Pediatric Occupational Therapy
Introduction Substance use disorder (SUD), substance abuse or substance dependency, caused by a recurrent use of alcohol and/or drugs, leads to clinically and functionally significant impairment in one’s occupation, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. SUD can occur regardless of age, gender and ethnicity (DSM-IV, 2013). Various impairments to bodily, mental and social functions may hinder one’s participation in occupations, decrease quality of living (QOL) and life satisfaction; having a QOL and engaging in active daily livings (ADLs) are absolutely imperative for optimal well-being. Therefore, an occupational therapists (OT)s, who is specially trained to maintain or
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enhance the ADLs, work to aid in supporting the betterment of functional ADLs and QOL. And previous research has proven the effectiveness of occupational therapy with SUD patients (Hoxmark, Wynn& Wynn, 2011). Adolescent SUD is an especially rising concern among the various types of the SUD population because an untreated SUD can induce serious physiological and psychosocial issues and social crimes. As previous researchers found, untreated adolescent substance abuse has a higher risk of developing into a more serious form of SUD due to poor judgment processes by pre-mature brains. As such, adolescent substance abuse can have a worse prognosis than adults with SUD. (Casey, Jones, & Hare, 2008; reviewed by Winters & Arria, 2011). Thus, correcting an individual’s non-medical purpose alcohol use at early stage can prevent development of SUD. In particular, an adolescent alcohol abuser is more problematic because the limbic system of adolescents’ brains are not fully controlled by prefrontal lobe until the early 20s; they are not able to make logical judgments and easy to become severe substance abusers (Giedd, 2004; reviewed by Winters & Arria, 2011). Indeed, the importance of treating an alcohol abuse problem of adolescents is noticed by many others as well.
In 2006, American Occupational Therapy Association (AOTA)’s children and youth Ad Hoc Committee delineate one of the goals of AOTA’s Centennial Vision for pediatric occupational therapy as, “Studies that examine the emotional and social cost of occupational deprivation and occupational injustice for children and youth such as depression, alcohol and substance abuse, and suicide in disenfranchised youth, and what this is costing emotionally to youth and family as well as to society.” (Brown & Bourke-Taylor, 2014).
Etiology
The etiology of SUD is unknown, but it seems that a habit of persistent use of drugs, a desire to alter mood or to reach desired well-being causes SUD. The specific cause of children and adolescent SUD is unknown. Some possibilities include peer pressure, environment/context, genetic, failure to control impulsiveness and curiosity influences.
Alcohol Abuse …show more content…
(Alcoholics)
Alcohol is one of the most frequently used substances among any SUD populations and seems to be the initial form of substance abuse. According to the result from the 2014 national survey on drug use and health, 139.7 million Americans aged 12 or older reported current use of alcohol and 23.8 percent are heavy drinkers. The highest alcohol use population was young adults (age 18-25), 59.6 percent. The adolescent (12-17) population was only 11.6 percent but because they are vulnerable to addiction, they quickly become abusers and have the worse prognosis than other populations (HHS Publication No. SMA 15-4927, 2015).
Adolescent drug abuse typically begins with caffeine, nicotine, and alcohol to seek the desired effect because it is inexpensive to attain. As they build a tolerance to these, they move on to stronger substances such as marijuana and heroines and then it becomes harder to live without taking substances. Short term use of alcohol can be effective to alter the mood with only mild health problems, but prolonged use can lead to personality, mood, cognitive functioning, and various physiological problems. Persistent use can be fatal, when abuse is severe or if there is interaction with other drugs (Perkinson, 2012). Adolescents’ alcohol abuse can cause disruption in brain development leading to a various malfunctions of the brain, such as a malfunctions to cognitive function, mood control, executive function, communication, and personality. Alcohol abuse not only interrupts brain development, but also it can cause alcohol intoxication, alcohol amnestic disorder, Wernicke-Korsakoff syndrome, alcoholic idiosyncratic intoxication, alcohol withdrawal, alcohol withdrawal seizures, and alcohol withdrawal delirium which are all serious health problems (Perkinson, 2012).
Evidence-based Treatment
Model of Human Occupation (MOHO) A treatment session based on the model of human occupation (MOHO) can be beneficial. MOHO is an occupation-focused model to “provide an overarching context of occupation that emphasizes the occupational therapist's unique perspective on a client’s ability to engage in activities and participate in life” and “attempt to explain the relationship of occupation, person and environment” (Cole & Tufano, 2008, p. 61). MOHO focuses on the concept of volition, habituation and performance capacity, which are the keys to understanding human occupation (Kielhofner, 2002). Volition includes person’s values, which an individual finds meaningful and important, and interests and personal causation which refers to a sense of competence and effectiveness. The habituation is a given context of physical, temporal and social being which influences an individual to develop a certain behavioral pattern or take new actions and decisions. Performance capacity is mental and physical attribution and life experiences. As these three factors influence an individual to engage in an occupation, MOHO aims to explain how disability and illness hinder occupational performance and it focuses on supporting individuals to successfully perform the occupation (Kielhofner, 2002). Individuals with SUD are unable to engage in social participation successfully because a failure in emotional control and stress management, such as anger, aggression and impulsiveness, makes it difficult for the individuals to be accepted by peers.
As it continues, SUD hinders social participation in a serious manner. A good social participation can support better peer interaction which was the main caused of substance abuse within the population, what is hindering this occupation should be addressed. Thus, for that reason, therapy session can designed based on MOHO to bring benefit in improving one’s volition; good social
participation.
Assessment
Client interviews, biopsychosocial assessment and chemical use history of a client and their family can be used to understand how substance abuse has affected one’s ADLs, instrumental actives of daily living (IADLs) and people around the client. In addition, an addiction severity index (ASI) can be determined with a semi-structured interview to understand a client’s life, which will also suggest where to start therapy with the client. Then following assessments will help to assess the progress of clients undergoing treatment. The coping behavioral inventory (CBI) to assess behaviors and thoughts of clients, and behavioral assessment system for children- second edition (BAS-2) is used to assess behaviors and emotion in school and home environment. Also, the Canadian Occupational Performance Measure (COPM) may be used to access clients’ occupational performance, self-satisfaction or both.
Cognitive Behavioral therapy (CBT) Therapy sessions utilizing CBT will be effective for adolescents to control emotion, specifically anger. CBT is a client-centered therapy, which will guide clients’ to remove negative thoughts and build positive thoughts so that behavioral change can be made. Since the one's cognition is based on the assumptions of previous experiences, re-addressing the situation with evaluation can be helpful for the client to alter their thoughts. For example, role-playing anger causing situations, and self-monitoring (making a record of) anger in day-to-day living may be helpful for such purposes. A meta-analyses study of Hofmann, Asnaani, Vonk, Sawyer, & Fang in 2012 showed the efficacy of CBT with anger management. Moreover, CBT is used in various therapies, such as therapies for clients with TBI, OCD, depression, anxiety, psychosis, and many behavioral, emotional or psychosocial issues to recover occupational performance (Wheeler, Acord-Vira & Davis, 2016).
Treatment Goals Unregulated anger disrupts information processing, cognitive functions, and good judgment. Also, failure in anger management can result in unnecessary aggression-often a regrettable response that results in impaired social participation. Anger management based on CBT will bring improvement in social interaction to the individual.
When people can’t control emotion, they tend to make the wrong decisions. Having time to cool down will allow them to prevent making wrong decisions by having time to change their thoughts. Therefore a therapy session should focus on either taking time during stressful events, or reviewing self through self-reflection journals to alter thoughts causing angry behaviors. Long term Goal. By the end of the therapy session, the client will have 80% improvement in anger management during stressful events and will show improved social interaction.
Short term goal 1. By the end of the month, the patient will start to understand why he/she shouldn’t be angry at the more than 3/5 stressful events by utilizing daily anger journal.
Short term goal 2. By the end of 2 weeks, the patient will have time to cool down from angry thoughts during stressful events throughout the day, more than 3/5, by utilizing self-time out techniques.
Intervention.
Treatment Session 1. The individuals will write an anger journal every day for self-reflection. While keeping a daily journal, a participant will focus why anger was not necessary, what was the reason they were expressing anger and what was expected. By the end of the session, they should be able to be less angry with a similar situation because they understand being angry does not foster the result they seek. Participants are asked to mention what happened daily in detail, rate their anger levels for each incident, state what was the corresponding action he/she made and what was expected by expressing anger. Then, the clients are asked to write, whether they were able to receive the expected result and what other actions they could have taken to achieve their desired outcome.
At each weekly occupational therapy session, the individuals will discuss with the therapist and will receive a consultation on alternative ways to earn desired outcomes instead of expressing anger. Then, they will get a chance to change, by expressing emotions instead of anger and will follow up with the therapist to discuss resulting changes. The journal will be continued for one month, if it is necessary duration can be extended.
As the client monitors their own anger, they can observe their own progress and develop strategies to benefit in anger management (Perkinson, 2012). Their anger management will also be helpful in lowering stress level and preventing use of drugs or alcohol.
The author notes that this treatment session was modified from an anger journal session from Precin’s Living skills recover workbook (Precin, 2015).
Treatment Session 2. Individuals will learn how to take a “time-out” during an incident where they feel excessive stress and fail to control anger. Then, they will fill out the comparison chart how the outcome turned out. By experiencing less complication within social interaction with this technique, participants will start realizing expressed anger causes a negative impact to social interaction. Prior to the treatment sessions, a self-questionnaire is given to each participant for the therapist to construct stressful event scenarios. While the individual is exhibiting a failure to control their temper, the therapist will be given a verbal cue to stop the action and have a five-minute break. Clients are allowed to leave the situation and be isolated from the situation if it is necessary, then come back to continue participation. The individuals will write their self-reflections after participating in each situational scenario and compare how their emotions change before and after the break and how their social interaction changed with the change in their behavior.
The time-out technique is utilized to allow the client to take some time to regulate impulsive behaviors or anger and come up with alternative ways to express emotion. Improved social interaction and self-regulation in emotion are expected outcomes of adopting this method.
enhance the ADLs, work to aid in supporting the betterment of functional ADLs and QOL. And previous research has proven the effectiveness of occupational therapy with SUD patients (Hoxmark, Wynn& Wynn, 2011). Adolescent SUD is an especially rising concern among the various types of the SUD population because an untreated SUD can induce serious physiological and psychosocial issues and social crimes. As previous researchers found, untreated adolescent substance abuse has a higher risk of developing into a more serious form of SUD due to poor judgment processes by pre-mature brains. As such, adolescent substance abuse can have a worse prognosis than adults with SUD. (Casey, Jones, & Hare, 2008; reviewed by Winters & Arria, 2011). Thus, correcting an individual’s non-medical purpose alcohol use at early stage can prevent development of SUD. In particular, an adolescent alcohol abuser is more problematic because the limbic system of adolescents’ brains are not fully controlled by prefrontal lobe until the early 20s; they are not able to make logical judgments and easy to become severe substance abusers (Giedd, 2004; reviewed by Winters & Arria, 2011). Indeed, the importance of treating an alcohol abuse problem of adolescents is noticed by many others as well.
In 2006, American Occupational Therapy Association (AOTA)’s children and youth Ad Hoc Committee delineate one of the goals of AOTA’s Centennial Vision for pediatric occupational therapy as, “Studies that examine the emotional and social cost of occupational deprivation and occupational injustice for children and youth such as depression, alcohol and substance abuse, and suicide in disenfranchised youth, and what this is costing emotionally to youth and family as well as to society.” (Brown & Bourke-Taylor, 2014).
Etiology
The etiology of SUD is unknown, but it seems that a habit of persistent use of drugs, a desire to alter mood or to reach desired well-being causes SUD. The specific cause of children and adolescent SUD is unknown. Some possibilities include peer pressure, environment/context, genetic, failure to control impulsiveness and curiosity influences.
Alcohol Abuse …show more content…
(Alcoholics)
Alcohol is one of the most frequently used substances among any SUD populations and seems to be the initial form of substance abuse. According to the result from the 2014 national survey on drug use and health, 139.7 million Americans aged 12 or older reported current use of alcohol and 23.8 percent are heavy drinkers. The highest alcohol use population was young adults (age 18-25), 59.6 percent. The adolescent (12-17) population was only 11.6 percent but because they are vulnerable to addiction, they quickly become abusers and have the worse prognosis than other populations (HHS Publication No. SMA 15-4927, 2015).
Adolescent drug abuse typically begins with caffeine, nicotine, and alcohol to seek the desired effect because it is inexpensive to attain. As they build a tolerance to these, they move on to stronger substances such as marijuana and heroines and then it becomes harder to live without taking substances. Short term use of alcohol can be effective to alter the mood with only mild health problems, but prolonged use can lead to personality, mood, cognitive functioning, and various physiological problems. Persistent use can be fatal, when abuse is severe or if there is interaction with other drugs (Perkinson, 2012). Adolescents’ alcohol abuse can cause disruption in brain development leading to a various malfunctions of the brain, such as a malfunctions to cognitive function, mood control, executive function, communication, and personality. Alcohol abuse not only interrupts brain development, but also it can cause alcohol intoxication, alcohol amnestic disorder, Wernicke-Korsakoff syndrome, alcoholic idiosyncratic intoxication, alcohol withdrawal, alcohol withdrawal seizures, and alcohol withdrawal delirium which are all serious health problems (Perkinson, 2012).
Evidence-based Treatment
Model of Human Occupation (MOHO) A treatment session based on the model of human occupation (MOHO) can be beneficial. MOHO is an occupation-focused model to “provide an overarching context of occupation that emphasizes the occupational therapist's unique perspective on a client’s ability to engage in activities and participate in life” and “attempt to explain the relationship of occupation, person and environment” (Cole & Tufano, 2008, p. 61). MOHO focuses on the concept of volition, habituation and performance capacity, which are the keys to understanding human occupation (Kielhofner, 2002). Volition includes person’s values, which an individual finds meaningful and important, and interests and personal causation which refers to a sense of competence and effectiveness. The habituation is a given context of physical, temporal and social being which influences an individual to develop a certain behavioral pattern or take new actions and decisions. Performance capacity is mental and physical attribution and life experiences. As these three factors influence an individual to engage in an occupation, MOHO aims to explain how disability and illness hinder occupational performance and it focuses on supporting individuals to successfully perform the occupation (Kielhofner, 2002). Individuals with SUD are unable to engage in social participation successfully because a failure in emotional control and stress management, such as anger, aggression and impulsiveness, makes it difficult for the individuals to be accepted by peers.
As it continues, SUD hinders social participation in a serious manner. A good social participation can support better peer interaction which was the main caused of substance abuse within the population, what is hindering this occupation should be addressed. Thus, for that reason, therapy session can designed based on MOHO to bring benefit in improving one’s volition; good social
participation.
Assessment
Client interviews, biopsychosocial assessment and chemical use history of a client and their family can be used to understand how substance abuse has affected one’s ADLs, instrumental actives of daily living (IADLs) and people around the client. In addition, an addiction severity index (ASI) can be determined with a semi-structured interview to understand a client’s life, which will also suggest where to start therapy with the client. Then following assessments will help to assess the progress of clients undergoing treatment. The coping behavioral inventory (CBI) to assess behaviors and thoughts of clients, and behavioral assessment system for children- second edition (BAS-2) is used to assess behaviors and emotion in school and home environment. Also, the Canadian Occupational Performance Measure (COPM) may be used to access clients’ occupational performance, self-satisfaction or both.
Cognitive Behavioral therapy (CBT) Therapy sessions utilizing CBT will be effective for adolescents to control emotion, specifically anger. CBT is a client-centered therapy, which will guide clients’ to remove negative thoughts and build positive thoughts so that behavioral change can be made. Since the one's cognition is based on the assumptions of previous experiences, re-addressing the situation with evaluation can be helpful for the client to alter their thoughts. For example, role-playing anger causing situations, and self-monitoring (making a record of) anger in day-to-day living may be helpful for such purposes. A meta-analyses study of Hofmann, Asnaani, Vonk, Sawyer, & Fang in 2012 showed the efficacy of CBT with anger management. Moreover, CBT is used in various therapies, such as therapies for clients with TBI, OCD, depression, anxiety, psychosis, and many behavioral, emotional or psychosocial issues to recover occupational performance (Wheeler, Acord-Vira & Davis, 2016).
Treatment Goals Unregulated anger disrupts information processing, cognitive functions, and good judgment. Also, failure in anger management can result in unnecessary aggression-often a regrettable response that results in impaired social participation. Anger management based on CBT will bring improvement in social interaction to the individual.
When people can’t control emotion, they tend to make the wrong decisions. Having time to cool down will allow them to prevent making wrong decisions by having time to change their thoughts. Therefore a therapy session should focus on either taking time during stressful events, or reviewing self through self-reflection journals to alter thoughts causing angry behaviors. Long term Goal. By the end of the therapy session, the client will have 80% improvement in anger management during stressful events and will show improved social interaction.
Short term goal 1. By the end of the month, the patient will start to understand why he/she shouldn’t be angry at the more than 3/5 stressful events by utilizing daily anger journal.
Short term goal 2. By the end of 2 weeks, the patient will have time to cool down from angry thoughts during stressful events throughout the day, more than 3/5, by utilizing self-time out techniques.
Intervention.
Treatment Session 1. The individuals will write an anger journal every day for self-reflection. While keeping a daily journal, a participant will focus why anger was not necessary, what was the reason they were expressing anger and what was expected. By the end of the session, they should be able to be less angry with a similar situation because they understand being angry does not foster the result they seek. Participants are asked to mention what happened daily in detail, rate their anger levels for each incident, state what was the corresponding action he/she made and what was expected by expressing anger. Then, the clients are asked to write, whether they were able to receive the expected result and what other actions they could have taken to achieve their desired outcome.
At each weekly occupational therapy session, the individuals will discuss with the therapist and will receive a consultation on alternative ways to earn desired outcomes instead of expressing anger. Then, they will get a chance to change, by expressing emotions instead of anger and will follow up with the therapist to discuss resulting changes. The journal will be continued for one month, if it is necessary duration can be extended.
As the client monitors their own anger, they can observe their own progress and develop strategies to benefit in anger management (Perkinson, 2012). Their anger management will also be helpful in lowering stress level and preventing use of drugs or alcohol.
The author notes that this treatment session was modified from an anger journal session from Precin’s Living skills recover workbook (Precin, 2015).
Treatment Session 2. Individuals will learn how to take a “time-out” during an incident where they feel excessive stress and fail to control anger. Then, they will fill out the comparison chart how the outcome turned out. By experiencing less complication within social interaction with this technique, participants will start realizing expressed anger causes a negative impact to social interaction. Prior to the treatment sessions, a self-questionnaire is given to each participant for the therapist to construct stressful event scenarios. While the individual is exhibiting a failure to control their temper, the therapist will be given a verbal cue to stop the action and have a five-minute break. Clients are allowed to leave the situation and be isolated from the situation if it is necessary, then come back to continue participation. The individuals will write their self-reflections after participating in each situational scenario and compare how their emotions change before and after the break and how their social interaction changed with the change in their behavior.
The time-out technique is utilized to allow the client to take some time to regulate impulsive behaviors or anger and come up with alternative ways to express emotion. Improved social interaction and self-regulation in emotion are expected outcomes of adopting this method.