer to other services).

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TABLE 10. TYPES OF OUTCOMES


The examples listed specify how the broad outcome of engagement in occupation may be operationalized. The examples are not intended to be
all-inclusive.

Outcome Description
Occupational performance The act of doing and accomplishing a selected activity or occupation that results from the dynamic transac
tion among the client, the context, and the activity. Improving or enabling skills and patterns in occupational
performance leads to engagement in occupations or activities (adapted in part from Law et al., 1996, p. 16).
ImprovementUsed when a performance limitation is present. These outcomes document increased
occupational performance for the person, organization, or population. Outcome examples may
include (1) the ability of a child with autism to play interactively with a peer (person); (2) the ability of
an older adult to return to the home from a skilled-nursing facility (person); (3) decreased incidence
of back strain in nursing personnel as a result of an in-service education program in body mechanics
for carrying out job duties that require bending, lifting, and so forth (organizations); and (d) construc
tion of accessible playground facilities for all children in local city parks (populations).
EnhancementUsed when a performance limitation is not currently present. These outcomes docu
ment the development of performance skills and performance patterns that augment existing perfor
mance or prevent potential problems from developing in life occupations. Outcome examples may
include (1) increased condence and competence of teenage mothers to parent their children as a
result of structured social groups and child development classes (person); (2) increased membership
of the local senior citizen center as a result of diverse social wellness and exercise programs (organi
zation); (3) increased ability by school staff to address and manage school-age youth violence as a
result of conict resolution training to address bullying (organizations); and (4) increased opportu
nities for seniors to participate in community activities due to ride share programs (populations).

Adaptation A change in response approach that the client makes when encountering an occupational challenge. This
change is implemented when the [clients] customary response approaches are found inadequate for produc
ing some degree of mastery over the challenge (adapted from Schultz & Schkade, 1997, p. 474). Examples
of adaptation outcomes include (1) clients modifying their behaviors to earn privileges at an adolescent treat
ment facility (person); (2) a company redesigning the daily schedule to allow for an even workow and to
decrease times of high stress (organizations); and (3) a community making available accessible public trans
portation and erecting public and reserved benches for older adults to socialize and rest (populations).

Health is a resource for everyday life, not the objective of living. For individuals, it is a state of physical,
Health and wellness
mental, and social well-being, as well as a positive concept emphasizing social and personal resources and
physical capacities (WHO, 1986). Health of organizations and populations includes these individual aspects
but also includes social responsibility of members to society as a whole. Wellness is [a]n active process
through which individuals [organizations or populations] become aware of and make choices toward a
more successful existence (Hettler, 1984, p. 1170). Wellness is more than a lack of disease symptoms; it
is a state of mental and physical balance and tness (adapted from Tabers Cyclopedic Medical Dictionary,
1997, p. 2110). Outcome examples may include (1) participation in community outings by a client with
schizophrenia in a group home (person); (2) implementation of a company-wide program to identify prob
lems and solutions for balance among work, leisure, and family life (organizations); and (3) decreased
incidence of childhood obesity (populations).

Participation Engagement in desired occupations in ways that are personally satisfying and congruent with expectations
within the culture.

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TABLE 10. TYPES OF OUTCOMES


(Continued)

Outcome Description
Prevention [H]ealth promotion is equally and essentially concerned with creating the conditions necessary for health
at individual, structural, social, and environmental levels through an understanding of the determinants of
health: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and
equity (Kronenberg, Algado, & Pollard, 2005, p. 441). Occupational therapy promotes a healthy lifestyle at
the individual, group, organizational, community (societal), and governmental or policy level (adapted from
Brownson & Scaffa, 2001). Outcome examples may include (1) appropriate seating and play area for a child
with orthopedic impairments (person); (2) implementation of a program of leisure and educational activities
for a drop-in center for adults with severe mental illness (organizations); and (3) access to occupational
therapy services in underserved areas regardless cultural or ethnic backgrounds (populations).

Quality of life The dynamic appraisal of the clients life satisfaction (perceptions of progress toward ones goals), hope
(the real or perceived belief that one can move toward a goal through selected pathways), self-concept (the
composite of beliefs and feelings about oneself), health and functioning (including health status, self-care
capabilities, and socioeconomic factors, e.g., vocation, education, income; adapted from Radomski, 1995;
Zhan, 1992). Outcomes may include (1) full and active participation of a deaf child from a hearing family
during a recreational activity (person); (2) residents being able to prepare for outings and travel indepen
dently as a result of independent-living skills training for care providers of a group (organization); and (3)
formation of a lobby to support opportunities for social networking, advocacy activities, and sharing scien
tic information for stroke survivors and their families (population).

Role competence The ability to effectively meet the demands of roles in which the client engages.

Self-advocacy Actively promoting or supporting oneself or others (individuals, organizations, or populations); requires an
understanding of strengths and needs, identication of goals, knowledge of legal rights and responsibili
ties, and communicating these aspects to others (adapted from Dawson, 2007). Outcomes may include (1)
a student with a learning disability requesting and receiving reasonable accommodations such as textbooks
on tape (person); (2) a grassroots employee committee requesting and procuring ergonomically designed
keyboards for their computers at work (organization); and (3) people with disabilities advocating for univer
sal design with all public and private construction (population).

Occupational justice Access to and participation in the full range of meaningful and enriching occupations afforded to others.
Includes opportunities for social inclusion and the resources to participate in occupations to satisfy person
al, health, and societal needs (adapted from Townsend & Wilcock, 2004). Outcomes may include (1) people
with intellectual disabilities serving on an advisory board to establish programs offered by a community
recreation center (person); (2) workers who have enough of break time to have lunch with their young chil
dren at day care centers (organization); (3) people with persistent mental illness welcomed by community
recreation center due to anti-stigma campaign (organization); and (4) alternative adapted housing options
for older adult to age in place (populations).

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Historical and Future Perspectives on ly reviewed this document. In light of those


changes and the feedback received during the
the Occupational Therapy Practice
review process of UTIII, the COP decided that
Framework practice needs had changed and that it was time
The Occupational Therapy Practice Framework to develop a different kind of document.
emerged out of the examination of documents Because the Framework is an ofcial AOTA
related to Uniform Terminology. The rst docu document, it is reviewed on a 5-year cycle.
ment was the Occupational Therapy Product During the review period, the COP collected
Output Reporting System and Uniform Terminology feedback from membership, scholars, authors,
for Reporting Occupational Therapy Services and practitioners to determine the needed
(AOTA, 1979). This original text created consis changes. Revisions ensued to maintain the
tent terminology that could be used in ofcial integrity of the Framework and change only what
documents, practice, and education. The second was necessary. The revisions reect the contribu
edition of Uniform Terminology for Occupational tions of the current COP, renement of the writ
Therapy (AOTA, 1989) was adopted by the ing of the document, and emerging concepts and
AOTA Representative Assembly (RA) and pub changes in occupational therapy. The rationale for
lished in 1989. The document focused on delin specic changes is listed in Table 11.
eating and dening only the occupational perfor The Framework is an evolving document and
mance areas and occupational performance will undergo another review in 5 years, which
components that are addressed in occupational again will examine the usefulness of the docu
therapy direct services. The last revision, Uniform ment and need for further renements and
Terminology for Occupational TherapyThird change. The next iteration likely will change as
Edition (UTIII; AOTA, 1994), was adopted by the result of the professions progress toward
the RA in 1994 and was expanded to reect cur AOTAs 2017 Centennial Vision of occupational
rent practice and to incorporate contextual therapy [as] a powerful, widely recognized, sci
aspects of performance (p. 1047). Each revision ence-driven, and evidence-based profession with a
reected changes in current practice and provided globally connected and diverse workforce meeting
consistent terminology that could be used by the society's occupational needs" (AOTA, 2007a).
profession. Originally a document that responded Although the Framework represents the latest
to a federal requirement to develop a uniform in the professions evolution, it builds on a set of
reporting system, the text gradually shifted to values that the profession of occupational therapy
describing and outlining the domain of concern has held since its founding in 1917. This found
of occupational therapy. ing vision had at its center a profound belief in
In the fall of 1998, the AOTA Commission the value of therapeutic occupations as a way to
on Practice (COP) embarked on the journey that remediate illness and maintain health (Slagle,
culminated in the Occupational Therapy Practice 1924). It emphasized the importance of establish
Framework: Domain and Process (Framework; ing a therapeutic relationship with each client and
AOTA, 2002b). During that time, AOTA pub designing a treatment plan based on knowledge
lished The Guide to Occupational Therapy Practice about the individuals environment, values, goals,
(Moyers, 1999), which outlined many of the con and desires (Meyer, 1922). And it advocated for a
temporary shifts of the day, and the COP careful scientic practice based on systematic observation

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TABLE 11. SUMMARY OF SIGNIFICANT FRAMEWORK REVISIONS


Domain Area Change Intended Benet Rationale
Title Supporting Health Increase clarity of Changing from the original title of Figure 1, Engagement in Occupation to
and Participation in intent Support Participation in Context or Contexts, emphasizes that the vehicle
Life Through for occupational therapy to health and participation is engagement in
Engagement in occupation. Deleted in context to shorten the title, because it is dis-
Occupation cussed in the text and implied by the denition of occupation.

Spirituality Move from Context Reect the way in More commonly, individuals consider spirituality residing within the client
to Client Factor which occupational rather than as part of a context. Moreira-Almeida and Koenig (2006) dis-
therapy practition- cussed spirituality, religion, and personal beliefs as components of quality
ers view and of life. Their denitions are included in the text.
analyze meaning,
values, and beliefs
of a broad range
of clients

Performance Broaden categories Provide language Based on her work with the Assessment of Motor and Process Skills
Skills with more generic inclusive of a (AMPS), Fisher (2006) provides the most distinct categories and deni
language broad range of tions of skill functions. An attempt is made in this revision to address
assessments and critiques of the 2002 Framework that Fishers categories are limited. To
interventions as broaden skill categories to more generic and inclusive language, the COP
well as commonly considered at length the differences among body functions, abilities,
used terms in the capacities, skills, levels of skills, and components of occupations. In
literature related to most articles, authors use terms related to skills interchangeably with
skills abilities and capacities, confusing the issue.

To add to the difculty in providing readers with a list of performance


skills, the proposed categories are not completely distinct from one anoth
er. Without creating an articial distinction between categories, it is neces
sary to tolerate the overlap in these skill areas. For example, according to
Filley (2001), skill learning and acquisition of praxis may well be identi
cal phenomena (p. 89). Perception often is discussed in cognitive litera
ture; social cognition implies a specic skill set, as do socialemotional
skills; and sensorymotor skills are often considered together.

Rest and Sleep Move from ADL to Highlight the Rest and sleep are two of the four main categories of occupation dis
Area of Occupation importance of rest cussed by Adolf Meyer (1922). Unlike any other area of occupation, all
and sleep, espe people rest as a result of engaging in occupations and engage in sleep for
cially as they relate multiple hours per day throughout their life span. Within the occupation of
to supporting or rest and sleep are activities such as preparing the self and environment for
hindering engage- sleep, interactions with others who share the sleeping space, reading or
ment in other areas listening to music to fall asleep, napping, dreaming, nighttime care of toi
of occupation leting needs, nighttime caregiving duties, and ensuring safety. Sleep sig
nicantly affects all other areas of occupation. Jonsson (2007) suggested
that providing sleep prominence in the framework as an area of occupation
will promote the consideration of lifestyle choices as an important aspect
of participation and health.

Context Change to context Allow use of broader The terms context and environment are not the same but often are used
and environment language consistent interchangeably. In the general literature, environment is used more fre
with external audi quently. Occupational therapy theories often use environment rather than
ences and existing context. This change allows for a cross-walk between the two terms. In the
occupational therapy narrative, context is used to include environment.
theories
(Continued)

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TABLE 11. SUMMARY OF SIGNIFICANT FRAMEWORK REVISIONS


(Continued)

Domain Area Change Intended Benet Rationale


Occupational Include narrative Highlight the The discussion of concepts of occupational justice encourages practitioners
justice about the impor importance of to examine the multiple contributors to engagement and social participation.
tance of social occupational Townsend and Wilcock (2004) are leaders in our understanding of this
justice specic therapy values important concept. Gupta and Walloch (2006) provide a nice summary of
to occupational in the global this work.
therapy community

Process Area Change Intended Benet Rationale


Client Include person, Broaden the scope Consistent with The Guide to Occupational Therapy Practice (Moyers &
organization, of occupational Dale, 2007). Language in occupational therapy literature often is focused
population therapy services on the individual or person. This change highlights the way in which
and provides occupational therapy contributes to groups of persons, populations, and
language consis organizations, often in nontraditional practice arenas.
tent with advocacy
and policy-making
groups.

Clinical Identify the way in Highlight the Clinical reasoning was expanded in the document to emphasize its impor
Reasoning which the practi importance of tance throughout the occupational therapy process. Intrinsic to any interac
tioners view of the the practitioners tion between the practitioner and the client is the critical thinking implicit
client is informed problem-solving within clinical-reasoning skills that inform and guide the intervention.
via knowledge, skills in the inter
skills, and evidence action with the
client

Activity Analysis Include discussion Highlight the Occupational therapy practitioners have a high level of skill in identifying the
Activity Synthesis about analyzing importance of demands of an activity and then synthesizing this information by comparing
activities in and of this critical skill it with the clients needs and abilities to identify specic occupational perfor
themselves and in that informs mance difculties.
relation to the intervention
client

Self-Advocacy Include self- Provide focus on When working with individuals, populations, or organizations, occupation
advocacy as empowerment al therapy provides intervention, which promotes self-advocacy as a
an outcome as a key feature means toward improved health and participation.
in health and
participation

Evidence-based Emphasize the role Articulate the value Occupational therapy is a profession founded on basic and applied
practice of research in of a science-driven science informing practice.
informing practice profession

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TABLE 11. SUMMARY OF SIGNIFICANT FRAMEWORK REVISIONS


(Continued)

Terminology Change Intended Benet Rationale


Transactive and Include the idea Create distinction Transactive is used to describe the dynamic way in which the areas of the
interactive that areas of the between the occupational therapy domain intersect.
domain are trans- relationships of Interactive is the way in which clients and occupational therapy practitioners
active and the concepts within engage together or with others.
client is interactive the domain and
Occupational therapy is therefore the interaction between practitioners and
interactions
clients within one or more areas of the domain to meet the overarching
between clients
objective of engagement in occupation to support health and participation.
and practitioners

Activity/ Use occupation to To increase Recognizing the work of scholars in the eld, the authors acknowledge the
occupation include activity in readability of differences in activity and occupation. However, this document does not
and purposeful the narrative the document engage in this debate. In the Framework, occupation is used to include
activity activity. Activity is used specic to tasks considered in isolation of the client.
Purposeful activity is used to describe a type of intervention determined by
the therapist to be purposeful for achieving the goals of intervention, not
in judging whether or not a clients chosen activity is purposeful or not.

Outcomes Change Intended Benet Rationale


Outcomes Added occupational To acknowledge Recognizing that an important outcome of occupational therapy intervention
justice and self- occupational may be enabling all individuals to be able to meet basic needs and to have
advocacy to Table therapys commit equal opportunities and life chances to reach toward his or her potential
10: Types of ment to occupa through engagement in diverse and meaningful occupation.
Outcomes tional justice and
self-determination
for all people

below, the COP wishes to thank everyone who has


and treatment (Dunton, 1934). Paraphrased
contributed to the dialogue, feedback, and con
using todays lexicon, the founders proposed a
cepts presented in the document.
vision that was occupation-based, client-centered,
Sincere and heartfelt appreciation is extended
contextual, and evidence-basedthe vision artic
to Wendy Schoen for all her support; to AOTAs
ulated in the Framework today.
past-president, Carolyn Baum, PhD, OTR/L,
FAOTA, and current president Penelope A.
Acknowledgments Moyers Cleveland, EdD, OTR/L, BCMH,
The Commission on Practice (COP) expresses FAOTA, for their insights and direction; the
sincere appreciation to all those who participated Representative Assembly Coordinating Council
in the development of the Occupational Therapy (RACC) members, especially Brent Braveman,
Practice Framework: Domain and Process, 2nd PhD, OTR/L, FAOTA, and Wendy Hildenbrand,
Edition. This new edition represents the combined MPH, OTR/L, FAOTA; to those providing signif
efforts of numerous esteemed colleagues providing icant content and reviews, including Ina Elfant
a collective description of the architecture of occu Asher, MS, OTR/L; Kathleen Barker Schwartz,
pational therapy within which the ecology of the EdD, OTR/L, FAOTA; Mary Frances Baxter,
profession occurs. In addition to those named PhD, OTR/L; Christine Beall, OTR/L; Stefanie

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Bodison, MA, OTR/L; Sarah Burton, MS, OT/L; Kramer, PhD, OTR/L, FAOTA; Patricia LaVesser,
Denea S. Butts, OTD, OTR/L; Jane Case-Smith, PhD, OTR/L; Donna Lucente-Surber, OTR/L;
EdD, OTR, BCP, FAOTA; Florence Clark, PhD, Stephen H. Luster, MS, OTR, CHT; Zoe
OTR/L, FAOTA; Gloria Frolek Clark, MS, Mailloux, MA, OTR/L, FAOTA; Jean McKinley-
OTR/L, FAOTA; Elizabeth Crepeau, PhD, OTR, Vargas, MS, OTR/L; David Nelson, PhD,
FAOTA; Anne E. Dickerson, PhD, OTR/L, OTR/L, FAOTA; L. Diane Parham, PhD,
FAOTA; Winifred Dunn, PhD, OTR, FAOTA; OTR/L, FAOTA; Marta Pelczarski, OTR; Kathlyn
Lisa Ann Fagan, MS, OTR/L; Anne G. Fisher, L. Reed, PhD, OTR, FAOTA; Barbara Schell,
PhD, OTR, FAOTA; Naomi Gil, MSc, OT; Lou PhD, OTR/L, FAOTA; Camille Skubik-Peplaski,
Ann Griswald, PhD, OTR, FAOTA; Sharon A. MS, OTR/L, BCP; Virginia Carroll Stoffel, PhD,
Gutman, PhD, OTR/L; Jim Hinojosa, PhD, OT, OT, BCMH, FAOTA; Marjorie Vogeley, OTR/L;
FAOTA; Hans Jonsson, PhD, OT(Reg); Paula and Naomi Weintraub, PhD, OTR.

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Glossary Analysis of occupational performance


Part of the evaluation process. Collecting infor
A mation via assessment tools designed to observe,
Activities of daily living (ADLs) measure, and inquire about selected factors that
Activities oriented toward taking care of ones own support or hinder occupational performance.
body (adapted from Rogers & Holm, 1994, pp.
181202). ADL also is referred to as basic activities Areas of occupations
of daily living (BADL) and personal activities of daily Various kinds of life activities in which people
living (PADL). These activities are fundamental to engage, including the following categories: ADLs,
living in a social world; they enable basic survival IADLs, rest and sleep, education, work, play,
and well-being (Christiansen & Hammecker, leisure, and social participation (see Table 1).
2001, p. 156) (see Table 1 for denitions of terms). Assessment
Activity (Activities) Specic tools or instruments that are used during
A class of human actions that are goal directed. the evaluation process (AOTA, 2005, p. 663).

Activity analysis B
...addresses the typical demands of an activity, the Belief
range of skills involved in its performance, and the Any cognitive content held as true by the client
various cultural meanings that might be ascribed (Moyers & Dale, 2007).
to it (Crepeau, 2003, p. 192).
Body functions
Activity demands The physiological functions of body systems
The aspects of an activity, which include the objects (including psychological functions) (WHO,
and their physical properties, space, social demands, 2001, p. 10) (see Table 2).
sequencing or timing, required actions or skills, and
required underlying body functions and body struc Body structures
tures needed to carry out the activity (see Table 3). Anatomical parts of the body such as organs,
limbs, and their components [that support body
Adaptation
function] (WHO, 2001, p. 10) (see Table 2).
The response approach the client makes encoun
tering an occupational challenge. This change is C
implemented when the individuals customary
Client
response approaches are found inadequate for pro
The entity that receives occupational therapy ser
ducing some degree of mastery over the challenge
vices. Clients may include (1) individuals and
(Schultz & Schkade, 1997, p. 474).
other persons relevant to the individuals life,
Advocacy including family, caregivers, teachers, employers,
The pursuit of inuencing outcomesincluding and others who also may help or be served indi
public policy and resource allocation decisions rectly; (2) organizations such as business, indus
within political, economic, and social systems and tries, or agencies; and (3) populations within a
institutionsthat directly affect peoples lives community (Moyers & Dale, 2007).
(Advocacy Institute, 2001, as cited in Goodman-
Lavey & Dunbar, 2003, p. 422).

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Client-centered approach D
An orientation that honors the desires and priori Domain
ties of clients in designing and implementing A sphere of activity, concern, or function
interventions (adapted from Dunn, 2000a, p. 4). (American Heritage Dictionary, 2006).
Client factors
Those factors residing within the client that may E
affect performance in areas of occupation. Client
Education
factors include values, beliefs, and spirituality;
Includes learning activities needed when partici
body functions; and body structures (see Table 2).
pating in an environment (see Table 1).
Clinical reasoning
Emotional regulation skills
Complex multi-faceted cognitive process used by
Actions or behaviors a client uses to identify, man
practitioners to plan, direct, perform, and reect
age, and express feelings while engaging in activi
on intervention (Crepeau et al., 2003, p. 1027).
ties or interacting with others.
Communication and social skills
Engagement
Actions or behaviors a person uses to communi
The act of sharing activities.
cate and interact with others in an interactive envi
ronment (Fisher, 2006). Environment
The external physical and social environment that
Cognitive skills
surrounds the client and in which the clients daily
Actions or behaviors a client uses to plan and man
life occupations occur (see Table 6).
age the performance of an activity.
Evaluation
Context
The process of obtaining and interpreting data
Refers to a variety of interrelated conditions with
necessary for intervention. This includes planning
in and surrounding the client that inuence per
for and documenting the evaluation process and
formance. Contexts include cultural, personal,
results (AOTA, 2005, p. 663).
temporal, and virtual (see Table 6).

Co-occupations G
Activities that implicitly involve at least two peo Goals
ple (Zemke & Clark, 1996). The result or achievement toward which effort
Cultural (context) is directed; aim; end (Websters Encyclopedic
Customs, beliefs, activity patterns, behavior stan Unabridged Dictionary of the English Language,
dards, and expectations accepted by the society of 1994, p. 605).
which the [client] is a member. Includes ethnicity
and values as well as political aspects, such as laws H
that affect access to resources and afrm personal Habits
rights. Also includes opportunities for education, Automatic behavior that is integrated into more
employment, and economic support (AOTA, complex patterns that enable people to function
1994, p. 1054). on a day-to-day basis (Neistadt & Crepeau,
1998, p. 869). Habits can be useful, dominating,

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or impoverished and either support or interfere Independence


with performance in areas of occupation. A self-directed state of being characterized by an
individuals ability to participate in necessary and
Health
preferred occupations in a satisfying manner irre
Health is a resource for everyday life, not the
spective of the amount or kind of external assis
objective of living. It is a state of complete physi
tance desired or required
cal, mental, and social well-being, as well as a pos
itive concept emphasizing social and personal Self-determination is essential to achieving
resources, as well as physical capacities (adapted and maintaining independence;
from WHO, 1986). An individuals independence is unrelated to
whether he or she performs the activities
Health promotion related to an occupation himself or herself,
[T]he process of enabling people to increase control performs the activities in an adapted or mod
over, and to improve, their health. To reach a state of ied environment, makes use of various
complete physical, mental, and social well-being, an devices or alternative strategies, or oversees
individual or group must be able to identify and activity completion by others;
realize aspirations, to satisfy needs, and to change or Independence is dened by the individuals
cope with the environment (WHO, 1986). culture and values, support systems, and
[C]reating the conditions necessary for health ability to direct his or her life; and
at individual, structural, social, and environmental
An individuals independence should not be
levels through an understanding of the determi
based on preestablished criteria, perception
nants of health: peace, shelter, education, food,
of outside observers, or how independence is
income, a stable ecosystem, sustainable resources,
accomplished (AOTA, 2002a, p. 660).
social justice, and equity (Trentham & Cockburn,
2005, p. 441). Instrumental activities of daily living (IADLs)
Activities to support daily life within the home and
Hope
community that often require more complex inter
The real or perceived belief that one can move
actions than self-care used in ADL (see Table 1).
toward a goal through selected pathways (Lopez et
al., 2004). Interdependence
The reliance that people have on each other as a
I natural consequence of group living (Christiansen
Identity & Townsend, 2004, p. 277). Interdependence
A composite denition of the self and includes an engenders a spirit of social inclusion, mutual aid,
interpersonal aspectan aspect of possibility or and a moral commitment and responsibility to rec
potential (who we might become), and a values ognize and support difference (p. 146).
aspect (that suggests importance and provides a
Interests
stable basis for choices and decisions). Identity
What one nds enjoyable or satisfying to do
can be viewed as the superordinate view of our
(Kielhofner, 2002, p. 25).
selves that includes both self-esteem and self-con
cept but also importantly reects and is inuenced Intervention
by the larger social world in which we nd our The process and skilled actions taken by occupa
selves (Christiansen, 1999, pp. 548549). tional therapy practitioners in collaboration with

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the client to facilitate engagement in occupation meaning. Occupations involve mental abilities and
related to health and participation. The interven skills and may or may not have an observable phys
tion process includes the plan, implementation, ical dimension (Hinojosa & Kramer, 1997, p. 865).
and review (see Table 7). [A]ctivitiesof everyday life, named, orga
nized, and given value and meaning by individu
Intervention approaches
als and a culture. Occupation is everything people
Specic strategies selected to direct the process of
do to occupy themselves, including looking after
interventions that are based on the clients
themselvesenjoying lifeand contributing to
desired outcome, evaluation date, and evidence
the social and economic fabric of their communi
(see Table 9).
ties (Law et al., 1997, p. 32).
A dynamic relationship among an occupa
L
tional form, a person with a unique developmen
Leisure
tal structure, subjective meanings and purpose,
A nonobligatory activity that is intrinsically moti
and the resulting occupational performance
vated and engaged in during discretionary time,
(Nelson & Jepson-Thomas, 2003, p. 90).
that is, time not committed to obligatory occupa
[C]hunks of daily activity that can be named
tions such as work, self-care, or sleep (Parham &
in the lexicon of the culture (Zemke & Clark,
Fazio, 1997, p. 250).
1996, p. vii).
M Occupation-based intervention
Motor and praxis skills A type of occupational therapy interventiona
Motor client-centered intervention in which the occupa
Actions or behaviors a client uses to move and tional therapy practitioner and client collabora
physically interact with tasks, objects, contexts, tively select and design activities that have specic
and environments (adapted from Fisher, 2006). relevance or meaning to the client and support the
Includes planning, sequencing, and executing clients interests, need, health, and participation in
novel movements. daily life.
Also see Praxis.
Occupational justice
Justice related to opportunities and resources
O
required for occupational participation sufcient
Occupation to satisfy personal needs and full citizenship
Goal-directed pursuits that typically extend over (Christiansen & Townsend, 2004, p. 278). To
time have meaning to the performance, and experience meaning and enrichment in ones occu
involve multiple tasks (Christiansen et al., 2005, pations; to participate in a range of occupations
p. 548). for health and social inclusion; to make choices
Daily activities that reect cultural values, and share decision-making power in daily life; and
provide structure to living, and meaning to indi to receive equal privileges for diverse participation
viduals; these activities meet human needs for self- in occupations (Townsend & Wilcock, 2004).
care, enjoyment, and participation in society
(Crepeau et al., 2003, p. 1031). Occupational performance
Activities that people engage in throughout The act of doing and accomplishing a selected
their daily lives to fulll their time and give life activity or occupation that results from the

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dynamic transaction among the client, the con P


text, and the activity. Improving or enabling skills Participation
and patterns in occupational performance leads to Involvement in a life situation (WHO, 2001,
engagement in occupations or activities (adapted p. 10).
in part from Law et al., 1996, p. 16).
Performance patterns
Occupational prole Patterns of behavior related to daily life activities
A summary of the clients occupational history, pat that are habitual or routine. They can include
terns of daily living, interests, values, and needs. habits, routines, rituals, and roles (see Table 5).
Occupational science Performance skills
An interdisciplinary academic discipline in the The abilities clients demonstrate in the actions
social and behavioral sciences dedicated to the they perform (see Table 4).
study of the form, the function, and the meaning
of human occupations (Zemke & Clark, 1996). Persons
Individuals, including families, caregivers, teach
Occupational therapy ers, employees, and relevant others.
The practice of occupational therapy means the ther
apeutic use of everyday life activities (occupations) Personal
with individuals or groups for the purpose of partici Features of the individual that are not part of a
pation in roles and situations in home, school, work health condition or health status (WHO, 2001, p.
place, community, and other settings. Occupational 17). Personal context includes age, gender, socioe
therapy services are provided for the purpose of pro conomic, and educational status. Can also include
moting health and wellness and to those who have or organizational levels (i.e., volunteers, employees)
are at risk for developing an illness, injury, disease, and population levels (i.e., members of a society).
disorder, condition, impairment, disability, activity
Physical environment
limitation, or participation restriction. Occupational
The natural and built nonhuman environment
therapy addresses the physical, cognitive, psychoso
and objects in them.
cial, sensory, and other aspects of performance in a
variety of contexts to support engagement in every Play
day life activities that affect health, well-being, and Any spontaneous or organized activity that pro
quality of life (AOTA, 2004a). vides enjoyment, entertainment, amusement, or
diversion (Parham & Fazio, 1997, p. 252) (see
Organizations
Table 1).
Entities with a common purpose or enterprise
such as businesses, industries, or agencies. Populations
Large groups as a whole, such as refugees, home
Outcomes
less veterans, and people who need wheelchairs.
What occupational therapy actually achieves for the
consumers of its services (adapted from Fuhrer, Praxis
1987). Change desired by the client that can focus Skilled purposeful movements (Heilman & Rothi,
on any area of the clients occupational performance 1993). The ability to carry out sequential motor acts
(adapted from Kramer, McGonigel, & Kaufman, as part of an overall plan rather than individual acts
1991). (Liepmann, 1920). The ability to carry out learned

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motor activity, including following through on a ver pation or occupations. Specically selected activi
bal command, visual spatial construction, ocular and ties that allow the client to develop skills that
oralmotor skills, imitation of a person or an object, enhance occupational engagement.
and sequencing actions (Ayres, 1985; Filley, 2001).
Organization of temporal sequences of actions with Q
in the spatial context; which form meaningful occu Quality of life
pations (Blanche & Parham, 2002). A clients dynamic appraisal of life satisfactions (per
Also see Motor. ceptions of progress toward identied goals), self-
concept (the composite of beliefs and feelings about
Preparatory methods
themselves), health and functioning (including
Methods and techniques that prepare the client for
health status, self-care capabilities), and socioeco
occupational performance. Used in preparation
nomic factors (e.g., vocation, education, income)
for or concurrently with purposeful and occupa
(adapted from Radomski, 1995; Zhan, 1992).
tion-based activities.

Prevention R
[H]ealth promotion is equally and essentially Re-evaluation
concerned with creating the conditions necessary A reassessment of the clients performance and goals
for health at individual, structural, social, and to determine the type and amount of change.
environmental levels through an understanding of
Rest
the determinants of health: peace, shelter, educa
Quiet and effortless actions that interrupt physical
tion, food, income, a stable ecosystem, sustainable
and mental activity, resulting in a relaxed state
resources, social justice, and equity (Kronenberg,
(Nurit & Michel, 2003, p. 227).
Algado, & Pollard, 2005, p. 441).
Promoting a healthy lifestyle at the individual, Ritual
group, organizational, community (societal), gov Symbolic actions with spiritual, cultural, or social
ernmental/policy level (adapted from Brownson meaning, contributing to the clients identity and
& Scaffa, 2001). reinforcing the clients values and beliefs (Fiese et al.,
2002; Segal, 2004). Rituals are highly symbolic,
Process with a strong affective component and representa
A description of the way in which occupational tive of a collection of events.
therapy practitioners operationalize their exper
tise to provide services to clients. The process Roles
includes evaluation, intervention, and outcome Roles are sets of behaviors expected by society,
monitoring; occurs within the purview of the shaped by culture, and may be further conceptual
domain; and involves collaboration among the ized and dened by the client.
occupational therapist, occupational therapy
Routines
assistant, and the client.
Patterns of behavior that are observable, regular,
Purposeful activity repetitive, and that provide structure for daily life.
A goal-directed behavior or activity within a ther They can be satisfying, promoting, or damaging.
apeutically designed context that leads to an occu Routines require momentary time commitment

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and are embedded in cultural and ecological con as widely as possible, and nally the requirement
texts (Fiese et al., 2002; Segal, 2004). that we reduce and where possible eliminate
unjustied inequalities (Commission on Social
Self-advocacy
Justice, 1994, p. 1).
Understanding your strengths and needs, identify
The promotion of social and economic
ing your personal goals, knowing your legal rights
change to increase individual, community, and
and responsibilities, and communicating these to
political awareness, resources, and opportunity for
others (Dawson, 2007).
health and well-being (Wilcock, 2006, p. 344).
Sensoryperceptual skills Social participation
Actions or behaviors a client uses to locate, identi Organized patterns of behavior that are charac
fy, and respond to sensations and to select, inter teristic and expected of an individual in a given
pret, associate, organize, and remember sensory position within a social system (Mosey, 1996, p.
events via sensations that include visual, auditory, 340) (see Table 1).
proprioceptive, tactile, olfactory, gustatory, and
vestibular sensations. Spirituality
[T]he personal quest for understanding answers
Sleep to ultimate questions about life, about meaning,
A natural periodic state of rest for the mind and and about relationship with the sacred or tran
body, in which the eyes usually close and con scendent, which may (or may not) lead to or arise
sciousness is completely or partially lost, so that from the development of religious rituals and the
there is a decrease in bodily movement and formation of community (Moreira-Almeida &
responsiveness to external stimuli. During sleep Koenig, 2006, p. 844).
the brain in humans and other mammals under
goes a characteristic cycle of brain-wave activity T
that includes intervals of dreaming (The Free Temporal
Dictionary, 2007) (see Table 1). Location of occupational performance in time
A series of activities resulting in going to sleep, (Neistadt & Crepeau, 1998, p. 292). The experience
staying asleep, and ensuring health and safety of time as shaped by engagement in occupations.
through participation in sleep involving engage The temporal aspects of occupations which con
ment with the physical and social environments. tribute to the patterns of daily occupations are the
Social environment rhythm...tempo...synchronization...duration...and
Is constructed by the presence, relationships, and sequence (Larson & Zemke, 2004, p. 82; Zemke,
expectations of persons, organizations, and pop 2004, p. 610). It includes stages of life, time of day,
ulations. duration, rhythm of activity, or history.

Social justice Transactional


Ethical distribution and sharing of resources, A process that involves two or more individuals
rights, and responsibilities between people, recog or elements that reciprocally and continually
nizing their equal worth as citizens. [It recognizes] inuence and affect one another through the
their equal right to be able to meet basic needs, ongoing relationship (Dickie, Cutchin, &
the need to spread opportunities and life chances Humphry, 2006).

The American Journal of Occupational Therapy 675


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V American Occupational Therapy Association. (1994).


Uniform terminology for occupational therapy
Values
(3rd ed.). American Journal of Occupational
Principles, standards, or qualities considered Therapy, 48, 10471054.
worthwhile or desirable by the client who holds American Occupational Therapy Association. (2002a).
them (Moyers & Dale, 2007). Broadening the construct of independence [Position
Paper]. American Journal of Occupational Therapy,
Virtual 56, 660.
Environment in which communication occurs by American Occupational Therapy Association.
means of airways or computers and an absence of (2002b). Occupational therapy practice frame
physical contact. Includes simulated or real-time work: Domain and process. American Journal of
or near-time existence of an environment, such as Occupational Therapy, 56, 609639.
chat rooms, email, video conferencing, and radio American Occupational Therapy Association. (2004a).
Denition of occupational therapy practice for the
transmissions.
AOTA Model Practice Act. Bethesda, MD: Author.
(Available from the State Affairs Group, 4720
W Montgomery Lane, PO Box 31220, Bethesda, MD
Wellness 208241220)
An active process through which individuals become American Occupational Therapy Association. (2004b).
aware of and make choices toward a more successful Guidelines for supervision, roles, and responsibili
existence (Hettler, 1984, p. 1117). Wellness is more ties during the delivery of occupational therapy ser
vices. American Journal of Occupational Therapy, 58,
than a lack of disease symptoms. It is a state of men
663667.
tal and physical balance and tness (adapted from American Occupational Therapy Association. (2004c).
Tabers Cyclopedic Medical Dictionary, 1997, p. 2110). Occupational therapys commitment to nondis
crimination and inclusion (edited 2004). American
Work
Journal of Occupational Therapy, 58, 666.
Activities needed for engaging in remunerative American Occupational Therapy Association. (2005).
employment or volunteer activities (Mosey, 1996, Standards of practice for occupational therapy.
p. 341) (see Table 1). American Journal of Occupational Therapy, 59,
663665.
American Occupational Therapy Association. (2006).
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Authors With contributions from


M. Carolyn Baum, PhD, OTR/L, FAOTA
THE COMMISSION ON PRACTICE:
Ellen S. Cohn, ScD, OTR/L, FAOTA
Susanne Smith Roley, MS, OTR/L, FAOTA,
Penelope A. Moyers Cleveland, EdD, OTR/L,
Chairperson, 20052008
BCMH, FAOTA
Janet V. DeLany, DEd, OTR/L, FAOTA,
Mary Jane Youngstrom, MS, OTR, FAOTA
Chairperson-Elect, 20072008
Cynthia J. Barrows, MS, OTR/L
for
Susan Brownrigg, OTR/L
DeLana Honaker, PhD, OTR/L, BCP
THE COMMISSION ON PRACTICE
Deanna Iris Sava, MS, OTR/L
Susanne Smith Roley MS, OTR/L, FAOTA,
Vibeke Talley, OTR/L
Chairperson
Kristi Voelkerding, BS, COTA/L, ATP
Deborah Ann Amini, MEd, OTR/L, CHT,
Adopted by the Representative Assembly 2008C5.
SIS Liaison
Emily Smith, MOT, ASD Liaison
This document replaces the 2002 Occupational
Pamela Toto, MS, OTR/L, BCG, FAOTA,
Therapy Practice Framework: Domain and Process.
Immediate-Past SIS Liaison
Sarah King, MOT, OTR, Immediate-Past
Copyright 2008, by the American Occupational
ASD Liaison
Therapy Association. To be published in the
Deborah Lieberman, MHSA, OTR/L, FAOTA,
American Journal of Occupational Therapy, 62
AOTA Headquarters Liaison
(November/December).

The American Journal of Occupational Therapy 683