Professional Documents
Culture Documents
Case Smiths Occupational Therapy For Children and Adolescents 8E 8Th Edition Jane Clifford Obrien Full Chapter PDF
Case Smiths Occupational Therapy For Children and Adolescents 8E 8Th Edition Jane Clifford Obrien Full Chapter PDF
https://ebookmass.com/product/occupational-therapy-for-children-
and-adolescents-case-review-7th-edition/
https://ebookmass.com/product/occupational-therapy-evaluation-
for-children-a-pocket-guide-2nd-edition-ebook-pdf/
https://ebookmass.com/product/infants-and-children-prenatal-
through-middle-childhood-berk-infants-children-and-adolescents-
series-8th-edition-ebook-pdf/
https://ebookmass.com/product/occupational-therapy-in-action-a-
library-of-case-studies-first-edition-ebook-pdf/
Counseling Children and Adolescents: Connecting Theory,
Development,
https://ebookmass.com/product/counseling-children-and-
adolescents-connecting-theory-development/
https://ebookmass.com/product/the-intentional-relationship-
occupational-therapy-and-use-of-self-occupational-therapy-and-
the-use-of-self-1st-edition-ebook-pdf/
https://ebookmass.com/product/conditions-in-occupational-therapy-
effect-on-occupational-performance-5th-edition-ebook-pdf/
https://ebookmass.com/product/frames-of-reference-for-pediatric-
occupational-therapy-4th-edition-ebook-pdf/
https://ebookmass.com/product/willard-and-spackmans-occupational-
therapy-thirteenth-north-american/
Case-Smith's
Occupational Therapy for
Children and Adolescents
EIGHTH EDITION
1
Table of Contents
Cover image
Title page
Copyright
Dedication
Contributors
Reviewers
Preface
Acknowledgments
Chapter 2. Using Occupational Therapy Models and Frames of Reference With Children and Youth
Introduction
Theory
2
3. Working With Families
Family Subsystems
Communication Strategies
Summary
Neurophysiological Development
3
Becoming A Competent Test User
Scoring Methods
What is evaluation?
Areas of Evaluation
Purpose of Evaluation
Top-Down Evaluation
Evaluation Process
Interpretation
Goal Writing
9. Documenting Outcomes
Introduction
Defining Play
4
Theories of Play
Leisure
Play Goals
12. Assessment and Treatment of Activities of Daily Living, Sleep, Rest, and Sexuality
Summary
Chapter 13. Assessment and Treatment of Instrumental Activities of Daily Living and Leisure
5
Goals for Social Participation and Social Skills
Education as an Occupation
Interventions
Introduction
Cognitive Strategies
Cognitive Interventions
18. Mobility
Mobility Evaluation
6
19. Assistive Technology
The AT Evaluation
Specific Types of AT
Changing The Landscape in Education: Planning for Every Student in The Twenty-First Century
Introduction
Understanding Behavior
7
Specific Therapeutic Interventions in the NICU
Reflective Practice
Rehabiltation Services
Outpatient Services
Assessment
8
28. Mental Health Conditions
Introduction
Medical-Based Interventions
Introduction
Burn Injury
Therapeutic Relationships
Models of Vision
9
Prevalence of Vision Problems in Children
Intervention
Appendix A
Index
10
Copyright
3251 Riverport Lane
St. Louis, Missouri 63043
OCCUPATIONAL THERAPY FOR CHILDREN AND ADOLESCENTS, EIGHTH EDITION ISBN: 978-
0-323-51263-3
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Copyright © 2015, 2010, 2005, 2001, 1996, 1989, 1985 by Mosby, Inc., an affiliate of Elsevier Inc.
No part of this publication may be reproduced or transmi ed in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies and our arrangements with organizations such
as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds or experiments described herein. Because of rapid
advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors,
editors or contributors for any injury and/or damage to persons or property as a ma er of products
liability, negligence or otherwise, or from any use or operation of any methods, products, instructions,
or ideas contained in the material herein.
Previous editions Copyright © 2015, 2010, 2005, 2001, 1996, 1989, 1985 by Mosby, Inc., an affiliate of
Elsevier Inc.
Library of Congress Cataloging-in-Publication Data
11
Dedication
Dr. Jane Case-Smith was soft-spoken, thoughtful, and a brilliant scholar, who believed strongly in
using science as a foundation for intervention, while never overlooking the art of therapy. Her ability
to integrate these two important aspects of occupational therapy will forever influence the profession
and help many children and their families participate in daily occupations. Jane valued people,
consistently striving to foster strong relationships with her colleagues, coauthors, and the families
she served. She mentored many students, practitioners, and colleagues and her legacy exists in those
who will carry on the work she loved, including this text. Her spirit is infused throughout the
pictures and words of this book. Jane, we dedicate this edition that now carries your name in the title
to you, and hope you would be happy with the results.
12
Contributors
Beth Ann Ball, MS, OTR/L , Ohio OT, PT, AT Board, Chair , The Ohio State University ,
Occupational Therapy Program, Advisory Board Member, Columbus, OH, United States
Susan Bazyk, PhD, OTR/L, FAOTA , Director, Every Moment Counts, Professor Emerita,
Occupational Therapy, Cleveland State University, Cleveland, OH, United States
Rosemarie Bigsby, ScD, OTR/L, FAOTA , Clinical Professor of Pediatrics, Psychiatry and Human
Behavior, Warren Alpert Medical School, Coordinator, NICU Services, Brown Center for Children at
Risk, Department of Pediatrics, Women and Infant’s Hospital, Brown University, Providence, RI,
United States
Susan M. Cahill, PhD, OTR/L, FAOTA , Associate Professor & Program Director, Occupational
Therapy Program, Lewis University, Romeoville, IL, United States
Theresa Carlson Carroll, OTD, OTR/L , Clinical Assistant Professor, Occupational Therapy,
University of Illinois at Chicago, Chicago, IL, United States
Kaitlyn Carmichael, OT Reg. (Ont.) , School Health Occupational Therapist, Western University,
London, ON, Canada
Jana Cason, DHSc, OTR/L, FAOTA , Professor, Auerbach School of Occupational Therapy, Spalding
University, Louisville, KY, United States
Megan C. Chang, PhD, OTR/L , Associate Professor, College of Health and Human Sciences, San
Jose State University, San Jose, CA, United States
Gloria Frolek Clark, PhD, OTR/L, BCP, FAOTA , Owner, Gloria Frolek Clark, LLC, Adel, IA,
United States
Dennis Cleary, BA, BS, MS, OTD , Founding Program Director, Occupational Therapy, School of
Rehabilitative Science, Indiana University South Bend, South Bend, IN, United States,
Pa y Coker-Bolt, PhD, OTR/L, FAOTA , Professor, Medical University of South Carolina, Division
of Occupational Therapy, College of Health Professions, Charleston, SC, United States
Sharon M. Cosper, EdD, MHS, OTR/L , Associate Professor, Department of Occupational Therapy,
Augusta University, Augusta, GA, United States
Jenny M. Dorich, MBA, OTR/L, CHT , Occupational Therapist III , Division of Occupational
Therapy and Physical Therapy, Cincinnati Children’s Medical Center, Adjunct Faculty, College of
Health Sciences, University of Cincinnati, Cincinnati, OH, United States
Brian J. Dudgeon, PhD, OTR, FAOTA , Professor, retired, Occupational Therapy, School of Health
Professions, University of Alabama at Birmingham, Birmingham, AL, United States
13
Sarah E. Fabrizi, PhD OTR/L , Assistant Professor, Occupational Therapy Program, Florida Gulf
Coast University , Fort Myers, FL, United States
Patricia Fingerhut, PhD, OTR , Associate Professor and Chair, Robert K. Bing Distinguished
Professor, Distinguished Teaching Professor, Department of Occupational Therapy, School of Health
Professions, University of Texas Medical Branch, Galveston, TX, United States
Sandy Hanebrink, OTR/L, CLP, FAOTA , Executive Director , Touch the Future Inc, Anderson, SC,
United States
Karen Harpster, PhD, OTR/L , Assistant Professor, Division of Occupational Therapy and Physical
Therapy , Cincinnati Children’s Medical Center , College of Health Sciences, University of Cincinnati,
Cincinnati, OH, United States
Claudia List Hilton, PhD, MBA, OTR, FAOTA , Associate Professor of Occupational Therapy &
Rehabilitation Sciences, Distinguished Teaching Professor, University of Texas Medical Branch,
Galveston, TX, United States
Carole K. Ivey, PhD, OTR/L , Associate Professor, Department of Occupational Therapy, Virginia
Commonwealth University, Richmond, VA, United States
Lynn Jaffe, ScD, OTR/L, FAOTA , Professor & Program Director for Occupational Therapy ,
Department of Rehabilitation Sciences, Marieb College of Health & Human Services, Florida Gulf Coast
University, Fort Myers, FL, United States
Mary A. Khetani, Sc.D, OTR/L , Associate Professor, Department of Occupational Therapy, College
of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, United States
Kimberly Korth, MEd, OTR/L, SCFES , Occupational Therapist, Feeding Program Coordinator,
Children’s Hospital Colorado, Denver, CO, United States
Jessica Kramer, PhD, OTR/L , Associate Professor, Department of Occupational Therapy, College of
Public Health and Health Professions, University of Florida, Gainesville, FL
Heather Kuhaneck, PhD OTR/L FAOTA , Associate Professor, Occupational Therapy, Sacred Heart
University, Fairfield, CT, United States
Cheryl B. Lucas, EdD, OTR/L , Graduate Coordinator, Assistant Professor, Occupational Therapy
Department, Worcester State University, Worcester, MA, United States
Zoe Mailloux, OTD, OTR/L, FAOTA , Adjunct Associate Professor, Occupational Therapy, Thomas
Jefferson University, Philadelphia, PA, United States
Angela Mandich, PhD, OT Reg. (Ont.) , Director School of Occupational Therapy, Western
University, London, ON, Canada
Nancy Creskoff Maune, OTR/L , Occupational Therapist, Occupational Therapy, Feeding and
Swallowing Program, Children’s Hospital Colorado, Aurora, CO, United States
Christine T. Myers, PhD, OTR/L , Clinical Associate Professor and Program Director, Department
of Occupational Therapy, University of Florida, Gainesville, FL, United States
Erin Naber, PT, DPT , Senior Physical Therapist, Fairmount Rehabilitation Programs, Kennedy
Krieger Institute, Baltimore, MD, United States
Jane O’Brien, PhD, MS. EdL, OTR/L, FAOTA , Professor, Occupational Therapy, University of New
England, Portland, ME, United States
14
L. Diane Parham, PhD, OTR/L, FAOTA , Professor, Occupational Therapy Graduate Program,
University of New Mexico, Albuquerque, NM, United States
Andrew C. Persch, PhD, OTR/L, BCP , Assistant Professor, Department of Occupational Therapy,
Colorado State University, Fort Collins, CO, United States
Karen Ratcliff, PhD, OTR , Professor, Occupational Therapy, University of Texas Medical Branch
Galveston, Galveston, TX, United States
Teressa Garcia Reidy, MS, OTR/L , Fairmount Rehabilitation Programs, Hunter Nelson Sturge-
Weber Center, Kennedy Krieger Institute, Baltimore, MD, United States
Pamela Richardson, PhD, OTR/L, FAOTA , Interim Dean, College of Health and Human Sciences,
San Jose State University, San Jose, CA, United States
Lauren E. Rosen, PT, MPT, MSMS, ATP/SMS , Motion Analysis Center Program Coordinator, St.
Joseph’s Children’s Hospital, Tampa, FL, United States
Lisa Rotelli, PTA , Director, Adaptive Switch Laboratories, Austin, TX, United States
Andrina Sabet, PT, ATP , Cleveland Clinic Children’s Hospital for Rehabilitation, Mobility Ma ers,
LLC, Cleveland, OH, United States
Mitchell Scheiman, OD, PhD , Dean of Research and Sponsored Programs, Director of Graduate
Programs in Biomedicine, Professor, Salus University, Elkins Park, PA, United States
Colleen Schneck, ScD, OTR/L, FAOTA , Department Chair and Part-time Associate Dean, College
of Health Sciences, Department of Occupational Science and Occupational Therapy, Eastern Kentucky
University, Richmond, KY, United States
Judith Weenink Schoonover, MEd, OTR/L, ATP, FAOTA , Occupational Therapist, Assistive
Technology Professional, Specialized Instructional Facilitator-Assistive Technology, Loudoun County
Public Schools, Ashburn, VA, United States
Winifred Schul -Krohn, PhD, OTR/L, BCP, SWC, FAOTA , Professor and Chair of Occupational
Therapy, San Jose State University, San Jose, CA, United States
Pa i Sharp, OTD, MS, OTR/L , Occupational Therapist II, Division of Occupational Therapy and
Physical Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
Amber Sheehan, OTR/L , Occupational Therapist II, Division of Occupational Therapy and Physical
Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
Jayne Shepherd, MS, OTR/L, FAOTA , Professor Emeritis, Department of Occupational Therapy,
Virginia Commonwealth Universitys, Richmond, VA, United States
Natasha Smet, OTD, OTR/L , Assistant Professor , Occupational Therapy , A.T. Still University ,
Mesa, AZ, United States
Susan L. Spi er, PhD, OTR/L , Owner/Director, Occupational Therapist, Private Practice, Pasadena,
CA, United States
Ashley Stoffel, OTD, OTR/L, FAOTA , Clinical Associate Professor, Department of Occupational
Therapy, University of Illinois at Chicago, Chicago, IL, United States
15
Renee R. Taylor, MA, PhD , Professor and Associate Dean for Academic Affairs, Licensed Clinical
Psychologist, Department of Occupational Therapy, College of Applied Health Sciences , 1919 W.
Taylor St. (MC 811), Chicago, IL, United States
Beth Warnken, OTD, OTR/L, ATP , Occupational Therapist II, Division of Occupational Therapy
and Physical Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
Renee Watling, OTR/L, PhD, FAOTA , Visiting Assistant Professor, School of Occupational
Therapy, University of Puget Sound, Tacoma, WA, United States
Jessie Wilson, PhD, OT Reg. (Ont.) , Assistant Professor, School of Occupational Therapy, Western
University, London, ON, Canada
16
Reviewers
Meredith P. Gronski, OTD, OTR/L , Program Director and Chair, Methodist
University, Faye eville, NC, United States
Rebecca S. Herr, MOT, OTR , Instructor of Occupational Therapy, The
University of Findlay, Findlay, OH, United States
Diana Gantman Kraversky, OTD, MS, OTR/L, AP , Assistant Professor, West
Coast University, Los Angeles, CA, United States
Ann E. McDonald, PhD, OTR/L, SWC , Associate Professor, West Coast
University, Los Angeles, CA, United States
Deb McKernan-Ace, MOT/OTR, COTA , OTA Program Director, Bryant &
Stra on College, Wauwatosa, WI, United States
17
Preface
Organization
The current edition is organized into six sections to reflect the knowledge and skills needed to practice
occupational therapy with children and to help readers apply concepts to practice. The first section
describes foundational knowledge for occupational therapy for children and youth and includes
chapters on theories and practice models, child and adolescent development, family-centered care, and
therapeutic use of self.
The second section of the book focuses on the ability to evaluate and assess children and adolescents,
write goals, measure outcomes, and document progress from intervention. This section begins with a
chapter on the occupational therapist’s skill with observation and activity analysis as a primary method
of assessment. This is followed by an explanation of the use of standardized tests, including how to
administer a standardized test, score items, interpret test scores, and synthesize the findings.
Additional chapters provide information regarding the creation of goals and outcome measures based
on evaluation findings.
Section three highlights the specific assessment and intervention methods for each of the areas of
occupation. Chapters 10 to 15examine the assessment and treatment of feeding, play, activities of daily
living, instrumental activities of daily living, social participation, and educational performance. The
authors describe interventions to target performance areas (e.g., hand skills) and occupations (e.g.,
feeding, activities of daily living, play, social participation). Section four (Chapters 16 to 21) continues
with chapters related to specific intervention approaches used across areas of occupation. The authors
describe a variety of intervention approaches, including motor control/motor learning, cognitive,
mobility, assistive technology, sensory integration, and behavioral. The authors explain both the theory
and science of occupational therapy practice and discuss issues that frequently occur in practice.
Together these chapters reflect the breadth and depth of occupational therapy with children and
adolescents.
The fifth section (Chapters 22 to 27) of the book describes the specific contexts of occupational
therapy practice with children. These chapters illustrate the rich variety of practice opportunities and
define how practice differs in medical versus education systems and institutions. Only by
understanding the intervention context and the child’s environments can occupational therapists select
appropriate intervention practices.
The final and sixth section, (Chapters 28 to 32) provide readers with strategies for specific
populations. For example, the chapters illustrate how practitioners help children with mental health
disorders, including neuromotor conditions such as cerebral palsy, autism, trauma-induced conditions,
or visual impairments, engage in occupations.
Distinctive Features
Although the chapters contain related information, each chapter stands on its own, such that the
chapters do not need to be read in a particular sequence. Each chapter begins with key questions to
guide reading. Case reports exemplify concepts related to the chapter and are designed to help the
reader integrate the material. Research literature is cited and used throughout. The goal of the authors
is to provide comprehensive, research-based, current information that can guide practitioners in
making optimal decisions in their practice with children.
Distinctive features of the book include the following:
18
• Research Notes
• Evidence-based summary tables for intervention specific chapters
• Case Studies
Ancillary Materials
The Case-Smith’s Occupational Therapy for Children and Adolescents text is linked to an Evolve website that
provides a number of learning aids and tools. The Evolve website provides resources for each chapter,
including the following:
The Evolve learning activities and video clip case studies relate directly to the text; it is hoped that
readers use the two resources together. In addition, readers are encouraged to access the Evolve
website for supplemental information.
19
Acknowledgments
We would like to thank all the children who are featured in the video clips and case studies:
Adam
Ana
Annabelle
Camerias
Christian
Christina
Eily
Ema
Emily
Emily
Faith
Isabel
Jessica
Jillian
Katelyn
Luke
Ma
Micah
Nathan
Nathaniel
Nicholas
Paige
Peggy
Samuel
Sydney
Teagan
Tiandra
William
Zane
A special thank you to the parents who so openly shared their stories with us:
20
Shawn Holden
Luann Hoover
Sandra Jordan
Joanna L. McCoy
Maureen P. McGlove
Jill McQuaid
Stephanie L. Mills
David J. Petras
Theresa A. Philbrick
Ann Ramsey
Teresa Reynolds-Armstrong
Tuesday A. Ryanhart
Julana Schu
P. Allen Shroyer
Douglas Warburton
We are very appreciative of the siblings and buddies who agreed to help us out:
Aidan
Lori
Megan
Robert
Todd and Keith
Tommy, Owen, and Colin
We thank all the therapists and physicians who allowed us to videotape their sessions and provided
us with such wonderful examples:
Chrissy Alex
Sandy Antoszewski
Mary Elizabeth F. Bracy
Amanda Cousiko
Emily de los Reyes
Katie Finnegan
Karen Harpster
Terri Heaphy
Katherine Inamura
Lisa A. King
Dara Krynicki
Marianne Mayhan
Taylor Moody
Julie Po s
Ann Ramsey
Suellen Sharp
Carrie Taylor
A special thanks to Ma Meindl, Melissa Hussey, David Stwarka Jennifer Cohn, Stephanie Cohn, and
all the authors who submi ed videotapes. Thank you to Emily Krams, Alicen Johnson, Britanny Peters,
Katherine Paulaski, Carol Lambdin Pa avina, Sco McNeil, Alison O’Brien, MaryBeth Patnaude, Molly
O’Brien, Keely Heidtman, Greg Lapointe, Caitlin Cassis, Judith Cohn, Jazmin Photography, Michelle
Lapelle, Stacie Townsend, and Barbara Price. A special thanks to Mariana D’Amico, Peter Goldberg,
and Carrie Beyer for all their expertise with videotaping. Lisa Newton and Lauren Willis were
instrumental in developing and completing this text and were a pleasure with whom to work. Thank
you to Srividhya Vidhyashankar for finalizing the pages and supporting us.
Jane O’Brien would like to thank her family—Mike, Sco , Alison, and Molly—for their continual
support. Thank you to my colleagues and students at the University of New England, the children and
21
families who provided inspiration for the material, and Heather Kuhaneck for her expertise, support,
and ability to keep the process fun.
Heather Kuhaneck would like to thank her family, in particular, her husband, Shayne, for his
unwavering support. Thank you to Jane O’Brien for making my transition into this process as smooth
as possible. Thank you also to Malia Norman and Jeffrey Homan, student assistants who gathered
articles, checked citations, and generally made things easier. Lastly, thank you to my Sacred Heart
colleagues, students, and alum for all of their help and support.
We both thank all the authors for their willingness to share their expertise, labor, and time in
producing excellent chapters. And finally, we both would like to express our appreciation to Jane Case-
Smith for leaving us with such an excellent text to start with and such an amazing group of authors
with whom to work.
22
SECTION 1
23
1
GUIDING QUESTIONS
1. How are occupational therapy principles and practices applied to pediatrics?
2. What are the key characteristics of pediatric practice?
3. How does the pediatric occupational therapist function across varied environments and settings?
KEY TERMS
Adulthood
Bo om-up
Childhood
Cultural competence
Family-centered care
Inclusion
Just-right challenge
Occupations
Self-efficacy
Self-determination
Standardized assessment
Top-down
Therapeutic use of self
24
presented across multiple chapters to clarify the similarities and differences between pediatric practice
and other practice areas.
25
Family-Centered Care
Family-centered care is identified throughout this text as a key feature of pediatric practice. Multiple
components of family-centered care have been identified including open communication, mutual trust
and respect, the sharing of information with parents and families to allow shared decision making, and
the consideration and incorporation of family preferences and needs into intervention ( Almasri, An, &
Palisano, 2018; An, & Palisano, 2014; King, & Chiarello, 2014; Kuo et al. , 2012). Recently, the literature
has been reviewed and concepts distilled into three primary core beliefs: (1) respect for children and
families; (2) appreciation of the family’s impact on the child’s well-being; and (3) family-professional
collaboration (King, & Chiarello, 2014).
Multiple studies using qualitative methods and surveys have investigated what parents want from
service providers. Parents of children with Down syndrome, cerebral palsy, autism, and other
developmental and neurological disabilities state that what they seek from therapists is (1) a true
partnership; (2) a dependable resource for specific, objective information; (3) flexibility in service
delivery and in communication style; (4) sensitivity and responsiveness to their concerns; (5) positive,
optimistic a itudes; and (6) effectiveness in generating outcomes ( Bailes et al., 2018; Case-Smith et al.
2007; Edwards, Brebner, Mccormack, & Macdougall, 2016; Hayles, Harvey, Plummer, & Jones, 2015;
Kruijsen-Terpstra et al, 2014; Marshall, Tanner, Kozyr, & Kirby, 2015; McWilliam, Tocci, L., & Harbin,
1998; Scime, Bartle , Brunton, & Palisano, 2017 ). Parental satisfaction with services may be most related
to their relative feelings of self-efficacy in the situation and their opinion regarding the purpose of the
services that they have received (Robert, Leblanc, & Boyer, 2015), making the partnership between
therapist and parent even more important.
Additional important components of family-centered intervention include respecting parents’
knowledge of their child, acknowledging their resilience, accepting their values, and facilitating the
building of a network of social resources (Dunst, & Dempsey, 2007). In a meta-analysis of family-
centered practice in early intervention service, two types of family-centered services were identified: (1)
services that fostered positive professional-family relationships and (2) services that enabled the
family’s participation in intervention activities (Dunst, & Dempsey, 2007). In relationship building
practices, occupational therapists actively listen, show compassion and respect, and believe in the
family’s capabilities. Occupational therapists enable and promote the family’s participation by
individualizing their services, demonstrating flexibility in meeting family needs, and being responsive
to family concerns. Dunst, Trive e, and Hamby (2007) found that the provision of family-centered
services was highly related to the family’s self-efficacy beliefs, parents’ satisfaction with the program,
parenting behaviors, and child behavior and functioning.
Parents report that they want family-centered care (which results in be er outcomes) but recent
national surveys suggest that not all parents receive services that are family-centered and significant
regional, geographic, and socioeconomic disparities exist (Almasri, An, & Palisano, 2018; Azuine, Singh,
Ghandour, & Kogan, 2015; Kuo et al 2012). An occupational therapist’s or organization’s use of family
centered care can be evaluated through three primary areas, context, process, and outcomes (Arango,
2011) (Table 1.1). Reviews of literature across many years suggest that some aspects of family-centered
care are managed well, such as the provision of services in respectful partnerships with families, but
other areas, such as providing information to parents and families, are not routinely family-centered
(Cunningham & Rosenbaum, 2014). This suggests that professionals may need to do a be er job of
providing some aspects of family-centered care and may need to specifically evaluate their own services
to determine if they are practicing family-centered care with clients. See Appendix A for assessment
tools to evaluate family-centered care. Chapter 3 provides more information on this topic.
Strength-Based Focus
Children and youth with disabilities often have unique strengths that are overlooked by others, but if
these strengths are identified and encouraged, they can lead to increased participation. Occupational
therapists evaluate the strengths of a child or youth in addition to trying to understand their difficulties
and challenges. Interventions in pediatric occupational therapy build on those strengths. By identifying
the positive aspects of a child’s behavior and areas of greatest competence as well as performance
limitations, occupational therapists can reframe the child’s behavior for his or her parents, allowing
caregivers to see the child in a new light. For example, focusing on strengths in communication about a
child during parent education for parents of autism led to parents displaying more positive affect,
making more positive statements about their child, and exhibiting greater physical affection toward
26
their child (Steiner, 2011). As explained throughout this text, strength-based approaches can lead to
increased self-efficacy and self-determination for the child.
Table 1.1
Table based on information provided in Almasri, An, & Palisano, 2018; Arango, 2011; Dunst, 2002; Schreiber et al.,
2011.
The strength-based model contrasts with the traditional medical model, which focuses intervention
on identifying the health or performance problem and resolving that problem. As explained in many
chapters of this book, focusing on a child’s performance problem does not always lead to optimal
participation and improved quality of life. Because occupational therapists are concerned with a child’s
full participation in life activities, focusing solely on impairment narrows the vision of what the child
can become and do.
Although a strength-based approach is often recommended, it may be more difficult to note in
practice. For example, research suggests that the occupational therapist’s documentation may be more
frequently wri en with a deficit focus (Braun, Dunn, & Tomchek, 2017). Pediatric occupational
therapists must emphasize a strength-based approach throughout all aspects of the occupational
therapy process to fully embrace the potential of this approach to produce positive changes for families
and pediatric clients. Case 1.1 provides an example of using a strength-based focus with a child with
autism.
Cultural Competence
Cultural competence means that the pediatric occupational therapist is able to practice effectively with
clients from a different cultural group. A system that provides “culturally competent” care is one that
“acknowledges and incorporates—at all levels—the importance of culture, assessment of cross-cultural
relations, vigilance toward the dynamics that result from cultural differences, expansion of cultural
knowledge, and adaptation of services to meet culturally unique needs” (Betancourt, Green, Carrillo, &
27
Owusu Ananeh-Firempong, 2016 pp 294). A culturally competent therapist must be open to exploring
differences, valuing the client’s unique perspectives and expertise, and engaging in self-reflection about
the impact of his or her own culture on his or her practices as an occupational therapist. Recent research
suggests that important antecedents to cultural competence include openness, awareness, desire,
sensitivity, and knowledge (Henderson, Horne, Hills, & Kendall, 2018).
Specific practices to engage in to provide culturally competent care include many of the behaviors
identified as family-centered care, including building a collaborative partnership with the family,
understanding the specific situation of the family, and then tailoring therapy to that specific situation. In
addition, for culturally competent care, the therapist must ensure that the parents understand all
information provided and specifically understand the specific therapeutic procedures (King, Desmarais,
Lindsay, Piérart, & Tétreault, 2015). Other specific strategies identified by occupational therapists
working with immigrant parents of children with disabilities include those that helped overcome a
language barrier, those that helped develop a shared understanding regarding the child’s disability, and
those that assisted the parents in understanding the process of intervention (Brassart, Prévost, Bétrisey,
Lemieux, & Desmarais, 2017). The outcomes of cultural competence include client satisfaction with care,
greater perception of quality care, be er adherence, more effective interaction, as well as improved
outcomes (Henderson, Horne, Hills, & Kendall, 2018).
A child’s occupations are embedded in the cultural practices of his or her family and community.
Pediatric occupational therapists need to be aware of the potential for cultural differences in family
makeup, parenting practices, expectations for child behavior and autonomy, engagement with health
professionals, as well as the impact of race, ethnicity, and culture on child outcomes, overall health, and
well-being of families (Campos, & Kim, 2017; Fi gerald, 2004; Rowe, Denmark, Harden, & Stapleton,
2016 ). See Table 1.2 for specific questions to consider in relation to family culture and family
occupations. Culture impacts family and the occupations of the family and the child. For example, a
family’s culture may make it more or less likely for those family members to encourage independence
for a child or to want to do things for a child. Families are extremely diverse but may often be judged by
professionals when they do not conform to the typical standards of the dominant culture (Fi gerald,
2004). Parenting style ma ers and can have an impact on long-term childhood outcomes (Castro et al.,
2015; Pinquart, 2017); however cultural differences in parenting may be only a small part of the impact
(Pinquart & Kauser, 2018). Pediatric occupational therapists must take care not to judge the parenting
styles of others based on their own notions of parenting.
For occupational therapists in the United States, cultural competence is critical as the diversity of the
United States continues to increase and the makeup of the population is changing. In 2016, 43.7 million
immigrants were living in the United States, which was 13.5% of the population (Radford & Budimen,
2018). Asian Americans and Latino/a Americans comprise the two largest and fastest growing groups in
the United States (Radford & Budimen, 2018; U.S. Census Bureau, 2010) with Asia surpassing Latin
America as the number one source of new immigration (Cohn & Caumont, 2016). However, change in
the country is not evenly dispersed.
Depending on where the occupational therapist works, he or she may be more or less exposed to
different cultures and/or immigrant populations and the changes may happen more slowly or quite
rapidly ( Keating & Karklis, 2016; MPI, 2018). For example, a large population of Hmong migrated to the
Minneapolis–St. Paul region in a relatively brief period of time, requiring the health professionals of that
area to rapidly learn to provide care to a new culture (Stratis Health, 2012; Williams, 2011). Culturally
competent pediatric occupational therapists must be a une to these types of regional changes and do
what is necessary to provide culturally competent care to any new population of immigrants.
28
Table 1.2
Adapted from Wayman, K. I., Lynch, E. W., & Hanson, M. J. (1990). Home-based early childhood services:
cultural sensitivity in a family systems approach. Topics in Early Childhood Special Education, 10, 65–66.
Pediatric occupational therapists must also understand the extent of actual disparities in healthcare
and the consequences of those disparities ( Barr, 2014; Goodman, Gilbert, Hudson, Milam, & Coldi ,
2017; National Center for Health Statistics US, 2016; Paradies et al., 2015 ). Health disparities have been
found for a multitude of conditions and diseases, including birth weight and cancer, as well as overall
mortality (Barr, 2014). Although much of the literature on health care disparities centers on adults, a
recent review found that disparities exist for children as well (Ridgeway et al., 2017).
Child health is different from adult health, “as summarised in the five D’s: developmental change,
dependency on adults, differential epidemiology, demographic pa erns, and dollars” (Ridgeway et al,
2017 p. 2). In children, the data supports that disparities exist for cancer and asthma as well as unequal
access to care. Disparities also exist in the provision of therapy services. Using national data, the
percentage of children with unmet therapy needs was different for black, Hispanic, and white children
(Magnusson & Mistry, 2017).
Engaging in evidence-based practice, the pediatric occupational therapist also needs to consider the
evidence of healthcare disparities carefully in relation to race, ethnicity, culture, and socioeconomic
status. Although in the United States people are often classified by either race, ethnicity, or both, in
reality there is overlap between race and ethnicity as both consider ancestry in the way the concept is
defined (Barr, 2014). The use of race to examine outcomes in healthcare is controversial and ethnicity
may be more important to cultural practices and health outcomes than the more broad designation of
race (Barr, 2014). Sorting people into categories of any type is influenced by the social conventions of the
time (Barr, 2014), and in the United States both race and ethnicity can be associated with
socioeconomics. Therefore in examining the impact of race and ethnicity of health and outcomes in
research, there are many confounding factors.
There are many barriers that hinder equal access to healthcare. These barriers have been identified as
organization and institutional, structural, and clinical (Betancourt et al, 2003). Specifically, barriers
include the lack of diversity in healthcare workers, educators, and leaders, language barriers and lack of
interpreters, access to specialists in certain areas or regions, and poor communication and a itudinal
barriers. One method available to pediatric occupational therapists to a empt to address unequal
regional access to services is telehealth (Marcin, Shaikh & Steinhorn, 2015).
29
practice and to the outcomes they achieve with clients (Taylor, Lee, Kielhofner, & Ketkar, 2009). The
Intentional Relationship Model (see h p://irm.ahslabs.uic.edu/what-is-the-irm/) provides a structure for
examining the therapist- client relationship. Although much of the research on the model to date is with
adults, the model can be applied to pediatric practice (see Chapter 5 for further description of the model
and its application to children).
As described throughout this text, the therapeutic relationship with a child is critical for the success of
pediatric occupational therapy. The pediatric occupational therapist establishes a relationship with the
child that encourages, supports, and motivates. In order to do so, the occupational therapist first creates
trust. This trust enables the child to feel safe and to be willing to take risks. The therapeutic relationship
involves respecting the child’s emotions and creating a climate of emotional safety. Occupational
therapists demonstrate a positive affect and seek opportunities for personal connection while conveying
positive regard. The occupational therapist shows interest in the child, makes efforts to enjoy his or her
personality, and values his or her preferences and goals.
Similarly, trust building between professionals and family members is a first step in building a
relationship. Demonstrating mutual respect, being positive, and maintaining a nonjudgmental position
with a family creates trust. Occupational therapists cultivate positive relationships with families when
they establish open and honest communication and encourage participation of parents in their child’s
program to the extent that they desire.
Many of the concepts of the therapeutic alliance that have been adopted throughout pediatric practice
originated in the intervention methods of sensory integration (see Chapter 20). These include the ideas
that it is important to collaborate with a child on activity choice, the therapist must ensure success, and
support intrinsic motivation as well as the concept of presenting the “just-right challenge” (Parham
et al., 2011). These concepts are discussed in the following sections and chapters.
30
Chapters 28, 29, 30, 31, and 32). In this type of approach, the therapist might examine strength and range
of motion, or manipulation skills first. The assumption is that deficits in these skills will hinder
performance in functional tasks such as coloring or bu oning and therefore limit performance in
broader occupations of ADLs and education.
However, some authors argue for the importance of both types of assessment approaches and a
combined approach (Scho , Holfelder, & Mousouli, 2014; Weinstock-Zlotnick & Hinojosa, 2004). There
is some level of agreement but not total agreement between evaluation results obtained either way
(Kennedy, Brown, & Stagni i, 2013; Scho , Holfelder, & Mousouli, 2014)). Children appear to provide a
source of information that differs from that provided by parents, teachers, and direct observation
(Brown, 2012; Kennedy, Brown, & Chien, 2012; Lalor, Brown, & Murdolo, 2016). Therefore whichever
approach is adopted, occupational therapists are encouraged to seek information from a variety of
informants and methods.
Importance of Context
The pediatric occupational therapist considers how the environment influences performance and
completes observations of the child in the child’s natural environment. Occupational therapists evaluate
the contexts in which the child learns, plays, and interacts. Evaluating performance in multiple contexts
(e.g., home, school, childcare center, community se ing) allows the occupational therapist to appreciate
31
how different contexts affect the child’s performance and participation. By considering the child’s
performance in the context of physical and social demands, assessment in natural environments helps
determine the discrepancy between the child’s actual performance and expected performance. The
occupational therapist considers cultural influences, resources, and value systems of the child’s family
context. The occupational therapist also considers the fit or match between the performance of the child
or youth and the demands and expectations of the environment (e.g., in school-based practice, the
relationship between the child’s performance and the educational context and curriculum). To support
adolescents preparing for employment, occupational therapists consider the adolescent’s performance
as it relates to specific job tasks and work contexts. Through in-depth task analysis and performance
analysis, the occupational therapist identifies the skills required for the job tasks and the discrepancy
between the task requirements and the youth’s performance. If the team seeks to identify the student’s
interests and abilities as they relate to future community living, the assessment takes place in the
community and the home.
Research suggests a variety of contextual barriers that hinder participation for students with
disabilities (Anaby et al., 2013; Anaby et al., 2014; Coster et al., 2013; Law et al., 2013). Barriers include
physical barriers that limit access and mobility, such as lack of equipment, lack of transportation,
inadequate parking or ramps for wheelchairs, or lack of elevators. A itudinal barriers also exist, such as
overprotectiveness, family values in relation to independence, stigma, and bullying in the community.
Policy barriers include lack of programs, lack of flexibility, segregation, or financial hardship due to
program/services costs.
Standardized assessments of context are available (Coster et al., 2011; Khetani, 2015; Khetani, Graham,
Davies, Law, & Simeonsson, 2015; McCauley et al., 2013). Many of these tools are relatively new and
need to become more routinely used by pediatric occupational therapists. Often the occupational
therapist evaluates contextual factors informally through observation. (See Chapter 6 for more
information and see Tables 1.2 and 1.3 for guiding questions to frame observation of context).
32
Table 1.3
Inclusion in natural environments or regular education classrooms succeeds only when specific
supports and accommodations are provided to children with disabilities (Guralnick & Bruder, 2016).
Occupational therapists are important team members in making inclusion successful for children with
disabilities. To support inclusion of children and youth with disabilities in natural environments,
occupational therapists may recommend modifications to increase physical access, accommodations to
increase social participation, or strategies to improve the child’s ability to meet the performance and
behavioral expectations. For example, occupational therapists often have roles in evaluating physical
access in schools or jobs and recommending assistive technology or task modification. Chapter 19
explains assistive technology evaluation and intervention.
Occupational therapists need to take care in their efforts at providing interventions to foster inclusion
rather than impede it. Many small decisions made in natural environments regarding the
implementation of therapy services can create barriers and actually exclude children with disabilities
(Fallang, Øien, Østensjø, & Gulbrandsen, 2017). For example, children may be inadvertently excluded
from doing something that the rest of the class is doing, while instead working on their “therapy
program” with a paraprofessional. Occupational therapists may need to spend time observing in the
classroom to determine the types of activities that are leading to exclusion. For example, if the rest of the
class is doing an activity on the floor in prone with the teacher, a child in a wheelchair may be excluded
and instead of feeling a sense of belonging with the class, may feel alone and different while si ing
behind and above peers in the wheelchair (Fallang et al., 2017). In situations such as these, an important
aspect of therapy to improve inclusion may be the education of others.
33
pediatric occupational therapists select interventions that target the occupations of importance to the
client.
Pediatric occupational therapy must be child-centered. In child-centered practice, children are given
choices to the extent that they are able to participate in making them. Children participate in decision
making about goals and occupational therapists use activities that are meaningful and preferred by the
child, knowing that they engage the child’s efforts. Children are more motivated to take on skill
challenges that they have designated as important and that the occupational therapist embeds in
preferred activities. The occupational therapist collaborates with the child to select an activity of
interest, makes the activity fun and playful, and gives the child choices (Kuhaneck, Spi er, & Miller,
2010).
The child’s engagement in an activity is an essential component of a therapy session. This engagement
funnels the child’s energy into the activity, helps him or her sustain full a ention, and implies that the
child has adopted a goal and purpose that fuels his performance in the activity. When children are given
supports that enable them to focus on and engage fully in a learning activity, they are more likely to
persevere and a empt challenging aspects of the activity. Generally, the intrinsic sense of mastery is a
stronger reinforcement to the child and youth with greater probability of sustained effects than external
rewards, such as verbal praise or other contingent reward systems. When children are motivated to
participate and share positive affect and the experience with others involved in an activity, they will
more readily sustain engagement with that activity and thereby promote their learning (Froiland, &
Oros, 2014; Gopalan et al., 2017; Kindermann, 2007; Master, Cheryan, & Mel off, 2017 ). Activities
without social features or those that provide additional extrinsic motivation may not capture and
sustain engagement for as long and may not improve learning outcomes (McKernan et al., 2015;
Ronimus, Kujala, Tolvanen, & Lyytinen, 2014). Key features of sensory integration intervention (Parham
et al, 2011) include soliciting the child’s active engagement and tapping the child’s inner drive.
Engagement is essential because the child’s brain responds differently and learns more effectively when
he or she is actively involved in a task rather than merely receiving passive stimulation (see Chapter 20
for more information about inner drive).
The Cognitive Orientation to daily Occupational Performance (CO-OP) approach (Rodger &
Polatajko, 2017)(see Chapter 17 for a more thorough description of this approach) also promotes the
child’s intrinsic motivation and engagement through the use of a performance goal of interest to the
child and chosen by the child. CO-OP is a task-oriented, problem-solving approach that engages the
child or youth in se ing goals and planning strategies to improve performance. By guiding the child to
identify the performance problem and then se ing a feasible goal and plan for reaching that goal, the
occupational therapist encourages the child’s own problem-solving and investment in achieving that
goal. Engaging the child as a collaborator in the intervention process enhances the child’s motivation,
best efforts to improve performance, and sustained engagement. This approach has been used
effectively with a variety of children with different diagnoses.
The use of occupation-centered approaches for children are supported by research ( Pfeiffer, Clark, &
Arbesman, 2018; Kreider et al., 2014; Rodger & Polatajko, 2017 ) and by theories of motor control and
motor learning (Cano-De-La-Cuerda et al., 2015). Whole activities with multiple steps and a meaningful
goal (versus repetition of activity components) elicit the child’s full engagement and participation.
Repeating a single component (e.g., squeeze the Play-Doh or place pennies in a can) has minimal
therapeutic value. By engaging in an activity with a meaningful goal (e.g., cooking or an art project),
children use multiple systems and organize their performance around that goal. For example, if a game
requires that a preschool child a end to a peer, wait for his turn, and correctly place a game piece, the
child is developing the joint a ention that he needs to participate in circle time or a family meal. Motor
learning approaches use such task-oriented interventions, acknowledge the importance of engaging
children in meaningful, purposeful activities to harness their motivation and full efforts (see Chapter
16).
Pediatric Occupational Therapists Modify and Adapt Activities to Create the “Just-
Right Challenge”
A child’s active participation and efforts to achieve a task are elicited when therapeutic activities are at
just the right level of complexity; that is, where the child not only feels comfortable and nonthreatened
but also experiences some challenge that requires effort. An activity that is a child’s just-right challenge
has the following elements: the activity (1) matches the child’s developmental skills and interests; (2)
provides a reasonable challenge to current performance level; (3) engages and motivates the child; and
(4) can be mastered with the child’s focused effort.
34
Based on careful analysis of performance and behavior, the occupational therapist selects an activity
that matches the child’s strengths and limitations across performance domains. The analysis allows the
occupational therapist to individualize the difficulty, pace, and supports needed for a child to
accomplish a task. The occupational therapist vigilantly a ends to the child’s performance during an
activity to provide precise levels of support that enable the child to succeed. Cognitive, sensory, motor,
perceptual, or social aspects of the activity may be made easier or more difficult (see Case 1.2). By
precisely assessing the adequacy of the child’s response, the occupational therapist finds the just-right
challenge. A child’s self-esteem and self-image are influenced by skill achievement and by success and
task mastery. Self-determination is described throughout the book.
Although the occupational therapist often presents challenges and asks the child to take risks, the
therapist supports and facilitates the child’s performance so that either the child succeeds, or feels okay
when he or she does not. By choosing activities that allow the child to feel important and by grading the
activity to match the child’s abilities, the occupational therapist gives the child the opportunity to
achieve mastery and a sense of accomplishment.The therapist is invested in the child’s success, and
reinforces the importance of the child’s efforts. Concepts of mastery, self-efficacy, and self-determination
are illustrated in many chapters.
35
Occupational therapists often help children with disabilities participate by applying assistive
technology. Technology is pervasive throughout society, and its increasing versatility makes it easily
adaptable to an individual child’s needs. Technology is often divided into low-tech and high-tech
options.
Low-technology solutions are often applied to increase the child’s participation in activities of daily
living. Examples include built-up handles on utensils, weighted cups, elastic shoelaces, and electric
toothbrushes. Adapted techniques can be used to increase independence and reduce caregiver
assistance in eating, dressing, or bathing. Low-technology solutions can also be used to support
participation in play activities. Adapted techniques for play activities may include switch toys, ba ery-
powered toys, enlarged handles on puzzle pieces, or magnetic pieces that can easily fit together.
High-technology solutions are often used to increase mobility or functional communication. Examples
are power wheelchairs, augmentative communication devices, and computers. Occupational therapists
frequently support the use of assistive technology by identifying the most appropriate device or system
and features of the system. They often help families obtain funding to purchase the device, set up or
program the system, train others to use it, and monitor its use. Occupational therapists also make
themselves available to problem-solve the inevitable technology issues that arise.
In many school systems, the occupational therapist serves as an assistive technology consultant or
becomes a member of a district-wide assistive technology team. Assistive technology teams have been
formed to provide support and expertise to school staff members in applying assistive technology with
students. These teams make recommendations to administrators on equipment to order, train students
to use computers and devices, troubleshoot technology failures, determine technology needs, and
provide ongoing education to staff and families. Use of assistive technology is particularly helpful to
adolescents preparing for supported employment. The role of the pediatric occupational therapist with
high-tech devices is further explored in Chapters 18 and 19. Low-tech options are discussed in Chapters
12, 15, 19, and 25.
Often a role of the occupational therapist is to recommend adaptations to the sensory environment
that accommodate children with sensory processing problems in the home or at school ( Dunn, Cox,
Foster, Mische-Lawson, & Tanquary, 2012; Kuhaneck & Kelleher, 2018). Preschool and elementary
school classrooms usually have high levels of auditory and visual input (Kuhaneck & Kelleher, 2015).
Classrooms with high noise levels may be overwhelmingly disorganizing to a child who is
hypersensitive to auditory stimulation. Young children who need calming techniques or quiet times
during the day may need their own physical space in the corner of the room where they are allowed to
“take a break” intermi ently throughout the school day. The occupational therapist may suggest that a
preschool teacher implement a quiet time with lights off to provide a period to calm children. Other
environmental modifications may improve arousal and a ention in children such as si ing on movable
surfaces. Modifications should enhance the child’s performance; make life easier for the parent or
teachers; and have a neutral or positive effect on siblings, peers, and others in the environment. Owing
to the dynamic nature of the child and the environment, adaptations to the environment may require
ongoing assessment to evaluate the goodness-of-fit between the child and the modified environment
and determine when adjustments need to be made. Contextual modifications to accommodate a child
who has sensory processing problems are described in multiple chapters including 15, 20, 24, and 30. A
recent review of these approaches (Bodison & Parham, 2018) suggests that certain techniques may be
effective while others are not. See Chapter 20 for a more detailed discussion of this evidence.
36
recommendations for practice. These guidelines translate the research evidence to practice by making
specific recommendations for evaluations and interventions that prioritize the recommendations using a
grading system.
Hospitals and medical systems have promoted the use of EBP guidelines to improve the consistency
and effectiveness of medical interventions (Kredo et al., 2016). Schools and educational systems have
also called for research evidence to be used to guide educational practices and policies (Russo-Campisi,
2017). Clinical guidelines enable efficient consumption of efficacy research; however, implementing the
guidelines consistently also requires commitment, system and environmental supports, and consensus
among the agency’s or program’s team. EBP clinical guidelines have been adopted by children’s
hospitals and medical systems as tools to promote quality improvement and patient outcomes
(Cincinnati Children’s Evidence-Based Care Recommendations, n.d.). When EBP guidelines are
implemented within quality improvement processes, they also are embedded in existing processes that
include monitoring and examining outcomes. Numerous steps are needed to ensure that use of EBP
guidelines results in improved outcomes (Box 1.1).
Case 1.3 describes using an EBP guideline in clinical decision making for a young child with autism
spectrum disorder.
There are benefits to using the recommendations from EBP guidelines; they:
1. Are relevant because experts in the diagnosis or type of intervention determine the scope and
methods for developing the recommendations.
Step 1
• Convert the need for information (about intervention effects, prognosis, therapy
methods) into an answerable question.
Step 2
• Search the research databases using the terms in the research question.
• Track down the best evidence to answer that question.
Step 3
• Critically appraise the evidence for its:
• validity (truthfulness)
• impact (level of effect)
• clinical meaningfulness
Step 4
• Critically appraise the evidence for its applicability and usefulness to your practice.
Step 5
• Implement the practice or apply the information.
• Evaluate the process.
Following clinical guidelines has the potential of increasing the consistency of practice and its efficacy.
The likelihood of positive outcomes is high when occupational therapists (1) select EBP guidelines with
optimal fit to their clientele and environment; (2) adapt the guidelines to fit their work environment; (3)
modify them into user-friendly protocols; (4) examine and resolve barriers to implementation; and (5)
establish systems to monitor their outcomes (Carey, Buchan, & Sanson-Fisher, 2009). All of the chapters
in this book use research evidence in describing evaluation and intervention.
Pediatric Occupational Therapists Educate and Advocate for Others and Engage in
Competent Interprofessional Practice
Pediatric occupational therapy involves working intimately with caregivers and teachers to create
opportunities for the child to participate optimally across environments. This aspect of service delivery
is challenging and fulfilling because it requires a complementary skill set to assess, plan, implement,
and evaluate the effects of parent and teacher consultation, coaching, and education.
37
Consultation and Coaching
Services “on behalf of” children complement and extend direct service delivery. Occupational therapists
provide these indirect services by consulting with, coaching, and educating parents, assistants, childcare
providers, and any adults who spend a significant amount of time with the child. Through these models
of service delivery, the occupational therapist helps develop solutions that fit into the child’s natural
environment and promotes the child’s transfer of new skills into various environments.
A major role for school-based occupational therapists is to support teachers in providing optimal
instruction to students and helping children succeed in school (Hanft, Shepherd, & Read, 2013) (see
Chapters 15 and 24). Occupational therapists accomplish this role by promoting the teacher’s
understanding of the physiologic and health-related issues that affect the child’s behavior and helping
teachers apply strategies to promote the child’s school-related performance. Occupational therapists
also support teachers in adapting instructional activities that enable the child’s participation and
collaborate with teachers to collect data on the child’s performance. This focus suggests that, in the role
of consultant, the occupational therapist sees the teacher’s needs as a priority and focuses on supporting
his or her effectiveness in the classroom. Consultation is most likely to be effective when occupational
therapists understand the curriculum, academic expectations, and classroom environment.
• It is recommended that the following behavioral interventions within a treatment package may be
used to increase intake for children with feeding problems:
• Differential a ention
• Positive reinforcement
• Escape extinction/escape prevention
• Stimulus fading
• Simultaneous presentation
It is recommended that a child (4 months to 7 years old) with feeding difficulties be exposed 10 to 15
times to a previously unfamiliar or nonpreferred food to increase intake (Cincinnati Children’s Hospital
Medical Center, 2013).
An intervention was designed in which a nonpreferred food was placed on Rebecca’s plate with her
preferred foods twice a day. The teacher or occupational therapist implemented the intervention at
school, and the mother implemented it once each day at home. The occupational therapist, teacher, or
parent gave Rebecca praise and a ention when she touched, played with, or tasted the nonpreferred
foods. The occupational therapist and parent ate some of the nonpreferred hamfood with her, modeling
for her and having fun with that food. The same nonpreferred food was presented at least 10 times. The
occupational therapist and parent used highly positive affect during the meal, and although Rebecca
38
was allowed to eat her preferred foods, she was praised and reinforced only when she ate a
nonpreferred food. The table was arranged to make escape very difficult, and she was encouraged to
stay at the table.
In the first week, Rebecca did not eat any nonpreferred foods, but she touched and played with these
foods (fruits, cream cheese, peanut bu er, and pita bread). In the second week, she took several bites of
nonpreferred foods each week, and by the third week, her regular diet had increased to 11 foods,
including fruit, cream cheese, and peanut bu er. Meg, the teacher, and Rebecca’s mother recorded and
tracked her eating and mealtime behavior each day to decide which foods to try and which
reinforcement seemed most effective.
Summary
This guideline on feeding problems effectively improved Rebecca’s eating and diet because:
Adapted from Cincinnati Children’s Hospital Medical Center (2013). Best evidence statement (BESt). Behavioral
and oral motor intervention for feeding problems in children. h p://www.guideline.gov/content.aspx?
id=47062&search=autism%2c+eating. Accessed March 10, 2014.
Effective consultation also requires that the teacher or caregiver be able to assimilate and adapt the
strategies offered by the occupational therapist and make them work in the classroom or the home. The
occupational therapist asks the teacher how he or she learns best and accommodates that learning style.
Teachers need to be comfortable with suggested interventions, and occupational therapists should offer
strategies that fit easily in the classroom routine. The occupational therapist and teacher can work
together to determine which interventions would benefit the child and be least intrusive to other
students.
Specific methods of coaching, such as occupational performance coaching (OPC), allow an
occupational therapist to collaborate with a parent or teacher. Coaching methods aim to empower
parents and enable their success, and increase their feelings of competence and efficacy. Studies to date
on coaching methods with parents have been positive ( Dunn, Cox, Foster, Mische-Lawson, & Tanquary,
2012; Foster et al., 2013; Graham, Rodger, & Ziviani, 2014; 2013; Graham et al., 2010; Graham, Rodger, &
Ziviani, 2013). One model based on collaborative coaching has been successfully implemented with
teachers for students with developmental coordination disorder (DCD) (Dancza, Missiuna, & Pollock,
2017; Missiuna et al., 2012).
39
changes allowing greater physical activity levels (Engelen et al., 2013) which are recommended to aid in
the reduction of childhood obesity (CDC, 2018) and perhaps improve performance in school (Singh
et al., 2018)
Occupational therapists advocate for environments that are both physically accessible and welcoming
to children with disabilities. With an extensive background on which elements create a supportive
environment, occupational therapists can help design physical and social environments that facilitate
the participation of every child. To change the system on behalf of all children, including children with
disabilities, requires communication with stakeholders or persons who are invested in the change. The
occupational therapist needs to share confidently the rationale for change, appreciate the views of others
invested in the system, and change and negotiate when needed.
A system change through education is most accepted when the benefits appear high and the costs are
low. Can all children benefit? Which children are affected? If administrators and teachers in a childcare
center are reluctant to enroll an infant with a disability, the occupational therapist can advocate for
accepting the child by explaining specifically the care that the child would need, the resources available,
the behaviors and issues to expect, and the benefits to other families.
Convincing a school to build an accessible playground or establish a completely accessible computer
lab are examples of how a focused education effort can create system change. Occupational therapists
are frequently involved in designing playgrounds that are accessible to all and promote the
development of sensory motor skills. Another example is helping school administrators select computer
programs that are accessible to children with disabilities. The occupational therapist can serve on the
school commi ee that selects computer software for the curriculum and advocate for software that is
easily adaptable for children with physical or sensory disabilities. A third example is helping
administrators and teachers select a handwriting curriculum to be used by regular and special
education students. The occupational therapist may advocate for classroom instruction that emphasizes
prewriting skills or one that takes a multisensory approach to teaching handwriting. The occupational
therapist may also advocate for adding sensory-motor-perceptual activities to an early childhood
curriculum.
Interprofessional Teamwork
Most occupational therapists work on teams with other professionals. In pediatric practice, the team
members always include the parent(s) or primary caregiver(s), as well as other professionals such as
speech language pathologists, physical therapists, teachers, social workers, doctors, nurses, and
psychologists. Although professions have been characterized in the past as having vast differences
related to the process of professionalization, they actually share many of the same values (Grace et al.,
2017). Two of these include valuing client’s rights and valuing the capacity of one’s particular profession
to provide needed care to clients. Authors have recently conceptualized interprofessional practice
therefore as an intersection between the client’s right to receive healthcare that is the best that is
currently available, and the recognition of contributions of each of the individual professions involved
in that care (Grace et al., 2017). This type of model challenges the paradigm distinguishing professions
based on scope of practice.
Although to date, the evidence related to the impact on healthcare outcomes of interprofessional
practice is inconclusive, there has been an explosion of research as well as a huge growth in programs to
institute interprofessional practice in healthcare and interprofessional education in healthcare education
(Reeves et al., 2017). In recent years, the greater focus on interprofessional practice has led to a variety of
initiatives to be er educate students in healthcare and improve the interprofessional skills of current
practitioners using methods of be er teamwork and specific teaming competencies (Muhlenhaupt,
Pizur-Barnekow, Sche ind, Chandler, & Harvison, 2015). The Interprofessional Education
Collaborative Expert Panel (2011) has identified four core competency domains of interprofessional
practice. These include (1) working with professionals in a climate of mutual respect and shared values;
(2) using knowledge of each team members role to manage the healthcare needs of clients served; (3)
communicating with clients and other professionals in a manner that supports a team approach; and (4)
applying principles of group dynamics to perform effectively in varied roles to provide safe, effective,
and equitable care. Working in teams requires a shared identity, a clear role, task, and or goals,
interdependence of team members, integration of teamwork, and a shared responsibility (Reeves,
Xyrichis, & Zwarenstein, 2018). However, teamwork is just one way in which to work
interprofessionally. Team members also must engage in collaboration, coordination, and networking,
and each of these focuses differently on the varied requirements of teamwork (Reeves, Xyrichis, &
Zwarenstein, 2018; Xyrichis, Reeves, & Zwarenstein, 2018).
40
Networking is the most different form of “teamwork.” In a hospital or acute care se ing, the care
network for one client can be massive and complex, thus making face to face collaboration almost
impossible (Dow et al., 2017). In these type of interprofessional networks the members may not meet
face-to-face, but may communicate via email or online conferencing. Interprofessional networks vary
over time and different professionals enter and leave at varied times, often unpredictably. Much of the
work on teams that has been the basis of interprofessional practice is based in teams that are smaller,
and more fixed, such as in business. However this work may have limited usefulness in certain arenas of
healthcare where networking may be more important.
The literature on interprofessional practice and healthcare suggests that for new practitioners entering
pediatric practice, it is critical that the practitioner understand his or her practice se ing and the value
and importance of both teams and networks in that se ing. Although healthcare practitioners may value
interprofessional practice (Bode, Giesler, Heinzmann, Krueger, & Straub, 2016), they often lack training
in it. Therefore the practitioner must learn to be competent with the skills that are appropriate for
interprofessional practice in that particular se ing. Further information regarding working with teams
is provided in Chapter 3.
41
provide direct intervention 3 weeks per month and have 1 week per month for indirect services
(Garfinkel & Seruya, 2018).
There is limited research to guide occupational therapists’ decision making related to direct versus
indirect interventions, and much of it is old (Davies & Gavin, 1994; Dunn, 1990; Dreiling & Bundy, 2003;
Kingsley & Mailloux, 2013). However, in the early studies and more recent ones, few, if any, differences
were found in effectiveness between direct and consultative services. Occupational therapists continue
to use and often prefer more traditional models of practice (Clough, 2018). Occupational therapists may
tend to choose the model of service delivery based on their planned interventions and the schedule of
the classroom activities and these decisions may be made based on the child’s age or grade level
(Clough, 2018).
Recent research does suggests that collaborative, inclusive interventions are the most effective (Anaby
et al., 2018) indicating that indirect and push in models would be best. Occupational therapists who
have made the change to a workload model such as the 3”1 model may feel be er equipped to provide
indirect services and manage their time to be er intervene in natural environments (Garfinkel & Seruya,
2018). Other models for school-based service delivery that offer the possibility for greater flexibility
(Case-Smith & Holland, 2009) include block scheduling and co-teaching. These models of flexible
scheduling allow occupational therapists to move fluidly between direct and consultative services.
In block scheduling, occupational therapists spend 2 to 3 hours in the early childhood classroom
working with children with special needs one on one and in small groups, while supporting the
teaching staff. Block scheduling allows occupational therapists to learn about the classroom, develop
relationships with the teachers, and understand the curriculum so that they can design interventions
that are easily integrated into the classroom. By being present in the classroom for an entire morning or
afternoon, the occupational therapist can find natural learning opportunities to work on a specific
child’s goals. During the blocked time, the occupational therapist can run small groups, collaborate with
the teacher and assistants, evaluate the child’s performance, and monitor the child’s participation in
classroom activities.
Another integrated model of service delivery is co-teaching (Solis, Vaughn, Swanson, & Mcculley,
2012). In this model, the occupational therapist and teacher plan and implement the sessions together.
Collaborative planning allows interdisciplinary perspectives on student issues and behaviors; enables
the occupational therapist to align interventions closely with the curriculum; and ensures that
interventions can be feasibly implemented in the classroom, with consideration given to the teacher’s
goals and curricular expectations. Co-teaching models have been successfully implemented for
handwriting programs, in which occupational therapists take on teaching roles while providing
individualized supports and interventions for students who have handwriting difficulties (Case-Smith,
Holland, & White, 2014). Benefits of co-teaching are that occupational therapy services are embedded
into the classroom instruction; students at risk receive more intensive instruction with individualized
supports; and students with individualized education programs receive integrated services that support
performance throughout their school day.
In a fluid service delivery model, therapy services increase when naturally occurring events create a
need—for example, when the child obtains a new adapted device, when the child has surgery or casting,
or when a new baby brother creates added stress for a family. Similarly, therapy services should be
reduced when the child has learned new skills that primarily need to be repeated and practiced in his or
her daily routine or the child has reached a plateau on therapy-related goals.
42
different boundaries around occupational therapy practice by specifying the role of the occupational
therapist within that policy’s implementation.
Additionally, these unique practice se ings influence the structure of the teams with whom pediatric
occupational therapists work. Although most occupational therapists work with some sort of care team,
the people on the team vary by se ing. Since the large majority of pediatric occupational therapists
work in the public schools, they collaborate with teachers and school psychologists rather than with
doctors or nurses.
Funding issues for occupational therapy for minor children may also be different than those of
working or unemployed adults or the elderly who have Medicare. For example, over 9 million children
received funding for their healthcare through the Children’s Health Insurance Program (CHIP) (Centers
for Medicaid and Medicare Services, 2018). Children may also receive funding for occupational therapy
from Medicaid, or from employer sponsored insurance. Under Medicaid, occupational therapy is an
optional program that is decided on a state by state basis. For adults, 36 states provide coverage for
occupational therapy (Kaiser Family Foundation, 2018). However, coverage for occupational therapy for
children varies from 67% of states providing some coverage for occupational therapy services to 100% of
states providing some coverage, based on the way in which funding is provided (i.e., by employer-
based insurance or by CHIP either as a Medicaid extension or a separate program). Recent health care
changes may impact funding for services provided to children (AOTA, 2018b).
Although all occupational therapists consider the life stage of their clients, the rapid changes in child
development that occur during early childhood create an additional facet for managing pediatric
assessment and intervention. Similarly, although all occupational therapists need to consider the client’s
family members and their reaction to a client’s disability, pediatric practitioners may also have to
consider the stage of development the family is in, and the way in which the parents or primary
caregivers are dealing with the initial diagnosis of their child (Seligman & Darling, 2007).
In pediatric practice, occupational therapists must balance and navigate conflicts between the
occupational needs and desires of their clients who are minors with those of their parents and other
adults who influence them and may a empt to exercise control of their access to specific occupations.
Occupational therapists may also need to navigate the differences in opinion regarding a child’s
capabilities, as parents and children do not always agree on their individual assessment of the child’s
ability level (Hemmingsson, Ólafsdó ir, & Egilson, 2017). Pediatric occupational therapists may also
have to be good detectives to uncover a child’s preferred or favored occupations, as very young or
language impaired pediatric clients may be less able to communicate their desires and contribute fully
to decisions regarding their intervention plan.
The balance of engagement in varied occupations shifts and changes across the lifespan. In pediatric
practice, especially with children as opposed to youth, the occupational therapist may find him or
herself more frequently concerned with play and education rather than work, for example. Working on
co-occupations may also be very common in certain aspects of pediatric occupational therapy, where the
client, for example an infant, may require the assistance of a caregiver to engage in occupations such as
feeding.
Lastly, the ability of a child to say, “No” is legendary and child noncompliance can occur in reaction
to an adult’s behavior or language choice (Crockenberg & Litman, 1990; Pesch et al., 2018). Compliance
with activity can similarly be influenced by adult behavior, affect, a ention, engagement, and language
use (Kochanska & Aksan, 1995). Zaidman-Zait, Marshall, Young, & Her man, 2014). In pediatric
practice, the occupational therapist may need to be quite playful and creative, as well as immersed in
the activity with the child, to gain the child’s active engagement in therapeutic activities (Kuhaneck,
Spi er, & Miller, 2010; Singer, 2013). The occupational therapist will also need to understand how to
communicate with children and youth at an appropriate level for their development (PBS, 2018; Traub,
2016).
Summary
This chapter introduces many of the essential concepts that characterize occupational therapy with
children. The occupational therapy process was briefly explained and is illustrated in depth in the
subsequent chapters of the book. Occupational therapy practice with children has matured in recent
decades from a profession that relied on basic theories and practice models to drive decision making to
one that uses scientific evidence in clinical reasoning. All chapters of this book emphasize evidence-
based interventions for children and youth across practice se ings. The subsequent chapters expand on
the basic concepts presented in this chapter by exploring the breadth of occupational therapy for
43
children, explaining theories that guide practice, illustrating practice models in educational and medical
systems, and describing interventions with evidence of effectiveness. Case examples are provided
throughout the text to allow readers to visualize occupational therapy practice with children and
adolescents. The chapter authors have provided summaries of current research in research notes and
evidence-based tables.
Summary Points
• Occupational therapists provide child-centered services to ensure that interventions are
developmentally appropriate, meaningful and motivating to the child, and well aligned
with the child’s goals.
• In family-centered services, occupational therapists develop positive relationships with
families, demonstrate compassion, exhibit responsiveness and sensitivity, and
fosterparental self-efficacy.
• Culturally competent occupational therapists respect the child and family’s culture and
design services that demonstrate respect for the family’s culture.
• Occupational therapists use top-down assessment with performance analysis to determine
how context, task demands, and performance strengths and limitations influence
theparticipation of the child or adolescent.
• Occupational therapists access, interpret, and use evidence to make clinical decisions;
high-quality, efficacious intervention uses EBP guidelines.
• Occupation-centered models include establishing a therapeutic relationship, using
occupation as a means and an end, providing a just-right challenge, providing appropriate
supports for and reinforcement of performance, and supporting generalization ofnewly
learned skills to natural environments.
• Occupational therapists advocate for inclusion and recognize the value of services
withinthe child’s natural environments.
• Environmental modifications increase the participation of the child or adolescent
inactivities for daily living, play, school functions, and work.
• Collaborative models of services delivery, such as classroom-embedded services or co-
teaching, allow occupational therapy services to be integrated into the child’s goals
forparticipating in the curriculum and functioning in the school environment.
• Occupational therapists have important roles in consulting with, coaching, and
educatingcaregivers, teachers, and other professionals who support the participation
ofchildren and adolescents with disabilities.
References
American Occupational Therapy Association. Why and How Often Do OT Practitioners Leave
Jobs? 2018. h ps://www.aota.org/Education-Careers/Advance-Career/Salary-Workforce-Survey/why-OT-
OTA-leave-jobs.aspx.
American Occupational Therapy Association. Children and
Youth. 2018. h ps://www.aota.org/Practice/Children-Youth.aspx.
American Occupational Therapy Association, . Guidelines for occupational therapy services in early
intervention and schools. American Journal of Occupational Therapy . 2017;71 doi: 10.5014/ajot.2017.716S01.
American Occupational Therapy Association, . Inclusion of children with
disabilities. 2015. h ps://www.aota.org/∼/media/Corporate/Files/Practice/Children/Inclusion-of-Children-
With-Disabilities-20150128.PDF.
American Occupational Therapy Association, . Occupational therapy practice framework: Domain and
process 3rd ed. American Journal of Occupational Therapy . 2014;68(Suppl. 1):S1–
44
Another random document with
no related content on Scribd:
More generous were the caciques of two towns at the other end
of the valley, who brought a few golden trifles and eight female
slaves.[278] The revelations of the Cempoalans and of Marina
concerning the wonderful power of the Spaniards, and the honors
paid them by Montezuma’s envoys, had the effect of making Olintetl
also more liberal with provisions at least. Being asked about the road
to Mexico he recommended that through Cholula, but the
Cempoalans representing the Cholultecs as highly treacherous, and
devoted to the Aztecs, the Tlascalan route was chosen, and four
Totonac chiefs were despatched to ask permission of the republican
rulers to pass through their lands. A letter served as mystic
credentials, and a red bushy Flemish hat for a present.[279]
After a stay of four days the army proceeded up the valley,
without leaving the customary cross, it seems, with which they had
marked their route hitherto; the reason for this was the objection of
Padre Olmedo to expose the emblem to desecration in a place not
wholly friendly to them.[280] The road lay for two leagues through a
densely settled district to Iztacmixtitlan, the seat of Tenamaxcuicuitl,
a town which Cortés describes as situated upon a lofty height, with
very good houses, a population of from five to six thousand families,
and possessing comforts superior to those of Xocotlan. “It has a
better fortress,” he writes, “than there is in half Spain, defended by a
wall, barbican, and moats.” The cacique who had invited the visit
made amends for the cold reception of the previous chief, and the
Spaniards remained for three days waiting in vain for the return of
the messengers sent to Tlascala. They then passed onward,
reinforced by about three hundred warriors from the town.[281] Two
leagues’ march brought them to the boundary of Tlascala,
conspicuous by a wall of stone and mortar nine feet in height and
twenty in breadth, which stretched for six miles across a valley, from
mountain to mountain, and was provided with breastworks and
ditches.[282]
Between latitude 19° and 20° ranges of hills cut the plain of
Anáhuac into four unequal parts. In the centre of the one eastward
stood the capital of Tlascala. The state so carefully protected was
about the same small territory which we now see on the map,[283]
with twenty-eight towns, and one hundred and fifty thousand
families, according to the rough census taken by Cortés.[284] A
branch of the Teo-Chichimec nation, the Tlascaltecs had, according
to tradition, entered upon the plateau shortly before the cognate
Aztecs, and, after occupying for a time a tract on the western shore
of Tezcuco Lake, they had tired of the constant disputes with
neighboring tribes and proceeded eastward, in three divisions, the
largest of which had, late in the thirteenth century, taken possession
of Tlascala, ‘Place of Bread.’ The soil was rich, as implied by the
name, but owing to the continued wars with former enemies,
reinforced by the Aztecs, they found little opportunity to make
available their wealth by means of industries and trade, and of late
years a blockade had been maintained which deprived them of many
necessaries, among others salt. But the greater attention given in
consequence to agriculture, had fostered temperate habits and a
sinewy constitution, combined with a deep love for the soil as the
source of all their prosperity. Compelled also to devote more time
and practice to warfare for the preservation of their liberty than to the
higher branches of culture, they presented the characteristics of an
isolated community, in being somewhat behind their neighbors in
refinement, as well as in the variety of their resources.
In government the state formed an aristocracy, ruled by a senate
of the nobility, presided over by four supreme hereditary lords, each
independent in his own section of the territory. This division extended
also to the capital, which consisted of four towns, or districts,
Tizatlan, Ocotelulco, Quiahuiztlan, and Tepeticpac, ruled respectively
by Xicotencatl, Maxixcatzin, Teohuayacatzin, and Tlehuexolotl.[285]
It was before this senate that the messengers of Cortés
appeared, informing them in the name of the Cempoalan lord of the
arrival of powerful gods from the east, who having liberated the
Totonacs from Montezuma’s sway, now desired to visit Tlascala in
passing through to Mexico, and to offer their friendship and alliance.
The messengers recommended an acceptance of the offer, for
although few in number the strangers were more than equal to a
host. They thereupon depicted their appearance, their swift steeds,
their savage dogs, their caged lightning, as well as their gentle faith
and manners. The messengers having retired, the senate proceeded
to discussion. Prudent Maxixcatzin, lord of the larger and richer
industrial district, called attention to the omens and signs which
pointed to these visitors, who from all accounts must be more than
mortal, and, if so, it would be best to admit them, since resistance
must be vain. Xicotencatl, the eldest lord, replied to this that the
interpretation of the signs could not be relied on. To him these beings
seemed monsters rejected by the sea-foam, greedy of gold and
luxuries, whose steeds devoured the very ground. To admit them
would be ruinous. Besides, should the invincible Tlascaltecs submit
to a mere handful? The gods forbid! It was further argued that the
amicable relations of the strangers with Montezuma and his vassals
did not accord with their protestations of friendship. This might be
one of the many Aztec plots to obtain a footing in the country. Nor
did the destruction of idols at Cempoala increase the confidence of a
people so jealous of its institutions. The discussion waxing warmer,
senator Temilotecatl suggested the middle course of letting the
Otomí frontier settlers, who were thoroughly devoted to their
Tlascaltec patrons, make an attack on the invaders, aided by their
own general Axayacatzin Xicotencatl, son of the old lord, and known
by the same name. If successful, they could claim the glory; if not,
they might grant the victors the permission they had desired, while
casting the blame for the attack on the Otomís. This was agreed to.
[286]
FOOTNOTES
[265] ‘Y todos â vna le respondimos, que hariamos lo que ordenasse, que echada
estaua la suerte de la buena ò mala ventura.’ Bernal Diaz, Hist. Verdad., 40.
[266] Bernal Diaz states, 65, that on reaching Mexico City ‘no llegauamos á 450
soldados,’ intimating that they must have amounted to fully this figure on leaving
Villa Rica. This would allow fully 120 men to Escalante, which appears a large
garrison, even after making allowances for the old and infirm. Gomara places the
force at 400 Spaniards, with 15 horses, 6 guns, and 1300 Indians, including
Cubans and carriers. Conq. Mex., 67; Herrera, dec. ii. lib. vi. cap. i.; Torquemada,
i. 411, 517. Ixtlilxochitl increases this to 7 guns, 1300 warriors, and 1000 carriers.
‘Con quince de caballo y trescientos peones.’ Cortés, Cartas, 52. Cortés refers
later on to 400 Cempoalans. He mentions merely 200 carriers. Clavigero has 415
Spaniards, a figure resulting from a misreading of his original. Storia Mess., iii. 36.
Solis, Hist. Mex., i. 216-17, followed of course by Robertson, changes the figures
to 500 men, 200 carriers, and 400 Indian troops. A page, twelve years old, was left
with the lord of Cempoala to learn the language. ‘Tomaron un indio principal que
llamaban Tlacochalcatl para que los mostrase el camino,’ taken from the country
by Grijalva, and brought back by Cortés. Sahagun, Conq. Mex., 16. Shortly before
beginning the march, says Duran, a messenger arrived from Mexico in the person
of Motelchiuh, sent by Montezuma to serve as guide, and to provide for the proper
service and hospitality on the way. Being told that no guide was needed, he
returned, leaving orders with the caciques en route to tender good reception to the
strangers. Duran, Hist. Ind., MS., ii. 405-10.
[267] Meaning ‘Spring in the Sand.’ Rivera, Hist. Jalapa, i. app. 7. ‘Y la primera
jornado fuimos â vn pueblo, que se dize Xalapa.’ Bernal Diaz, Hist. Verdad., 41.
But the road was too long for one day’s march. I may here observe that Bernal
Diaz is remarkably faulty in his account of this march and of the campaign into
Tlascala, and this is admitted by several writers, who nevertheless follow him
pretty closely. The place is known the world over for its fairs and productions,
particularly for the drug bearing its name, and is famous in the neighboring
districts for its eternal spring and beautiful surroundings.
[269] Cortés refers to a friendly chat with the governor, who mentioned the orders
he had received to offer the Spaniards all necessities. Cartas, 57.
[270] ‘Por ser el primero que en estas tierras habíamos pasado. El cual es tan
agro y alto, que no lo hay en España otro.’ Cortés, Cartas, 57. ‘Hoy se llama el
Paso del Obispo.’ Lorenzana, ubi sup. ‘Ay en ella muchas parras con vuas, y
arboles cõ miel.’ Gomara, Hist. Mex., 68.
[272] ‘De Nauhcampa, quatre parties, et tepetl, montagne.’ Humboldt, Vues, ii.
191. Equivalent to the Spanish name of Cofre de Perote.
[273]Lorenzana believes it to be the later Sierra de la Agua. A map with profile of
the route is given in Carbajal Espinosa, Hist. Mex., ii. 201; and a still better map by
Orozco y Berra, Itinerario, in Noticias Mex., 233.
[274] The name must not be confounded with Zacatlan, as Ixtlilxochitl calls it, for
this lies north of Tlascala. ‘Este valle y poblacion se llama Caltanmi.’ ‘Tenia las
mayores y mas bien labradas casas que hasta entonces ... habiamos visto.’
Cortés, Cartas, 58. Lorenzana says, ‘the present Tlatlanquitepec,’ in the lower
lying portion of which stood the palace of Caltanni, ‘house below;’ and there
stands the big tree to which the natives say that Cortés tied his horse. Viage, pp.
iii.-iv. ‘Llamase ... Zaclotan aquel lugar, y el valle Zacatami.’ Gomara, Hist. Mex.,
68; Oviedo, iii. 260. Cocotlan. Bernal Diaz, Hist. Verdad., 41.
[275] Gomara intimates that the Spaniards were well received, and had 50 men
sacrificed in their honor. Hist. Mex., 68. The native records state that bread
sprinkled with the blood of fresh victims was offered to them, as to idols, but this
being rejected with abhorrence, pure food was brought. Before this sorcerers had
been sent to use their arts against them, by spreading diseases, casting spells to
prevent their advance, and otherwise opposing them. But everything failed before
the magic influence shed perhaps by the banner of the cross. Duran, Hist. Ind.,
MS., ii. 401-8; Sahagun, Hist. Conq., 14; Acosta, Hist. Ind., 518; Torquemada, i.
417-8.
[277] Conq. Mex., 42. ‘A muchos valientes por ventura desmayara,’ says to the
contrary Gomara, Hist. Mex., 69.
[278] Cortés, Cartas, 59. Bernal Diaz assumes that Olintetl was persuaded by the
Cempoalans to conciliate Cortés with four slaves, a few paltry pieces of jewelry,
and a load of cloth.
[279] Camargo sends the letter from Cempoala, together with a sword, a
crossbow, and a red silk cap. Hist. Tlax., 145. But it is not probable that Cortés
would deprive himself of such needful articles, not overabundant with him, even if
he had no objection to let Indians examine them. Bernal Diaz, Hist. Verdad., 42-3,
despatches two Cempoalans from a later station, and this on hearing that the
Tlascaltecs had risen to oppose them.
[280] Still Gomara, in his sweeping way, declares that Cortés ‘puso muchas
cruzes en los templos, derrocãdo los idolos como lo hazia en cada lugar.’ Hist.
Mex., 70; Tapia, Relacion, in Icazbalceta, Col. Doc., ii. 567. Twenty leading
warriors were taken from here, says Bernal Diaz.
[281] Clavigero calls them ‘un competente numero di truppe Messicane del
presidio di Xocotla,’ Storia Mess., iii. 41, which is unlikely.
[283] Fifteen leagues from west to east, ten from north to south, says
Torquemada, i. 276. Herrera extends it to 30 leagues in width.
[284] ‘Hay en esta provincia, por visitacion que yo en ella mandé hacer, ciento
cincuenta mil vecinos.’ Cortés, Cartas, 69. In the older edition of these letters by
Lorenzana, it reads, 500,000 families, a figure which in itself indicates an
exaggeration, but has nevertheless been widely copied. Gomara, Hist. Mex., 87.
[285] For further information about Tlascala, see Native Races, ii. and v.
Torquemada gives a detailed history of the state in i. 259-78. See also Prescott’s
Mex., 411-19; Soria, Istoria y Fundacion de la Ciudad de Tlaxcala, MS. in Aztec,
sm. 4o of 48 leaves.
[286] Herrera, dec. ii. lib. vi. cap. iii., confounds the two Xicotencatls, and
Torquemada, in seeking to correct him, applies the title of general to Maxixcatzin,
i. 416, supposing besides, with Clavigero, that Temilotecatl may be another name
for Tlehuexolotl. Storia Mess., iii. 40; Brasseur de Bourbourg, Hist. Nat. Civ., iv.
133. Jealous of the honor of his countrymen, and eager to vindicate them against
the charge of duplicity or enmity toward the Spaniards, Camargo lets the
messengers go back with a friendly invitation. After they had started on this
mission the idols were consulted, but remained mute; the temples were
overthrown by earthquakes, and comets appeared, creating a general panic. Hist.
Tlax., 144-6. The account of the conquest by this author is particularly interesting
since Diego Muñoz Camargo was a native of the valiant little republic of Tlascala,
a mestizo, says Veytia, Hist. Ant. Méj., ii. 91, who calls him Domingo, while
Clavigero gives him nobility. Storia Mess., i. 10. Born shortly after these events,
and in contact with the very men who figured therein, his stories are reproduced
from their lips, though colored with the spirit of a convert and patriot who, like
nearly all of his countrymen, was only too eager to curry favor with the dominant
race. This is apparent in nearly every line of his text, wherein the terms of praise
bestowed on the conquerors become not unfrequently absurd from the
contradictions implied by other passages. Nor does he neglect to hold forth on his
own people for their bravery and exploits in fighting the detested Aztecs, and their
unswerving devotion to the Spaniards. In the pursuit of this pleasing theme he
scruples not to sacrifice truth when it proves a stumbling-block. He leaves the
impression, for instance, that the Tlascaltecs never raised sword against Cortés.
Many of the misstatements are due to a non-critical acceptance of tales, for
Camargo was as simple and superstitious as any of his contemporaries. Although
acting as interpreter in the province, Torquemada, i. 523, he exhibits a not very
thorough acquaintance with Spanish, which is the cause of errors and repetitions.
The conquest forms but a portion of his narrative, which treats chiefly of aboriginal
history and customs, and touches lightly the events that passed before his eyes. It
was written in 1585, and lay for some time in the Felipe Neri convent archives,
where it was consulted by Torquemada. Taken afterward by Panes to Spain, it was
deposited by Muñoz with the Royal Academy of History at Madrid, from which
source copies were obtained, among others one by Ternaux-Compans, and a
faulty translation was published in the Nouvelles Annales des Voyages, xcviii.-ix.
[287] A short distance further they passed through a pine grove, wherein threads
and papers were fixed and scattered across the path, the work of Tlascaltec
sorcerers, who thus sought to cast a spell upon the invaders. Herrera, dec. ii. lib.
vi. cap. iv.
[288] ‘Segun algunos que lo vieron, cortaron cercen de vn golpe cada pescueço
con riendas y todo.’ Gomara, Hist. Mex., 71. ‘Io viddi che cõbattẽdosi vn dì, diede
vn Indiano vna cortellata a vn cauallo ... nel petto, che glielo aperse fin alle
ĩteriora, et cadde icõtanẽte morto, & ... che vn’ altro Indiano diede vn’ altra
cortellata a vn’ altro cauallo su il collo che se lo gettò morto.’ Relatione per vn
gentil’huomo, in Ramusio, Viaggi, iii. 305. According to Duran two warriors
stepped forth from a vast Tlascalan army before the regular battle, and issued a
challenge, which was accepted by two horsemen. After a short combat the
Indians, by deft movements, killed both horses, cutting off the neck of one, and
wounding the other in the pasterns. Hist. Ind., MS., ii. 411-20; Tezozomoc, Hist.
Mex., ii. 255-6. This attack is the only resistance admitted by Camargo. The
assailants were all Otomís, who killed one Spaniard and two horses. Hist. Tlax.,
146.
[289] ‘Hirieron á quatro de los nuestros, y pareceme que desde alli á pocos dias
muriò el vno de las heridas ... quedaron muertos hasta diez y siete dellos.’ Bernal
Diaz, Hist. Verdad., 43; Cortés, Cartas, 61; Lorenzana calls the scene of this battle
the plain of Quimichoccan. Viage, p. viii.
[290] See Native Races, ii. 413; Solis, Hist. Mex., i. 230. According to Bernal Diaz
the messengers are met before the Tlascalan border is reached, and they deliver
the announcement that the Tlascaltecs will kill the Spaniards and eat their flesh, in
order to test their reputed strength. The Cempoalans shall suffer the same fate,
since they are assumed to be plotting in behalf of the Aztecs, loc. cit. Sahagun
supposes that the Cempoalan guide had treacherously led the Spaniards against
the Otomís. Conq. Mex. (ed. 1840), 40; Clavigero, Storia Mess., iii. 42-3.
[293] Tapia gives the higher and Herrera the lower figure, while Ixtlilxochitl makes
it 80,000.
[294] During the battle one of the late Cempoalan envoys recognized the captain
who had bound him for sacrifice, and with Cortés’ permission he sent him a
challenge. The duel was held in front of the armies, and after a tough struggle the
Cempoalan, with a feint, threw his opponent off guard, and secured his head,
which served as a centre-piece during the Cempoalan victory celebration. Herrera,
dec. ii. lib. vi. cap. vi. This author also relates that one of the final acts of the battle
was the capture by Ordaz, with 60 men, of a pass. ‘Les matamos muchos Indios, y
entre ellos ocho Capitanes muy principales, hijos de los viejos Caciques.’ Five
horses were wounded and fifteen soldiers, of whom one died. The other chronicles
admit of no dead. Bernal Diaz, Hist. Verdad., 44.
[295] Robertson, Hist. Am., ii. 38-9; Wilson’s Conq. Mex., 360-70; Benzoni, Hist.
Mondo Nvovo, 51. It is seldom that I encounter a book which I am forced to regard
as beneath censure. He who prints and pays the printer generally has something
to say, and generally believes something of what he says to be true. An idiot may
have honest convictions, and a knave may have talents, but where a book carries
to the mind of the reader that its author is both fool and knave, that is, that he
writes only foolishness and does not himself believe what he says, I have not the
time to waste in condemning such a work. And yet here is a volume purporting to
be A New History of the Conquest of Mexico, written by Robert Anderson Wilson,
and bearing date Philadelphia, 1859, which one would think a writer on the same
subject should at least mention. The many and magnificent monuments which to
the present day attest the great number and high culture of the Nahua race, and
the testimony to this effect offered by witnesses on all sides, are ignored by him
with a contempt that becomes amusing as the pages reveal his lack of
investigation and culture. Indeed, the reader need go no further than the
introduction to be convinced on the latter point. Another amusing feature is that
the work pretends to vindicate the assertions of Las Casas, who, in truth, extols
more than other Spanish author the vast number and advanced culture of the
natives. In addition to this mistaken assumption, which takes away his main
support, he states that Prescott worked in ignorance of his subject and his
authorities, and to prove the assertion he produces wrongly applied or distorted
quotations from different authors, or assumes meanings that were never intended,
and draws erroneous conclusions. Thus it is he proves to his own satisfaction that
Mexico City was but a village occupied by savages of the Iroquois stamp, and that
Cortés was the boastful victor over little bands of naked red men. As for the ruins,
they were founded by Phœnician colonists in remote ages. Another tissue of
superficial observations, shaped by bigotry and credulous ignorance, was issued
by the same author under the title of Mexico and its Religion, New York, 1855,
most enterprisingly reprinted in the disguise of Mexico: its Peasants and its
Priests, New York, 1856. In common with Mr Morgan, and others of that stamp, Mr
Wilson seems to have deemed it incumbent on him to traduce Mr Prescott and his
work, apparently with the view of thereby attracting attention to himself. Such men
are not worthy to touch the hem of Mr Prescott’s garment; they are not worthy of
mention in the same category with him.
[296] Lorenzana, Viage, ix., wherein the appearance of the hill is described as the
bishop saw it. Ixtlilxochitl, Hist. Chich., 292; Camargo, Hist. Tlax., 146. Other
authors differ. ‘Teoatzinco, cioè il luogo dell’acqua divina.’ Clavigero, Storia Mess.,
iii. 44. Duran assumes that the battle was for the possession of this place, which
he calls Tecoac. Hist. Ind., MS., ii. 418, 422; Tezozomoc, Hist. Mex., ii. 256. ‘Aldea
de pocas casas, que tenia vna torrezilla y tẽplo.’ Gomara, Hist. Mex., 74.
[297] So Cortés distinctly says. Bernal Diaz writes, however, that this day was
devoted to rest. Still, a later observation indicates that Cortés is right.
[298] Id. Bernal Diaz, Hist. Verdad., 44, admits only twenty captives, and blames
the allies for firing the villages; but Cortés is frank enough about it.
[299] Prescott, Mex., 438-42, gives a pretty description of the army, but is so
carried away that he dons it with helmets glittering with gold and precious stones,
etc.; and this in spite of the efforts of the chroniclers to exhibit the Tlascaltecs as
very poor in anything but rude comforts.
[300] Under five captains, to whom he applies the names of the four lords, as he
understands them, and of the ruler of Huexotzinco. Hist. Verdad., 45; Gomara,
Hist. Mex., 75. 149,000 men, says Cortés, in his second letter, 62, but this
exactness is probably due to a printer’s mistake.
[301] For colors and banners, and how carried, see Native Races, ii. 411-12, and
Torquemada, i. 436.
[302] He was detected in this trick afterward. ‘Lo qual fue gran refrigerio y socorro
para la necesidad que tenian.’ Gomara, Hist. Mex., 76. Oviedo increases the gift
to 700 baskets. iii. 495. Gomara proceeds to relate that in sign of contempt for the
small number of the enemy, whom it could be no honor for his large army to
overcome, Xicotencatl detached 2000 warriors—200 says Oviedo—to seize and
bring him the strangers bound. They attacked, and were routed with an almost
total destruction of their number. ‘No escapo hombre dellos, sino los q̄ acertaron el
passo de la barranca.’ loc. cit. 76.
[303] Bernal Diaz states that they did not wait for the enemy to attack, but
marched forth and met them one eighth of a league from camp. Hist. Verdad., 45.
But Cortés says distinctly, ‘Otro dia en amaneciendo dan sobre nuestro real mas
de ciento y cuarenta y nueve mil hombres.’ Cartas, 62. Gomara and Herrera also
allow Indians to attack the camp first. Cortés is too fond of announcing when he
takes the initiative to have failed to say so had he done it in this case.
[304] ‘Son of Chichimeclatecle,’ says Bernal Diaz, a name which should read
Chichimeca-tecuhtli.
[306] This soldier himself received two wounds, which did not prevent him from
fighting, however. ‘Nos mataron vn soldado,’ he says, and a few lines further
down, ‘y enterramos los muertos ... porque no viessen los Indios que eramos
mortales.’ Hist. Verdad., 45. Thus even the ‘True Historian’ reveals the common
weakness. Hazart, Kirchen-Geschichte, ii. 512-14; West-Indische Spieghel, 224-
35; Franck, Weltbuch, ccxxix.
CHAPTER XIII.
ENTRY INTO TLASCALA.
September, 1519.
In the late battle three chiefs had been captured, and they
together with two others were sent, this time to the Tlascalan capital
direct, to carry an offer of peace, and to explain that the Spaniards
would not have harmed their warriors had they not been obliged to
do so. If peace was still declined they would come and destroy them
all. Meanwhile Cortés set out on another foraging and raiding
expedition, and “burned more than ten towns, one exceeding three
thousand houses,” retiring by the early afternoon, when the Indians
began to gather in aid of the raided neighbors.[307]
Tired of the fruitless fighting, attended with loss of life and
property only to themselves as it appeared, the peace party in
Tlascala had been gaining the ascendancy, with the efforts of
Maxixcatzin, supported as he now was by the powerful factions
which had quarrelled with the general. When the peace messengers
of Cortés arrived they were therefore received with favor. His
previous friendly offers were considered, also his kind treatment of
captives, so unusual with the natives, and the oracles and signs of a
coming race of rulers. Whether gods or men, they were evidently
invincible, and the friendship and alliance held out by them must be
desirable, and ought to be secured before the strangers, embittered
by further resistance, should pass on to join their enemies. An
embassy, headed by Costomatl and Tolinpanecatl,[308] was
accordingly despatched with provisions and some other trifling gifts
to open negotiations for peace. Humbly these men appeared before
Cortés, expressing the sorrow of the lords for the hostility shown,
and their desire for peace. With a grave reproval for their obstinacy,
Cortés said that he would admit their apology, and the envoys
departed, after leaving beside the other gifts a number of male and
female slaves.[309]
Smarting under the disgrace of his defeats, Xicotencatl had
meanwhile been laying plans to retrieve himself. Among other
counsellors he had summoned diviners to his aid, and they, calling to
mind the assumption that the Spaniards were children of the sun,
declared that as such the new-comers were invincible only when
animated by its beams, and at night, when deprived of this
invigorating power, they became mortals, who must bow to superior
force. Knowing the strength of the party opposed to him in the
Tlascalan capital, he does not appear to have submitted his projects
there, but to have ventured upon detaining the envoys as they were
returning from the Spanish camp until the result of his plans should
have been ascertained; and this in face of the command to desist
from hostility.[310] In order to make everything as sure as possible for
the intended blow, Xicotencatl sent fifty Indians to the camp, with
instructions to gather information concerning the approaches, the
condition of the soldiers, and other points. They appeared before
Cortés with the usual demonstrations of respect, and, placing before
him five female slaves, a quantity of food, and other presents, they
said: “Lord, behold these slaves! If you are fierce gods, eat their
flesh and blood, and more shall be brought; if gentle gods, take
these feathers and incense; if men, here are fowl, bread, and fruit.”
Cortés answered that they required no sacrifices of men. Had they
desired such they could have taken by force all the victims needed.
He rebuked their obstinacy and advised submission.[311] They were
then taken aside to receive the hospitalities of the camp, after which
they dispersed to satisfy their curiosity, and to question the allies.
This aroused the suspicions of Teuch, the Cempoalan chief, who
warned the general. Seizing the men he examined them singly, and
soon ascertained that their object was not only to spy, but to fire the
huts, and otherwise to aid the attack which would be made upon the
camp that very night. Finding that his friendly advances had been
scorned, Cortés resolved to inflict a lesson that would be understood
by a people so deeply intent upon war and sacrifices. This was to cut
off the hands of the leading spies, and the thumbs of others, and to
send them back with the message that this would be the punishment
of spies, and that the Spaniards were prepared, night or day, to face
their enemies.[312]
Fearing the confusion and danger of a night attack, when the
artillery and other means would be less effective, Cortés resolved to
anticipate the enemy by a counter charge, wherein the cavalry might
render particular service. Learning that Xicotencatl was hidden with
ten thousand or twenty thousand men behind a hill not far off, Cortés
did not despatch the mutilated spies till after dusk, in order to let him
approach nearer to camp.[313] When his messengers returned to
Xicotencatl and displayed their bleeding stumps, the general was
troubled, and throughout his army there was consternation, and