ANATOMY 2110 MENTAL HEALTH ASSESSMENT NOTES TEST 2 QUESTIONS NAD ANSWERS

ANATOMY 2110 MENTAL HEALTH ASSESSMENT NOTES TEST 2 QUESTIONS NAD ANSWERS (Communication & Social Skills) Overview • Key to functional social participation and occupational roles • Includes linguistic ability, emotional regulation, perception of others, social pragmatics, etc. o Verbal (words) o Facial expressions o Sounds (yelling, grunting, etc) • Helps us make social connections with others • Communication relies on a partner o Ways it can go awry: ▪ Lack of clarity ▪ Poor perception of others (body language, tone of voice) ▪ Logical issues • Consequences of poor communication o Rejection o Isolation o Poor performance in occupations o Low mood o Decreased confidence in self • Symptoms of mental illness can impact these abilities o Schizophrenia, ASD, DD, TBI, SUD, personality disorders, dementia Relation to OT Framework • Client Factors o Mental Functions: Higher level cognitive skills, attention, memory, emotion regulation o Voice and Speech Functions: Fluency and rhythm o Examples of issues ▪ Poor Attention à can’t hold a conversation in general, forgetting previous conversations ▪ Working memory à repetition ▪ Decreased processing speed à poor comprehension ▪ Poor planning à vagueness to what they are saying, long winded to getting to point ▪ Abstract thinking à miss sarcasm, jokes, hints (like ending a convo) • Performance Skills o Social Interaction Skills: social pragmatics o Approaches, gesticulates, regulates, questions, takes turns • Context o Personal, social, virtual, etc. o Assistive devices / translators will change the whole interaction Attachment Theory • Development of an emotional connection between infant and caregiver • Infant needs met? à degree of security • Four attachment styles: 1. Secure: Needs met à allows for independence 2. Insecure Avoidant: Needs not met a. Parent is emotional distant / unresponsive à child learns needs will not be met b. With other relationships, individuals will avoid intimacy & be fiercely independent 3. Insecure Resistant/Ambivalent: Unsure a. Parent inconsistently available à child is unsure if needs will be met b. Leads to dependency and/or distrust of future partners 4. Disorganized/Disoriented: Confused a. Parent is abusive b. Leads to inconsistent behaviors + dissociation • Using Attachment Theory o Teaching parenting skills to at-risk parents o Framing child behavior to adoptive parents o Developing coping skills for adult clients with emotion regulation issues Social Cognition Theory • Promotes (cognitive) understanding of the underlying aspects of social interaction (i.e., intentions, disposition, mental states) o Perception of social cues: using facial expressions, tone of voice, gestures, etc. to interpret meaning of information o Theory of mind/mentalizing: recognition of the mental state of others (i.e., beliefs, desires) o Weak central coherence: trouble interpreting the overall intent of content and getting caught up in the details ▪ Common in autism (ex: focusing on letters, and not stringing letters together into words) • Using Social Cognition Theory o Skill development: Increase attention to nonverbal communication so interactions appear inviting o Compensation (external assist): Use a checklist for a particular situation that has consistency Social Learning Theory (Bandura) • Much of learning is accomplished by observing others in context • Use of modeling and feedback to teach appropriate social skills • Desired behavior à natural positive reinforcement (+) à increase likelihood of that behavior • Undesirable behavior à criticism (-) à decrease likelihood of that behavior • Process of social learning o Attention à Retention à Reproduction à Motivation • Using Social Learning Theory o Focusing on components of the process ▪ Attention (focus initially) ▪ Retention (external supports, cue sheets) ▪ Reproduction (role play) ▪ Motivation (positively reinforced) o Social skills training for serious mental illness: ▪ Repetitive practice of social skills so that they become “automatic” ▪ Shape the behavior by starting with simple tasks and progressing to more complex skills ▪ Work towards generalization Group Development Theory • We gain insights into communication by participating in groups as we age (e.g., family, religious, cultural, etc.) • OTs use groups as mediums to practice social skills and communication • OTPF: “Use of distinct knowledge of the dynamics of group and social interaction and leadership techniques to facilitate learning and skill acquisition across the lifespan.” (p. 62) • You can set up group situations where they learn about themselves and others and the communication process Group Process: Group Leadership & Group Dynamics • Settings for OT groups are varied • OT groups focus on ACTIVITES or TASKS and how performance of activity can lead to change • Possible organization of OT groups: o Occupation-focused o Population-focused – ex: at risk youths o Context-focused – ex: support group o Client Factor-focused – ex: development of particular cognitive skill or social skill • Cole’s 7 Steps o Purpose: to enable participation of group members in completing a shared task or activity and to reflect upon the meaning 1. Introduction • Introduce self, title, name of group à “welcome back” • Warm-up: can be a structured activity or casual, such as a conversation • Setting the mood: occurs through an appropriate warm-up activity, presentation of the therapist, and environmental setup • Expectation of the group: therapist sets up expectations with a direct and authoritative manner, serving as a role model for expected behavior • *Explaining the purpose clearly: describing goals and relevance • Brief outline of the session: time frame, media to be used, and procedures for the duration of the group 2. Activity – 1/3 of the time • Client-centered when possible • **Timing: should be no more than 1/3 of the time of the total session • Therapeutic goals: developed prior to developing the activity by assessing clients’ needs and considering their abilities and disabilities • Physical and mental capacities of group members: activity should meet the skill level and abilities of all group members • Knowledge and skill of leader: group leader should be comfortable with activity material • Adaptation of the activity: using knowledge of task analysis, modifications can be made to the activity to meet the group members’ abilities 3. Sharing • Invitation, not a requirement (parameters are set up-front) • Acknowledge and model empathy • Create a low-pressure, welcoming environment 4. Processing – getting at emotional component **Most challenging step to learn and is often skipped by novice leaders • Group members share their feelings about the experience, the leader, and each other • Can help explain behaviors that occurred during the group • Open discussion of group dynamics or group roles 5. Generalizing – more group oriented - broader • Mental review of the group’s responses • Summary of general principles (anticipated and unanticipated) • Tips for determining the general principle: o Look for commonalities amongst the response of members o Look for disagreements amongst members o Look for issues that led to spontaneous conversations amongst the members 6. Application • Personal application of principles to enhance functioning • What is the significance of the group process? • Focus is on how the group content can help improve individual participation in life • May engage group problem-solving • (benign) Self-disclosure by therapist, if a model is needed and won’t detract 7. Summary • Verbally emphasize the most important aspects of the group • Summarize the goals, content, and process of the group • Involve group members, as appropriate • Thank group members for their participation o Additional Considerations ▪ Group Motivation • Confidence in leader: sense of authority, but trusting environment • Encouraging enthusiasm: gauge your group, encourage appropriately • Encouraging interaction ▪ Setting limits: balance between control & leniency • Assuming appropriate authority • Equal time • Limiting inappropriate behavior • Respectful limit setting • Group Leadership o Primary Roles of Leaders 1. Aid the group members in achieving their goals 2. Help maintain the integrity of the group • Leadership style selected will vary with the constitution and goals of the group • Refer to table 1-2, p. 15 of Cole for guidance in selection of appropriate leadership styles o Leadership Styles ▪ Directive leadership: had clients with low cog capabilities – need direction & decision assistance • Frames of reference: cognitive disability model, cognitive-behavioral, sensorimotor • Some groups are just more directive in nature ▪ Facilitative leadership: clients have to have some degree of skill/understanding pertaining to group • Frames of reference: Developmental, psychodynamic, MOHO • Can lead to a lot of group cohesion b/c collaboration o Even with usual group challenges ▪ Advisory leadership: • Use when working with families, caregivers, self-help groups, community organizations (e.g., prevention or self-maintenance programs) • Problem solving, attitude change in participants • Participants shape direction ▪ How do you choose? • Established role + cog processing à advisory • Accomplish specific task à directive • Learning a skill from experience in group à facilitative o Co-Leadership ▪ Advantages • Mutual support • Increased objectivity: leaders can compare observations to fully understand group process • Collective knowledge • Models for each other: different strengths, weaknesses, styles • Different roles (good cop/bad cop?) ▪ Disadvantages • Splitting – may favor one leader over another and can try to play them against each other • Competition between the leaders • Unequal contribution among group leaders o Overworking not giving underworker a chance o Underworker allowing/putting too much burden on overworker ▪ Stages of Co-Leadership 1. Formative stage: co-leaders are focused on their own self-worth as a leader (i.e., worried about inadequacy), resulting in natural competition with other leader 2. Development stage: co-leaders must discuss issues and recognize differences in order to work together effectively 3. Stabilization: therapists work out differences and recognize each other’s strengths and weaknesses, utilizing each for the betterment of the group 4. Refreshment: a relationship between leaders that allows for each to grow in their role • Group Decision-Making 1. Decision by authority – no discussion 2. Decisions by authority – after discussion 3. Expert member leads group decision process 4. Members’ opinions average to make a decision 5. Decisions by a minority of the group 6. Majority rules (51% or 2/3) – democratic decision 7. Total agreement (consensus) o How do you choose? Type of group, insight they have, how familiar they are with each other, etc o Fallacy of a democratic decision • Conflict Resolution o Arguing: ineffective method focused on winning by use of power o Avoiding: ineffective method centered on avoiding the problem in the hopes that it will go away o Compromise: each side gives up some portion of their argument 1. Agree to talk 2. Acknowledge some validity to the others’ argument 3. Communicate the most important points on each side, and acknowledge how each side has given in to some aspects of their initial position • Group Dynamics & Process o Group dynamics:“the forces that influence the interrelationships of members and ultimately affect group outcome” o Group process: ▪ NOT referring to content ▪ Underlying process, including feelings and motives of members that impact group functioning • How they interact with each other • What is happening in the group • How do they accomplish goals o Role of the leader ▪ Need to be watching behaviors of group members, hypothesize reasons for behaviors, help members understand those experiences taking place in the group process o Effectively addressing group process issues takes practice, but remember… the process is what leads to change ▪ Ask yourself, “What does the group really need?” o Yalom’s Therapeutic Factors 1. Interpersonal learning (input): through participation and feedback from group, members learn how they are viewed by others, compare this with their own self-concept, and can become aware of their own negative social behaviors or habits that impact daily life 2. Catharsis: “emotional unburdening”; an individual expresses a strong emotion, which is then examined in the group setting to lead to greater understanding for the individual 3. Group cohesiveness: connectedness of group members and leaders; group solidarity encourages attendance, participation, and mutual support 4. Self-understanding: “discovering and accepting previously unknown or unaccepted parts of the self” (including internalizing previous negative behaviors and discovering new strengths) 5. Interpersonal learning (output): learning how to improve self-expression and get along better with others 6. Existential factors: accepting unfair factors of the human condition, such as the realities of life including pain and death; accepting responsibility for life choices rather than blaming 7. Universality: realization that one is not alone; when group members seek to identify similarities between each other 8. Instillation of hope: believing the group is meant to help 9. Altruism: when group members help each other and subsequently feel an improved sense of well- being 10. Family re-enactment (corrective emotional experiences): when clients break free from unhealthy family roles they have been locked in 11. Imparting information (guidance): when group members offer guidance and suggestions (can be helpful or hurtful depending on the stage of the group) 12. Imitative behaviors (identification): social learning (using others as models, role playing) • Tuckman: Group Development o Predictable stages ▪ Knowing these can help you understand group behaviors, and anticipate challenges that may arise o Group cohesiveness = ultimate desired outcome 1. Forming: members become acquainted with each other and the task; dependence on the leader 2. Storming: Members challenge each other and the leader 3. Norming: Members trust each other and get along to focus on the task 4. Performing: Members work as a cohesive unit; conflicts are resolved à therapeutic change is possible 5. Reforming: Evaluation of what went well or not so well and changes are implemented to improve group functioning o This and the following are just some examples – she wants us to get the gist, probably not the details? • Schutz’s Theory: Group Development o Schutz (1958) – interpersonally focused 1. Inclusion: individual is concerned with being accepted 2. Control: individual is concerned how they are positioned in relation to power and authority a. Can be beneficial for leader to switch from authoritative to facilitative so they can make decisions and work together 3. Affection: conflict in leadership is resolved; members have positive feelings about each other and are emotionally invested in the group o Possibility of regression with changes (membership, schedule, etc) • Group Norms o Reflect expectations for behavior and attitudes o Explicit norms: set by the leader (e.g. punctuality, be respectful, confidentiality) o Implicit norms: not verbalized but are understood (e.g., avoidance of conflict in the beginning stages, do not discuss inappropriate topics) o Shaping norms • Group Roles o Individuals display patterns of behavior within groups à “roles” o Common roles are categorized by function 1. Group Task Roles: help get targeted work done 2. Group Building and Maintenance Roles: supportive roles that keep the group functioning as a unit 3. Individual Roles: benefit the individual rather than the group o People can play different roles within the group - often a reflection of their functioning and interpersonal skills o Stages of development will impact roles played and may shift over time as people/needs change • Group Task Roles – YES, we need to know these 1. Initiator-contributor: comes up with new ideas & new ways to organize 2. Information seeker: seeks clarification of suggestions; fact-focused 3. Opinion seeker: seeks clarification of values 4. Information giver: provides info on facts or generalizations 5. Opinion giver: states opinions 6. Elaborator: provides suggestions, citing examples 7. Coordinator: “clarifies relationships among various ideas” 8. Orienter: “defines position of group with respect to its goals” 9. Evaluator-critic: uses standards to evaluate accomplishments 10. Energizer: encourages the group to act 11. Procedural technician: speeds up group activities by passing out materials, arranging seats, etc. 12. Recorder: writes down ideas, decisions • Group Building and Maintenance Roles – YES, we need to know these 1. Encourager: praises and agrees with others 2. Harmonizer: helps to keep the peace amongst members 3. Compromiser: modifies own position to support the group 4. Gatekeeper and expediter: regulates flow and facilitation of communication 5. Standard-setter: verbalizes ideal standards for the group 6. Group observer and commentator: comments on and interprets group process 7. Follower: passively accepts ideas and goes along with the group • Individual Roles – YES, we need to know these 1. Aggressor: deflates status of others; attacks group or task 2. Blocker: negatively or stubbornly resistant; highly oppositional 3. Recognition-seeker: boasts to call attention to self 4. Self-confessor: uses group as an audience for expressing non-group related interests/ideologies 5. Playboy: lack of involvement through joking or cynicism 6. Dominator: manipulatively monopolizes group and interrupts contributions of others 7. Help-seeker: looks for sympathy from group, sometimes through self-depreciation 8. Special interest pleader: uses stereotypes of social causes to covertly express own biases (ie. Housewife, laborer, homeless, etc) • Managing Challenges in the Group o Leader vs. member input o Good of the group by addressing issues with individuals or as part of the process of the group o Unequal participation: members who take excessive time (monopolist) and those who are passive (silent member) need to be dealt with by the leader ▪ Consider cultural and gender contributions to behavior o Attention-Getting Behavior: ▪ Self-Deprecator: repeated communication de-valuing self or personal work ▪ Help- Rejecting Complainer: seek and then reject help - “yes but” • Increase insight into behavior + model empathy so no rejection ▪ The Narcissist: demand constant attention (are vulnerable to rejection) • Facilitate supportive discussion about listening to others o Psychotic Behavior: ▪ Typically not appropriate for group ▪ Individuals with Borderline Personality Disorder (unless for that disorder as can “destroy a group”) o Group Outing (Girl, Interrupted) ▪ ▪ What roles you see these group members playing. Can you identify any? ▪ Background info: These patients from a mental hospital are on a group outing to get ice cream. This type of group could be a typical OT group. • Identifying Types of Groups o From the AOTA Practice Framework – types of clients: ▪ Groups of individuals • Families • Caregiving teams ▪ Groups of organizations • Existing community groups • Groups of service providers • Nonprofit organizations ▪ Population groups • Examples, such as at-risk youth, people in recovery, wellness and prevention for older adults o From the AOTA Practice Framework – areas of occupation: ▪ Children’s play groups ▪ Education as group focus ▪ Work and volunteering as group focus ▪ Social participation as group focus o From the AOTA Practice Framework – performance skills and client factors ▪ Includes medically-based domains of concern; includes all physical and mental functions related to occupational performance o From the AOTA Practice Framework – groups based on the framework process ▪ Evaluation in groups • Ex: focus groups ▪ Groups as intervention • Therapeutic use of self (occurs in the context of other types of groups) • Therapeutic occupations as the focus • Consultation • Education • Advocacy • OT Intervention Groups o Client-centered Groups ▪ Use of humanistic concepts during group process (ex: respect for the choices individuals make is key to therapist-client interactions) ▪ Facilitate self-expression, identification of strengths and weaknesses, prioritizing problems and setting relevant goals, and examination of environmental impact o Developmental Groups ▪ Highlight the level of functioning of the group (not based on age) • Ex: parallel groups ▪ Simulations of real-life groups that occur across the lifespan o Task-Oriented Groups ▪ Members work together to accomplish a task, and in the process, work on many functional skills ▪ Integrates thinking, feeling, behaving in a structured context ▪ Ex: developing a newsletter for an organization o Functional Groups ▪ Focus is on improved adaptation and health through motivating group action ▪ Activities may include school, work, play, leisure, social participation • Role of OTR & OTA o Reference: • Practice Activity (OT Student Groups) o o o Were all 7 steps of the group process completed? o What was the group leader’s leadership style? o Did the group leader use techniques to foster motivation among group members? o Did the group leader use limit setting techniques? o Did any conflict resolution occur? o Did you observe any group task roles, group building and maintenance roles, or individual roles? o Describe the type of group based on the AOTA practice framework. Communication in Relation to Specific Conditions • Autism Spectrum Disorder o Individuals with ASD appear to have trouble understanding social norms (i.e., reciprocal communication) and social interaction and often have language impairments ▪ Difficulties attending to spoken language, facial expressions ▪ Vocab & rhythm of their speaking can be limited or different ▪ Unusual gaze, limited gesture, limited abstract thinking o Childhood (issues with imitation behavior and play) & Adolescence • Schizophrenia o Social reciprocity and language are typically intact; challenges are with picking up on social cues o Cognitive processing issue • Personality Disorders o Dysfunctional relationships and communication styles are hallmarks of these disorders o Lack of insight into behaviors, limited empathy, rigid thinking patterns, poor emotion regulation • Substance Use o Maintaining relationships that were formally centered on substance use o Using communication skills to develop healthy and trusting relationships o Demonstrating assertiveness with refusing use during recovery • Dementia o Rambling, incoherent speech that does not stay on topic o With progressive decline, individuals may withdraw o Use language less and less (incoherent speech/rambling) Assessments • Assessments of Communication & Interaction Skills (ACIS) o MOHO based (so looking at strengths & weaknesses) o Observation of strengths & weaknesses during occupational performance ▪ 1 on 1 and group interactions o 20 items; 4- point scale rating (child & adult) o Components ▪ Physicality (non-verbal communication) ▪ Information exchange (language skills) ▪ Relations (connecting with others) • Social Profile o Measures level of group participation & observation of behaviors during group activity o 40 items (adult) o 27 items (child) o Components ▪ Group Participation: Parallel, associative, basic cooperative, supportive cooperative, mature ▪ Observations: (a)activity participation, (b) social interaction, (c) group membership and roles • Comprehensive Occupational Therapy Evaluation (COTE) o Observation tool – esp in a group task o Measures occupational performance in the areas of 1. general behaviors 2. interpersonal/communication skills 3. task behaviors o 26-items with rating scale for each item (should have interrater reliability b/c definitions of score) o COTE (adult) o KidCOTE (children) o Skills observed in OT environment: 1. Independence 2. Cooperation 3. Self-assertion 4. Sociability 5. Attention-getting behavior 6. Negative response from others • Children’s Assessment of Participation & Enjoyment (CAPE) and Preferences for Activities of Children (PAC) o Measures exposure to and preferences for out-of-school activities o Helps with planning leisure activities – could include social play (a component of social participation) o Dual package in one booklet ▪ A lot of pictures and diagrams ▪ Ratings ▪ Items (doing puzzles, going to a party, hanging out) à rate on: • Diversity • Intensity • With whom • Where • Enjoyment ▪ Standardized assessment to gather info and inform goal making ▪ Separate score sheets ▪ Social Profile Levels and Rating Guidelines • Level, activity requires, individuals interact, member, roles • NEED TO GET OFF OF ICOLLEGE Interventions • Environment-based interventions and interventions focused on the person • Interventions may address skill development or engagement in social participation • Augmentative and Alternative Communication o AAC = devices or systems that support or replace language (spoken & written) o Low tech (e.g., picture boards) to high tech (e.g., SGD) o Autism, Dementia o Visual supports- use of pictures or text ▪ Examples: Pictures/picture schedules, choice boards, timers, signs, maps, checklists, written instructions ▪ Benefits of visual supports: • Enhance understanding for the child • Make transitions amongst activities easier • Indicate start/stop of activity to increase predictability • Help to understand sequencing of activities • Substitute for verbal instructions to individuals can reach the desired outcome • Help with identification of emotions or moods • Picture Exchange Communication (PECS) o Intent: functional communication (not necessarily verbal speech) o Initially used in preschoolers with autism ▪ Evolved to be used for aphasia, Alzheimer’s disease, brain tumor/ABI, autism, Asperger’s o Conceptual basis: applied behavior analysis ▪ Set up situations that interest the individual to facilitate learning ▪ Teaches individual to initiate communication for a specific outcome o Materials: PECS training manual, communication book with sentence strip, sample pictures o Six phases to PECS protocol 1. How to Communicate: Individual learns to exchange single pictures for an item or an activity he/she desires 2. Distance and Persistence: Generalization of learned skill with different people and in different environments 3. Picture Discrimination: Individual learns to select from two or more pictures to ask for a desired object or activity (PECS communication book holds all pictures) 4. Sentence Structure: Individual learns to create a simple sentence. On a sentence strip (strip of Velcro), individual places the card ”I want” and adds to the sentence his desired object/activity 5. Responsive Requesting: Individuals learn to use PECS to respond to simple questions (E.g., “What do you want?”) 6. Commenting: Individuals learn to comment in response to simple questions and learn to make up simple sentences startling with “I see” or “I feel” etc. o Evidence for PECS ▪ In a systematic review of interventions that target social participation, restricted and repetitive behaviors, play and leisure in individuals with autism, there was strong evidence that PECS is an effective strategy for improving social communication and socialization (Tanner, et. al., 2015) ▪ PECS can facilitate long-term improvement of specific social-communicative skills in children with autism (Lerna, A, et al, 2014) ▪ Videos • Initial training video: • o 2018 Cochrane Review – Communication in minimally verbal children with ASD ▪ 32-82 months old ▪ Two RCT: (1) focused playtime intervention (2) PECS ▪ Overall result, neither intervention led to long-term gains in spoken or non-verbal communication ▪ Both studies with limited quality ▪ • Peer-Mediated Interventions o ”Typical” peers are selected for training o Peers are taught similarities and differences between themselves and the peer that will be supported o Peers are taught strategies and participate in role-play with facilitator (e.g., how to say hello, how to share, asking for help) o Facilitator provides feedback to the trainee in order to support the child in need of social assistance o Mixed results on effectiveness o Ex: Stay Play Talk for preschoolers • Social Skills Training (based on Bandura’s Social Learning Theory) o Observation, modeling, reinforcement, and generalization can facilitate social skills (from social learning theory) o Well-suited for group implementation, but can be done individually o General sequence: 1. Identify the skill: Why is the skill important? 2. Discuss the steps of the skill: What are the component parts? 3. Model the skill in role play: Leaders model 4. Practice the skill: Group members practice through role play 5. Provide positive reinforcement: Tell what the client did well. Group members also help. 6. Provide corrective feedback: Leader focuses on 1-2 key things; group members also help 7. Assign homework: Practice the skill before the next group 8. Review homework: Participants relay specific info; leader provides feedback o Note: Cognitive-Behavioral Social Skills Training – intervention for individuals with schizophrenia (social skills + problem-solving training) • Joint Attention Training o Utilized with Autism Spectrum Disorder o Specific program: Joint Attention in Symbolic Play for Engagement and Regulation (JASP/ER) o Teaching caregivers strategies to facilitate joint attention (shared attention to an activity) ▪ Setting up the environment ▪ Engaging in play ▪ Modeling joint attention and prompting ▪ Encouraging eye contact • Social Stories o Elements of a social story- 1. Descriptive- relays situation and people in the story 2. Perspective- reactions, feelings, responses of others 3. Directive- explains appropriate action 4. Cooperative- describes what others will do to help 5. Affirmative- reinforces cultural values 6. Control- child-generated statement to provide strategies for using appropriate behaviors o Example uses: ▪ Increasing prosocial behavior; improving conflict resolution strategies • PEERS Program o Manualized intervention to train social skills for teenagers with developmental and autism spectrum disorders o • Developmental Groups – separate PPT o Different types of interactions can be facilitated in groups o Clients may be functioning at different levels, so match the group activity to the current client level o Clients gain skills from therapist grading group activities and providing reinforcement for appropriate behaviors o Clients continue to participate in more and more mature groups as they gain skills o Recognize that there are MANY ways to conceptualize development (i.e., social, cognitive, motor, etc.) o Match group activity to dev level o Hierarchy of development of skills à follow natural progression and place people in appropriate groups ▪ As they gain skills, move to more mature groups o Dysfunction & Motivation ▪ Dysfunction/focus for treatment: • Client does not meet developmentally appropriate goals • Causes: skills have never developed (e.g., developmental delay), skills have been lost (e.g., TBI), skills have regressed (e.g., depression or schizophrenia) ▪ Motivation: • Gaining a sense of mastery over a skill ▪ Therapist will likely play a directive role o Mosey’s 5 types of Groups ▪ Parallel group (18-24 mos.): Awareness of others w/little interaction ▪ Project group (2-4 yrs): Interaction focused on a task ▪ Ego-centric cooperative (5-7 yrs): Jointly engaged in task, but participation based on self-interest ▪ Cooperative group (9-12 yrs): Mutual need fulfillment is the goal whereas the task is secondary; group membership is homogeneous; group leader is a consultant ▪ Mature group (15-18 yrs): Both task completion and need fulfillment occurs; heterogeneous group membership; members serve different roles, including leader ▪ Refer to p. 437 in Cole for Mosey’s adaptive skills o Donahue’s 5 levels of social participation ▪ Parallel: focus is task; min interaction ▪ Associative: focus is task; interaction is based on task completion ▪ Basic Cooperative Group: Awareness of group norms; joint interaction; focus is on exploring roles and impact of behavior ▪ Supportive Cooperative: Relationships within a homogeneous group are the focus (relationship is primary) ▪ Mature: Heterogeneous members work comfortably and flexibly as they accomplish a task (task- relationship balance) o Strategies During Developmental Groups ▪ Encourage imitation of the behavior of the leader or other members ▪ Encourage clients to try different behavioral responses in the safety of this group setting ▪ Provide positive feedback for appropriate interactions ▪ Role play different behavioral options o Examples of Different Development Groups ▪ Cognitive skill or sensorimotor skill development for young children ▪ Career exploration for adolescents transitioning to adulthood ▪ Retirement planning for later adulthood ▪ Adapting to loss of a loved one ▪ Note that clients are assigned to groups based on developmental level/stage, not just by age • Sample Goals for Social Skills o Using appropriate greetings o Asking someone for help o Increasing social initiations o Taking turns in conversation o Using good manners o Dealing appropriately with irritating behavior of others o Engage in conversational topics that are appropriate to specific peer groups o Use appropriate volume in your voice o Note there are MANY pediatric-focused interventions since social participation is a major developmental goal for children and adolescents Sensorimotor Approaches for Groups Related Frames of Reference • Approaches that relate to perceptual, cognitive, motor, and sensorimotor challenges (developmental or acquired in nature) – including individuals with mental health issues o Trombly’s Occupation Functioning Model – motivating activities as both means and ends ▪ Build self-esteem and competency in client o Task-oriented approach – used a lot with stroke, o Motor learning theory – general, neurorehab o Carr & Shepherd’s Motor Relearning and traditional motor control theories ▪ Therapist provides graded feedback o Ayres’s Sensory Integration o Sensory modulation approaches Function & Dysfunction • Function: ability to learn and use all adaptive skills, as appropriate to developmental age • Dysfunction o Functioning below developmentally appropriate level (due to physiological/neurological issues – mental illness included as a source) o Adults – cannot participate or perform daily activities o Children – limited in participation, education, play Intervention (from sensory stimulation) • Physical activity à Change in muscle tone, strength, ROM and brain chemistry • CNS changes result from o Sensory stimulation o Repetitive movements • Clients benefit from performing tasks (with adaptive strategies) across contexts and with feedback from the therapist to develop (adapted) movement patterns and process skills • Observable changes – self-correction with body posture, attention to the environment, and later, the ability to build on skills for participation in functional activity (so preparatory in nature) Groups • Typically use games and movement • Goals/Intent o Use sensory stimulation à facilitate an adaptive response and strengthen sensory integration o Promote purposeful movement à improve/maintain muscle tone, posture, motor planning o Promote cognition and affect à enhance participation/motivation for activity; facilitate higher level cognitive skills o Incorporate real tasks and activities • Group Leadership o Leadership – Directive ▪ Clients often imitate therapist ▪ OT considers physical, cognitive, and sensory aspects of activity that should be targeted o Steps ▪ Introduction • Depth depends on cognitive level of the members • Usually light in nature in order to test the members’ response to increasing sensory stimulation or physical activity ▪ Activity • Address neurologic or physical functioning • Timing depends on endurance and attention span of participants ▪ Sharing and Processing • Verbal expression about feelings related to participation in group; clients may observe movements of others ▪ Generalizing and Application • Discussion of the effects of the activities on the body (e.g., emotional, physical response) • Examples • For lower levels, application may be initiation of spontaneous movement or laughter; demonstration of an adaptive response o Parachute game o Dancing ▪ ROM Dance Program for adults with rheumatoid arthritis ▪ o Sensorimotor techniques to cope with anger, anxiety, etc. ▪ Punching pillows, wrapping in blankets, walking, o Task-oriented groups for UE function ▪ Breakfast group: clients with UE non-use eat breakfast together o Movement/exercise groups – use music to match mood/intent of group Tourette’s Syndrome Front of the Class (Movie) Diagnostic Criteria • Have 2 or more motor tics (eye blinking, facial grimacing, head bobbing, shoulder shrugging) • Have 1 or more vocal tic (sniffing, throat clearing, grunting, shouting, coprolalia) • Recurrent tics for at least a year and onset is before age 18 Onset: 2 • Age 2 yrs old • Severity peak at age 9 • Get better/decrease in adulthood (most of the time) Treatment • Exercise and quiet hobbies make tics in kids better • Impact on occupational performance o Education: more likely to have an IEP, school “problems”, HW completion o Health: ↑↓chronic comorbidities o Social: ↓ social competence, ↑ behavioral problems, ↓ social skills IRL things from the movie • Stigma – issues getting jobs, taking tests, leisure, peer rejection • Supportive factors: high degree of education, ADA, resilience • Inhibiting factors: bullying, low confidence in romantic relationships Parachute Activity Very fun • Mushroom • Waves (quick) • Small balls (popcorn) • Big ball (keep out of middle) • Pairs run under • Grabbing the shoe from under • Sitting under • Processing After • Motor o Fine motor with different grasps o Gross motor, mostly UE • Participation o Most people participated, but maybe not enough • Social Interaction o Some groups were disorganized, could have coordinated better o Lots of noise • Frame of Reference? • Application o Can be used with many different populations o Building teamwork o Building inclusion in a group o Everyone wins Vineland-3 à Vineland Adaptive Behavior Scales • 4 assessments total • Caregiver • Teacher • Two interview forms o Domain level interview form (multiple domains) ▪ Communications ▪ Daily living ▪ Socializations ▪ Motor skills ▪ Maladaptive o Comprehensive interview form ▪ Domain (multiple) & subdomain level (multiple) Uses: • Differentiating Cognitive Ability from Adaptive Function • Cognitive Ability - knowledge of something o Changes with age – what you are expected to do at that age o Cognitive ability is generally defined as an individual’s repertoire of skills/knowledge that are either innate or acquired • Adaptive o application or practice of it o Something you can learn – can be modified o What you actually do (related to cog and social abilities) o Adaptive behavior is generally defined as performance of skills that are necessary for person and social sufficiency • 3+ to 90 years of age – irregardless of population • Domain level caregiver (or teacher) form • Compare where they are having difficulty with chronological age expectations & mental-age expectations (i.e. IQ) • Whatever intervention plan/goal – make sure it translates to the real world Bailey • Good alongside with vineland • Not an interview - you play with child and - identify if the child has learned these skills • Looking at developmental milestones more than adaptive behavior COGNITIVE AND SENSORY APPROACHES & ALLEN COGNITIVE DISABILITIES MODEL Cognitive Disabilities Model (Claudia Allen) • Theory development began in early 1970’s à Claudia Allen is one of the originators of the model • Theory was developed by observing similar behavior patterns in individuals in inpatient psychiatric facilities as they participated in ADLs, IADLs, and leisure activities o Common components of behavior à formulate different levels of cognitive functioning o How can you intervene, based on the person’s level? • Core concept = Functional behavior is a product of cognitive processing, so thought processes must change for individuals to demonstrate more functional behavior o Allen believed impairments were related to biological and chemical problems in the brain, such as: ▪ Injury / illness ▪ Change in activity level ▪ Change in hormones ▪ Diet ▪ Medications o Many individuals will plateau with recovery of function à levels provide info for safe discharge • An OT using this model will enable highest level of functioning by making recommendations about (1) level of assistance needed from caregivers (both physical and cognitive) and (2) environmental setup/adaptation Using Allen Cognitive Disabilities Model • Individuals with serious cognitive issues are assessed and then participate in activities that match their current level of cognitive functioning so that they have a successful outcome; remediation (nor alteration) is not the goal o Meet client where they are at currently • Assessment and intervention are simultaneously occurring during group activities • Appropriate for both acute and chronic conditions Interventions: Overview • Overarching theme is to adapt the environment or the task o Manipulate the physical space (e.g., location, supplies available, etc.) o Manipulate the social context (e.g., provide more or less cueing) o Manipulate the demands of the task (i.e., task analysis for type of activity undertaken) • Desired outcome is to capitalize on the client’s current strengths to enable functioning Planning Intervention • Cognitive level is determined by use of Allen Cognitive Level Screen (ACLS) and then confirmed with Allen Diagnostic Modules (craft projects), Routine Task Inventory (ADL), or Cognitive Performance Test (ADL) o ADM rationale: cognitive processing required to complete crafts is assumed to be similar to processing needed for daily activities ▪ Span different cognitive levels à craft is a reflection of processing level • Group activities for clients with common levels are designed at the “just-right” challenge by adapting materials, level of assistance, and the demands of the activity (i.e., adaptation of task and environment) Allen’s Task Analysis • Activities are analyzed for the following characteristics to correlate to each level of functioning o Cues (Environment): include materials and instructions ▪ Type of cues given will dictate successfulness for an individual • Some levels will be correlated with provision of a verbal cue; another level is going to be correlated with provision of visual cue, or tactile cue • Match to levels o Attention to cues: varied by altering placement of materials and amount/type of feedback provided ▪ Some individuals will only reach out for materials that are in their visual field, but some may respond to those across the table, but will need to ask people around them (indicating a certain level) ▪ Some people will not expect other tools they can’t see, others will think to look places they can’t see o Action: the performance of functional activity (problem-solving is a key component) – therapists observe for this processing during participation in activity – specific guidelines are provided by the model o Speed: speed of response (levels 2-4 usually have problems) Intervention Focus • Assistance during therapy is allowed and encouraged to promote success • Ways to provide cognitive assistance: o Facilitate: Provide appropriate sensory cues o Probe: Ask questions to encourage client problem-solving o Observe: Allow time for the client to problem-solve and respond to cues o Rescue: Provide direct assistance (e.g., doing a step) when client becomes frustrated • The purpose of these graded cues is to promote functional performance by the client o Ex: Goal of UB dressing: At level 3, hand over the shirt and touch the hand to be threaded, follow-up with probing questions, observe response, if not successful increase support with more cues, finally thread arm if continued difficulties • Environment must be setup for functional task at hand and match clients abilities o i.e., decreased clutter, availability of supplies, lighting, seating, steps and instructions • When cognitive level is considered stable (after acute illness) or deemed progressive in nature, environmental adaptation and family training are recommended to promote highest level of functioning • Interventions are not directed at cognitive skill training, but serve as a way for therapists and clients to determine the most appropriate environmental and task setup to promote the highest level of functioning in the client • Interventions can be conceived as ongoing assessment opportunities o Environmental Setup • Level 1: Body (Remember person is total assist/dependent) • Level 2: ROM à uses movement functionally, but would not initiate reach (e.g., uses an object placed in the hand) • Level 3: Arm’s reach • Level 4: Can widen environment to visual field • Level 5: Task environment (i.e., outside visual field but in contextual environment) • Level 6: Potential task environment (e.g., shopping for IADLs) Six Cognitive Levels • Cognitive factors that impact functional performance o Attention: degree of response to sensory cues (e.g., body position, vision, touch) o Motor Actions: motor actions and verbalizations displayed during task performance that indicate perception and understanding o Conscious Awareness: awareness of surroundings that elicit actions • Six cognitive levels with sublevels • • • • • Level 1 – Automatic Actions o Bedridden o Respond primarily to cues coming from the body (e.g., pain or hunger) o Behavior is reflexive; dependent for care o OT role: provide sensory stimulation in attempt to get a response • Level 2 – Postural Actions o Proprioceptive cues promote postural changes in the individual o Able to imitate gross motor skills; can help with ADL but require 24 hour care o Lowest level at which individuals could participate in a group intervention ▪ Imitating positions in movement based groups o Differentiating level 2 from 3 à if a person can imitate you clapping 3 times (level 3) • Level 3 – Manual Actions o First level at which group interaction is anticipated o Clients move their hands to manipulate objects in response to tactile cues o Place objects within arm’s reach o Attention up to 30 minutes o Functional abilities might include: routing to familiar places, basic ADL with reminders, repetitive tasks, can repeat multi-step task with demo of each step o Safety issues: May use tools inappropriately or engage in dangerous behaviors because they do not necessarily relate objects to their functional use à supervise use of potentially harmful objects and repeat usage of these objects for increased familiarity ▪ Note that tools that are an extension of the hand (e.g., fork) are typically safe • Level 4 – Goal-Directed Actions o Actions are goal-directed and purposeful (previous levels include habitual or random actions) o Able to complete familiar ADLs and some simple IADL independently, but still need assistance for more complex tasks (ex. Managing money); can reproduce a concrete sample product o Respond to visual cues (note: checklists won’t work – they don’t follow written or verbal directions) o Attention up to 1 hour o New routines are created as a consequence of “drilling” and imitation of short sequences o Are able to ask for help because they have awareness of the goal at hand** o Safety issues: Related to more abstract qualities of objects (e.g., recognizing that flammable objects placed near a grill top may catch fire) o No hard and fast lines that say who is safe, but: ▪ Can live alone at level 4.6 (per Levy and Burns) – may be appropriate level, but would still need support for more complex skills • Level 5 – Overview o Use trial-and-error and can learn new information o Can remember multi-step sequence and can respond to choices o Problem areas relate to planning and anticipation, so long-term consequences are not often considered ▪ Ex: Difficulties related to sensible money management; grocery shopping in prep for meals o Interventions might focus on social skills and increasing insight with help to avoid problematic consequences of actions/inactions • Level 6 – Overview o “Normal functioning” o Can plan and anticipate consequences o No demonstrations are needed; can follow verbal and written directions o Although we would typically fall in this category, note that our level fluctuates throughout the day based on our engagement in activities – some activities require higher cognitive processing than others Allen Cognitive Level Screen-5 (ACLS-5) • Screen that tests individuals’ ability to complete three leather-lacing stitches • Three versions: o standard version o disposable version o version which can accommodate both visual and hand function impairments • Population: Adolescents and adults with psychiatric conditions, dementia, TBI, CVA • Purpose: o Just a screen – correlates to level, but then you have to verify with other assessments o Not a diagnostic tool, but measures functional cognition (and ability to learn) ▪ global cognitive functioning ▪ ability to learn ▪ functional performance abilities o Other Pertinent Assessments that can be used to verify ▪ Cognitive level determined by everyday occupations • Routine Task Inventory • Cognitive Performance Test (refer to peer summary provided in OT7120) ▪ Observation of individual during standardized craft activities • Allen Diagnostic Module (ADM) o Utilizes dynamic approach à watching clients response to stimuli o Appropriate for individuals Level 3 or above • Administration: o OTs/healthcare professionals experienced with standardized testing and who have knowledge of this model and experience working with individuals with cognitive disorders ▪ Three leather-lacing tasks that increase in complexity • Running stitch à whipstitch è single cordovan stitch • Required skills match corresponding Allen Cognitive Level ▪ Person is requested to complete all 3 types of stitches even if they fail to complete less complex ones • Measurement of success: ability to complete 3 stitches o Indicating client can respond to: ▪ Sensory cues from the leather, lace, and needle ▪ Verbal and visual demo by the administrator ▪ Personal feedback as the client uses motor skills o • Stitches 1. Running Stitch • No evaluative component or request to correct errors • Client primarily follows a demo • Correlates to Level 3 à person focuses on action, not outcomes or analysis of performance 2. Whipstitch • Client requesting to make a comparative analysis between his and administrator’s • Two errors: reverse an action and modify an action • Correlates to Level 4 à awareness of short-term goals, use of visual cues for simple problem- solving, awareness of verbalized standards 3. Single Cordovan Stitch • Client is expected to initiate comparison to sample, demonstrating self-directed learning • Requires attention to complex cues and visuospatial skills • Problem-solving is expected; administrator can give one verbal cue and repeat demo • Correlates to Level 5 à respond to complex visual cues, use of inductive or deductive reasoning Brief Scoring Summary • Level 3: completion of at least two running stitches • Level 4: completion of at least two whip stitches, without twisting lace – no new learning o Correlates with repetitive ADL • Level 5: completion of cordovan stitch using trial-and-error • Level 6: corrects an error using deductive reasoning – can solve new problems with objects • Tables provided that include proposed cognitive level, rating criteria (observed behaviors), frequently observed behaviors (not required), proposed performance abilities • Leading Allen Groups • Directive in approach • Selects tasks or limits options available so options are appropriate • Skilled in task analysis, controlling environment, instructing appropriately • Group size of 8 (or 12 if 2 staff- OT or OTA) Allen Groups • Level 2 o Movement groups focused on gross motor skills o Simple games (e.g., ball toss) may be possible o Barriers: clients do not respond to verbal redirection if disruptive, so use demonstration/modeling • Level 3 o Activities focused on manipulation and repetition o Clients challenged by starting and stopping steps of a project o Therapist structures activity in steps to keep clients progressing with the activity • Level 4 ▪ Ex: stuffing envelopes, packing supplies, stringing beads, crafts requiring repetitive action o Craft projects lend to problem-solving (e.g., tile trivets, Indian key fobs, ribbon cards) o Items can be more distantly placed within the visual field, but keep only pertinent items in view o Clients will not search for items that are not in plain view (in the home, clothes would need to be laid out in preparation for dressing) o Food preparation should not involve heating or cooling (safety) o “What do I do now?’; need help with processes that are not visible (e.g., when is a painted object dry?) o Demo needs to be provided along with verbal instruction • Level 5 o More complex tasks are offered with a focus on safety and organization/planning (e.g., sewing clothes, iron- on decals, grilling, hiking, fishing) o Require demo of safe tool use Videos on • Simulated ACLS-5/LACLS-5 Administration (11:22 min) o She asked if she has ever sewn before o Very straightforward o ACLS – screen o LACLS – “large” • Inserting whip stitch errors (3:22 min) o • ACLS set up (13:26 min) or LACLS-5 set up (13:06 min) o • Bargello Bookmark Assessment - How to make samples A and B (19:24 min) • Three components: o ACLS-5 à screening ▪ Original tool, most well known o ADM à ▪ Have table with list of assessment (activities) ▪ Choose a follow up diagnostic activity to follow the screener based on the screener score o RTI à Group Protocol • Group protocol à detailed outline of a group o Research shows the importance of careful design for improved outcomes Identifying your population • Setting (e.g., skilled nursing facility, school system, support group, hippotherapy, inpatient psych, supported employment, etc.) • Population definition – the population that would most benefit from this level of care o In practice, a needs assessment would be ideal for defining a population o Ideas for your community practice sites? ▪ Promoting a change in lifestyle? ▪ Changing knowledge, skills, behaviors, or attitudes? ▪ Maintaining improved health and wellness? • Context – for the group intervention o Admission/eligibility requirements o Length of stay o Typical services offered o Funding issues o What is OTs role? Needs Assessment • Gather background data: through a review of the organization in which you will be working; research your population • Identify participants for a survey: potential participants for your group • Written survey: no more than one page survey with both open-ended and closed-ended questions o Face-to-face interviews o Telephone interviews o Use key informants: selecting a few people to survey or interview who would be most helpful o Focus group (of potential participants) • Use secondary data (i.e. – archives, prior surveys, and reports with data regarding your population) • Analyze the data and summarize the information to help plan the group o Look at survey/interview responses o Highlight level of interest that respondents provided for “marketing” the group later • Write a profile of the “typical” participant o Gender, age, educational and cultural factors, diversity, family background o Client factors o Define inclusion and exclusion criteria Selecting a Model and/or FOR What will most likely work best with your population? • View of function and dysfunction: what model or FOR best describe the function-dysfunction continuum of your clients? • Client physical and cognitive level of function • Change strategies: what changes do your clients need to make? What model or FOR most aligns with anticipated process for change in clients? • View of motivation: which FOR or model best describes how the clients could be motivated? • Intervention time frame: length of sessions and how many days/weeks • Intervention options: activity selection for your groups that would best interest your clients Select a focus for intervention • Use AOTA Practice Framework as a guide o Domains of occupations: ADLs, IADLs, rest and sleep, education, work, play, leisure, social participation o Performance skills (e.g., sensory-perceptual, emotional regulation) o Performance patterns (e.g., habits, roles) o Contexts (e.g., cultural, physical, spiritual) o Activity demands (e.g., sequencing, space demands) o Client factors (e.g., body functions, values) • Intervention Approaches: 1. Create, promote (health promotion) 2. Establish, restore (remediation, restoration) 3. Maintain 4. Modify (compensation, adaptation) 5. Prevent (disability prevention) Components of a Group Intervention • Group title • Author • Frame of reference • Purpose • Group membership and size • Group goals and rationale • Outcome criteria • Method • Time and place of meeting • Supplies and cost • References Writing a Group Intervention Outline • Group title: important and gives the first impression; should reflect the content and goals while attracting interest (i.e. – “Re-entering your kitchen” (a group for postoperative cardiac clients) • Author: name and professional title • Frame of reference: name of FOR or model and why you chose it • Purpose: general goals & nature of activities • Group membership and size: o Describe characteristics of the group (include inclusionary/exclusionary criteria) o Generally not cost-effective for less than three and not effective for groups greater than eight o You will plan a closed group (vs. open) • Group goals and rationale: o no less than three and no more than eight o ideally, there is one goal per individual session planned o goals should be measurable o Good words to use: define, discuss, report, demonstrate o Vague words: understand, learn, develop, attend, participate o Include limitations of the group & precautions under rationale • Outcome criteria: should have a direct relationship to the client goals, however they also need to relate to occupational engagement and participation. o Example: “The client will demonstrate interpersonal skills by verbal participation at least three times in each weekly session.” • Methods: an outline of how you will lead and structure your group is described here (i.e. – structured discussions) and the type of leadership should reflect your FOR or model • Time and place of meeting: should also include characteristics of the setting such as size of room, lighting, noise factors, accessibility of medical assistance, safety factors, etc. • Supplies and cost • References: APA format Planning Individual Sessions • Session: #1-6 • Group title • Session title • Format (time sequence) o i.e. – 10 minutes introduction; 15 minutes activity • Supplies • Description: step by step description of what will be included Family Systems Theory Family systems Framework • What a family is: o US census à two or more people who are related by birth, marriage, or adoption who reside together o Our view à two or more people who regard themselves as family and who carry out the functions families typically perform ▪ May or may not be related by blood or marriage ▪ May or may not live together • Assumptions of the Family Systems Framework o Boundaries ▪ Families vary in the degree to which they are closed/open to non-members ▪ Within a family à define members roles across subsystems o Wholeness/subsystems ▪ Family system must be understood as a whole entity – not component parts or one member ▪ Families consist of subsystems (marital, parental, sibling, extended) • Child with disability may have a negative, positive, or mixed impact on each of these subsystems • Family Characteristics o Family size and form: # of children, # of parents, presence of step parents, # family members unrelated by blood or marriage, extended family (think about blended families) o Interrelated variables: ▪ Geographic location: it can refer to where the individual/family is from, or it can refer to infrastructure • rural vs urban à advantages/disadvantages ▪ Socioeconomic status: odds that child will receive special ed services is 1.5x greater for children in poverty • Vulnerable families • Although parents from low SES may find it difficult to engage in child’s services or education, there could be other families of similar status who are highly motivated ▪ Cultural background: foundation values and beliefs that set the standard on how people perceive, interpret, and interact with their environment • Microcultures • Cultural values (different than c. identity) – the way in which a family envisions or participates in service partnership (including with you as the therapist) • Immigration status • Limited English proficiency o Characteristics of individual family ▪ Each family member (an individual can serve/strengthen/impact/limit entire family) ▪ Communication style ▪ Motivation o Variables Impacting a Family’s Response to Disability ▪ Extend and age of onset of disability ▪ Nature of disability ▪ Severity ▪ Time it was discovered o Life Management Skills – techniques people use to solve their problem ▪ Reframing, passive appraisals ▪ Social or professional support o Unique Circumstances – can change throughout the lifetime ▪ Parents with disabilities ▪ Teenage parents Family Interaction • Family Subsystems (4) – disability can have pos, neg, or neutral affect on each of these o Marital – many factors provide input to this subsystem o Parental – each member of parental unit has different strengths and different needs o Sibling o Extended family • Rules of interaction: o (Degrees of) Cohesion: close emotional bonding with each other and to the level of independence they feel within the family system ▪ High disengagement vs high enmeshment – exists over continuum ▪ Highly enmeshed à blurring of family subsystems ▪ High disengagement à limited amount of interaction & emotional support o (Degrees of) Adaptability: family’s ability to change in response to situational and developmental stress ▪ Adaptability exists across a continuum ▪ Low control & structure vs High control & structure • High control à hierarchy an