Occupation-based Theory and Participation Spring 2013

1. Occupation-based Theory and Participation Spring 2013 “Sunshine @ AIC”: An Occupation-based Physical Activity Program for Adults with Intellectual and Developmental DisabilitiesAllison SullivanTemple University

2. Some people I know

3. Obesity: a national health crisis • According to the Centers for Disease Control and Prevention (CDC), obesity is “common, serious, and costly” • over one-third of adult Americans meet the body mass index (BMI) criteria for obesity • Heart disease, stroke, diabetes, and some cancers are obesity-related conditions that the CDC considers some of the leading causes of preventable deaths U. S. Department of Health and Human Services, 2001

4. Sedentary lifestyle is one of the most significant risk factors for obesity The Best Practices Statement for promoting physical activity (PA) developed by a coalition of national organizations led by The American College of Sports Medicine include the following recommendations: • Individually tailored PA programs and interventions that include principles of behavior change. • Emphasize the need to increase PA in underserved populations primarily because these groups are at higher risk of poor health and have lower levels of PA than their counterparts Stewart, et al.,2006

5. Adults with intellectual and developmental disabilities face multiple challenges in addressing the health-related risks of sedentary lifestyle : They are more likely to: • Be people with low socioeconomic status • Require assistance with everyday life skills • Have poor dietary habits, low physical activity, and weight disturbances • Have more chronic disease conditions than that of the general population Elinder, et al, 2010 Although a significant amount of research exists on obesity &interventions designed to promote weight loss, very little research has been conducted to date to identify those interventions that most effectively promote weight loss in this population

6. Context: Sunshine Village • A private, nonprofit organization located in Western Massachusetts serving people with developmental disabilities. • Staff of more than 150 people. Over 350 adults attend its day habilitation &employment services operations in 6 locations. • The day habilitation development training includes IADL, ADL, social, communication support & health care services. It is accredited by CARF • Sunshine Village offers speech, physical, and occupational therapies, as well as behavioral counseling for consumers in its day program. • The organization’s programs are licensed by Massachusetts Department of Developmental Disabilities.

7. Theoretical context: MOHO and CDM • Kielhofner’s Model of Human Occupation • MOHO as a model for individual intervention within a public health care setting is a compatible and consistent approach to treatment because both MOHO and the public health model are grounded in open systems theory • MOHO-based constructs of client volition and habituation via expansion of occupational roles and choices are key features of this program that differentiate it from traditional exercise and health-education interventions

8. Evidence-based support for MOHO-grounded interventions • Braveman & Suarez-Balcazar’s study “Social Justice and Resource Utilization In a Community-Based Organization: A Case Illustration of the Role of the Occupational Therapist” (2009). • “Through the application of occupational therapy processes, occupational therapy personnel are positioned to guide organizations to support people to achieve self-sufficiency and self-determination, concurrently establishing reasonable expectations for people to contribute to this process”

9. Allen’s Cognitive Disabilities Model • Allen Cognitive Levels and Modes identify problem solving skills in the program participants • facilitates clinicians’ ability to: • anticipate safety issues • develop specific interventions and environmental and communication supports to maximize positive outcomes.

10. Evidenced-based support forAllen’s Cognitive Disabilities Model • A study by Mary Ann Mayer (1988) provides convincing support that Allen's model “can be useful in guiding occupational therapy planning when expected outcomes depend on the patient's learning potential”. Mayer, M., A, (1988). Analysis of information processing and cognitive disability theory. American Journal of Occupational Therapy. 42, 176-183. doi: 10.5014/ajot.42.3.176

11. Sunshine@AIC Program Components Use of a college gymnasium twice a week for two hours • Provide a safe and accessible environment conducive to physical activity for adults with significant developmental disabilities from Sunshine Village • Identification of a facility that is safe and appropriate for the purpose of creating an opportunity for adults with significant developmental disabilities to get physical activity is a key factor in being able to successfully address the occupational deprivation caused by the effects of sedentary lifestyle.

12. Program Components Continued • The college provides the facilities, basketballs for consumer use during that time, and a device for playing music in the gym • The low level of demand placed on college employees and materials makes the program very appealing to The College • College can promote its role as a good community partner • Also promotes disability awareness in the college community • Provides an opportunity for student fieldwork

13. Program Components Sunshine Village provides: • Up to 50 consumers each visit who are identified as candidates for the programfrom all 6 locations • Staff supervision of program participants as designated by attendees’ staffing protocol • Transportation of program participants and their staff to and from the college • Occupational therapist to supervise the program

14. Program Components Continued • Features of the college gymnasium that promote successful intervention for this population: • Large size accommodates the free movement of many people at one time. • No furniture or environmental hazards such as rugs or small objects in the gymnasium that can be safety issues for consumers (some consumers have pica). • The facility is completely handicapped accessible, including its restrooms and water fountain. • The parking lot is fenced in, which is a significant safety feature, due to the fact that some individuals who attend the program have decreased safety and environmental awareness and can behave unpredictably during transition times.

15. Specific physical activities that are offered at the program • Walking around the gym to music • Shooting basketballs into baskets around the gym perimeter • Kicking soccer balls at designated targets. The activities selected are appropriate for participants functioning within the Allen Cognitive Levels 3-4.and promote physical activity.

16. CDM Rationale for Activity Choices Based on Allen’s CDM, skills of individuals functioning in the Cognitive Level 3-4 range include: • the ability to manipulate objects • be engaged in activities of interest • follow simple commands when appropriate communication techniques are learned • complete steps of familiar tasks • complete familiar activities that don’t require precision • socialize • demonstrate improved performance in familiar tasks involving structure and routine

17. Other intervention components • Water cooler breaks • Donning and doffing outer garments • Toileting and toilet hygiene Spectating/observing • Dancing • Van to gym transition • Socializing with staff, peers and students Tasks that are not essentially “physical” are crucial to consider within the overall structure of the program when establishing the MOHO-based constructs of volition and habituation

18. MOHO Rationale: Volition Influences Performance & Adaptation • Emphasis on clients’ ability to exercise personal choice within program activities is a key feature of this intervention • Participants choose what they want to do in terms of the activities offered, how long they want to do it for, and with whom they do it • People may move freely from one activity to the next or remain with one choice for the duration of their visit • “Me time” is Key Time!

19. MOHO-based Consideration of the Impact of Environment on Occupational Performance • Kielhofner and Barret describe the “contribution of the environment to occupational adaptation” • Severely circumscribed environmental constraints by the day program setting diminishes people’s natural human potential- work and play occupations are limited by lack of choices. • Motivation for occupation is diminished as occupational role choices are sparse, not necessarily client-centered • Volition, habituation and performance subsystems are negatively affected by a lack of opportunities to grow or change. The addition of a new environment that offers opportunities to increase individuals’ occupational choices is an ideal way to influence change at the systems level and in that way influence health of individuals in the system positively.

20. External Factors to Consider Based on ICF Domains • Include items identified within the Activities and Participation and Environmental Factor Domains • In particular, attention should be directed to to those items identified in the following subheadings: Learning and Apply Knowledge, General Tasks and Demands, Communicating, Mobility, Self-Care, Interpersonal Interactions and Relationships, Community, Social and Civic Life (specific items)

21. Program Evaluation • Voluntary Participation indicates huge success as a choice-based avenue for participation • Success as a Falls Prevention Program • Weight Management Program for obese participants • MOHOST • Pretest and posttest Likert scales for rating health status • Instrumental and Activities of Daily Living Scales completed by a guardian • Pre and posttest self-report measures including the Cognitive-Emotional Barriers to Exercise Scale, Exercise Perception Scale, a non-standardized measure of self-efficacy, Life Satisfaction Scale, and an adapted Children’s Depression Inventory (Heller, et. al, 2004).

22. Conclusions • Adults with intellectual disabilities are an under-studied group of individuals in our population. • A paucity of evidence indicates that there is still much to be learned about the usefulness and best methods for this type of intervention with this population. • Doing nothing almost guarantees negative health outcomes in this vulnerable population • clinicians seeking to implement physical activity interventions to address health risks related to sedentary lifestyle with this population are encouraged to seek alternative environments such as local college gymnasiums to develop these interventions, given the occupational deprivation that is a frequent consequence of the day program setting

23. References • Bazzano, A., Zeldin, A., Shihady, D., Garro, N., Allevato, N., & Lehrer, D. (2009). The healthy lifestyle change program. American Journal of Preventive Medicine, 37, S201-S208. doi:10.1016/j.amepre.2009.08.005. Retrieved November 28, 2012 from American Journal of Preventive Medicine Online database. • Bodde, A., Dong-Chul, S., Frey, G., Van Puymbroeck, & M., Lohrmann, D. (2012). Correlates of moderate-to-vigorous physical activity participation in adults with intelllectual disabilities. Health Promotion Practice, 20 1-8. Doi: 10.1177/1524839912462395. Retrieved December 2, 2012 from Sage Journals Online database. • Brown, C., Goetz, J., Van Sciver, A., Sullivan, D., & Hamera, E. (2006). A psychiatric rehabilitation approach to weight loss. Psychiatric Rehabilitation Journal, 29, 267-273. Retrieved November 28, 2012 from EBSCOhost database. • Braveman, B. & Suarez-Balcazar, Y. (2009).Social justice and resource utilization in a community-based organization: a case illustration of the role of the occupational therapist. American Journal of Occupational Therapy, 63, 13-23 • Chapman, M., Craven, M., & Chadwick, D. (2005). Fighting fit? an evaluation of health practitioner input to improve healthy living and reduce obesity for adults with learning disabilities. Journal of Intellectual Disabilities, 9, 131-144. doi:10/1177/1744629505053926. Retrieved December 2, 2012 from Sage Journals Online database. • Chapman, M., Craven, M., & Chadwick, D. (2008). Following up fighting fit: the long-term impact of health practitioner input on obesity and BMI amongst adults with intellectual disabilities. Journal of Intellectual Disabilities, 12, 309-323. doi: 10.1177/1744629508100557. Retrieved November 28, 2012 from Sage Journals Online database.

24. References con’d • Elinder, L., Bergstrom, H., Hagberg, J., Wihlman, W., & Hagstromer, M. (2010). Promoting a healthy diet and physical activity in adults with intellectual disabilities living in community residences: design and evaluation of a cluster-randomized intervention. BioMed Central Public Health, 10, 761-766. doi: 10.1186/1471-2458-10-761. Retrieved October 18, 2012 from BioMed Central. • Emerson, E. (2005). Underweight, obesity, and exercise among adults with intellectual disabilities in supported accommodation in Northern England. Journal of Intellectual Disability Research, 49, 134-143. doi: 10.1111/j.1365-2788.2004.00617.x. Retrieved November 28, 2012 from Wiley-Blackwell. • Ewing, G., McDermott, S., Thomas-Koger, M., Whitner, W., & Pierce, K. (2004). Evaluation of a cardiovascular health program for participants with mental retardation and normal learners. Health, Education, and Behavior, 31, 77-87. doi: 10.1177/1090198103259162. Retrieved November 28, 2012 from Sage Journals Online database. • Harris, M., Bloom, S. (1984). A pilot investigation of a behavioral weight control program with mentally retarded adolescents and adults: effects on weight, fitness, and knowledge of nutritional and behavioral principles. Rehabilitation Psychology, 29, 177-182. Retrieved December 2, 2012 from EBSCOhost database. • Heller, T., Hsieh, K., & Rimmer, J. (2004). Attitudinal and psychosocial outcomes of a fitness and health education program on adults with down syndrome. American Journal on Mental Retardation, 109, 175-185. • Heller, T., McCubbin, J., & Peterson, J. (2011) Physical activity and nutrition health promotion interventions: what is working for people with intellectual disabilities? Intellectual and Developmental Disabilities, 49, 26-36. doi:10.13652/1934-9556-49.1.26.

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