Occupational therapy practice guidelines for mental health promotion, prevention, and intervention for children and youth.
General
Guideline Title
Occupational therapy practice guidelines for mental health promotion, prevention, and intervention for children and youth.
Bibliographic Source(s)
- Bazyk S, Arbesman M. Occupational therapy practice guidelines for mental health promotion, prevention, and intervention for children and youth. Bethesda (MD): American Occupational Therapy Association, Inc. (AOTA); 2013. 171 p. [315 references]
Guideline Status
This is the current release of the guideline.
Recommendations
Major Recommendations
Note from the National Guideline Clearinghouse: In addition to the evidence-based recommendations below, the guideline includes extensive information on the evaluation process and intervention strategies at each tier.
Definitions for the strength of recommendations ( A–D, I ) and levels of evidence ( I–V ) are provided at the end of the “Major Recommendations” field.
Recommendations for Occupational Therapy Interventions for Mental Health Promotion, Prevention, and Intervention for Children and Youth
| Recommended* | No Recommendation | Not Recommended | |
|---|---|---|---|
| Tier I | |||
| Social Skills Interventions | |||
|
|||
| Health Promotion | |||
|
|
||
| Play/Recreation/Leisure | |||
|
|
||
| Tier II | |||
| Social Skills | |||
|
|||
| Health Promotion | |||
|
|||
| Play/Recreation/Leisure | |||
|
|||
| Tier III | |||
| Social Skills | |||
|
|||
| Play/Recreation/Leisure | |||
|
|||
*The terminology used for the recommendations was language used in the article(s) from which the evidence was derived.
**Note : Criteria for levels of evidence are based on the standard language from the Agency for Healthcare Research and Quality (2009). Suggested recommendations are based on the available evidence and content experts’ clinical expertise regarding the value of using the intervention in practice.
Definitions:
Strength of Recommendations
A –There is strong evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. Good evidence was found that the intervention improves important outcomes and concludes that benefits substantially outweigh harm.
B –There is moderate evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. At least fair evidence was found that the intervention improves important outcomes and concludes that benefits outweigh harm.
C –There is weak evidence that the intervention can improve outcomes, and the balance of the benefits and harms may result either in a recommendation that occupational therapy practitioners routinely provide the intervention to eligible clients or in no recommendation as the balance of the benefits and harm is too close to justify a general recommendation.
D –Recommend that occupational therapy practitioners do not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harm outweighs benefits.
I –Insufficient evidence to determine whether or not occupational therapy practitioners should be routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harm cannot be determined.
Levels of Evidence for Occupational Therapy Outcomes Research
| Evidence Level | Definitions |
|---|---|
| I | Systematic reviews, meta-analyses, randomized controlled trials |
| II | Two groups, nonrandomized studies (e.g., cohort, case control) |
| III | One group, nonrandomized (e.g., before and after, pretest and posttest) |
| IV | Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series) |
| V | Case reports and expert opinion that include narrative literature reviews and consensus statements |
Note: Adapted from “Evidence-based medicine: What it is and what it isn’t.” D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British Medical Journal, 312, pp. 71-72. Copyright © 1996 by the British Medical Association. Adapted with permission.
Clinical Algorithm(s)
None provided
Scope
Disease/Condition(s)
- Positive mental health and well-being
- Mental health disorders or behavioral problems
Guideline Category
- Counseling
- Evaluation
- Management
- Prevention
- Rehabilitation
- Risk Assessment
- Screening
- Treatment
Clinical Specialty
- Family Practice
- Neurology
- Pediatrics
- Physical Medicine and Rehabilitation
- Preventive Medicine
- Psychiatry
- Psychology
Intended Users
- Advanced Practice Nurses
- Allied Health Personnel
- Health Care Providers
- Health Plans
- Managed Care Organizations
- Nurses
- Occupational Therapists
- Patients
- Physical Therapists
- Physician Assistants
- Physicians
- Psychologists/Non-physician Behavioral Health Clinicians
- Public Health Departments
- Social Workers
- Students
- Utilization Management
Guideline Objective(s)
- To define the occupational therapy domain and process and interventions that occur within the boundaries of acceptable practice
- To help occupational therapists and occupational therapy assistants, as well as the individuals who manage, reimburse, or set policy regarding occupational therapy services, understand the contribution of occupational therapy in promoting mental health for children and youth ages 3 to 21
- To serve as a reference for teachers and other related services personnel, school principals and administrators, health care professionals, health care facility managers, education and health care regulators, third-party payers, and managed care organizations
- To present a public health model to envision and guide occupational therapy services in the promotion of mental health and prevention and intervention of mental ill health for school, community, and health care settings
Target Population
Children and youth ages 3 to 21 years, including children and youth with or without mental health or behavioral problems
Note : The occupational therapy process described in the original guideline document clearly differentiates service provision for three different tiers specific to evaluation and intervention:
- Tier 1: Universal Mental Health Promotion and Prevention Services – Services at this level are geared toward the entire population, including children and youth with or without mental health or behavioral problems, as well as with other disabilities and illnesses. At the universal level, the occupational therapy process focuses less on direct, individualized care and more on indirect services geared toward groups of children and youth.
- Tier 2: Targeted Mental Health Services – Targeted interventions are designed to support children and youth who have learning, emotional, or life experiences that place them at risk of engaging in problematic behavior and/or developing mental health challenges.
- Tier 3: Intensive Mental Health Services – Intensive individualized services are provided for children and youth with identified mental, emotional, or behavioral disorders that limit participation in needed and desired areas of occupational performance.
Interventions and Practices Considered
- Evaluation for needed services at each tier
- Universal mental health promotion and prevention services (tier 1) * Universal social skills programs * Universal health promotion programs * Universal play/recreation/leisure programs
- Targeted mental health services (tier 2) * Targeted social skills interventions * Targeted health promotion interventions * Targeted play/recreation/leisure interventions
- Intensive mental health services (tier 3) * Intensive social skills programs * Intensive play/recreation/leisure programs
Major Outcomes Considered
Effectiveness of activity-based occupational therapy interventions for mental health promotion, prevention and intervention:
- Peer and social interaction
- Compliance with adult directives and social rules and norms
- Participation in productive and task-focused behavior
Methodology
Methods Used to Collect/Select the Evidence
- Hand-searches of Published Literature (Primary Sources)
- Hand-searches of Published Literature (Secondary Sources)
- Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
The following focused question was included in the review:
- What is the effectiveness of activity-based interventions for mental health promotion, prevention and intervention with children and youth? The interventions include those focused on peer and social interaction; compliance with adult directives and social rules and norms; and participation in productive and task-focused behavior.
To conduct the evidence-based literature review, reviewers evaluated research studies published in the peer-reviewed scientific literature according to their quality (scientific rigor and lack of bias) and levels of evidence. The evidence-based reviews incorporated into the American Occupational Therapy Association, Inc. (AOTA) Practice Guidelines consist of a review and ranking of the literature relevant to occupational therapy interventions published since 1980 used to treat a variety of clinical conditions. An initial review covered articles published between 1980 and 2002. An updated review included articles published between 2003 and 2009. In addition, more recent articles covering the period 2010 to 2012 were included on the basis of recommendations from content experts in the field. Specific inclusion criteria were as follows:
- The article was published either in a peer-reviewed journal or in a peer-reviewed evidence-based review since 1980 in the English language.
- The age range of study participants was 3 to 21 years.
- The intervention described in each study was embedded in activities and within the domain of occupational therapy, although it did not have to be a common occupational therapy intervention or administered by an occupational therapist or an occupational therapy assistant.
- The outcomes measured in the study included social or peer interactions or compliance with adult directives or social rules and norms.
- Level I, II, and III evidence (see the “Rating Scheme for the Strength of the Evidence” field).
Exclusion criteria were the following:
- Presentations and conference proceedings
- Non–peer-reviewed literature
- Dissertations and theses
- Study did not include an activity-based component
- Study was outside the scope of occupational therapy practice
- Level IV and V evidence
Reviewers and AOTA staff first identified search terms, and these were reviewed by the advisory group. The search terms were developed not only to capture pertinent articles but also to make sure that the terms relevant to the specific thesaurus of each database were included. Table B.2 in the original guideline document lists the search terms related to populations and interventions included in each systematic review. For the updated review, additional search terms were added to reflect changes in terminology that had taken place since the earlier review. Search terms for the updated reviews were developed by the consultant to the AOTA Evidence-Based Practice Project and AOTA staff in consultation with the author of the questions and were reviewed by the advisory group. A medical research librarian with experience in completing systematic review searches conducted all updated searches.
The following sources were searched:
- Bibliographic databases (MEDLINE, ERIC, EMBASE, PsycINFO; OTseeker was included in the updated review)
- Consolidated information sources (e.g., evidence-based medicine reviews, including the Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Register, and the Database of Abstracts of Reviews of Effectiveness)
The AOTA consultant completed the initial review of the database results. The updated review was completed by an academic partnership of Susan Nochajski and master’s students in occupational therapy at the University at Buffalo, State University of New York. The team of reviewers also scanned the bibliographies of selected key articles.
Number of Source Documents
A total of 124 articles were included in the earlier and updated reviews.
Methods Used to Assess the Quality and Strength of the Evidence
- Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Levels of Evidence for Occupational Therapy Outcomes Research
| Evidence Level | Definitions |
|---|---|
| I | Systematic reviews, meta-analyses, randomized controlled trials |
| II | Two groups, nonrandomized studies (e.g., cohort, case control) |
| III | One group, nonrandomized (e.g., before and after, pretest and posttest) |
| IV | Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series) |
| V | Case reports and expert opinion that include narrative literature reviews and consensus statements |
Note: Adapted from "Evidence-based medicine: What it is and what it isn't." D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British Medical Journal, 312, pp. 71-72. Copyright © 1996 by the British Medical Association. Adapted with permission.
Methods Used to Analyze the Evidence
- Review of Published Meta-Analyses
- Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence
After the literature search, reviewers then evaluated the quality of the studies and ranked them using the evidence-based standards described in the “Rating Scheme for the Strength of the Evidence” field.”
The teams working on the focused question reviewed the articles according to their quality and levels of evidence. Each article included in the review then was abstracted using an evidence table that provides a summary of the methods and findings of the article and an appraisal of the strengths and weaknesses of the study based on design and methodology. American Occupational Therapy Association, Inc. (AOTA) staff and the evidence-based practice project consultant reviewed the evidence tables to ensure quality control. All studies identified by the review are summarized in Appendix C of the original guideline document. (Readers are encouraged to read the full articles for more details.)
The articles included in the systematic review have several overarching limitations, including the following: small sample size; wide variation in interventions, diagnoses, and clinical conditions; wide variation in outcomes measured; and the use of self-report outcome measures. Depending on the level of evidence, there may have been a lack of randomization, lack of control group, and limited statistical reporting. A wide range of diagnoses and clinical conditions may have been included in meta-analyses and systematic reviews incorporated in these reviews.
Methods Used to Formulate the Recommendations
- Expert Consensus
Description of Methods Used to Formulate the Recommendations
The evidence-based literature review undertaken for this Practice Guideline examined studies that evaluated the effects of activity-based intervention on peer and social interaction, compliance with adult directives and social rules and norms, or productive or task-focused behavior in individuals from ages 3 to 21 years at the universal, targeted, and intensive tiers. These topics were chosen by a consensus group of clinical experts, because it was felt that these areas were the most representative of the psychosocial components that predict participation in school and in the home and community. In other words, on the basis of expert opinion, children who were able to interact in peer and social environments and/or comply with adult directives and engage in task behavior were more likely to successfully participate in school and in the home and community environments.
Rating Scheme for the Strength of the Recommendations
Strength of Recommendations
A –There is strong evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. Good evidence was found that the intervention improves important outcomes and concludes that benefits substantially outweigh harm.
B –There is moderate evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. At least fair evidence was found that the intervention improves important outcomes and concludes that benefits outweigh harm.
C –There is weak evidence that the intervention can improve outcomes, and the balance of the benefits and harms may result either in a recommendation that occupational therapy practitioners routinely provide the intervention to eligible clients or in no recommendation as the balance of the benefits and harm is too close to justify a general recommendation.
D –Recommend that occupational therapy practitioners do not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harm outweighs benefits.
I –Insufficient evidence to determine whether or not occupational therapy practitioners should be routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harm cannot be determined.
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
- Peer Review
Description of Method of Guideline Validation
Not stated
Evidence Supporting the Recommendations
Type of Evidence Supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see the “Major Recommendations” field).
A total of 124 articles were included in the reviews. Seventy-seven of the articles (62%) were classified as Level I evidence, 27 of the articles (22%) were classified as Level II studies, and 20 (16%) were classified as Level III studies.
| Table. Number of Articles in Each Tier at Each Level of Evidence | ||||||
|---|---|---|---|---|---|---|
| Evidence Level | ||||||
| Review | I | II | III | IV | V | Total in Each Review |
| Tier 1 | 26 | 7 | 2 | 0 | 0 | 35 |
| Tier 2 | 36 | 13 | 8 | 0 | 0 | 57 |
| Tier 3 | 15 | 7 | 10 | 0 | 0 | 32 |
| Total | 77 | 27 | 20 | 0 | 0 | 124 |
Benefits/Harms of Implementing the Guideline Recommendations
Potential Benefits
These guidelines may be used to assist:
- Occupational therapists and occupational therapy assistants in communicating about their services to external audiences
- Other health care providers, teachers, families and caregivers, mental health providers, and program administrators in determining whether referral for occupational therapy services would be appropriate
- Third-party payers in determining the therapeutic need for occupational therapy
- Legislators, third-party payers, and administrators in understanding the professional education, training, and skills of occupational therapists and occupational therapy assistants
- Health and education planning teams in determining the developmental and educational need for occupational therapy
- Program developers, administrators, legislators, and third-party payers in understanding the scope of occupational therapy services
- Program evaluators and policy analysts in this practice area in determining outcome measures for analyzing the effectiveness of occupational therapy intervention
- Policy, education, and health care benefit analysts in understanding the appropriateness of occupational therapy services for mental health promotion in children and youth
- Occupational therapy educators in designing appropriate curricula that incorporate the role of occupational therapy for mental health promotion in children and youth
Potential Harms
It is important to consider the possibility that some well-meaning prevention efforts may be more harmful than beneficial to children who are overweight. Child obesity prevention programs and untested health education messages have the potential to further stigmatize children who are overweight. The majority of children who are overweight are well aware of their body size and are at risk of developing a poor body image. Negatively focused health messages (e.g., that emphasize the undesirability of being overweight) may lead students to feel worse about themselves. Professionals must carefully consider how prevention messages are framed in order to avoid the potential psychosocial (e.g., poor self-esteem) and physical health (e.g., binge dieting) consequences that can result.
Qualifying Statements
Qualifying Statements
- This guideline does not discuss all possible methods of care, and although it does recommend some specific methods in practice, the occupational therapist makes the ultimate judgment regarding the appropriateness of a given procedure in light of a specific client’s circumstances and needs.
- This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold or distributed with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the services of a competent professional person should be sought.
- It is the objective of the American Occupational Therapy Association, Inc. (AOTA) to be a forum for free expression and interchange of ideas. The opinions expressed by the contributors to this work are their own and not necessarily those of the AOTA.
Implementation of the Guideline
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
- Patient Resources
- Resources
- Staff Training/Competency Material
Institute of Medicine (IOM) National Healthcare Quality Report Categories
IOM Care Need
- Getting Better
- Living with Illness
IOM Domain
- Effectiveness
- Patient-centeredness
Identifying Information and Availability
Bibliographic Source(s)
- Bazyk S, Arbesman M. Occupational therapy practice guidelines for mental health promotion, prevention, and intervention for children and youth. Bethesda (MD): American Occupational Therapy Association, Inc. (AOTA); 2013. 171 p. [315 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
2013
Guideline Developer(s)
- American Occupational Therapy Association, Inc. - Professional Association
Source(s) of Funding
American Occupational Therapy Association, Inc.
Guideline Committee
Not stated
Composition of Group That Authored the Guideline
Authors : Susan Bazyk, PhD, OTR/L, FAOTA, Professor, Occupational Therapy Program, Cleveland State University School of Health Sciences, Cleveland, OH; Marian Arbesman, PhD, OTR/L, President, ArbesIdeas, Inc., Consultant, AOTA Evidence-Based Practice Project, Clinical Assistant Professor, Department of Rehabilitation Science, State University of New York at Buffalo, New York
Series Editor : Deborah Lieberman, MHSA, OTR/L, FAOTA, Director, Evidence-Based Practice, Staff Liaison to the Commission on Practice, American Occupational Therapy Association, Bethesda, MD
Financial Disclosures/Conflicts of Interest
The authors of this Practice Guideline have signed a Conflict of Interest statement indicating that they have no conflicts that would bear on this work.
Guideline Status
This is the current release of the guideline.
Guideline Availability
Available for purchase from the American Occupational Therapy Association (AOTA) Web site.
Availability of Companion Documents
The following are available:
- Occupational therapy practice framework: domain and process. 2nd ed. Bethesda (MD): American Occupational Therapy Association, Inc. (AOTA); 2008.
- Mental health in children and youth: the benefit and role of occupational therapy. Bethesda (MD): American Occupational Therapy Association, Inc. (AOTA); 2011. 2 p. Available from the American Occupational Therapy Association (AOTA) Web site.
In addition, case studies are available in the original guideline document.
Patient Resources
A podcast titled “Mental Health in Children” is available from the American Occupational Therapy Association (AOTA) Web site.
Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline’s content.
NGC Status
This NGC summary was completed by ECRI Institute on February 3, 2014.
Copyright Statement
This NGC summary is based on the original guideline, which is subject to the guideline developer’s copyright restrictions.
Disclaimer
NGC Disclaimer
The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria.
NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.