Thursday, March 30, 2006

The role of occupational therapy in family reunification

For background information, you may first choose to reference this entry:
An analysis of foster care policy and its impact on occupational therapy


Children are placed in temporary foster homes when their parents are unable to care for them; foster care is generally designed as a temporary service for children and families who are experiencing a crisis. Children in foster care are more likely to experience psychological and developmental problems (Simms, Dubowitz, & Szilagyi, 2000); therefore, there is an increased likelihood that they attend early intervention and preschool programs where occupational therapists provide services.

Occupational therapy education programs have been successful in increasing therapists’ knowledge and skills in working with parents of children who have disabilities (Hinojosa, Sproat, Mankhetwit, & Anderson, 2002). However, little has been written about occupational therapist’s interactions within the foster care system, particularly as it relates to parent training programs for families that are going through reunification.

Research indicates that 57% of the children in foster care are reunified with their birth parents, although in recent years, reunification rates have declined (Department of Health and Human Services, 2003). Additionally, some studies show that reunification efforts are not always successful for the long term. Terling (1999) states that reentry into foster care due to additional maltreatment occurs too frequently, and that 37% of the children reunited with their families reenter the system within 3 1/2 years.


This data indicates that there is an acute need for parental training programs that are effective and that will support the occupational performance of both children and parents. Hanna and Rodger (2002) reviewed the occupational therapy literature and identified that the available evidence regarding the efficacy of occupational therapy intervention for parent training and collaboration is limited. From a broader perspective, several studies have been commissioned by the Assistant Secretary for Planning and Evaluation of the U.S. Department of Health and Human Services (1992, 1995) and they indicate that few states have programs that address the reunification problem, and those that do address the issue do so from the perspective of placement prevention. Currently, there is very little evidence to guide the participation of occupational therapy in parent training programs.

The most specific parent training program that is described in the literature is Eyberg’s Parent Child Interaction Therapy (1988). This technique involves specific training in real-time by providing feedback on parenting during a play session with a child. Although this is described primarily as a counseling intervention, it is very functionally oriented and related to direct parenting occupations. Articles that describe this intervention were included as they related to emotional problems of the child (Johnson, Franklin, Hall, Prieto, 2000) as well as coping problems of the parent (Borrego, Urquiza, Rasmussen, & Zebell, 1999).

Another interesting perspective on parenting training involves an assessment of speech and communication patterns between mothers and their children who have cerebral palsy (Pennington & McConachie, 2001). This study indicated that a multitude of developmental factors can have an influence on interaction and communication between parents and children. Again, as many children in the foster care system have multiple developmental difficulties, this article identifies a myriad of issues that are important to consider when providing intervention for this population.

Finally, two occupational therapy articles (Ganadaki, & Magill-Evans, 2003; Nakamura, Stewart, & Tatarka, 2000) are included in the review, but both of these have significant methodological problems. Both studies used the Nursing Child Assessment Teaching Scale which is normed for mothers only. These studies both attempted to document the participation of fathers in parenting. Use of a standardized tool that is normed on mothers leads to questions regarding the appropriateness of use for measuring father performance. Additionally, in the Nakamura, Stewart, & Taturka study, there was a very small sample size and they had many problems with data collection; in the end they found no difference between intervention and non-intervention groups. Other studies (Pennington & McConachie, 2001) specifically excluded fathers from their research because of known and accepted differences in parenting interactions between mothers and fathers.

An interesting article describes therapists’ qualitative perceptions of parent-child relationships in therapy (Mayer, White, Ward, & Barnaby, 2002). The authors identify several themes of interest that may help provide guidance for future research on specific therapist interactions in parent education.

In summary, there is a notable lack of research and identification of methodologies for occupational therapists to provide parent training programs. This lack of information is troubling in consideration of the high frequency of contact between occupational therapists and families that are in the foster care system.

Case Study


Sam is a 35 month old child who was initially referred for occupational therapy when he was 26 months old. He has been seen for direct occupational therapy twice weekly for thirty minute sessions since the time of his initial referral. Sam is now splitting his time between his foster parents and his biological parents. Because of previously identified interaction and bonding problems with the biological parents, all occupational therapy intervention is now being provided in the biological parent’s home.

All previous observations about the parent-child interactions were qualitative. Quantitative data could provide different information that might guide intervention more specifically and promote parenting skills of the biological parents. For the purposes of this case study my initial plan was to administer the Parenting Stress Index (Abidin, 1995). Unfortunately, I experienced some logistical problems with obtaining the instrument due to qualification requirements that are strictly enforced by the current test publisher. Instead, I administered the Parental Stress Scale (Berry & Jones, 1995).

The Parental Stress Scale is a very brief self-report scale that contains 18 items representing positive and negative themes of parenthood. Parents read statements and either agree or disagree with them in terms of their typical relationship with their child. The parents rate each item on a five-point Likert scale with higher scores on the scale indicating greater stress.

The Parental Stress Scale demonstrated good internal and test-retest reliability. Additionally, it had good concurrent validity with other tests such as the Parenting Stress Index. Factor analysis was completed and a four factor solution was identified by the researchers but these specific factors were not labeled.

Both of Sam’s parents willingly participated in the assessment and they filled out the Parental Stress Scale independent of each other. Sam’s father scored a 36 and his mother scored an 18. There is no normative data to compare their scores to, but the pattern of their responses provides useful clinical data.

Statements that Sam’s father agreed with on the Scale included: “Caring for my children sometimes takes more time and energy than I have to give,” “I sometimes worry whether I am doing enough for my children,” and “Having children leaves little time and flexibility in my life.” These statements are completely consistent with other statements he has made and reflects his anxiety regarding the sudden addition of having to care for Sam again. He felt undecided about statements including “The major source of stress in my life is my children,” “It is difficult to balance different responsibilities because of my children,” and “Having children has meant having too few choices and too little control over my life.” I believe that these statements are more difficult to answer affirmatively to, but the father’s undecided response indicates that this may be a concern for him on some level.

Sam’s mother had a score of 18; she responded to every question in a way that indicates she perceives no stress at all with regard to Sam and her parenting responsibilities. Based upon my observations in the home, the apparent lack of bonding and interaction that she has with Sam, and the simple reality of having three more children to care for, I don’t believe that this is a valid measure of her parental stress. Rather, it is likely that issues relating to social desirability strongly influenced her responses. This is not completely unexpected given her passive traits and the experiences she has had of having her children removed from her by the Child Protection Services system.

Sam’s father is willing to admit to stressors that he experiences, and this assessment provides some direction into how his confidence could be increased with his parenting skills. He requires modeling of appropriate limit setting and interactive play participation, and then additionally requires positive feedback on interactions that he has that are beneficial. He may benefit from a program that incorporates elements of Parent Child Interaction Therapy.

Sam’s mother will require a different approach in terms of facilitating her parenting skills. First, she has to develop some trust with the people providing intervention. It is understandable that this will be a significant obstacle based on her previous experiences that the roles of outside professionals were primarily punitive (from her perspective), despite her own admissions that “young age and stupidity” caused her to lose custody of Sam. After some greater degree of trust is established, it might be useful to re-administer the Parental Stress Scale so that targeted areas for intervention could be determined.


The high rate of recidivism for children within the foster care system is an indicator that families and children would benefit from specific and well-designed programs that facilitate parenting skills. Although this concept is nearly universally accepted, very little research has been done that identifies what interventions are most helpful in promoting positive parenting skills and concomitantly, supporting typical child development. Occupational therapists interact with children in foster care frequently and they require more knowledge of what kinds of parenting interventions are best to use in clinical practice. Literature review substantiates that there is little knowledge available to promote program development for these children and families.

Occupational therapists working with this population of children and families should explore areas for program development and document intervention strategies that support parental skill development. Although the children in the foster care system will demonstrate significant developmental delays in multiple areas, it is critical to also address the larger issues of children’s adapting to reunification and promoting positive parenting practices that support child development.


Abidin, R. (1995). Parenting stress index (PSI) 3rd ed. Odessa, FL : Psychological Assessment Resources, Inc.

Berry, J. O., & Jones, W. H. (1995). The Parental Stress Scale: Initial psychometric evidence. Journal of Social and Personal Relationships, 12, 463-472.

Borrego, Jr., J., Urquiza, A.J., Rasmussen, R.A., & Zebell, N. (1999). Parent-Child Interaction Therapy with a family at high-risk for physical abuse. Child Maltreatment, 4(4), 331-342

Eyberg, S. (1988). Parent Child Interaction Therapy: Integration of Traditional and Behavioral Concerns. Child and Family Behavior Therapy, 10(1), 33-45.

Ganadaki, E. & Magill-Evans, J. (2003). , Mothers' and fathers' interactions with children with motor delays. American Journal of Occupational Therapy, 57, 463-467.

Hanna, K. & Rodger, S. (2002) Towards family-centred practice in paediatric occupational therapy: A review of the literature on parent-therapist collaboration. Australian Occupational Therapy Journal 49 (1), 14-24.

Hinojosa, J., Sproat, C., Mankhetwit, S., & Anderson, J. (2002). Shifts in Parent-therapist Partnerships: Twelve Years of Change. American Journal of Occupational Therapy, 56, 556-563.

Johnson, B. D., Franklin, L. C., Hall, K., & Prieto, L. R. (2000). Parent training through play: Parent-Child Interaction Therapy with a hyperactive child. Family Journal-Counseling & Therapy for Couples & Families, 8, 180-186.

Mayer, M. L., White, B. P., Ward, J. D., & Barnaby, E. M. (2002). Therapists’ perceptions about making a difference in parent-child relationships in early intervention occupational therapy services. American Journal of Occupational Therapy, 56, 411-421.

Nakamura, W.M., Stewart, K.B., & Tatarka, M.E. (2000). Assessing Father-Infant Interactions Using the NCAST Teaching Scale: A Pilot Study. American Journal of Occupational Therapy, 54, 44-51.

Pennington L., McConachie, H. (2001). Predicting patterns of interaction between children with cerebral palsy and their mothers. Developmental Medicine and Child Neurology, 43, 83-90.

Simms, M.D., Dubowitz, H., Szilagyi, M.A. (2000). Health care needs of children in the foster care system. Pediatrics. 106, 909-918.

Terling, T. (1999). The efficacy of family reunification practices: Reentry rates and correlates of reentry for abused and neglected children reunited with their families. Child Abuse & Neglect. 23, 1359-1370.

U.S. Department of Health and Human Services (1992). Intensive foster care reunification programs, Executive Summary. Retrieved March 13, 2004 from

U.S. Department of Health and Human Services (1995). A review of family preservation and family reunification programs. Retrieved March 13, 2004 from

U.S. Department of Health and Human Services. (2003). The AFCARS report: FY 1999, FY 2000, FY 2001 and FY 2002 Foster Care: Entries, Exits, and In Care on the Last Day. Retrieved March 3, 2004, from entryexit2002.htm.

Tuesday, March 28, 2006

Blog business

Hi everyone...

Just a quick note to let you know that after playing around a lot between ATOM and RSS I decided to keep the ATOM format for feeds. So if you saw a funny version of the blog in the last 24 hours with RSS feeds enabled, I was just kidding.

Occupational therapists are not supposed to know about programming these changes, and that is my excuse.

Either that or Blogger doesn't like RSS.

I am wondering now how much damage and confusion to my site feeds I have caused with these changes. Oh well.

Sunday, March 26, 2006

Lessons about healing

Tony was a middle-aged man of Italian-American descent. I watched him limp toward me slowly as he leaned a little too heavily on his cane for support. He had a difficult time walking: his left leg was held relatively stiff and he struggled to avoid dragging his toes as he worked diligently to advance his hemiplegic extremity. His left arm was not faring much better. It hung limply at his side, obscenely lifeless. "My arm feels like a puppet on a string," he would say to me, "but there is no Gepetto to make this tired old body move."

Tony wasn't really that old. He had just retired from the railroad where he had worked for the last 35 years as a conductor. His only child was grown - a successful radiologist in the rural community where we lived. Tony and his wife had no real plans for retirement. They didn't have much of an opportunity to formulate plans before he had the stroke.

The stroke primarily affected Tony's left arm and leg. He was able to communicate well and there didn't seem to be any cognitive deficits. "At least I still have my noodle," Tony would say. Professionals use terms like 'intact cognitive skills,' but sometimes patients using colloquialisms can describe the situation quite well.

Whenever I asked Tony what his goals were he always told me the same thing: " I want to be well enough to go to the country club, play cards, and hang out with the boys." That meant walking better, using his left arm more, and not being dependent on others for eating and using the bathroom. Still, his goal seemed odd to me: Tony just did not seem like the country club type. I tried to discard my stereotypes and prejudices and I accepted what he told me.

He has goals to work on, I thought. And we embarked together on a process that would help him meet those goals.

With each day, Tony's hand continued to swell. The left arm was useless, and he regained no movement at all. His muscles continued to atrophy and there was no support to keep his arm well placed in the socket. This caused what we refer to as a 'shoulder subluxation.' This causes pain, and the pain is exacerbated by the swelling in the hand, and this contributes to an overall cycle of pain and lack of movement that is very difficult to overcome.

I always try to be honest with my patients. "Tony, I just don't know what I can do for this arm. The swelling is terrible, you don't seem to be able to move it at all, and all this is making the pain worse and worse." I felt as though I was letting him down.

"I think we need to try a poultice," he said to me one day. I had never seen him so serious before.

"A poultice?" I replied cluelessly. "What in the world is a poultice?" I was newly transplanted into the rural area and had no experience with such things.

"It's a mixture that you put on your arm and it will draw all the swelling out. My mom used them on us for bee stings all the time. I asked my son the big shot radiologist but he thinks I am crazy. Do you think I should try a poultice?"

"Well I think it might be a little out of my league, and I certainly don't have any poultice recipes, so I think you are on your own for this one."

Tony responded, "Well the one I remember best is the one that smelled the worst, but I know that my mom told me it was the most powerful one. Now my son tells me not to do it and that I am wasting my time. But I need to get equal parts of Pennsylvania crude oil - it has to be straight out of the well, you know - and mix it in a bag with fresh horse manure. Then I have to place it all over my arm and it will draw that swelling out. So can I do it?"

I mentally withdrew, but couldn't help noticing how badly he wanted to believe in this poultice. I could see that he believed in it. "I'll tell you what, Tony. You go try that poultice. Just wash your hands real well before you show up in my clinic again."

"Deal!" he said. He left my clinic that day a very happy man.

Tony kept his word, and I never saw or smelled any trace of his poultice when he came in for therapy. I also don't know where in the world he found Pennsylvania crude oil (straight out of the well, of course). There were still a few small derricks operating locally and I imagine he talked someone into helping him out.

His left arm didn't get much better in regard to movement. Some of the swelling went away over time, but I don't know if it was the poultice or the range of motion and massage.

I taught him how to dress himself using only one hand, and how to complete other important self care activities as well. I also purchased a card holder for him so that he had something to hold his cards when we played in the clinic. Tony loved coming to see me, and after my approval of his poultice ideas he developed a deep trust in my opinions.

One day he came to see me in my office and pronounced himself healed.

"I don't think I need to come to therapy any more," he stated. "This arm just isn't going to get any better, and I can't sit around waiting for it to happen. You helped me to learn how to do things without having to use it, and it is high time I just stopped waiting for everything to be the same again. You have done so much for me, and you even let me believe in my poultices. Will you just be my guest at the country club - just once - so I can thank you properly?"

I was so touched by his acceptance of his disability, and felt warmed by his kind words to me, so I accepted his invitation.

A couple days later I received a note from him in the mail, complete with directions to the Johnstown Country Club, located on Johnstown-Reynoldsville Road. I always chuckled at the lack of imagination when it came to naming rural roads - they always seem to be named after the two largest towns that the road connects.

Strange, I thought. I have traveled that road many times, and I just don't seem to remember any country club anywhere. I called Tony to be sure of the directions. "Oh it's there all right - don't you worry."

"How should I dress?" I asked, not wanting to be out of place when I arrived.

"Oh gosh, wear something comfortable," he replied. "What matters most is that we have a good time." Hm... 'casual country club' I imagined. It was enough to go on.

The day of our dinner soon arrived, and I made sure that I was dressed in a pair of casual slacks and a collared shirt and nice tie. I wore a sport jacket over it all, different color than the pants naturally. I was trying to be casual.

I followed the directions exactly, and they were quite accurate. However, I began to worry when I found myself on small dirt roads off of the main road. I saw no signs. No manicured lawn. No fountains or golf course or statues. But then I did see it: the Johnstown Country Club.

Tony was sitting out front, chomping on a cigar and playing cards on the front porch with a bunch of sloppily dressed retired gentlemen. It was little more than a hunting cabin. Off to the side was an open fire pit, busily manned by other friends of his that were cooking steaks and dousing the flames with their beer when the fire started to get a little out of control.

Tony, myself, and about a dozen or so of his buddies sat in that old dilapidated hunting shack on top of a mountain in the middle of nowhere (somewhere between Reynoldsville and Johnstown, I guess) - we ate steaks, drank beer, and played cards until it was dawn.

When the sun started to rise and the party started to break up they came up to me as a group and said, "Thanks for helping to get Tony back up here. It just hasn't been the same without him."

"Gentleman," I replied, "this is the finest country club that I have ever been to. This is also the only country club that I have ever been to." They laughed at this. " But I doubt that I will ever be in such fine company again in my life."

As I looked from face to face and watched them gather around their friend Tony I realized how young I was. And how wise they were.

Whenever I think about true healing I think of Tony, his friends, and that country club. I remember that healing is not about the swelling in a man's hand or the movement that he has in his shoulder. Rather, I think it is all about the things that a person believes in and what he does to find his way home again.

Monday, March 20, 2006

Snoezelen: The continuing slide of occupational therapy mental health practice into the abyss

Let me first say that I have no doubt in my mind whatsoever that Snoezelen-type environments are soothing, relaxing, and stress-reducing. I don't need to read any scientific articles to tell me this - although I did do an OVID search tonight and was not surprised to see many studies (of varying degrees of quality) say that Snoezelen was effective toward these ends. But I don't even doubt the poorly designed studies - I accept their reports of support for the calming effects of Snoezelen environments.

Snoezelen and other sensory based interventions for adults who have psychiatric disorders were discussed in this week's OT Practice (Costa, Morra, Solomon, Sabino, & Call, 2006). The article describes Snoezelen as 'failure-free' and 'passive' but apparently some of the interventions involved actively teaching the clients relaxation exercises and deep breathing techniques. The authors report that the clients had some increased relaxation, even to the point of sleep. Most of the clients indicated that they had a hard time following through on the sensory diet aspect of the program.

Several literature reviews on Snoezelen have been published that are worth considering (Chung, Lai, Chung, & French, 2004; Hogg, Cavet, Lambe, & Smeddle, 2001). The Cochrane Review simply indicated that there were too few studies to make broad conclusions. The other indicated that although there may be some support for client improvement within a session, there was little indication that the skills were generalized.

The lack of generalization and lack of contextual application to the real world is what has me most concerned about Snoezelen and any other passive sensory intervention strategy. Dunn, Brown, & McGuigan (2004) developed the Ecology of Human Performance framework to address this problem. This framework was designed with the purpose of accounting for the influence of the environment on human performance. Under the assumption that “occupational therapy is most effective when it is imbedded in real life,” temporal and environmental contextual factors are identified that allow practitioners to interpret behavior and choose appropriate and meaningful therapeutic interventions. This framework raises important questions about the subjective nature of contextual relevance and the questionable validity of interventions that involve de-contextualized strategies. The question remains: Is Snoezelen 'real life?'

Breines (1989) identifies that “human action can be understood only in terms of the relationships that it generates with the world." The concept of contributing to self, family, or society is expressed as being central to the core of meaningfulness in occupational therapy. Therefore, consideration of contextual factors is requisite for true understanding of human behavior and occupational therapy is only relevant when contextual factors are incorporated into assessment and intervention. From a pragmatic perspective, Breines states that a person’s ability to ‘connect’ with the world is dependent upon active and meaningful engagement with the environment. Not only is this a functional outcome for the individual, but it is also a functional outcome for all of society. What are we saying about meaningful engagement when we reduce the interaction down to the level of reaching toward a vibrating wall?

These are not the rantings of mad occupational therapy theorists. Some Snoezelen researchers are saying the same things. Cuvo, May, & Post (2001) talk about the positive effects of a normal outdoor environment as compared to a Snoezelen environment. Vlaskamp, de Geeter, Huijsmans, and Smit (2003) state that people with profound multiple disabilities have strong responses towards talking to or touching a staff person. They report that normal living environments are as good a place as a multisensory environment for promoting alertness and interactions.

With this kind of evidence, why do we provide space for these discussions in our publications? Occupational therapy mental health practice has been circling the drain for many years, and I believe that this kind of decontextualized intervention strategy contributes even more to the disconnect. How does Snoezelen make sense in the larger context of supporting occupational participation and promoting function?

If we think that the greatest function we can hope and dream for our mental health patients is for them to interact more freely within a Snoezlen environment, our profession deserves to be passed by. At a minimum, let's link these interventions with Winnie Dunn's Ecology of Human Performance framework. This will help us acknowledge a higher level of complexity that our patients need to function within.


Breines, E.B. (1989). Making a difference: A premise of occupation and health, American Journal of Occupational Therapy, 43, 51-52.

Chung, J.C.C., Lai, C.K.Y., Chung, P.M.B., French, H.P. (2004). Snoezelen for Dementia (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.

Costa, D.M., Morra, J., Solomon, D., Sabino, M. & Call, K. (2006, March 16). Snoezelen and sensory-based treatment for adults with psychiatric disorders. OT Practice.

Cuvo, A.J., May, M.E., & Post, T.M. (2001). Effects of living room, Snoezelen room, and outdoor activities on stereotypic behavior and engagement by adults with profound mental retardation.
Research in Developmental Disabilities, 22, 183-204.

Dunn, W., Brown, C., & McGuigan, A. (1994). The ecology of human performance: a framework for considering the effect of context. American Journal of Occupational Therapy, 48, 595-607.

Hogg, J., Cavet, J., Lambe, L. & Smeddle, M. (2001) The use of 'Snoezelen' as multisensory stimulation with people with intellectual disabilities: A review of the research. Research in Developmental Disabilities, 22, 353-372.

Vlaskamp, C. de Geeter, K.I. , Huijsmans, L.M. and Smit, I.H. (2003). Passive activities: The effectiveness of multisensory environments on the level of activity of individuals with profound multiple disabilities, Journal of Applied Research in Intellectual Disabilities, 16, 135-143.

Monday, March 13, 2006

Occupational justice? Analysis of Palestinian occupational therapy student access to the West Bank

There is a longstanding lack of access to educational programs for students from the Gaza strip. This issue is very controversial as it is steeped in the regional geopolitical quagmire of the Israeli-Palestinian conflict. Some of the reasons for Israeli control of movement between the occupied territories seem legitimate - from their perspective, people under the age of 35 represent the greatest threat with regard to terrorism. Are the ten occupational therapy students currently in the news likely to have explosive belts under their clothing? I don't know - but this is a topic worthy of discussion - it is a real-life manifestation of the concept of 'occupational justice.'

Occupational justice may not be a term that is well known to all occupational therapists, particularly those in the United States. Wilcock first identified the term, stating that it was an extension of social justice and specifically relating to opportunities or lack of opportunities for normal human occupation. A good summary can be found in the Journal of Occupational Science's Occupational terminology interactive dialogue.

I was saddened at the human story involved, but glad to see a real issue at the very core of occupational justice that could be debated. Too often practitioners hear 'ivory tower' conversations about lofty ideas like 'occupational justice' but don't see where the proponents of these ideas have the opportunity to link theory to practice, or to address the 'real' side of the discussion.

I am not convinced that this debate can take place without addressing the fundamental issues underlying the Israeli-Palestinian conflict - but then I suppose this makes a good test for the concept.

I should start by revealing my own political bias - I am an American, living in a post-9/11 world. Although I dislike the concept of 'profiling' I can see its merits. I don’t think that most people like the idea of racial profiling, but there are some specific realities that we need to identify. It is difficult to justify ignoring the one fact that we know about a majority of the terrorism that occurs in the world against Western interests: most of the perpetrators of this terrorism have been young Middle Eastern Islamic men. Profiling in general tells us certain things about terrorists: Young Middle Eastern Islamic men were involved in most of the PFLP hijackings and the Olympics incident in Munich. Young Middle Eastern Islamic men hijacked the Achille Lauro and dumped Leon Klinghoffer into the ocean. A young Middle Eastern Islamic man masterminded the La Belle disco bombing in Germany. Young Middle Eastern Islamic men blew up a truck in the basement of the World Trade Center. Young Middle Eastern Islamic men blew up an airliner over Lockerbie, Scotland. Young Middle Eastern Islamic men blew up U.S. embassies in Africa. Young Middle Eastern Islamic men blew a hole in the side of the U.S.S. Cole in Yemen. Young Middle Eastern Islamic men hijacked four airliners, and flew them into the Trade Center and Pentagon. This is not an exhaustive list by any means.

The US Constitution is certainly not applicable worldwide, but it is my frame of reference. Terry vs. Ohio in 1968 indicated that 4th amendment rights were not violated when a person was stopped if a law enforcement official had reasonable suspicion that a crime might occur. Profiling only on race would certainly be debatable, but profiling based on a confluence of factors including identification, travel patterns, observed behavior, and other factors does not seem unreasonable to me. This way we wouldn’t miss people like Abdel Rahim (aka Richard Reid), Abdullah al-Muhajir (aka Jose Padilla), and Suleyman al-Faris (aka John Walker Lindh). So even if all the people are not of Middle Eastern descent, all of their associations were – and profiling could have possibly been helpful.

So I think our (US) society has a long record of tolerating profiling in various forms and to varying degrees at different times. In this sense, I understand the Israeli position.

Alternately, there are Palestinan realities that are impossible to ignore. The economy of the Palestinian territories is in shambles. Rising unemployment, multigenerational poverty, and continued restriction on access and travel and commerce in general continues to decimate the social and cultural base of the populace. An interesting United Nations report can be viewed here. It is evident that security, humanitarian, and political issues are inextricably woven together in a way that contributes to the destabilizing forces within the society. Additionally, this negative confluence of factors may be exactly what Israel and the United States wants. I can understand this too, and don't think that Hamas strategies should ever be supported, much less apologized for - despite the tremendous economic oppression that exists. However, on some level, as a moral society we need to address the humanitarian problems that exist.

I don't have answers to this issue. It seems that Palestinians could use some occupational therapists. A lack of productive occupation may certainly be contributing to some of the problems there. I would hope that anyone could support a humanitarian solution to the problem - particularly in the form of more trained health professionals. I believe that they should have access to the West Bank. Some kind of secure humanitarian solution must be possible.

Bethlehem University is listed as a WFOT recognized program. Interesting to note: occupational justice is not mentioned in any of their course descriptions. This is a challenge to the rest of the world occupational therapy community. Do we sit idly by and watch this? Or do we have something to say about it?


Erlanger, S. (2006, February 14). U.S. and Israel are said to talk of Hamas ouster. The New York Times.

Izenberg, D. (2006, March 12). Obligations to Gaza at heart of latest High Court petition. The Jerusalem Post.

Office of the United Nations Special Coordinator (2002, October). The impact of closure and other mobility restrictions on Palestinian productive activities. Retrieved March 13, 2006 from

Wikipedia (2006, February 14). Palestinian economy. Retrieved March 13, 2006 from

Wilcock, A. (1998). An Occupational Perspective of Health, Thorofare, NJ: Slack, Inc.

Wilcock, A.A., & Townsend, E.A. (2000). Occupational terminology interactive dialogue: Occupational justice. Journal of Occupational Science, 7, 84-86.

Friday, March 10, 2006

A new world for Billy

This is a follow-up of another story that you can find here: Billy's World

I was surprised as I read the fax that was printing out the new referral. The school system wanted Billy re-evaluated - which I thought was odd because last I knew he was already enrolled in a preschool program.

The information on the referral indicated that he was now in the custody of his aunt and that she was trying to get him re-enrolled in the preschool program. I called the referral source and stated that I knew Billy and that I looked forward to seeing him again.

My immediate thought as I entered his aunt's home was that it was much cleaner than where he previously lived. The strong odor of cigarette smoke hung in the air and in every corner, so despite the fact that the home was superficially clean I still knew that I would have to de-fumigate myself after the visit. This made me feel badly for Billy, because he has to live in it every day. Still, this in itself is nothing that is reportable - many kids live in homes where the parents are heavy smokers - I just wish that they didn't have to be exposed to it.

Billy's Dad, the apparent source of the smoke, was in the house. He took a long drag on his cigarette and then shook my hand as he exhaled and said, "My sister has custody of Billy now, and I'm just busy trying to stay out of jail." I found it interesting that he described busy-ness as an expression of actively avoiding something. I thought briefly that he spent his whole adult life as busy as possible to avoid taking real responsibility for his son and his life. Rather than express my thoughts, I just remembered to myself that he had epilepsy and had limited cognitive skills as I smiled and said, "Nice to see you, John."

Billy was as happy as I have ever seen him - smiling, interactive, imitative, and very purposeful in his play. Still, he was 36 months old and functioning at an approximate 18 month old level in all areas. John asked, "Is that a problem - is that a lot of delay?" I automatically started to answer that it was a 50% delay in his skill development, but I imagined that the numbers wouldn't make sense so I instead said, "You know, John- there are a lot of things that Billy ought to be doing now that he can't. Things like feeding himself with the spoon, being able to stack blocks, and beginning to tell us when he needs a diaper change." John's eyebrows knitted together in concern, and he seemed to understand. "So he probably needs therapy, huh?" he asked. I was glad that he was conversing and interested, so I told him, "Probably, John. Therapy wouldn't be a bad idea to try to catch him up some." John understood plain talk.

I was a little disappointed that 'the system' didn't take care of Billy. Technically, the change in custody shouldn't have impacted anything, but Billy went several months with no therapy because he 'aged out' of early intervention and he was never referred to the school district. Mom was apparently unable to meet his needs and complete the transitional paperwork, so Billy was only treated like a number that was billed at the end of each month. When the funds dried up, the interest in Billy dried up too. Billy just fell through the cracks until someone thought to re-refer him for services.

Billy seems happy for now though, and he is no longer within line of sight of that bridge and its toll. Instead, he is living in the part of the town that has a large landfill that makes the biggest 'hill' in the city. I am frightened to know what is buried under all that dirt, and I wonder why workers walk those 'hills' in chem suits. When I drive by, I often think that there will never be a shortage of work for me in this city. This is not a good thing.

Some kids can never catch a break, I guess.

Monday, March 06, 2006

Hermeneutic rediscovery of personal context through ego-surfing

The Occupational Therapy Practice Framework (AOTA, 2002) identifies personal contextual factors that support occupational performance. The Framework identifies these factors as “features of the individual that are not part of a health condition or health status.” This definition is directly quoted from the International Classification of Functioning (WHO, p. 17). Unfortunately, although contextual factors are identified in the Framework, the relationship to occupational performance is not clearly stated. So although personal contextual factors are not clearly defined, this Framework represents another step that explicitly identifies contextual factors as being critical to occupational performance.

Several different sources in the post-modern period had a strong influence on the inclusion of personal contextual factors in practice models. New practice models that specifically emphasize these factors are still being developed and refined.

Many concepts from the new discipline of occupational science have emphasized personal contextual factors in occupational therapy. Clark’s Slagle Lecture (1992) introduces the concept of individualized ethnography to elicit personal contextual factors that can guide occupational therapy intervention. Clark expresses that it may not be feasible for clinicians to conduct detailed ethnographies with their patients, but that her case example provided a “thick description” through occupational storytelling and occupational story making.

In unrelated work outside of the occupational therapy profession, Polkinghorne (1988), Frank (1979), and Bruner (1990) were advancing their own ideas about the use of narration to elicit life histories. These differing perspectives were brought together by Clark and ultimately had a significant influence on other researchers (Mattingly, 1998) that have made important contributions to occupational science. The contributions of occupational science are notable for the way that they underscored personal contextual concepts that we already knew, had partially forgotten, but still need to critically apply.

Since Clark’s Slagle lecture there has been a plethora of articles and books that specifically focus on the personal contextual aspects that influence occupational performance. The idea of “personal meaningfulness” (Clark,, 1991) is now frequently mentioned in the occupational therapy literature. Gray (1997) proposed a phenomenological methodology for considering occupations; this in effect is identification that occupation can’t be interpreted separately from the person who is experiencing it, which is at the core of personal contextual meaning. Hasselkus (2002) devoted an entire book to the subject of personal meaning and occupation. Her text provides an in depth study of how occupations must be considered within a personal context.

Some recent practice models explicitly identify the relationship between the individual, the occupation being performed, and the environment. The P-E-O model (Law, Cooper, Strong, Stewart, Rigby, & Letts, 1996) explicitly states that the behavior can’t be separated from its contextual influences. Additionally, this model re-introduced the importance of history-taking for establishing personal contextual relevance for goal setting. Similarly, the Lifestyle Performance Model (Velde & Fidler, 2002) takes a congruent approach by completely embracing phenomenology as being the only possible method for understanding the personal contextual relationships between an individual and the occupations that they engage in.

Anyway, it is high time I make the rubber meet the road here. This was my train of thought (just in case you were wondering how this crazy mind works): I got to thinking about personal context because I saw a BP commercial on 'carbon footprints.' I started thinking about my own footprints in general, and the factors that make me... me. Of course I have a definition of myself, but outside of my own personal conceptualization of the world is the world itself. Certainly the world must have an opinion of me - but what is it? What constitutes my own personal contextual factors, as understood and objectified by the external world?

There are several different ways to get at this question, but I assumed that the easiest and most immediate method would be through ego-surfing. Of course this led to a rather uni-dimensional representation of myself that was centered almost totally around my work occupations.

But how exciting was it to find THIS! Yes, in another lifetime I actually enjoyed computer programming old bulletin board systems. Although I never had any formal training, I taught myself BASIC and C+ which made me dangerous enough to be able to produce add-on command modules for the Atari BBS Express Pro bulletin board system. Although my programming days actually pre-dated the public use of the WWW, my old computer programs apparently made their way onto Internet.

This was exciting stuff (to me, at least). It would be so wonderful to be able to rely on technology to catalogue and track all of our personal contextual factors. Pre-teenagers try to do this now, as evidenced by the plethora of (sometimes dangerous) personal information being left on places like

In the future, what will the role of the Internet be in helping us catalogue and track these factors? Will OTs be able to use this data in assessment and intervention? What kind of permission will we need before we access the information? How interesting is it that what the pre-teen population is now putting on may someday lead to improved intervention planning?

I don't have the answers to this. But I sure was thrilled to re-discover my previous occupations of computer programming.


AOTA. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609-39.

Bruner, J. (1990). Acts of meaning. Cambridge: Harvard University Press.

Clark, F. (1995). Occupation embedded in a real life: Interweaving occupational science and occupational therapy: 1993 Eleanor Clark Slagle Lecture. The American Journal of Occupational Therapy, 47, 1067-1078.

Clark, F.A., Parham, D., Carlson, M.E., Frank, G., Jackson, J., Pierce, D., Wolfe, R.J. & Zemke, R. (1991). Occupational science: Academic innovation in the service of occupational therapy's future. American Journal of Occupational Therapy, 45, 577-85.

Frank, G. (1979). Finding the common denominator: A phenomenological critique of life history method. Ethos, 7(1), 68-93.

Gray, J.M. (1997). Application of the phenomenological method to the concept of occupation. Journal of Occupational Science, 4, 5-17.

Hasselkus, B.R. (2002). The Meaning of Everyday Occupation. Thorofare, NJ: SLACK, Inc.

Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The Person-Environment-Occupation Model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63, 9-23.

Mattingly, C. (1998). Healing Dramas and Clinical Plots. The Narrative Structure of Experience. Cambridge: Cambridge University Press.

Polkinghorne, D. E. (1988). Narrative knowing and the Human Sciences. Albany, New York: State University of New York Press.

Velde, B., & Fidler, G. (2002). Lifestyle Performance: A model for engaging the power of occupation. Thorofare, NJ: SLACK, Inc.

World Health Organization (2001). International classification of functioning, disability, and health (ICF), Geneva, Switzerland: Author.

Thursday, March 02, 2006

The Passion of the Christ: A Kid's Perspective

A fairly standard component of my pediatric occupational therapy evaluations is to ask the child to draw a picture of themselves. This assessment technique provides an opportunity to evaluate the child's skill with writing and also is a functional assessment of their cognitive and perceptual ability.

Sometimes kids draw things that just beg to be probed and questioned - as was the case today. I watched intently as 6 year old Patrick drew a decent representation of himself, but then he began adding odd details to his picture. First he colored dark spots on his figure's hands and feet, and then added a row of X's across the forehead.

I leaned forward and quizically asked, "Patrick, what are these marks here?"

He looked at me for a moment and then responded: "Jesus died for you, you know. He got nailed to a cross, in his hands and his feet. My Dad said that he had to wear prickers on his head and it made him bleed."

"Oh," I replied, not knowing what else to say. I figured he was hearing about the Easter season and the beginning of Lent. "Keep drawing, Patrick," I added. I was curious about what else he would add to his picture.

I wasn't disappointed. Patrick added a few more shapes to his drawing. The first looked like a cross, so I asked him "And what is this?"

Patrick didn't disappoint my curiousity. "It's the cross, Mr. Chris. That is where Jesus died. And this is all the people that wanted him to die, but now they are really sad." He added a few sad faces to the drawing, around the base of the cross.

At this point I wasn't really looking at his drawing ability; I was just interested in how much this very young child knew about the Passion. These are the kinds of things that make boring assessments interesting.

I pointed to the next shape, expecting him to tell me that it was where Jesus was buried, and where he rose from the dead. "Tell me, Patrick, what is this over here?"

Patrick looked at me as if I flew in from another planet, and with a look of disbelief on his face he said, "Mr. Chris... That's a square. Don't you even know that?"

These are the things I learn from the children I work with.