Common Theories, Models of Practice and Frames of

Reference Used in Occupational Therapy

By Rebekah Brown

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 Introduction

Theories, models of practice and frames of reference are what shape occupational therapy as a

practice and how practitioners look at their clients and design the interventions they use. A theory is an

overarching description of a set of circumstances and their relationship with each other. Models of

practice, as Fisher (1998) discusses, help to organize how one views and assesses the things about a

person or their environment that support or limit their performance. A frame of reference is a practical

guide of what specifically is being addressed, how to look for those deficits and how to go about working

with them. While a practitioner will likely use only one model when working with a client, they will

likely use multiple frames of reference so as to create the best individualized intervention them. Below

I will address some of the most often used theories, models of practice and frames of reference and

provide example of interventions that use them.

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 Model of Human Occupation (MOHO)

MOHO looks at human occupation as complex and being influenced by a person’s volition, a

person’s habituation, the aspects of performance, and the environment in which it occurs. Volition

refers to a “person’s motivation, interests, values, and belief in skill.”(Kielhofner, 2009) Habituation

means a person’s roles in life, with their rules/expectation, their regular pattern of behavior, and their

routines. The aspects of performance that are looked at include the motor, cognitive and emotional

skills needed to act within their environment, gained from their own physical attributes as well as their

life experience. Environment in itself influences occupation, be it physical, social or societal.

MOHO is a client-centered and holistic model, which focuses on the idea that through

participation in occupations humans can increase in their adaptive response. The goal therefore, is to

“engage people in occupations that restore, reorganize or maintain their motivation, patterning and

performance capacity, therefore their occupational lives” (Ramafikeng, 2011) by providing opportunities

for the person to themselves accomplish their own change.

To apply MOHO in a school district setting it is all about looking at the aspects of occupation and

then applying them in interventions through a frame of reference. Volition would be a child’s favorite

thing to talk about, how much self-confidence they have and/or any cultural factors involved.

Habituation would involve observing or reviewing reports of their emotional response to situations, and

applying the rules and expectations of what it means to interact in a classroom with classmates.

Performance would be what skills are needed to act within a classroom, such as social skills and

handwriting. The environments include the classroom, the playground, the gym, and the lunchroom,

with both the physical and the behavioral expectations included in each one.

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 Occupational Adaptation

Occupational adaptation is sometimes seen as a frame of reference but is better used as a

model of practice or a theory because of its large concepts and versatility in application. The focus of

occupational adaptation is on the person, the environment and their interaction with each other and

the assumption that within occupational adaptation “occupation is used to promote adaptation and

adaptation is accomplished to perform occupation” (Dirette, 2005), or, that adaptation will lead to

further adaptation. In this model of practice the client is viewed holistically, and as their own “agent of

change”, so to lead a successful adaptation the therapist and the client work together to make changes

that lead to the adaptation. These changes can be made to the person, the task or the environment,

with the use of compensatory devices as needed.

An example of this would be having a child work with different staff members throughout the

day instead of merely staying with only one. By doing this the child learns to interact with more than

just one person, and also is able to more easily adapt when someone new joins that rotation.

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 Person-Environment-Occupation Model (PEOM)

The PEOM is based on the idea that optimal occupation performance occurs when there is a

“good fit” in the interaction between the person, the occupation and the environment. When looking at

the person in this model what is most focused on is their behavior; this includes their motivations for

activities, the way they emotionally respond to situations and their level of independence. Ramafikeng

(2011) defines the environment as “the context within which occupational performance takes place and

it is categorized into cultural, socioeconomic, institutional, physical and social.” The environment has

both demands and cues as to the behavior expected from the person, and is in turn considered from the

perspective of the person. Occupations in the PEOM are self-care, productivity and leisure which a

person engages in to meet their intrinsic need for “self-maintenance, expression, and life satisfaction.”

(Ramafikeng, 2011) These occupations are analyzed as specific tasks, with the main focus on the

characteristics, the amount of structure, the complexity, the task demands and the task duration.

If PEOM is applied to activity such as handwriting, then performance could be improved by

focusing on either the child, the environment or the task. If one were to focus on the child, then

choosing a topic to write about or copy that interests them would help to increase their motivation. If

they are small and can’t put their feet flat on the floor to provide good balance while they are writing

then a different chair or a box could alter their environment. Lastly, to change task demands, one could

add a pencil grip to improve their grasp.

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 Ecology of Human Performance (EHP)

The model of EHP focuses primarily on the effect that the interaction between a person and

their context/environment has on occupational performance and the meaning a person finds in it.

Ramafikeng (2011) describes the interaction as persons being “embedded in their contexts”, with

contexts being either cultural, social, temporal or physical. Dependent on this interaction of a person’s

past experience and current resources with their context/environment, is the occupational performance,

because “performance results when the person interacts with the context to engage in

tasks.”(Ramafikeng, 2011) A task, as described by EHP, refers to a set of behaviors needed to reach a

goal, some of which can be dictated by a person’s roles.

With this framework in place, EHP has 5 collaborative intervention strategies to improve

performance, as described by Ramafikeng (2011):

1. Establish/Restore: Work to improve the person’s abilities and skills within their context

2. Alter: Choose the best context in which the person can act with their current skill and ability, as

opposed to modifying their current context

3. Adapt: Modify the current context or task demands

4. Prevent: Look at features of the context, person or task to prevent the development or

occurrence of dysfunctional performance

5. Create: Generate circumstances that lead to performance of greater complexity and adaptability

without the assumption of interference by or presence of disability

When working within a school district any or all of these strategies can be used. Establishing skills

such as handwriting and social interaction can help kids in successful functioning within the context of

school. Altering the child’s context from being in the general population full-time to being in it part-time

can provide opportunities for the child to find success. An example of adapting a child’s task demands

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would be in having the child in the general population PE class, but to have them do a modified version

of the game. An example of prevention would be creating an environment that would prevent

behavioral responses such as working in a quieter place. Lastly, “creating” can be done by providing

interventions of increasing difficulty and complexity, to foster the child’s growth.

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 Behaviorism

This theory is based on the idea that behavior is observable and that all behaviors are learned

through a person’s association of stimulus and response. It also assumes that because all behavior is

learned, it can also be unlearned by replacing it with another. This is can be done by reinforcing the

desired and/or punishing the undesired behavior; both approaches can be done in positive or negative

ways. Behaviors can also be learned through modeling, shaping (grading) and cuing.

This theory is applied consistently when working with children in or out of school. Correcting an

undesired behavior as well as having a reward at the end of a session are both ways to encourage

desired behaviors.

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 Cognitive Theory

Cognitive theory was developed by Jean Piaget from his study of children, and is comprised of

what he identified as schemas, adaptation processes, and stages of development. Schema can be

defined as “the basic building block of intelligent behavior—a way of organizing knowledge” (McLeod,

2009), or as the thought process, pattern of behavior, and knowledge one has compiled and applies to a

specific experience. The process of adaptation is broken down into three sub-processes: assimilation,

accommodation and equilibration and progresses as:

Assimilation → Equilibration → New Situation → Disequilibrium → Accommodation

Assimilation is when a schema is applied to a new object or situation; this can either be successful, in

which case equilibrium is maintained, or it can be unsuccessful, which results to disequilibrium.

Accommodation occurs when a schema does not apply to the current situation and requires alteration.

Once this change is made, assimilation can once occur. The four stages of development Piaget identified

describe the cognitive skills that are usually present at a particular age, they are called: sensorimotor

(approx. 0-2y), preoperational (approx. 2-7y), concrete operations (approx. 7-12y), and formal

operations (approx. 12y+).

This theory is very applicable in the school district by helping to identify what general order skills

will emerge, as well as what goals a child needs to work toward to be at the “normal” stage of

development. Knowing about assimilation and accommodation as a part of the adaption process also

helps to identify the need to children to experience new and varying situation.

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 Motor Learning

The concept of motor learning is based primarily on the type of task to be performed, and the

principles of practice & feedback. The process of motor learning is broken down into three stages:

cognitive, associative and autonomous. At the cognitive stage there is a general idea of the movement

needed to complete a task, but there is difficulty in execution; improvement at this point is dependent

on the attention given to the task and its requirements. Once at the associative stage “skills become

more refined with practice, resulting in greater consistency of performance and fewer errors.” (Zwicker

& Harris, 2009) At this stage the therapist starts to provide less guidance, the increase in errors that

occur from this allow the client to begin to adjust independently and so help to generalize the skill. At

the autonomous stage a skill has been learned, and can be done while engaging in another task.

The types of tasks identified by motor learned include: discrete tasks, continuous tasks, and

serial tasks; the tasks are performed in an environment where the outcome can either be predictable or

unpredictable. Discrete tasks have a recognizable start and finish, where as continuous tasks, such as

walking, are more arbitrary.

The principles of practice and feedback are inseparable from motor learning concepts. Practice

can occur with or without rest within a span of time. The task can also be practiced as a whole or in

parts, though as noted by Peck and Detweiler (2000) practicing the task in part at later stages does little

to facilitate the skill within its intended context (as cited in Zwicker & Harris, 2009). Feedback can either

be intrinsic, as provided by the person’s sensory system, or extrinsic, which is provided by visual and

verbal cues.

Within a school district an application of this concept can be seen in working with children on

handwriting. At an early stage, the use of stencils or guiding with hand-over-hand would be used to

learn the idea of the movements. This would be followed by the use of “handwriting paper”, which

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provides visual cues and feedback as the movements are created more independently. As the

movements are practice, with feedback from both visual cues and from the therapist a child develops

the motor movements needed for the skill.

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 Sensory Integration (SI)

SI can either be referred to as either a frame of reference (FoR) or as a model of practice, but

since the focus of this paper is on practical application, it will be approached as a FoR.

Dirette (2005) lists the assumptions of SI as being that:

 The CNS is organized in a hierarchy

 There must be a minimal registration of stimuli to enable a response by the CNS

 The brain will naturally seek stimulation to organize/benefit itself

 Input from one sensory system can facilitate or inhibit any/all of the others

 The CNS has plasticity

 Normal human development is sequential

SI works to improve sensory modulation, ability for functional support, and “end-product” skills.

Function in the sensory system modulation is measure by the response to: the senses in the body, level

attention and emotional arousal; dysfunction could occur from either under-registration or over-

registration. Abilities for functional support include sensory and emotional discriminatory skills, balance,

muscle tone, developmental reflexes, and bilateral integration; dysfunction would be noted in the poor

development of any of these skills. End-product skills include praxis, space perception, academics,

language, emotional skills and behavior; poor development of these skills is an indicator of dysfunction.

Dirette (2005) describes the following postulates SI employs:

 Involving multiple sensory systems and requiring their integration will be more effective and be

more likely to create an adaptive response

 If a child is able to act on their own environment, then adaptive responses are more likely to

occur

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  Volitional movement, rather than passive, is more likely to lead to effective motor patterns

 To a facilitate an adaptive response and promote growth, a situation at the correct

developmental level must be used

 Having activities with a “just right” challenge makes engagement more likely

 A child is more likely to engage in activity if they have a sense of emotional safety

 Constant feedback leads to greater understanding for the child of what they are doing or have

done

 Activities of variety and a controlled change are more likely to lead towards an adaptive

response instead of a learned behavior

An example of using SI with a child who had poor modulation in their proprioception, would be to have

activities that involve jumping and crashing using mats or foam wedges.

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 Neurodevelopmental Treatment/Theory (NDT)

NDT can be considered a theory because of its larger concepts however because of its

practicality in clinical application this paper will approach it as a FoR.

The assumptions for this FoR, as described by Dirette (2005) are that:

 Foundational skills have to be addressed to allow for the normal process of skill acquisition

 Normal movement is gained through experience

 Postural stability is needed for limb mobility

 If abnormal muscle tone is present then normal movement cannot occur

 There is plasticity to the brain

The skills that are the focus of NDT are: control of the trunk/neck, automatic reactions and the

control of the limbs, specifically as they are influence by scapular/pelvic stability and mobility.

Dysfunction in NDT is measured by: the level of muscle tone present, the synergistic movements, the

automatic reactions, and the developmental level of reflex present in the person.

As described by Dirette (2005), NDT states that:

 Hypertonia can be inhibited by: passive elongation, the inhibition of reflexes, positioning and

weights shifts hypertonia can be inhibited

 If hypotonia exists, tone can be increased through: joint compression, joint traction, manual

resistance and weights shifts tone can be increased

 Control of the neck an trunk can be achieved by: passive elongation, active weight shifts, passive

pelvic tilts and active rotation of the trunk/neck

 Automatic reactions can be regained with: the inhibition of reflexes and the use of the desired

motor patterns

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 Limb control can increase by: breaking up synergy patterns, the inhibition of reflexes, limb

weight shifts, placing &holding, and the use of postures & movements that require rotational &

reciprocal limb movements

A clinical application for NDT would be working to decrease tone and increase control in the UE with

a post-CVA client. Through having the client perform weight shifts in a quadruped position, the

synergist tone can be decreased in the arm to facilitate controlled movement.

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 Cognitive Disability (CD) Frame of Reference

The main points of CD are to identify the functional cognitive capabilities of the person and then

provide activities at that level. Reed and Sanderson (1999) list these assumptions for CD:

 The severity of a mental disorder can be measured by the consequences it has on a person’s

ability to think, do an learn

 Mild disorders can be compensated for by learning alternatives to “normal” processing

 Severe disorders can be defined as presenting with limited mental abilities that cannot be

compensated for by the person

o These can however be compensated by both the environment and the identification of

the still present abilities

 The existent mental abilities should be engaged as appropriate

 If alternative psychological techniques are ineffective, then compensation through the

environment can increase the person’s quality of life

The level of function in CD is assessed with six categories; Reed and Sanderson (1999) list them as:

 Automatic actions: Responses to internal stimuli while the person is conscious

 Postural actions: Initiated gross motor movement

 Manual actions: Fine motor movement (purposeful or repetitive)

 Goal-directed actions: The engagement for achievement of a short-term goal

 Exploratory actions: Problem solving by trial and error

 Planned actions: Abstract thinking with the understanding and anticipation of future

consequences

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 Clinical application of this FoR in the school district can be seen in identifying and choosing the

environment or task that a child will have the most success with. An example would be decreasing

the number of steps in a task, or only providing them one at a time as it is being completed. This

can be applied to a fine motor craft task, or gross motor PE tasks.

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 Biomechanical Frame of Reference

This Frame of Reference is based on the following assumptions as described by Dirette (2005):

 Occupation can remediate the loss of ROM, strength and/or endurance

 By regaining ROM, strength and/or endurance functional skills can be enabled

 The body must rest, then work

 A level of cognition is required to produce isolated/coordinated movements

Dirette (2005) states that the Biomechanical Frame of Reference works to improve structural stability,

AROM, PROM, muscle strength, peripheral edema and endurance through:

 Orthoses and positioning to decrease structural damage

 Rest followed by stress to increase structural stability

 A graded increase in duration and intensity to increase endurance

 Elevation, pressure, ROM and temperature control to decrease edema

 PROM, AAROM, AROM, scar prevention, orthoses and positioning to maintain PROM

 Heat, scar remodeling, passive stretch, active stretch, orthoses, positioning and occupation to

increase ROM

 AROM and occupation to maintain strength

 Exercise via isometrics, active assistance, active motion, progressive or regressive resistance to

increase strength

A clinical application of this frame of reference can be seen when working with a post-CVA client

with a subluxed shoulder. To remediate this problem via the biomechanical frame of reference a

practitioner can work to improve positioning by using a sling or strapping tape. In addition a practitioner

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can use electrical stimulation for its alternating contractions to increase the strength in the surrounding

rotator cuff muscles as well as use PROM and AROM to help preserve and improve the ROM at the joint.

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 Rehabilitation Frame of Reference

The assumptions Dirette (2005) gives for the Rehabilitation FoR are, that:

 Independence can be reaching with compensation when deficits cannot be overcome

 The environment, volition and habits of a person are an integral part of their motivation for

independence

 A certain level of emotional and cognitive skill are required for a person to be independent

 That a top-down approach to taken in the order of

1. The demands/resources of the environment

2. The person’s volition and habituation

3. The person’s functional capabilities

4. The prerequisite skills and deficits

The focus of this FoR is to enable the greatest amount independence for the person in:

 Safely and in a timely manner completing their ADL’s

 Engaging in meaningful leisure occupations

 Having the needed skills and abilities to engage in work

This independence is achieved through “adaptive devices, orthotics, environmental modifications,

wheelchair modifications, ambulatory aids, adapted procedures, and/or safety education.” (Dirette,

2005)

A clinical application of this would be if working with a client with a degenerative disease that

has led to a decreasing amount of strength and ROM in their hands. A person with this kind of

dysfunction would have difficulty with the ADL of dressing, particularly of the LB. To enable greater

independence an adaptive device such as a dressing stick could be used.

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 Works Cited

Dirette, D. (2005). Ryan’s Occupational Therapy Assistant: Principles, Practice Issues, and Techniques (4th
ed.). K. Sladyk & S.E. Ryan (Ed.). Thorofare, NJ: Slack Incorporated.

Fisher, A.G. (1998). Uniting Practice and Theory in an Occupational Framework [PDF document].
Retrieved from http://www.aota.org/-
/media/Corporate/Files/Publications/AJOT/Slagle/1998.pdf

McLeod, S. (2009). Jean Piaget. Retrieved from http://www.simplypsychology.org/piaget.html

Ramafikeng, M. (2011). Ecology of Human Performance. In Conceptual Frameworks (2nd ed.) (Lecture 7).
Retrieved from https://vula.uct.ac.za/access/content/group/9c29ba04-b1ee-49b9-8c85-
9a468b556ce2/Framework_2/lecture7.htm

Ramafikeng, M. (2011). Model of Human Occupation. In Conceptual Frameworks (2nd ed.) (Lecture 1).
Retrieved from https://vula.uct.ac.za/access/content/group/9c29ba04-b1ee-49b9-8c85-
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Ramafikeng, M. (2011). Occupational Adaptation Theory. In Conceptual Frameworks (2nd ed.) (Lecture
2). Retrieved from https://vula.uct.ac.za/access/content/group/9c29ba04-b1ee-49b9-8c85-
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Ramafikeng, M. (2011). The Person Environment Occupation Model. In Conceptual Frameworks (2nd ed.)
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8c85-9a468b556ce2/Framework_2/lecture3.htm

Reed, D. L., & Sanderson, S.N. (1999). Concepts of Occupational Therapy (4th ed.). Retrieved from
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Standridge, M. (2012). Behaviorism. Retrieved from

Zwicker, F. G., & Harris, S. R. (2009). A reflection on motor learning theory in pediatric occupational
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