Occupational Therapy Practice Framework:

Domain and Process

Fourth Edition

Note. This is a prepublication draft of a manuscript that will be published

in the American Journal of Occupational Therapy, 74 (Supplement 2),
scheduled for publication in August 2020. Readers may notice minor
differences between this version and the final published version.

Citation. American Occupational Therapy Association. (in press).

Occupational therapy practice framework: Domain and process (4th ed.).
American Journal of Occupational Therapy, 74 (Supplement 2).
Advance online publication.

Copyright © 2020 by the American Occupational Therapy Association.

Direct permissions inquiries to [email protected].

PREPUBLICATION DRAFT. Page i of 96

 Contents

Preface ...........................................................................................................................................................................1
Definitions .................................................................................................................................................................1
Evolution of This Document .....................................................................................................................................2
Vision for This Work .................................................................................................................................................3
Introduction ...................................................................................................................................................................4
Occupation and Occupational Science.......................................................................................................................4
OTPF Organization ...................................................................................................................................................4
Cornerstones of Occupational Therapy Practice ........................................................................................................6
Domain ..........................................................................................................................................................................7
Occupations ...............................................................................................................................................................7
Contexts ................................................................................................................................................................... 10
Environmental Factors ......................................................................................................................................... 10
Personal Factors ................................................................................................................................................... 11
Application of Context to Occupational Justice .................................................................................................. 12
Performance Patterns ............................................................................................................................................... 13
Performance Skills ................................................................................................................................................... 14
Application of Performance Skills with Persons ................................................................................................. 16
Application of Performance Skills with Groups .................................................................................................. 16
Application of Performance Skills with Populations ........................................................................................... 17
Client Factors ........................................................................................................................................................... 17
Process ......................................................................................................................................................................... 18
Overview of the Occupational Therapy Process ...................................................................................................... 20
Service Delivery Approaches .............................................................................................................................. 20
Practice Within Organizations and Systems ........................................................................................................ 22
Occupational and Activity Analysis .................................................................................................................... 22
Therapeutic Use of Self ....................................................................................................................................... 22
Clinical and Professional Reasoning ................................................................................................................... 23
Evaluation ................................................................................................................................................................ 24
Occupational Profile ............................................................................................................................................ 24
Analysis of Occupational Performance ............................................................................................................... 26
Synthesis of the Evaluation Process .................................................................................................................... 26
Intervention Process ................................................................................................................................................ 27
Intervention Plan.................................................................................................................................................. 28
Intervention Implementation ............................................................................................................................... 29
Intervention Review ............................................................................................................................................ 30
Outcomes ................................................................................................................................................................. 30

PREPUBLICATION DRAFT. Page ii of 96

 Outcome Measurement ........................................................................................................................................ 31
Transition and Discontinuation ............................................................................................................................ 32
Conclusion ................................................................................................................................................................... 32
References ................................................................................................................................................................... 33
Tables .......................................................................................................................................................................... 43
Table 1. Examples of Clients: Persons, Groups, and Populations ........................................................................... 43
Table 2. Occupations ............................................................................................................................................... 44
Table 3. Examples of Occupations for Persons, Groups, and Populations .............................................................. 48
Table 4. Context: Environmental Factors ................................................................................................................ 49
Table 5. Context: Personal Factors .......................................................................................................................... 52
Table 6. Performance Patterns ................................................................................................................................. 53
Table 7. Performance Skills for Persons .................................................................................................................. 55
Table 8. Performance Skills for Groups .................................................................................................................. 62
Table 9. Client Factors ............................................................................................................................................. 63
Table 10. Occupation and Activity Demands .......................................................................................................... 67
Table 11. Occupational Therapy Process for Persons, Groups, and Populations .................................................... 70
Table 12. Types of Occupational Therapy Interventions ......................................................................................... 73
Table 13. Approaches to Intervention ...................................................................................................................... 77
Table 14. Outcomes ................................................................................................................................................. 79
Glossary ....................................................................................................................................................................... 83

PREPUBLICATION DRAFT. Page iii of 96

 Occupational Therapy Practice Framework: Domain and Process
Fourth Edition

Preface
The Occupational Therapy Practice Framework: Domain and Process, fourth edition
(hereinafter referred to as “the OTPF–4”), is an official document of the American Occupational
Therapy Association (AOTA). Intended for occupational therapy practitioners and students,
other health care professionals, educators, researchers, payers, policymakers, and consumers, the
OTPF–4 presents a summary of interrelated constructs that describe occupational therapy
practice.

Definitions
Within the OTPF–4, occupational therapy is defined as the therapeutic use of everyday life
occupations with persons, groups, or populations (i.e., the client) for the purpose of enhancing or
enabling participation. Occupational therapy practitioners use their knowledge of the
transactional relationship among the client, their engagement in valuable occupations, and the
context to design occupation-based intervention plans. Occupational therapy services are
provided for habilitation, rehabilitation, and promotion of health and wellness for clients with
disability- and non–disability-related needs. These services include acquisition and preservation
of occupational identity for clients who have or are at risk for developing an illness, injury,
disease, disorder, condition, impairment, disability, activity limitation, or participation restriction
(AOTA, 2011; see the glossary in Appendix A for additional definitions).
When the term occupational therapy practitioner is used in this document, it refers to both
occupational therapists and occupational therapy assistants (AOTA, 2015b). Occupational
therapists are responsible for all aspects of occupational therapy service delivery and are
accountable for the safety and effectiveness of the occupational therapy service delivery process.
Occupational therapy assistants deliver occupational therapy services under the supervision of
and in partnership with an occupational therapist (AOTA, 2014a).
The clients of occupational therapy are typically classified as persons (including those
involved in care of a client), groups (a collection of individuals having shared characteristics or a
common or shared purpose, e.g., family members, workers, students, people with similar
interests or occupational challenges), and populations (aggregates of people with common
attributes such as contexts, characteristics, or concerns, including health risks; Scaffa & Reitz,
2014). People may also consider themselves as part of a community, such as the Deaf community
or the disability community; a community is a collection of populations that is changeable and
diverse and includes various people, groups, networks, and organizations (Scaffa, 2019; World
Federation of Occupational Therapists [WFOT], 2019). It is important to consider the
community or communities with which a client identifies throughout the occupational therapy
process.
Whether the client is a person, group, or population, information about the client’s wants,
needs, strengths, contexts, limitations, and occupational risks is gathered, synthesized, and
framed from an occupational perspective. Throughout the OTPF–4, the term client is used

PREPUBLICATION DRAFT. Page 1 of 96

broadly to refer to persons, groups, and populations unless otherwise specified. In the OTPF–4,
“group” as a client is distinctly different from “group” as an intervention approach. For examples
of clients, see Table 1 (all tables are placed together at the end of this document). The glossary in
Appendix A provides definitions of other terms used in this document.

Evolution of This Document

The Occupational Therapy Practice Framework was originally developed to articulate
occupational therapy’s distinct perspective and contribution to promoting the health and
participation of persons, groups, and populations through engagement in occupation. The first
edition of the OTPF emerged from an examination of documents related to the Occupational
Therapy Product Output Reporting System and Uniform Terminology for Reporting
Occupational Therapy Services (AOTA, 1979). Originally a document that responded to a
federal requirement to develop a uniform reporting system, this text gradually shifted to
describing and outlining the domains of concern of occupational therapy.
The second edition of Uniform Terminology for Occupational Therapy (AOTA, 1989) was
adopted by the AOTA Representative Assembly (RA) and published in 1989. The document
focused on delineating and defining only the occupational performance areas and occupational
performance components that are addressed in occupational therapy direct services. The third
and final edition of Uniform Terminology for Occupational Therapy (UT–III; AOTA, 1994) was
adopted by the RA in 1994 and was “expanded to reflect current practice and to incorporate
contextual aspects of performance” (p. 1047). Each revision reflected changes in practice and
provided consistent terminology for use by the profession.
In fall 1998, the AOTA Commission on Practice (COP) embarked on the journey that
culminated in the Occupational Therapy Practice Framework: Domain and Process (AOTA,
2002b). At that time, AOTA also published The Guide to Occupational Therapy Practice
(Moyers, 1999), which outlined contemporary practice for the profession. Using this document
and the feedback received during the review process for the UT–III, the COP proceeded to
develop a document that more fully articulated occupational therapy.
The OTPF is an ever-evolving document. As an official AOTA document, it is reviewed on a
5-year cycle for usefulness and the potential need for further refinements or changes. During the
review period, the COP collects feedback from AOTA members, scholars, authors, practitioners,
AOTA volunteer leadership and staff, and other stakeholders. The revision process ensures that
the OTPF maintains its integrity while responding to internal and external influences that should
be reflected in emerging concepts and advances in occupational therapy.
The OTPF was first revised and approved by the RA in 2008. Changes to the document
included refinement of the writing and the addition of emerging concepts and changes in
occupational therapy. The rationale for specific changes can be found in Table 11 of the OTPF–2
(AOTA, 2008, pp. 665–667).
In 2012, the process of review and revision of the OTPF was initiated again, and several
changes were made. The rationale for specific changes can be found on page S2 of the OTPF–3
(AOTA, 2014).
In 2018, the process to revise the OTPF began again. Following member review and
feedback, several modifications were made and are reflected in this document:

PREPUBLICATION DRAFT. Page 2 of 96

  Focus is increased on group and population clients, and examples are provided for both.
 Cornerstones of occupational therapy practice are identified and described as foundational to the success of
occupational therapy practitioners.
 Occupational science is more explicitly described and defined.
 The terms occupation and activity are more clearly defined.
 For occupations, the definition of sexual activity as an ADL is revised, health management is added as a
general occupation category, and intimate partner is added in the social participation category (see Table 2).
 The contexts and environments aspect of the occupational therapy domain is changed to context on the basis
of the World Health Organization (WHO; 2008) taxonomy from the International Classification of
Functioning, Disability and Health (ICF) in an effort to adopt standard, well-accepted definitions (see Table
4).
 For the client factors category of body functions, gender identity is now included under “experience of self
and time,” the definition of psychosocial is expanded to match the ICF description, and interoception is added
under sensory functions.
 For types of intervention, “preparatory methods and tasks” has been changed to “interventions to support
occupations” (see Table 12).
 For outcomes, transitions and discontinuation are discussed as conclusions to occupational therapy services,
and patient-reported outcomes are addressed (see Table 14).
 Five new tables are added to expand on and clarify concepts:
○ Table 1. Examples of Clients: Persons, Groups, and Populations
○ Table 3. Examples of Occupations for Persons, Groups, and Populations
○ Table 7. Performance Skills for Persons (includes examples of effective and ineffective performance
skills)
○ Table 8. Performance Skills for Groups (includes examples of the impact of ineffective individual
performance skills on group collective outcome)
○ Table 11. Occupational Therapy Process for Persons, Groups, and Populations.
 Throughout, the use of OTPF rather than Framework acknowledges the current requirements for a unique
identifier to maximize digital discoverability and for brevity in social media communications, as well as the
long-term use of the acronym in academic teaching and clinical practice.
 Figure 1 has been revised to provide a simplified visual depiction of the domain and process of occupational
therapy.

Vision for This Work

Although this edition of the OTPF represents the latest in the profession’s efforts to clearly
articulate the occupational therapy domain and process, it builds on a set of values that the
profession has held since its founding in 1917. The original vision had at its center a profound
belief in the value of therapeutic occupations as a way to remediate illness and maintain health
(Slagle, 1924). The founders emphasized the importance of establishing a therapeutic
relationship with each client and designing a treatment plan based on knowledge about the
client’s environment, values, goals, and desires (Meyer, 1922). They advocated for scientific
practice based on systematic observation and treatment (Dunton, 1934). Paraphrased using
today’s lexicon, the founders proposed a vision that was occupation based, client centered,
contextual, and evidence based—the vision articulated in the OTPF.

PREPUBLICATION DRAFT. Page 3 of 96

 Introduction
The purpose of a framework is to provide a structure or base on which to build a system or a
concept (American Heritage Dictionary, 2020). The Occupational Therapy Practice
Framework: Domain and Process describes the central concepts that ground occupational
therapy practice and builds a common understanding of the basic tenets and vision of the
profession. The OTPF–4 does not serve as a taxonomy, theory, or model of occupational
therapy. By design, the OTPF–4 must be used to guide occupational therapy practice in
conjunction with the knowledge and evidence relevant to occupation and occupational therapy
within the identified areas of practice and with the appropriate clients. In addition, the OTPF-4 is
intended to be a valuable tool in the academic preparation of students, communicating to the
public and policymakers, and providing language that can shape and be shaped by research.

Occupation and Occupational Science

Embedded in this document is the occupational therapy profession’s core belief in the positive
relationship between occupation and health and its view of people as occupational beings.
Occupational therapy practice emphasizes the occupational nature of humans and the importance
of occupational identity (Unruh, 2004) to healthful, productive, and satisfying living. As Hooper
and Wood (2019) stated,
A core philosophical assumption of the profession, therefore, is that by virtue of our biological endowment,
people of all ages and abilities require occupation to grow and thrive; in pursuing occupation, humans
express the totality of their being, a mind–body–spirit union. Because human existence could not otherwise
be, humankind is, in essence, occupational by nature. (p. 46)

Occupational science is important to the practice of occupational therapy and “provides a

way of thinking that enables an understanding of occupation, the occupational nature of humans,
the relationship between occupation, health and wellbeing, and the influences that shape
occupation” (WFOT, 2012b, p. 2). Many of its concepts are emphasized throughout the OTPF,
including occupational justice and injustice, identity, time use, satisfaction, engagement, and
performance.

OTPF Organization
The OTPF is divided into two major sections: (1) the domain, which outlines the profession’s
purview and the areas in which its members have an established body of knowledge and
expertise, and (2) the process, which describes the actions practitioners take when providing
services that are client centered and focused on engagement in occupations. The profession’s
understanding of the domain and process of occupational therapy guides practitioners as they
seek to support clients’ participation in daily living, which results from the dynamic intersection
of clients, their desired engagements, and their contexts (including environmental and personal
factors; Christiansen & Baum, 1997; Christiansen et al., 2005; Law et al., 2005).
Achieving health, well-being, and participation in life through engagement in occupation is
the overarching statement that describes the domain and process of occupational therapy in its
fullest sense. This statement acknowledges the profession’s belief that active engagement in
occupation promotes, facilitates, supports, and maintains health and participation. These
interrelated concepts include

PREPUBLICATION DRAFT. Page 4 of 96

  Health—“a state of complete physical, mental, and social well-being, and not merely the absence of disease or
infirmity” (WHO, 2006, p. 1).
 Well-being—“a general term encompassing the total universe of human life domains, including physical,
mental, and social aspects” (WHO, 2006, p. 211).
 Participation—“involvement in a life situation” (WHO, 2008, p. 10). Participation occurs naturally when
clients are actively involved in carrying out occupations or daily life activities they find purposeful and
meaningful. More specific outcomes of occupational therapy intervention are multidimensional and support
the end result of participation.
 Engagement in occupation—performance of occupations as the result of choice, motivation, and meaning
within a supportive context (including environmental and personal factors). Engagement includes objective
and subjective aspects of clients’ experiences and involves the transactional interaction of the mind, body, and
spirit. Occupational therapy intervention focuses on creating or facilitating opportunities to engage in
occupations that lead to participation in desired life situations (AOTA, 2008).
Although the domain and process are described separately, in actuality they are linked
inextricably in a transactional relationship. The aspects that constitute the domain and those that
constitute the process exist in constant interaction with one another during the delivery of
occupational therapy services. Figure 1 represents aspects of the domain and process and the
overarching goal of the profession as achieving health, well-being, and participation in life
through engagement in occupation. While the figure illustrates these 2 elements, in reality the
domain and process interact in complex and dynamic ways as described throughout this
document. The nature of the interactions is impossible to capture in a static one-dimensional
image.

Figure 1. Occupational Therapy Domain and Process

PREPUBLICATION DRAFT. Page 5 of 96

Cornerstones of Occupational Therapy Practice
The transactional relationship between the domain and process is facilitated by the occupational
therapy practitioner. Occupational therapy practitioners have distinct knowledge, skills, and
qualities that contribute to the success of the occupational therapy process, described in this
document as “cornerstones.” A cornerstone can be defined as something of great importance on
which everything else depends, (Cambridge University Press, n.d.), and the following
cornerstones of occupational therapy help distinguish it from other professions:
 Core values and beliefs rooted in occupation (Cohen, 2019; Hinojosa, Kramer, Royeen, & Luebben, 2017) 23-
39)
 Knowledge and expertise in the therapeutic use of occupation (Gillen, 2013; Gillen, Hunter, Lieberman, &
Stutzbach, 2019)
 Professional behaviors and dispositions (AOTA 2015a; AOTA, 2015c)
 Therapeutic use of self (AOTA, 2015c; Taylor, 2020)

The cornerstones are not hierarchical; instead, each concept influences the others.
Occupational therapy cornerstones provide a fundamental foundation for practitioners from
which they view clients and their occupations and facilitate the occupational therapy process.
Practitioners develop the cornerstones over time through education, mentorship, and experience.
In addition, the cornerstones are ever evolving, reflecting developments in occupational therapy
practice and occupational science.
Many contributors influence each cornerstone. Like the cornerstones, the contributors are
complementary and interact to provide a foundation for the practitioner. The contributors
include, but are not limited to, the following:
 Client-centered practice
 Clinical and professional reasoning
 Competencies for practice
 Cultural humility
 Ethics
 Evidence-informed practice
 Inter- and intraprofessional collaborations
 Leadership
 Lifelong learning
 Micro and macro systems knowledge
 Occupation-based practice
 Professionalism
 Professional advocacy
 Self-advocacy
 Self-reflection
 Theory-based practice.

PREPUBLICATION DRAFT. Page 6 of 96

 Domain
Exhibit 1 identifies the aspects of the occupational therapy domain: occupations, contexts,
performance patterns, performance skills, and client factors. All aspects of the domain have a
dynamic interrelatedness. All aspects are of equal value and together interact to affect
occupational identity, health, well-being, and participation in life.

Exhibit 1. Aspects of the Occupational Therapy Domain

All aspects of the occupational therapy domain transact to support engagement, participation, and health. This
exhibit does not imply a hierarchy.
Performance
Occupations Contexts Patterns Performance Skills Client Factors
Activities of daily living Environmental Habits Motor skills Values, beliefs, and
(ADLs) factors Routines Process skills spirituality
Instrumental activities of Personal factors Roles Social interaction Body functions
daily living (IADLs) Rituals skills Body structures
Health management
Rest and sleep
Education
Work
Play
Leisure
Social participation

Occupational therapists are skilled in evaluating all aspects of the domain, the
interrelationships among the aspects, and the client within context. Occupational therapy
practitioners recognize the importance and impact of the mind–body–spirit connection on
engagement and participation in daily life. Knowledge of the transactional relationship and the
significance of meaningful and productive occupations forms the basis for the use of occupations
as both the means and the ends of interventions (Trombly, 1995). This knowledge sets
occupational therapy apart as a distinct and valuable service (Hildenbrand & Lamb, 2013) for
which a focus on the whole is considered stronger than a focus on isolated aspects of human
functioning.
The discussion that follows provides a brief explanation of each aspect of the domain. Tables
included at the end of the document provide additional descriptions and definitions of terms.

Occupations
Occupations are central to a client’s (person’s, group’s, or population’s) health, identity, and
sense of competence and have particular meaning and value to that client. “In occupational
therapy, occupations refer to the everyday activities that people do as individuals, in families,
and with communities to occupy time and bring meaning and purpose to life. Occupations
include things people need to, want to and are expected to do” (WFOT, 2012a, para. 2).
In the OTPF–4, the term occupation denotes personalized and meaningful engagement in
daily life events by a specific client. Conversely, the term activity denotes a form of action that is
objective and not related to a specific client’s engagement or context (Schell et al., 2019) and,
therefore, can be selected and designed to enhance occupational engagement by supporting the

PREPUBLICATION DRAFT. Page 7 of 96

development of performance skills and performance patterns. Both occupations and activities are
used as interventions by practitioners. For example, a practitioner may use the activity of
chopping vegetables during an intervention to address fine motor skills with the ultimate goal of
improving motor skills for the occupation of preparing a favorite meal. Participation in
occupations is considered both the means and the end in the occupational therapy process.
Occupations occur in contexts and are influenced by the interplay among performance
patterns, performance skills, and client factors. Occupations occur over time; have purpose,
meaning, and perceived utility to the client; and can be observed by others (e.g., preparing a
meal) or be known only to the person involved (e.g., learning through reading a textbook).
Occupations can involve the execution of multiple activities for completion and can result in
various outcomes.
The OTPF identifies a broad range of occupations categorized as activities of daily living
(ADLs), instrumental activities of daily living (IADLs), health management, rest and sleep,
education, work, play, leisure, and social participation (Table 2). Within each of these nine broad
categories of occupation are many specific occupations. For example, the broad category of
IADLs has specific occupations that include grocery shopping and money management.
When occupational therapy practitioners work with clients, they identify the types of
occupations clients engage in individually or with others. Differences among clients and the
occupations they engage in are complex and multidimensional. The client’s perspective on how
an occupation is categorized varies depending on that client’s needs, interests, and contexts.
Furthermore, values attached to occupations are dependent on cultural and sociopolitical
determinants (Wilcock & Townsend, 2019). For example, one person may perceive gardening as
leisure, whereas another person, who relies on the food produced from that garden to feed their
family or community, may perceive it as work. Additional examples of occupations for
individuals, groups, and populations can be found in Table 3.
The ways in which clients prioritize engagement in selected occupations may vary at
different times. For example, clients in a community psychiatric rehabilitation setting may
prioritize registering to vote during an election season and food preparation during holidays. The
unique features of occupations are noted and analyzed by occupational therapy practitioners,
who consider all components of the engagement and use them effectively as both a therapeutic
tool and a way to achieve the targeted outcomes of intervention.
The extent to which a client is engaged in a particular occupation is also important.
Occupational therapy practitioners assess the client’s ability to engage in occupational
performance, defined as the accomplishment of the selected occupation resulting from the
dynamic transaction among the client, their contexts, and the occupation. Occupations can
contribute to a well-balanced and fully functional lifestyle or to a lifestyle that is out of balance
and characterized by occupational dysfunction. For example, excessive work without sufficient
regard for other aspects of life, such as sleep or relationships, places clients at risk for health
problems. External factors, including war, natural disasters, or extreme poverty, may hinder a
client’s ability to create balance or engage in certain occupations (AOTA, 2017b; McElroy et al.,
2012).
Because occupational performance does not exist in a vacuum, context must always be
considered. For example, for a client who lives in food desert, lack of access to a grocery store
may limit their ability to have balance in their performance of IADLs such as cooking and

PREPUBLICATION DRAFT. Page 8 of 96

grocery shopping or to follow medical advice from health care professionals on health
management and preparation of nutritious meals. For this client, the limitation is not caused by
impaired client factors or performance skills but rather is shaped by the context in which the
client functions. This context may include policies that resulted in the decline of commercial
properties in the area, a socioeconomic status that does not enable the client to live in an area
with access to a grocery store, and a social environment in which lack of access to fresh food is
weighed as less important than the social supports the community provides.
Occupational therapy practitioners recognize that health is supported and maintained when
clients are able to engage in home, school, workplace, and community life. Thus, practitioners
are concerned not only with occupations but also with the variety of factors that disrupt or
empower those occupations and influence clients’ engagement and participation in positive
health-promoting occupations (Wilcock & Townsend, 2019).
Although engagement in occupations is generally considered a positive outcome of the
occupational therapy process, it is important to consider that a client’s history might include
negative, traumatic, or unhealthy occupational participation (Robinson Johnson & Dickie, 2019).
For example, a person who has experienced a traumatic sexual encounter might negatively
perceive and react to engagement in sexual intimacy. A person with an eating disorder might
engage in eating in a maladaptive way, deterring health management and physical health.
In addition, some occupations that are meaningful to a client might also hinder performance
in other occupations or negatively affect health. For example, a person who spends a
disproportionate amount of time playing video games may develop a repetitive stress injury and
may have less balance in their time spent on IADLs and other forms of social participation. A
client engaging in the recreational use of prescription pain medications may experience barriers
to participation in previously important occupations such as work or spending time with family.
Occupations have the capacity to support or promote other occupations. For example,
children engage in play to develop the performance skills to later facilitate engagement in leisure
and work. Adults may engage in social participation and leisure with an intimate partner that
may improve satisfaction with sexual activity. The goal of engagement in sleep and health
management includes maintaining or improving performance of work, leisure, social
participation, and other occupations.
Occupations often are shared and done with others. Those that implicitly involve two or more
individuals are termed co-occupations (Zemke & Clark, 1996). Co-occupations are the most
interactive of all social occupations. Central to the concept of co-occupation is that two or more
individuals share a high level of physicality, emotionality, and intentionality (Pickens & Pizur-
Barnekow, 2009). In addition, co-occupations can be parallel (beside each other, not connected;
e.g., reading while riding the subway) and shared (participating in the same occupation but not
interacting; e.g., using a stationary bike in a gym while others independently exercise; (Zemke &
Clark, 1996).
Caregiving is a co-occupation that requires active participation by both the caregiver and the
recipient of care. For the co-occupations required during parenting, the socially interactive
routines of eating, feeding, and comforting may involve the parent, a partner, the child, and
significant others (Olson, 2004). The specific occupations inherent in this social interaction are
reciprocal, interactive, and nested (Dunlea, 1996; Esdaile & Olson, 2004). Consideration of co-

PREPUBLICATION DRAFT. Page 9 of 96

occupations by practitioners supports an integrated view of the client’s engagement in the
context of relationship to significant others.
Occupational participation can be considered independent whether it occurs individually or
with others. It is important to acknowledge that clients can be independent in living regardless of
the amount of assistance they receive while completing occupations. Clients may be considered
independent even when they direct others (e.g., caregivers) in performing the actions necessary
to participate, regardless of the amount or kind of assistance required, if they are satisfied with
their performance. In contrast to definitions of independence that imply direct physical
interaction with the environment or objects within the environment, occupational therapy
practitioners consider clients to be independent whether they perform the specific occupations by
themselves, in an adapted or modified environment, with the use of various devices or alternative
strategies, or while overseeing activity completion by others (AOTA, 2002a). For example, a
person with spinal cord injury who directs a personal care assistant to assist them with ADLs is
demonstrating independence in this essential aspect of their life.
It is also important to acknowledge that not all clients view success as independence.
Interdependence, or co-occupational performance, can also be an indicator of personal success.
How a client views success may be influenced by their client factors, including their culture.

Contexts
Context is a broad construct defined as the environmental and personal factors specific to each
client (person, group, population) that influence engagement and participation in occupations.
Context affect clients’ access to occupations and the quality of and satisfaction with performance
(WHO, 2008). Practitioners recognize that for people to truly achieve full participation, meaning,
and purpose, they must not only function but also engage comfortably within their own distinct
combination of contexts.
In the literature, the terms environment and context often are used interchangeably, but this
may result in confusion when describing aspects of situations in which occupational engagement
takes place. Understanding the contexts in which occupations can and do occur provides
practitioners with insights into the overarching, underlying, and embedded influences of
environmental factors and personal factors on engagement in occupations.

Environmental Factors
Environmental factors are aspects of the physical, social, and attitudinal surroundings in which
people live and conduct their lives (Table 4). Environmental factors influence functioning and
disability and have positive aspects (facilitators) or negative aspects (barriers or hindrances;
WHO, 2008). Environmental factors include
 Natural environment and human-made changes to the environment: Animate and inanimate elements of the
natural or physical environment and components of that environment that have been modified by people, as
well as characteristics of human populations within that environment. Engagement in human occupation
influences the sustainability of the natural environment, and changes to human behavior can have a positive
impact on the environment (Dennis et al., 2015).
 Products and technology: Natural or human-made products or systems of products, equipment, and
technology that are gathered, created, produced, or manufactured.

PREPUBLICATION DRAFT. Page 10 of 96

  Support and relationships: People or animals that provide practical physical or emotional support, nurturing,
protection, assistance, and connections to other persons in the home, workplace, or school or at play or in
other aspects of daily occupations.
 Attitudes: Observable evidence of customs, practices, ideologies, values, norms, factual beliefs, and religious
beliefs held by people other than the client.
 Services, systems, and policies: Benefits, structured programs, and regulations for operations provided by
institutions in various sectors of society designed to meet the needs of persons, groups, and populations.
When people interact with the world around them, environmental factors can either enable or
restrict participation in meaningful occupations and can present barriers to or supports and
resources for service delivery. Examples of environmental barriers that restrict participation
include the following:
 For persons, doorway widths that do not allow for wheelchair passage
 For groups, absence of healthy social opportunities for those abstaining from alcohol use
 For populations, businesses that are not welcoming to people who identify as LGBTQ+. (Note: In this
document, LGBTQ+ is used to represent the large and diverse communities and individuals with nonmajority
sexual orientations and gender identities.)

Addressing these barriers, such as by widening a doorway to allow access, results in

environmental supports that enable participation. A client who has difficulty performing
effectively in one context may be successful when the natural environment has human-made
modifications or if the client uses applicable products and technology. Additionally, occupational
therapy practitioners must be aware of, for example, norms related to eating or deference to
medical professionals when working with someone from a culture or socioeconomic status that
differs from their own.

Personal Factors
Personal factors are the unique features of a person that are not part of a health condition or
health state and that constitute the particular background of the person’s life and living (Table 5).
Personal factors are internal influences affecting functioning and disability and are not
considered positive or negative, but rather reflect the essence of the person—“who they are.”
When clients provide demographic information, they are typically describing personal factors.
Personal factors also include customs, beliefs, activity patterns, behavioral standards, and
expectations accepted by the society or cultural group of which a person is a member.
Personal factors are generally considered to be enduring, stable attributes of the person,
although some personal factors change over time. They include, but are not limited to, the
following:
 Chronological age
 Sexual orientation (sexual preference, sexual identity)
 Gender identity
 Race and ethnicity
 Cultural identification and attitudes
 Social background, social status, and socioeconomic status

PREPUBLICATION DRAFT. Page 11 of 96

  Upbringing and life experiences
 Habits and past and current behavioral patterns
 Psychological assets, temperament, unique character traits, and coping styles
 Education
 Profession and professional identity
 Lifestyle
 Health conditions and fitness status (that may affect the person’s occupations but are not the primary concern
of the occupational therapy encounter).

For example, siblings share personal factors of race and age, yet for those separated at birth,
environmental differences may result in divergent personal factors in terms of cultural
identification, upbringing, and life experiences, producing different contexts for their individual
occupational engagement. Whether separated or raised together, as siblings move through life,
they may develop differences in sexual orientation, life experience, habits, education, profession,
and lifestyle.
Groups and populations are often formed or identified on the basis of shared or similar
personal factors that make possible occupational therapy assessment and intervention. Of course,
individual members of a group or population differ in other personal factors. For example, a
group of fifth graders in a community public school are likely to share age and, perhaps,
socioeconomic status. Yet race, fitness, habits, and coping styles make each group member
unlike the others. Similarly, a population of older adults living in an urban low-income housing
community may have few personal factors in common other than age and current socioeconomic
status.

Application of Context to Occupational Justice

Interwoven throughout the concept of context is that of occupational justice, defined as “a justice
that recognizes occupational rights to inclusive participation in everyday occupations for all
persons in society, regardless of age, ability, gender, social class, or other differences” (Nilsson
& Townsend, 2010, p. 58). Occupational therapy’s focus on engagement in occupations and
occupational justice complements WHO’s (2008) perspective on health. To broaden the
understanding of the effects of disease and disability on health, WHO emphasized that health can
be affected by the inability to carry out occupations and activities and participate in life
situations caused by contextual barriers and by problems that exist in body structures and body
functions. The OTPF–4 identifies occupational justice as both an aspect of contexts and an
outcome of intervention.

Occupational justice involves the concern that occupational therapy practitioners have with
respect, fairness, and impartiality and equitable opportunities when considering the contexts of
persons, groups, and populations (AOTA, 2015a). As part of the occupational therapy domain,
practitioners consider how these aspects can affect the implementation of occupational therapy
and the target outcome of participation. Practitioners recognize that for individuals to truly
achieve full participation, meaning, and purpose, they must not only function but also engage

PREPUBLICATION DRAFT. Page 12 of 96

comfortably within their own distinct combination of contexts (both environmental factors and
personal factors).

Examples of contexts that can present occupational justice issues include the following:
 An alternative school placement for children with mental health and behavioral disabilities that provides
academic support and counseling but limited opportunities for participation in sports, music programs, and
organized social activities
 A residential facility for older adults that offers safety and medical support but provides little opportunity for
engagement in the role-related occupations that were once a source of meaning
 A community that lacks accessible and inclusive physical environments and provides limited services and
supports, making participation difficult or even dangerous for people who have disabilities (e.g., lack of
screening facilities and services resulting in higher rates of breast cancer among community members).
 A community that lacks financial and other necessary resources, resulting in an adverse and disproportionate
impact of natural disasters and severe weather events on vulnerable populations.
Occupational therapy practitioners recognize areas of occupational injustice and work to
support policies, actions, and laws that allow people to engage in occupations that provide
purpose and meaning in their lives. By understanding and addressing the specific justice issues in
contexts such as an individual’s home, a group’s shared job site, or a population’s community
center, practitioners promote occupational therapy outcomes that address empowerment and self-
advocacy.

Performance Patterns
Performance patterns are the acquired habits, routines, roles, and rituals used in the process of
engaging consistently in occupations and can support or hinder occupational performance (Table
6). Performance patterns help establish lifestyles (Uyeshiro Simon & Collins, 2017) and
occupational balance (e.g., proportion of time spent in productive, restorative, and leisure
occupations; Eklund et al., 2017; Wagman et al., 2015) and are shaped, in part, by context (e.g.,
consistency, work hours, social calendars) and cultural norms (Eklund et al., 2017; Larson &
Zemke, 2003).
Time provides an organizational structure or rhythm for performance patterns (Larson &
Zemke, 2003); for example, an adult goes to work every morning, a child completes homework
every day after school, or an organization hosts a fundraiser every spring. The manner in which
people think about and use time is influenced by biological rhythms (e.g., sleep–wake cycles),
family of origin (e.g., amount of time a person is socialized to believe should be spent in
productive occupations), work and social schedules (e.g., religious services held on the same day
each week), and cyclic cultural patterns (e.g., birthday celebration with cake every year, annual
cultural festival; Larson & Zemke, 2003). Other temporal factors influencing performance
patterns are time management and time use; time management is the manner in which a person,
group, or population organizes, schedules, and prioritizes certain activities (Uyeshiro Simon &
Collins, 2017), and time use is the manner in which a person manages their activity levels, adapts
to changes in routines, and organizes their days, weeks, and years (Edgelow & Krupa, 2011).
Habits are specific, automatic adaptive or maladaptive behaviors. Habits may be healthy or
unhealthy (e.g., exercising on a daily basis vs. smoking during every lunch break), efficient or
inefficient (e.g., completing homework after school vs. in the few minutes before the school bus

PREPUBLICATION DRAFT. Page 13 of 96

arrives), and supportive or harmful (e.g., setting an alarm clock before going to bed vs. not doing
so; Clark, 2000; Dunn, 2000; Matuska & Barrett, 2019).
Routines are established sequences of occupations or activities that provide a structure for
daily life; these also can promote or damage health (Fiese, 2007; Koome et al., 2012; Segal,
2004). Shared routines involve two or more people and take place in a similar manner regardless
of the individuals involved (e.g., routines shared by parents to promote the health of their
children; routines shared by coworkers to sort the mail; Primeau, 2000). Shared routines can be
nested in co-occupations. For example, a young child’s occupation of completing oral hygiene
with the assistance of an adult is a part of the child’s daily routine, the adult who provides the
assistance may also view helping the young child with oral hygiene as a part of the adult’s own
daily routine.
Roles have historically been defined as sets of behaviors expected by society and shaped by
culture and context; they may be further conceptualized and defined by a person, group, or
population (Kielhofner, 2008; Taylor, 2017). Roles are an aspect of occupational identity—that
is, they help define who a person, group, or population believes themselves to be on the basis of
their occupational history and desires for the future. Certain roles are often associated with
specific activities and occupations; for example, the role of parent is associated with feeding
children (Kielhofner, 2008; Taylor, 2017). When exploring roles, occupational therapy
practitioners consider the complexity of identity and the limitations associated with assigning
stereotypical occupations to specific roles (e.g., on the basis of gender). Practitioners also
consider how clients construct their occupations and establish efficient and supportive habits and
routines to achieve health outcomes, fulfill their perceived roles and identity, and determine
whether their roles reinforce their values and beliefs.
Rituals are symbolic actions with spiritual, cultural, or social meaning. Rituals contribute to a
client’s identity and reinforce the client’s values and beliefs (Fiese, 2007; Segal, 2004). Some
rituals (e.g., those associated with certain holidays) are associated with different seasons or times
of the year (e.g., New Year’s Eve, Independence Day), whereas others are associated with times
of the day or days of the week (e.g., daily prayers, weekly religious services).
Performance patterns are influenced by all other aspects of the occupational therapy domain
and develop over time. Occupational therapy practitioners who consider clients’ past and present
behavioral and performance patterns are better able to understand the frequency and manner in
which performance skills and healthy and unhealthy occupations are, or have been, integrated
into clients’ lives. Although clients may have the ability to engage in skilled performance, if they
do not embed essential skills in a productive set of engagement patterns, their health, well-being,
and participation may be negatively affected. For example, a person may have skills associated
with proficient health literacy but not embed them into consistent routines (e.g., a dietitian who
consistently chooses to eat fast food rather than prepare a healthy meal) or struggle with
modifying daily performance patterns to access health systems effectively (e.g., a nurse who
struggles to modify work hours to get a routine mammogram).

Performance Skills
Performance skills are observable, goal-directed actions and consist of motor skills, process
skills, and social interaction skills (Fisher & Griswold, 2019; Table 7). The occupational

PREPUBLICATION DRAFT. Page 14 of 96

practitioner evaluates and analyzes performance skills during actual performance to understand
an individual client’s ability to perform an activity (defined as a smaller aspect of the larger
occupation) in natural contexts (Fisher & Marterella, 2019). This requires analysis of the quality
of the individual actions (performance skills) during actual performance. Regardless of the client
population, the performance skills defined in this document are universal and provide the
foundation for understanding performance (Fisher & Marterella, 2019).
Performance skills can be analyzed for all occupations with clients of any age and level of
ability, regardless of the setting in which occupational therapy services are provided (Fisher &
Marterella, 2019). Motor and process skills are seen during performance of an activity that
involves the use of tangible objects, and social interaction skills are seen in any situation in
which a person is interacting with others.
 Motor skills refer to how effectively a person moves self or interacts with objects, which includes positioning
the body, obtaining and holding objects, moving self and objects, and sustaining performance.
 Process skills refer to how effectively a person organizes objects, time, and space, which includes sustaining
performance, applying knowledge, organizing timing, organizing space and objects, and adapting
performance.
 Social interaction skills refer to how effectively a person uses both verbal and nonverbal skills to
communicate, which includes initiating and terminating, producing, physically supporting, shaping content of,
maintaining flow of, verbally supporting, and adapting social interaction.
For example, when a client catches a ball, the practitioner can analyze how effectively they
bend and reach for and then grasp the ball (motor skills). When a client cooks a meal, the
practitioner can analyze how effectively they initiate and sequence the steps to complete the
recipe in a logical order to prepare the meal in a timely and well-organized manner (process
skills). Or when a client interacts with a friend at work, the practitioner can analyze the manner
in which the client smiles, gestures, turns toward the friend, and responds to questions (social
interaction skills). In these examples, many other motor skills, process skills, and social
interaction skills are also used by the client.
By analyzing the client’s performance within an occupation at the level of performance
skills, the occupational therapist identifies effective and ineffective use of skills (Fisher &
Marterella, 2019). The result of this analysis indicates not only if the person is able to complete
an activity safely and independently but also the amount of physical effort and efficiency the
client demonstrates in activities.
After the quality of occupational performance skills has been analyzed, the practitioner
speculates about the reasons for decreased quality of occupational performance and determines
the need to evaluate potential underlying causes (e.g., occupational demands, environmental
factors, client factors; Fisher & Griswold, 2019). Performance skills are different from client
factors (see the “Client Factors” section that follows), which include values, beliefs, and
spirituality and body structures and functions (i.e., memory, strength) that reside within the
person. Occupational therapy practitioners analyze performance skills as a client performs an
activity, whereas client factors cannot be directly viewed during the performance of occupations.
For example, the occupational therapy practitioner cannot directly view the client factors of
cognitive ability or memory when a client is engaged in cooking but rather notes ineffective use
of performance skills when the person hesitates to start a step or performs steps in an illogical
order. The practitioner may then infer that a possible reason that the client hesitated may be due
to diminished memory and select to further assess the client factor of cognition.

PREPUBLICATION DRAFT. Page 15 of 96

 Similarly, context influences the quality of a client’s occupational performance. After
analyzing the client’s performance skills while completing an activity, the practitioner can
hypothesize how the client factors and context might have influenced the client’s performance.
Thus, client factors and contexts converge and may support or limit a person’s quality of
occupational performance.

Application of Performance Skills with Persons

When completing the analysis of occupational performance (described in the “Evaluation”
section), the practitioner analyzes the client’s challenges in performance and generates a
hypothesis about gaps between current performance and effective performance and the need for
occupational therapy services. To plan appropriate interventions, the practitioner considers the
underlying reason(s) for the gaps, which may involve performance skills, performance patterns,
and/or client factors. The hypothesis is generated on the basis of what the practitioner analyzes
when the client is actually performing occupations.

Regardless of the client population, the universal performance skills defined here provide the
foundations for understanding performance (Fisher & Marterella, 2019).The following example,
crosses many client populations. The practitioner views that a client rushes through the steps of
an activity toward completion. Based on what the client does, the practitioner may interpret this
to be due to lack of impulse control. This limitation may be seen in clients such as those living
with anxiety, attention deficit hyperactivity disorder, dementia, traumatic brain injury, and other
clinical conditions. The behavior of rushing may be captured in motor performance skills of
manipulates, coordinates, or calibrates; in process performance skills of paces, initiates,
continues, or organizes; or in social interaction performance skills of takes turn, transitions,
times response, or times duration. Understanding the client’s specific occupational challenges
enables the practitioner to determine the suitable intervention to address impulsivity to facilitate
greater occupational performance. Clinical interventions then address the skills required for the
client’s specific occupational demands on the basis of their alignment with the universal
performance skills (Fisher & Marterella, 2019). Thus, the application of the universal
performance skills guides practitioners in developing the intervention plan for the specific client
to address the specific concerns occurring in the specific practice setting.

Application of Performance Skills with Groups

Analysis of performance skills is always focused on individuals (Fisher & Marterella, 2019).
Thus, when analyzing performance skills with a group client, the occupational therapist always
focuses on one individual at a time (Table 8). The therapist may choose to analyze some or all
members of the group engaging in relevant group occupations over time as the group members
contribute to the collective actions of the group.
If all members demonstrate overall effective performance skills, then the group client may
achieve its collective outcomes. If one or more group members demonstrate ineffective
performance skills, the collective outcomes may be diminished. Only in cases in which group
members demonstrate ongoing limitations in performance skills that hinder the collective
outcomes of the group would the practitioner recommend interventions for individual group
members. Interventions would then be directed at those members demonstrating diminished
performance skills to facilitate their contributions to the collective group outcomes.

PREPUBLICATION DRAFT. Page 16 of 96

Application of Performance Skills with Populations
Using an occupation-based approach to population health, occupational therapy addresses the
needs of populations by enhancing occupational performance and participation for communities
of people (see “Service Delivery” in the “Process” section). Service delivery to populations
focuses on aggregates of people rather than on intervention for persons or groups; thus, it is not
relevant to analyze performance skills at the person level in service delivery to populations.

Client Factors
Client factors are specific capacities, characteristics, or beliefs that reside within the person,
group, or population and influence performance in occupations (Table 9). Client factors are
affected by the presence or absence of illness, disease, deprivation, and disability, as well as by
life stages and experiences. These factors can affect performance skills (e.g., a client may have
weakness in the right arm [a client factor] that affects their ability to manipulate a button [a
motor and process skill] to button a shirt; a child in a classroom may be nearsighted [a client
factor], affecting their ability to copy from a chalkboard [a motor and process skill]).
In addition, client factors are affected by occupations, contexts, performance patterns, and
performance skills. For example, a client in a controlled and calm environment might be able to
problem solve to complete an occupation or activity, but when they are in a louder, more chaotic
environment, their ability to process and plan may be adversely affected. It is through this
interactive relationship that occupations and interventions to support occupations can be used to
address client factors and vice versa.
Values, beliefs, and spirituality influence clients’ motivation to engage in occupations and
give their life or existence meaning. Values are principles, standards, or qualities considered
worthwhile by the client who holds them. A belief is “something that is accepted, considered to
be true, or held as an opinion” (Merriam-Webster, 2020). Spirituality is “a deep experience of
meaning brought about by engaging in occupations that involve the enacting of personal values
and beliefs, reflection, and intention within a supportive contextual environment” (Billock, 2005,
p. 887) It is important to recognize spirituality “as dynamic and often evolving” (Humbert, 2016,
p. 12).
Body functions and body structures refer to the “physiological function of body systems
(including psychological functions) and anatomical parts of the body such as organs, limbs, and
their components,” respectively (WHO, 2008, p. 10). Examples of body functions include
sensory, musculoskeletal, mental (affective, cognitive, perceptual), cardiovascular, respiratory,
and endocrine functions. Examples of body structures include the heart and blood vessels that
support cardiovascular function. Body structures and body functions are interrelated, and
occupational therapy practitioners consider them when seeking to promote clients’ ability to
engage in desired occupations.
Occupational therapy practitioners understand that, the presence, absence, or limitation of
specific body functions and body structures does not necessarily determine a client’s success or
difficulty with daily life occupations. Occupational performance and client factors may benefit
from supports in the physical, social, or attitudinal contexts that enhance or allow participation. It
is through the process of assessing clients engaging in occupations that practitioners are able to
determine the transaction between client factors and performance skills; to create adaptations,

PREPUBLICATION DRAFT. Page 17 of 96

modifications, and remediation; and to select occupation-based interventions that best promote
enhanced participation.
Client factors can also be understood as pertaining to group and population clients and may
be used to help define the group or population. Although client factors may be described
differently when applied to a group or population, the underlying principles do not change
substantively. Client factors of a group or population are explored by performing needs
assessments, and interventions might include program development and strategic planning to
help the members engage in occupations.

Process
This section operationalizes the process undertaken by occupational therapy practitioners when
providing services to clients. Exhibit 2 summarizes the aspects of the occupational therapy
process.

Exhibit 2. Operationalizing the Occupational Therapy Process

Ongoing interaction among evaluation, intervention, and outcomes occurs throughout the occupational therapy
process.
Evaluation
Occupational Profile
• Identify the following:
◦ Why is the client seeking services, and what are the client’s current concerns relative to engaging in
occupations and in daily life activities?
◦ In what occupations does the client feel successful, and what barriers are affecting their success in desired
occupations?
◦ What is the client’s occupational history (i.e., life experiences)?
◦ What are the client’s values and interests?
◦ What aspects of their contexts (environmental and personal factors) does the client see as supporting
engagement in desired occupations, and what aspects are inhibiting engagement?
◦ How are the client’s performance patterns supporting or limiting occupational performance and
engagement?
◦ What are the client’s patterns of engagement in occupations, and how have they changed over time?
◦ What client factors does the client see as supporting engagement in desired occupations, and what aspects
are inhibiting engagement (e.g., pain, active symptoms)?
◦ What are the client’s priorities and desired targeted outcomes related to occupational performance,
prevention, health and wellness, quality of life, participation, role competence, well-being, and
occupational justice?

Analysis of Occupational Performance

• The analysis of occupational performance involves one or more of the following:
◦ Synthesizing information from the occupational profile to determine specific occupations and contexts
that need to be addressed
◦ Completing an occupational or activity analysis to identify the demands of occupations and activities on
the client
◦ Selecting and using specific assessments to measure the quality of the client’s performance or
performance deficits while completing occupations or activities relevant to desired occupations, noting
the effectiveness of performance skills and performance patterns
◦ Selecting and using specific assessments to measure client factors that influence performance skills and
performance patterns
◦ Selecting and administering assessments to identify and measure more specifically the client’s contexts
and their impact on occupational performance.

PREPUBLICATION DRAFT. Page 18 of 96

 Synthesis of Evaluation Process
• This process may include the following:
◦ Determining the client’s values and priorities for occupational participation
◦ Interpreting the assessment data to identify supports and hindrances to occupational performance
◦ Developing and refining hypotheses about the client’s occupational performance strengths and deficits
◦ Considering existing support systems and contexts and their ability to support the intervention process
◦ Determining desired outcomes of the intervention
◦ Creating goals in collaboration with the client that address the desired outcomes
◦ Selecting outcome measures and determining procedures to measure progress toward the goals of
intervention, which may include repeating assessments used in the evaluation process.

Intervention
Intervention Plan
• Develop the plan, which involves selecting
◦ Objective and measurable occupation-based goals and related time frames
◦ Occupational therapy intervention approach or approaches, such as create or promote, establish or restore,
maintain, modify, or prevent
◦ Methods for service delivery, including what types of intervention will be provided, who will provide the
interventions, and which service delivery approaches will be used.
• Consider potential discharge needs and plans.
• Make recommendations or referrals to other professionals as needed.

Intervention Implementation
• Select and carry out the intervention or interventions, which may include the following:
◦ Therapeutic use of occupations and activities
◦ Interventions to support occupations
◦ Education
◦ Training
◦ Advocacy
◦ Self-advocacy
◦ Group intervention
◦ Virtual interventions.
• Monitor the client’s response through ongoing evaluation and reevaluation.

Intervention Review
• Reevaluate the plan and how it is implemented relative to achieving outcomes.
• Modify the plan as needed.
• Determine the need for continuation or discontinuation of services and for referral to other services.

Outcomes
Outcomes
• Select outcome measures early in the occupational therapy process (see the “Evaluation” section of this table)
on the basis of their properties:
◦ Valid, reliable, and appropriately sensitive to change in clients’ occupational performance
◦ Consistent with targeted outcomes
◦ Congruent with the client’s goals
◦ Able to predict future outcomes.
• Use outcome measures to measure progress and adjust goals and interventions by
◦ Comparing progress toward goal achievement to outcomes throughout the intervention process
◦ Assessing outcome use and results to make decisions about the future direction of intervention (e.g.,
continue, modify, transition, discontinue, provide follow-up, refer for other service).

The occupational therapy process is the client-centered delivery of occupational therapy

services. The three-part process includes (1) evaluation and (2) intervention to achieve (3)

PREPUBLICATION DRAFT. Page 19 of 96

targeted outcomes and occurs within the purview of the occupational therapy domain (Table 11).
The process is facilitated by the distinct perspective of occupational therapy practitioners
engaging in professional reasoning, analyzing occupations and activities, and collaborating with
clients. The cornerstones of occupational therapy practice underpin the process of service
delivery.

Overview of the Occupational Therapy Process

Many professions use a similar process of evaluating, intervening, and targeting outcomes.
However, only occupational therapy practitioners focus on the therapeutic use of occupations to
promote health, well-being, and participation in life. Practitioners use professional reasoning to
select occupations as primary methods of intervention throughout the process. To help clients
achieve desired outcomes, practitioners facilitate interactions among the clients, their contexts,
and the occupations in which they engage. This perspective is based on the theories, knowledge,
and skills generated and used by the profession and informed by available evidence.
Analyzing occupational performance requires an understanding of the complex and dynamic
interaction among the demands of the occupation and the client’s contexts, performance patterns,
performance skills, and client factors. Occupational therapy practitioners fully consider each
aspect of the domain and gauge the influence of each on the others, individually and collectively.
By understanding how these aspects influence one another, practitioners can better evaluate how
each aspect contributes to clients’ participation and performance-related concerns and potentially
to interventions that support occupational performance and participation.
The occupational therapy process is fluid and dynamic, allowing practitioners and clients to
maintain their focus on the identified outcomes while continually reflecting on and changing the
overall plan to accommodate new developments and insights along the way, including
information gained from inter- and intraprofessional collaborations. The process may be
influenced by the context of service delivery (e.g., setting, payer requirements); however, the
primary focus is always directed on occupation.

Service Delivery Approaches

Various service delivery approaches are used when providing skilled occupational therapy
services, of which intra- and interprofessional collaborations are a key component. It is
imperative to communicate with all relevant providers and stakeholders to ensure a collaborative
approach to the occupational therapy process. These providers and stakeholders can be within the
profession (e.g., occupational therapist and occupational therapy assistant collaborating to work
with a student in a school, a group of practitioners collaborating to develop community-based
mental health programming in their region) or outside the profession (e.g., a team of
rehabilitation and medical professionals on an inpatient hospital unit; a group of employees,
human resources staff, and health and safety professionals in a large organization working with
an occupational therapy practitioner on workplace wellness initiatives).
An occupational therapy approach to population health focuses on aggregates or
communities of people and the many factors that influence their health and well-being:
“Occupational therapy practitioners can develop and implement occupation-based population
health approaches to enhance occupational performance and participation, quality of life, and
occupational justice” (AOTA, in press-a).

PREPUBLICATION DRAFT. Page 20 of 96

 Regardless of the service delivery approach, the individual client may not be the exclusive
focus of the occupational therapy process. For example, the needs of an at-risk infant may be the
initial impetus for intervention, but the concerns and priorities of the parents, extended family,
and funding agencies are also considered. Occupational therapy practitioners understand and
focus intervention to include the issues and concerns surrounding the complex dynamics among
the client, caregiver, family, and community. Similarly, services addressing independent living
skills for adults coping with serious mental illness may also address the needs and expectations
of state and local service agencies and of potential employers.

Direct Services.

Services are provided directly to clients using a collaborative approach in settings such as
hospitals, clinics, industry, schools, homes, and communities. Direct services include
interventions completed when in direct contact with the client through various mechanisms such
as meeting in person with a client, leading a group session, and interacting with clients and
families through telehealth systems (AOTA, 2018c).
Examples of person-level direct service delivery include working with an adult on an
inpatient rehabilitation unit, working with a child in the classroom while collaborating with the
teacher to address identified goals, and working with an adolescent in an outpatient setting.
Direct group interventions include working with a cooking group in a skilled nursing facility,
working with an outpatient feeding group, and working with a handwriting group in a school.
Examples of population-level direct services include implementing a large-scale healthy lifestyle
or safe driver initiative in the community and delivering a training program for brain injury
treatment facilities regarding safely accessing public transportation.

Indirect Services.

When providing services to clients indirectly on their behalf, practitioners provide consultation
to entities such as teachers, multidisciplinary teams, and community planning agencies. For
example, an occupational therapy practitioner may consult with a group of elementary school
teachers and administrators about opportunities for play during recess to promote health and
well-being. A practitioner may also provide consultation on inclusive design to a park district or
civic organization to address how the built and natural environment can support occupational
performance and engagement. In addition, a practitioner may consult with a business regarding
the work environment, ergonomic modifications, and compliance with the Americans With
Disabilities Act of 1990 (Public Law 101-336).
Occupational therapy practitioners can advocate indirectly on behalf of their clients at the
person, group, and population levels to ensure their occupational needs are met. For example, an
occupational therapy practitioner may advocate for funding to support the costs of training a
service animal for an individual client. A practitioner working with a group client may advocate
for meeting space in the community for a peer support group of transgender youth. Examples of
population-level advocacy include talking with legislators about improving transportation for
older adults, developing services for people with disabilities to support their living and working
in the community of their choice, establishing meaningful civic engagement opportunities for
underserved youth, and assisting in the development of policies that address inequities in access
to health care.

PREPUBLICATION DRAFT. Page 21 of 96

Additional Approaches.

Occupational therapy practitioners use additional approaches that may also be classified as direct
or indirect for persons, groups, and populations. Examples include, but are not limited to, case
management (AOTA, 2018b), telehealth (AOTA, 2018c), episodic care (Centers for Medicare &
Medicaid Services, 2019), and family-centered care approaches (Hanna & Rodger, 2002).

Practice Within Organizations and Systems

Organization- or systems-level practice is a valid and important part of occupational therapy for
several reasons. First, organizations serve as a mechanism through which occupational therapy
practitioners provide interventions to support participation of people who are members of or
served by the organization (e.g., falls prevention programming in a skilled nursing facility,
ergonomic changes to an assembly line to reduce musculoskeletal disorders). Second,
organizations support occupational therapy practice and practitioners as stakeholders in carrying
out the mission of the organization. Practitioners have the responsibility to ensure that services
provided to organizational stakeholders (e.g., third-party payers, employers) are of high quality
and delivered in an ethical, efficient, and efficacious manner.
Finally, organizations employ occupational therapy practitioners in roles in which they use
their knowledge of occupation and the profession of occupational therapy indirectly. For
example, practitioners can serve in positions such as dean, administrator, and corporate leader
(e.g., CEO, business owner). In these positions, practitioners support and enhance the
organization but do not provide occupational therapy services in the traditional sense.
Occupational therapy practitioners can also serve organizations in roles such as client advocate,
program coordinator, transition manager, service or care coordinator, health and wellness coach,
and community integration specialist.

Occupational and Activity Analysis

Occupational therapy practitioners are skilled in the analysis of occupations and activities and
apply this important skill throughout the occupational therapy process. Occupational analysis is
performed with an understanding of “the specific situation of the client and therefore . . . the
specific occupations the client wants or needs to do in the actual context in which these
occupations are performed” (Schell et al., 2019, p. 322). In contrast, activity analysis is generic
and decontextualized in its purpose and serves to develop an understanding of typical activity
demands within a given culture. Many professions use activity analysis, whereas occupational
analysis requires the understanding of occupation as distinct from activity and brings an
occupational therapy perspective to the analysis process (Schell et al., 2019).
Occupational therapy practitioners analyze the demands of an occupation or activity to
understand the performance patterns, performance skills, and client factors that are required to
perform it (Table 10). Depending on the purpose of the analysis, the meaning ascribed to and the
contexts for performance of and engagement in the occupation or activity are considered either
from client-specific subjective perspective (occupational analysis) or a general perspective
within a given culture (activity analysis).

Therapeutic Use of Self

PREPUBLICATION DRAFT. Page 22 of 96

An integral part of the occupational therapy process is therapeutic use of self, which allows
occupational therapy practitioners to develop and manage their therapeutic relationship with
clients by using professional reasoning, empathy, and a client-centered, collaborative approach to
service delivery (Taylor & Van Puymbroeck, 2013). Occupational therapy practitioners use
professional reasoning to help clients make sense of the information they are receiving in the
intervention process, discover meaning, and build hope (Taylor, 2019; Taylor & Van
Puymbroeck, 2013). Empathy is the emotional exchange between occupational therapy
practitioners and clients that allows more open communication, ensuring that practitioners
connect with clients at an emotional level to assist them with their current life situation.
Practitioners develop a collaborative relationship with clients to understand their experiences
and desires for intervention. The collaborative approach used throughout the process honors the
contributions of clients along with practitioners. Through the use of interpersonal communication
skills, practitioners shift the power of the relationship to allow clients more control in decision
making and problem solving, which is essential to effective intervention. Clients have identified
the therapeutic relationship as critical to the outcome of occupational therapy intervention (Cole
& McLean, 2003).
Clients bring to the occupational therapy process their knowledge about their life experiences
and their hopes and dreams for the future. They identify and share their needs and priorities.
Occupational therapy practitioners must create an inclusive, supportive environment to enable
clients to feel safe in expressing themselves authentically. Building an inclusive environment
could include actions such as pursuing education on gender affirming care, acknowledging
systemic issues affecting underrepresented groups, and using a lens of cultural humility
throughout the occupational therapy process (AOTA, in press-b; Hammell, 2013).
Occupational therapy practitioners bring their knowledge about how engagement in
occupation affects health, well-being, and participation; they use this information, coupled with
theoretical perspectives and professional reasoning, to critically evaluate, analyze, describe, and
interpret human performance. Practitioners and clients, together with caregivers, family
members, community members, and other stakeholders (as appropriate), identify and prioritize
the focus of the intervention plan.

Clinical and Professional Reasoning

Throughout the occupational therapy process, practitioners are continually engaged in clinical
and professional reasoning about a client’s occupational performance. The term professional
reasoning is used throughout this document as a broader term to encompass reasoning that
occurs in all settings (Schell, 2019). Professional reasoning enables practitioners to
 Identify the multiple demands, required skills, and potential meanings of the activities and occupations, and
 Gain a deeper understanding of the interrelationships among aspects of the domain that affect performance
and that support client-centered interventions and outcomes.
Occupational therapy practitioners use theoretical principles and models, knowledge about
the effects of conditions on participation, and available evidence on the effectiveness of
interventions to guide their reasoning. Professional reasoning ensures the accurate selection and
application of client-centered evaluation methods, interventions, and outcome measures.
Practitioners also apply their knowledge and skills to enhance clients’ participation in

PREPUBLICATION DRAFT. Page 23 of 96

occupations and promote their health and well-being regardless of the effects of disease,
disability, and occupational disruption or deprivation.

Evaluation
The evaluation process is focused on finding out what the client wants and needs to do,
determining what the client can do and has done, and identifying supports and barriers to health,
well-being, and participation. Evaluation occurs during the initial and all subsequent interactions
with a client. The type and focus of the evaluation differ depending on the practice setting;
however, all evaluations should assess the complex and multifaceted needs of each client.
The evaluation consists of the occupational profile and the analysis of occupational
performance, which are synthesized to inform the intervention plan (Hinojosa et al., 2014).
Although it is the responsibility of the occupational therapist to initiate the evaluation process,
both occupational therapists and occupational therapy assistants may contribute to the evaluation,
following which the occupational therapist completes the analysis and synthesis of information
for the development of the intervention plan (AOTA, 2014a). The occupational profile includes
information about the client’s needs, problems, and concerns about performance in occupations.
The analysis of occupational performance focuses on collecting and interpreting information
specifically to identify supports and barriers related to occupational performance and establish
targeted outcomes.
Although the OTPF–4 describes the components of the evaluation process separately and
sequentially, the exact manner in which occupational therapy practitioners collect client
information is influenced by client needs, practice settings, and frames of reference or practice
models. The evaluation process for groups and populations mirrors that for individual clients.
In some settings, the occupational therapist first completes a screening or consultation to
determine the appropriateness of a full occupational therapy evaluation (Hinojosa et al., 2014).
This process may include
 Review of client history (e.g., medical, health, social, or academic records),
 Consultation with an interprofessional or referring team, and
 Use of standardized or structured screening instruments.
The screening or consultation process may result in the development of a brief occupational
profile and recommendations for full occupational therapy evaluation and intervention (Hinojosa
et al., 2014).

Occupational Profile
The occupational profile is a summary of a client’s (person’s, group’s, or population’s)
occupational history and experiences, patterns of daily living, interests, values, needs, and
relevant contexts (AOTA, 2017a). Developing the occupational profile provides the occupational
therapy practitioner with an understanding of the client’s perspective and background.
Using a client-centered approach, the occupational therapy practitioner gathers information
to understand what is currently important and meaningful to the client (i.e., what the client wants
and needs to do) and to identify past experiences and interests that may assist in the
understanding of current issues and problems. During the process of collecting this information,

PREPUBLICATION DRAFT. Page 24 of 96

the client, with the assistance of the practitioner, identifies priorities and desired targeted
outcomes that will lead to the client’s engagement in occupations that support participation in
daily life. Only clients can identify the occupations that give meaning to their lives and select the
goals and priorities that are important to them. By valuing and respecting clients’ input,
practitioners help foster their involvement and can more effectively guide interventions.
Occupational therapy practitioners collect information for the occupational profile at the
beginning of contact with clients to establish client-centered outcomes. Over time, practitioners
collect additional information, refine the profile, and ensure that the additional information is
reflected in changes subsequently made to targeted outcomes. The process of completing and
refining the occupational profile varies by setting and client and may occur continuously
throughout the occupational therapy process.
Information gathering for the occupational profile may be completed in one session or over a
longer period while working with the client. For clients who are unable to participate in this
process, their profiles may be compiled through interaction with family members or other
significant people in their lives. Information for the occupational profile may also be gathered
from available and relevant records.
Obtaining information for the occupational profile through both formal and informal
interview techniques and conversation is a way to establish a therapeutic relationship with clients
and their support network. Techniques used should be appropriate and reflective of clients’
preferred method and style of communication (e.g., use of a communication board, translation
services). Practitioners may use AOTA’s Occupational Profile Template as a guide for
completing the occupational profile (AOTA, 2017a). The information obtained through the
occupational profile contributes to an individualized approach in the evaluation, intervention
planning, and intervention implementation stages. Information is collected in the following
areas:
 Why is the client seeking services, and what are the client’s current concerns relative to engaging in
occupations and in daily life activities?
 In what occupations does the client feel successful, and what barriers are affecting their success in desired
occupations?
 What is the client’s occupational history (i.e., life experiences)?
 What are the client’s values and interests?
 What aspects of their contexts (environmental and personal factors) does the client see as supporting
engagement in desired occupations, and what aspects are inhibiting engagement?
 How are the client’s performance patterns supporting or limiting occupational performance and engagement?
 What are the client’s patterns of engagement in occupations, and how have they changed over time?
 What client factors does the client see as supporting engagement in desired occupations, and what aspects are
inhibiting engagement (e.g., pain, active symptoms)?
 What are the client’s priorities and desired targeted outcomes related to occupational performance, prevention,
health and wellness, quality of life, participation, role competence, well-being, and occupational justice?
After the practitioner collects profile data, the occupational therapist views the information
and develops a working hypothesis regarding possible reasons for the identified problems and
concerns. Reasons could include impairments in performance skills, performance patterns, or
client factors or barriers within relevant contexts. In addition, the therapist notes the client’s

PREPUBLICATION DRAFT. Page 25 of 96

strengths and supports in all areas because these can inform the intervention plan and affect
targeted outcomes.

Analysis of Occupational Performance

Occupational performance is the accomplishment of the selected occupation resulting from the
dynamic transaction among the client, their contexts, and the occupation. In the analysis of
occupational performance, the client’s ability to effectively complete desired occupations is
identified. The client’s assets and limitations or potential problems are more specifically
determined through assessment tools designed to analyze, measure, and inquire about factors that
support or hinder occupational performance.
Multiple methods often are used during the evaluation process to assess the client, contexts,
occupations, and occupational performance. Methods may include observation and analysis of
the client’s performance in specific occupations and assessment of specific aspects of the client
or their performance. The approach to the analysis of occupational performance is determined by
the information gathered through the occupational profile and influenced by models of practice
and frames of reference appropriate to the client and setting. The analysis of occupational
performance involves one or more of the following:
 Synthesizing information from the occupational profile to determine specific occupations and contexts that
need to be addressed
 Completing an occupational or activity analysis to identify the demands of occupations and activities on the
client
 Selecting and using specific assessments to measure the quality of the client’s performance or performance
deficits while completing occupations or activities relevant to desired occupations, noting the effectiveness of
performance skills and performance patterns
 Selecting and using specific assessments to measure client factors that influence performance skills and
performance patterns
 Selecting and administering assessments to identify and measure more specifically the client’s contexts and
their impact on occupational performance.
Occupational performance may be measured through standardized, formal, and structured
assessment tools, and when necessary informal approaches may also be used (Asher, 2014).
Standardized assessments are preferred, when available, to provide objective data about various
aspects of the domain influencing engagement and performance. The use of valid and reliable
assessments for obtaining trustworthy information can also help support and justify the need for
occupational therapy services (Doucet & Gutman, 2013; Hinojosa & Kramer, 2014). In addition,
the use of standardized outcome performance measures and outcome tools assists in establishing
a baseline of occupational performance to allow for objective measurement of progress after
intervention.

Synthesis of the Evaluation Process

The occupational therapist synthesizes the information gathered through the occupational profile
and analysis of occupational performance. This process may include the following:
 Determining the client’s values and priorities for occupational participation
 Interpreting the assessment data to identify supports and hindrances to occupational performance

PREPUBLICATION DRAFT. Page 26 of 96

  Developing and refining hypotheses about the client’s occupational performance strengths and deficits
 Considering existing support systems and contexts and their ability to support the intervention process
 Determining desired outcomes of the intervention
 Creating goals in collaboration with the client that address the desired outcomes
 Selecting outcome measures and determining procedures to measure progress toward the goals of
intervention, which may include repeating assessments used in the evaluation process.
Any outcome assessment used by occupational therapy practitioners must be consistent with
clients’ belief systems and underlying assumptions regarding their desired occupational
performance. Occupational therapy practitioners select outcome assessments pertinent to clients’
needs and goals, congruent with the practitioner’s theoretical model of practice. Assessment
selection is also based on the practitioner’s knowledge of and available evidence for the
psychometric properties of standardized measures or the rationale and protocols for
nonstandardized structured measures. In addition, clients’ perception of success in engaging in
desired occupations is a vital part of outcome assessment (Bandura, 1986). The occupational
therapist uses the synthesis and summary of information from the evaluation and established
targeted outcomes to guide the intervention process.

Intervention Process
The intervention process consists of services provided by occupational therapy practitioners in
collaboration with clients to facilitate engagement in occupation related to health, well-being,
and achievement of established goals consistent with the various service delivery models.
Practitioners use the information about clients gathered during the evaluation and theoretical
principles to select and provide occupation-based interventions to assist clients in achieving
physical, mental, and social well-being; identifying and realizing aspirations; satisfying needs;
and changing or coping with contextual factors.
Types of occupational therapy interventions are categorized as occupations and activities,
interventions to support occupations, education and training, advocacy, group interventions, and
virtual interventions (Table 12). Approaches to intervention include create or promote, establish
or restore, maintain, modify, and prevent (Table 13). Across all types of and approaches to
interventions, it is imperative that the occupational therapy practitioner maintain an
understanding of the Occupational Therapy Code of Ethics (AOTA, 2015a) and the Standards of
Practice for Occupational Therapy (AOTA, 2015c).
Intervention is intended to promote health, well-being, and participation. Health promotion is
“the process of enabling people to increase control over, and to improve, their health” (WHO,
1986). Wilcock (2006) stated,
Following an occupation-based health promotion approach to well-being embraces a belief that the potential
range of what people can do, be, and strive to become is the primary concern, and that health is a by-product.
A varied and full occupational lifestyle will coincidentally maintain and improve health and well-being if it
enables people to be creative and adventurous physically, mentally, and socially. (p. 315)

Interventions vary depending on the client—person, group, or population—and the context of

service delivery. The actual term used for clients or groups of clients receiving occupational
therapy varies among practice settings and delivery models. For example, when working in a
hospital, the person or group might be referred to as a patient or patients, and in a school, the
clients might be students. Early intervention requires practitioners to work with the family

PREPUBLICATION DRAFT. Page 27 of 96

system as their clients. When providing consultation to an organization, clients may be called
consumers or members. Terms used for others who may help or be served indirectly include, but
are not limited to, caregiver, teacher, parent, employer, or spouse.
Intervention can also be in the form of collective services to groups and populations. Such
intervention can occur as direct service provision or consultation. When consulting with an
organization, occupational therapy practitioners may use strategic planning, change agent plans,
and other program development approaches. Practitioners addressing the needs of a population
direct their interventions toward current or potential diseases or conditions with the goal of
enhancing the health, well-being, and participation of all members collectively. With groups and
populations, the intervention focus is often on health promotion, prevention, and screening.
Interventions may include (but are not limited to) self-management training, educational
services, and environmental modification. For instance, occupational therapy practitioners may
provide education on falls prevention and the impact of fear of falling to residents in an assisted
living center or training to people facing a mental health challenge in use of the internet to
identify and coordinate community resources that meet their needs.
Occupational therapy practitioners work with a wide variety of populations experiencing
difficulty in accessing and engaging in healthy occupations because of factors such as poverty,
homelessness, displacement, and discrimination. For example, practitioners can work with
organizations providing services to refugees and asylum seekers to identify opportunities to
reestablish occupational roles and enhance well-being and quality of life.
The intervention process is divided into three components: (1) intervention plan, (2)
intervention implementation, and (3) intervention review. During the intervention process, the
occupational therapy practitioner integrates information from the evaluation with theory, practice
models, frames of reference, and research evidence on interventions, including those that support
occupations. This information guides the practitioner’s professional reasoning in intervention
planning, implementation, and review. Because evaluation is ongoing, revision may occur at any
point during the intervention process.

Intervention Plan
The intervention plan, which directs the actions of occupational therapy practitioners, describes
the occupational therapy approaches and types of interventions selected for use in reaching
clients’ targeted outcomes. The intervention plan is developed collaboratively with clients or
their proxies and is directed by
 Client goals, values, beliefs, and occupational needs and
 Client health and well-being,

As well as by the practitioners’ evaluation of

 Client occupational performance needs;
 Collective influence of the contexts, occupational or activity demands, and client factors on the client;
 Client performance skills and performance patterns;
 Context of service delivery in which the intervention is provided; and
 Best available evidence.

PREPUBLICATION DRAFT. Page 28 of 96

 The occupational therapy practitioner designs the intervention plan on the basis of
established treatment goals, addressing the client’s current and potential situation related to
engagement in occupations or activities. The intervention plan should reflect the priorities of the
client, information on occupational performance gathered through the evaluation process, and
targeted outcomes of the intervention. Intervention planning includes the following steps:
1. Developing the plan, which involves selecting
○ Objective and measurable occupation-based goals and related time frames;
○ Occupational therapy intervention approach or approaches; and
○ Methods for service delivery, including what types of interventions will be provided, who will provide the
interventions, and which service delivery approaches will be used;

2. Considering potential discharge needs and plans; and

3. Making recommendations or referrals to other professionals as needed.

Steps 2 and 3 are discussed in the Outcomes section.

Intervention Implementation
Intervention implementation is the process of putting the intervention plan into action and
occurs after the initial evaluation process and development of the intervention plan. Interventions
may focus on a single aspect of the occupational therapy domain, such as a specific occupation,
or on several aspects of the domain, such as contexts, performance patterns, and performance
skills, as components of one or more occupations. Intervention implementation must always
reflect the occupational therapy scope of practice; occupational practitioners should not perform
interventions that do not use purposeful and occupation-based approaches (Gillen et al., 2019).
Intervention implementation includes the following steps (see Table 12):
 Select and carry out the intervention or interventions, which may include the following:
○ Therapeutic use of occupations and activities
○ Interventions to support occupations
○ Education
○ Training
○ Advocacy
○ Self-advocacy
○ Group intervention
○ Virtual interventions.
 Monitor the client’s response through ongoing evaluation and reevaluation.
Given that aspects of the domain are interrelated and influence one another in a continuous,
dynamic process, occupational therapy practitioners expect that a client’s ability to adapt,
change, and develop in one area will affect other areas. Because of this dynamic
interrelationship, evaluation, including analysis of occupational performance, and intervention
planning continue throughout the implementation process. Additionally, intervention

PREPUBLICATION DRAFT. Page 29 of 96

implementation includes monitoring of the client’s response to specific interventions and
progress toward goals.

Intervention Review
Intervention review is the continuous process of reevaluating and reviewing the intervention
plan, the effectiveness of its delivery, and progress toward outcomes. As during intervention
planning, this process includes collaboration with the client to identify progress toward goals and
outcomes. Reevaluation and review may lead to change in the intervention plan. Practitioners
should review best practices for using process indicators and, as appropriate, modify the
intervention plan and monitor progress using outcome performance measures and outcome tools.
Intervention review includes the following steps:
1. Reevaluating the plan and how it is implemented relative to achieving outcomes
2. Modifying the plan as needed
3. Determining the need for continuation or discontinuation of occupational therapy services and for referral to
other services.

Outcomes
Outcomes emerge from the occupational therapy process and describe the results clients can
achieve through occupational therapy intervention (Table 14). The outcomes of occupational
therapy are multifaceted and may occur in all aspects of the domain of concern. Outcomes
should be measured with the same methods used at evaluation and determined through
comparison of the client’s status at evaluation to the client’s status at discharge or transition.
Results of occupational therapy services are established through using outcome performance
measures and outcome tools.
Outcomes are directly related to the interventions provided and to the targeted occupations,
performance patterns, performance skills, client factors, and contexts. Outcomes may be traced
to improvement in areas of the domain, such as performance skills and client factors, but should
ultimately be reflected in clients’ ability to engage in their desired occupations. Outcomes
targeted in occupational therapy can be summarized as
 Occupational performance,
 Prevention,
 Health and wellness,
 Quality of life,
 Participation,
 Role competence,
 Well-being, and
 Occupational justice.
Occupational adaptation, or the way the client effectively and efficiently responds to
occupational and contextual demands (Grajo, 2019), is interwoven through all of these outcomes.

PREPUBLICATION DRAFT. Page 30 of 96

 The impact of outcomes and the way they are defined are specific to clients (persons, groups,
or populations) and to other stakeholders such as payers and regulators. Outcomes and their
documentation vary by practice setting and are influenced by the stakeholders in each setting
(AOTA, 2018a).
The focus on outcomes is woven throughout the process of occupational therapy. During
evaluation, occupational therapy practitioners and clients (and often others, such as parents and
caregivers) collaborate to identify targeted outcomes related to engagement in valued
occupations or daily life activities. These outcomes are the basis for development of the
intervention plan. During intervention implementation and review, clients and practitioners may
modify targeted outcomes to accommodate changing needs, contexts, and performance abilities.
Ultimately, the intervention process should result in the achievement of outcomes related to
health, well-being, and participation in life through engagement in occupation.

Outcome Measurement
Objective outcomes are measurable and tangible aspects of improved performance. Outcome
measurement is sometimes derived from standardized assessments with results reflected in
numerical data following specific scoring instructions. These data quantify a client’s response to
intervention in a way that can be used by all relevant stakeholders.

Outcomes are selected early in the occupational therapy process on the basis of their properties:
 Valid, reliable, and appropriately sensitive to change in clients’ occupational performance
 Consistent with targeted outcomes
 Congruent with the client’s goals
 Able to predict future outcomes.

Outcome measures are also used to measure progress and adjust goals and interventions by
 Comparing progress toward goal achievement to outcomes throughout the intervention
process.
 Assessing outcome use and results to make decisions about the future direction of
intervention (e.g., continue, modify, transition, discontinue, provide follow-up, refer for
other service).
In some settings, the focus is on patient-reported outcomes (PROs), which have been defined
as “any report of the status of a patient’s health condition that comes directly from the patient,
without interpretation of the patient’s response by a clinician or anyone else” (as quoted in
National Quality Forum, n.d., para. 1). PROs can be used as subjective measures of improved
outlook, confidence, hope, playfulness, self-efficacy, sustainability of valued occupations, pain
reduction, resilience, and perceived well-being. An example of a PRO is parents’ greater
perceived efficacy in parenting through a new understanding of their child’s behavior (Cohn,
2001; Cohn et al., 2000; Graham et al., 2013). Another example is an outpatient client with a
hand injury who reports a reduction in pain during the IADL of doing laundry. “PRO tools
measure what patients are able to do and how they feel by asking questions. These tools enable
assessment of patient-reported health status for physical, mental, and social well-being”
(National Quality Forum, n.d., para. 1).

PREPUBLICATION DRAFT. Page 31 of 96

 Outcomes can also be designed for caregivers—for example, improved quality of life for
both care recipient and caregiver. Studies of caregivers of people with dementia who received a
home environmental intervention found fewer declines in occupational performance, enhanced
mastery and skill, improved sense of self-efficacy and well-being, and less need for help with
care recipients (Gitlin & Corcoran, 2005; Gitlin et al., 2001, 2003, 2008; Graff et al., 2007;
Piersol et al., 2017).
Outcomes for groups that receive an educational intervention may include improved social
interaction, increased self-awareness through peer support, a larger social network, or improved
employee health and productivity. For example, education interventions for groups of employees
on safety and workplace wellness have been shown to decrease work injuries and increase
workplace productivity and satisfaction (Snodgrass & Amini, 2017).
Outcomes for populations may address health promotion, occupational justice and self-
advocacy, health literacy, community integration, community living, and access to services. As
with other occupational therapy clients, outcomes for populations are focused on occupational
performance, engagement, and participation. For example, outcomes at the population level as a
result of advocacy interventions include construction of accessible playground facilities,
improved accessibility for polling places, and reconstruction of a school after a natural disaster.

Transition and Discontinuation

Transition is movement from one life role or experience to another. Transitions in services, like
all life transitions, may require preparation, new knowledge, and time to accommodate to the
new situation (Orentlicher et al., 2015). Transition planning may be needed, for example, when a
client moves from one setting to another along the care continuum (e.g., acute hospital to skilled
nursing facility) or ages out of one program and into a new one (e.g., early intervention to
elementary school).
Collaboration among practitioners is necessary to ensure safety, well-being, and optimal
outcomes for clients (The Joint Commission, 2012, 2013). Transition planning may include a
referral to a provider within occupational therapy with advanced knowledge and skill (e.g.,
vestibular rehabilitation, driver evaluation, hand therapy) or outside the profession (e.g.,
psychologist, optometrist). Transition planning for groups and populations may be needed for a
transition from one stage to another (e.g., middle school students in a life skills program who
transition to high school) or from one set of needs to another (e.g., older adults in a community
falls prevention program who transition to a community exercise program).
Planning for discontinuation of occupational therapy services begins at initial evaluation.
Discontinuation of care occurs when the client has met short- and long-term goals or chooses to
discontinue receiving services (consistent with client-centered care). Safe and effective discharge
planning for a person may include education on the use of new equipment, adaptation of an
occupation, caregiver training, environmental modification, or determination of the appropriate
setting for transition of care. A key goal of discharge planning for individual clients is prevention
of readmission (Rogers et al., 2017). Discontinuation of services for groups and populations
occurs when goals are met and sustainability plans are implemented for long-term success.

Conclusion

PREPUBLICATION DRAFT. Page 32 of 96

The OTPF–4 describes the central concepts that ground occupational therapy practice and builds
a common understanding of the basic tenets and distinct contribution of the profession. The
occupational therapy domain and process are linked inextricably in a transactional relationship.
An understanding of this relationship supports and guides the complex decision making required
in the daily practice of occupational therapy and enhances practitioners’ ability to define the
reasons for and justify the provision of services when communicating with clients, family
members, team members, employers, payers, and policymakers.
The OTPF–4 provides a broader view than previous editions of occupational therapy as
related to groups and populations and current and future occupational needs of clients. This
edition also presents and describes the cornerstones of occupational therapy practice. These
discrete and critical qualities of occupational therapy provide practitioners with a foundation for
success in the occupational therapy process.
The OTPF–4 highlights the distinct value of occupation and occupational therapy in
contributing to health, well-being, and participation in life for persons, groups, and populations.
This document can be used to advocate for the importance of occupational therapy in meeting
society’s current and future needs, ultimately advancing the profession to ensure a sustainable
future.

References
American Heritage dictionary of the English language (5th ed.). (2020). Framework. Retrieved
from https://ahdictionary.com/word/search.html?q=framework
<unknown>American Occupational Therapy Association. (1979). Occupational therapy product
output reporting system and uniform terminology for reporting occupational therapy
services. (Available from [email protected])
American Occupational Therapy Association. (1989). Uniform terminology for occupational
therapy (2nd ed.). (Available from [email protected])
American Occupational Therapy Association. (1994). Uniform terminology for occupational
therapy (3rd ed.). American Journal of Occupational Therapy, 48, 1047–1054.
https://doi.org/10.5014/ajot.48.11.1047
American Occupational Therapy Association. (2002a). Broadening the construct of
independence [Position paper]. American Journal of Occupational Therapy, 56, 660.
https://doi.org/10.5014/ajot.56.6.660PubMed
American Occupational Therapy Association. (2002b). Occupational therapy practice
framework: Domain and process. American Journal of Occupational Therapy, 56, 609–639.
https://doi.org/10.5014/ajot.56.6.609PubMed</jrn>
American Occupational Therapy Association. (2008). Occupational therapy practice framework:
Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625–683.
https://doi.org/10.5014/ajot.62.6.625</eref>
American Occupational Therapy Association. (2011). Definition of occupational therapy
practice for the AOTA Model Practice Act. Retrieved from
http://www.aota.org/~/media/Corporate/Files/Advocacy/State/Resources/PracticeAct/Model
%20Definition%20of%20OT%20Practice%20%20Adopted%2041411.pdf

PREPUBLICATION DRAFT. Page 33 of 96

American Occupational Therapy Association. (2014a). Guidelines for supervision, roles, and
responsibilities during the delivery of occupational therapy services. American Journal of
Occupational Therapy, 68(Suppl. 3), S16–S22.
https://doi.org/10.5014/ajot.2014.686S03PubMed</jrn>
American Occupational Therapy Association. (2014b). Occupational therapy practice
framework: Domain and process (3rd ed.). American Journal of Occupational Therapy,
68(Suppl. 1), S1–S48. https://doi.org/10.5014/ajot.2014.682006<eref>
American Occupational Therapy Association. (2015a). Occupational therapy code of ethics
(2015). American Journal of Occupational Therapy, 69(Suppl. 3), 6913410030.
https://doi.org/10.5014/ajot.2015.696S03</eref>
<edb>American Occupational Therapy Association. (2015b). Policy A.23: Categories of
occupational therapy personnel and students. In Policy manual (2017 ed., pp. 26–27).
Bethesda, MD: Author.
<jrn>American Occupational Therapy Association. (2015c). Standards of practice for
occupational therapy. American Journal of Occupational Therapy, 69(Suppl. 3),
6913410057. https://doi.org/10.5014/ajot.2015.696S06PubMed</jrn>
<jrn>American Occupational Therapy Association. (2017a). AOTA’s occupational profile
template. American Journal of Occupational Therapy, 71(Suppl. 2), 7112420030.
https://doi.org/10.5014/ajot.2017.716S12
<jrn>American Occupational Therapy Association. (2017b). AOTA’s societal statement on
disaster response and risk reduction. American Journal of Occupational Therapy, 71(Suppl.
2), 7112410060. https://10.5014/ajot.2017.716S11PubMed</jrn>
American Occupation Therapy Association. (2017c). Occupational therapy’s role in medication
management. American Journal of Occupational Therapy, 71(Suppl. 2), 7112410025.
https://doi.org/10.5014/ajot.2017.716S02PubMed</jrn>
American Occupational Therapy Association. (2018a). Guidelines for documentation of
occupational therapy. American Journal of Occupational Therapy, 72(Suppl. 2),
7212410010. https://doi.org/10.5014/ajot.2018.72S203PubMed</jrn>
American Occupational Therapy Association. (2018b). Occupational therapy’s role in case
management. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410050.
https://doi.org/10.5014/ajot.2018.72S206PubMed</jrn>
American Occupational Therapy Association. (2018c). Telehealth in occupational therapy.
American Journal of Occupational Therapy, 72(Suppl. 2), 7212410059.
https://doi.org/10.5014/ajot.2018.72S219PubMed
American Occupational Therapy Association. (in press-a). Occupational therapy in the
promotion of health and the prevention of disease and disability. American Journal of
Occupational Therapy, 74(Suppl. 3).
American Occupational Therapy Association. (in press-b). Occupational therapy’s commitment
to diversity, equity, and inclusion. American Journal of Occupational Therapy, 74(Suppl. 3).

PREPUBLICATION DRAFT. Page 34 of 96

Americans With Disabilities Act of 1990, Pub. L. 101-336, 42 U.S.C. § 12101.
Asher, I. E. (Ed.). (2014). Asher’s occupational therapy assessment tools (4th ed.). Bethesda,
MD: AOTA Press.
Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory.
Englewood Cliffs, NJ: Prentice Hall.
<edb>Bedell, G. M. (2012). Measurement of social participation. In V. Anderson & M. H.
Beauchamp (Eds.), Developmental social neuroscience and childhood brain insult: Theory
and practice (pp. 184–206). New York: Guilford Press.
<edb>Bergen, D. (Ed.). (1988). Play as a medium for learning and development: A handbook of
theory and practice. Portsmouth, NH: Heinemann.
Billock, C. (2005). Delving into the center: Women’s lived experience of spirituality through
occupation (Publication No. AAT 3219812) [Doctoral dissertation, University of Southern
California]. ProQuest Dissertations and Theses Global.
Cambridge University Press. (n.d.). Cornerstone. In Cambridge Dictionary. Retrieved February
10, 2020, from https://dictionary.cambridge.org/us/dictionary/english/cornerstone
Centers for Medicare & Medicaid Services. (2019). Bundled Payments for Care Improvement
(BPCI) initiative: General information. Retrieved from
https://innovation.cms.gov/initiatives/bundled-payments
Christiansen, C. H., & Baum, M. C. (Eds.). (1997). Occupational therapy: Enabling function and
well-being. Thorofare, NJ: Slack.
Christiansen, C., Baum, M. C., & Bass-Haugen, J. (Eds.). (2005). Occupational therapy:
Performance, participation, and well-being. Thorofare, NJ: Slack.
<bok>Christiansen, C. H., & Townsend, E. A. (2010). Introduction to occupation: The art and
science of living (2nd ed.). Cranbury, NJ: Pearson Education.
<jrn>Clark, F. A. (2000). The concept of habit and routine: A preliminary theoretical synthesis.
OTJR: Occupation, Participation and Health, 20, 123S–137S.
https://doi.org/10.1177/15394492000200S114</jrn>
Cohn, E. S. (2001). Parent perspectives of occupational therapy using a sensory integration
approach. American Journal of Occupational Therapy, 55, 285–294.
https://doi.org/10.5014/ajot.55.3.285PubMed</jrn>
Cohn, E., Miller, L. J., & Tickle-Degnen, L. (2000). Parental hopes for therapy outcomes:
Children with sensory modulation disorders. American Journal of Occupational Therapy, 54,
36–43. https://doi.org/10.5014/ajot.54.1.36PubMed
Cohn, E. (2019). Asserting our competence and affirming the value occupation with confidence.
American Journal of Occupational Therapy, 63, 7306150010.
https://doi.org/10.5014/ajot.2019.736002
Cole, B., & McLean, V. (2003). Therapeutic relationships redefined. Occupational Therapy in
Mental Health, 19, 33–56. https://doi.org/10.1300/J004v19n02_03

PREPUBLICATION DRAFT. Page 35 of 96

Collins, J., & O’Brien, N. P. (2003). Greenwood dictionary of education. Westport, CT:
Greenwood Press.
Dennis, C. W., Dorsey, J. A., & Gitlow, L. (2015). A call for sustainable practice in occupational
therapy. Canadian Journal of Occupational Therapy, 82, 160–168.
https://doi.org/10.1177/0008417414566925PubMed
Dorsey, J., Ehrenfried, H., Finch, D., & Jaegers, L. (2019). Work. In B. A. B. Schell & G. Gillen
(Eds.), Willard and Spackman’s occupational therapy (13th ed., pp. 779–804). Philadelphia:
Wolters Kluwer.<edb>
Doucet, B. M., & Gutman, S. A. (2013). Quantifying function: The rest of the measurement
story. American Journal of Occupational Therapy, 67, 7–9.
https://doi.org/10.5014/ajot.2013.007096PubMed
<edb>Dunlea, A. (1996). An opportunity for co-adaptation: The experience of mothers and their
infants who are blind. In R. Zemke & F. Clark (Eds.), Occupational science: The evolving
discipline (pp. 227–342). Philadelphia: F. A. Davis.
Dunn, W. W. (2000). Habit: What’s the brain got to do with it? OTJR: Occupation, Participation
and Health, 20(Suppl. 1), 6S–20S. https://doi.org/10.1177/15394492000200S102</jrn>
Dunn, W., McClain, L. H., Brown, C., & Youngstrom, M. J. (1998). The ecology of human
performance. In M. E. Neistadt & E. B. Crepeau (Eds.), Willard and Spackman’s
occupational therapy (9th ed., pp. 525–535). Philadelphia: Lippincott Williams & Wilkins.
Dunton, W. R. (1934). The need for and value of research in occupational therapy. Occupational
Therapy and Rehabilitation, 13, 325–328.
Eberle, S. G. (2014). The elements of play: Toward a philosophy and a definition of play.
American Journal of Play, 6, 214–233.
Edgelow, M., & Krupa, T. (2011). Randomized controlled pilot study of an occupational time-
use intervention for people with serious mental illness. American Journal of Occupational
Therapy, 65, 267–276. https://doi.org/10.5014/ajot.2011.001313PubMed
Eklund, M., Orban, K., Argentzell, E., Bejerholm, U., Tjörnstrand, C., Erlandsson, L. K., &
Håkansson, C. (2017). The linkage between patterns of daily occupations and occupational
balance: Applications within occupational science and occupational therapy practice.
Scandinavian Journal of Occupational Therapy, 24, 41–56.
https://doi.org/10.1080/11038128.2016.1224271PubMed
Esdaile, S. A., & Olson, J. A. (2004). Mothering occupations: Challenge, agency, and
participation. Philadelphia: F. A. Davis.
<unknown>Fiese, B. H. (2007). Routines and rituals: Opportunities for participation in family
health. OTJR: Occupation, Participation and Health, 27(1 Suppl.), 41S–49S.
https://doi.org/10.1177/15394492070270S106
Fiese, B. H., Tomcho, T. J., Douglas, M., Josephs, K., Poltrock, S., & Baker, T. (2002). A review
of 50 years of research on naturally occurring family routines and rituals: Cause for
celebration. Journal of Family Psychology, 16, 381–390. https://doi.org/10.1037/0893-
3200.16.4.381PubMed</jrn>

PREPUBLICATION DRAFT. Page 36 of 96

Fisher, A. G. (2009). Occupational Therapy Intervention Process Model: A model for planning
and implementing top-down, client-centered, and occupation-based interventions. Fort
Collins, CO: Three Star Press.
<edb>Fisher, A. G., & Griswold, L. A. (2019). Performance skills: Implementing performance
analyses to evaluate quality of occupational performance. In B. A. B. Schell & G. Gillen
(Eds.), Willard and Spackman’s occupational therapy (13th ed., pp. 335–350). Philadelphia:
Wolters Kluwer.
<bok>Fisher, A. G., & Marterella, A. (2019). Powerful practice: A model for authentic
occupational therapy. Fort Collins, CO: Center for Innovative OT Solutions.

Gillen, G. (2013). A fork in the road: An occupational hazard? American Journal of

Occupational Therapy, 67, 641-652. https://doi.org/10.5014/ajot.2013.676002

Gillen, G., Hunter, E. G., Lieberman, D., & Stutzbach, M. (2019). AOTA’s top 5 Choosing
Wisely® recommendations. American Journal of Occupational Therapy, 73, 7302420010.
https://doi.org/10.5014/ajot.2019.732001
<bok>Gitlin, L. N., & Corcoran, M. A. (2005). Occupational therapy and dementia care: The
Home Environmental Skill-Building Program for individuals and families. Bethesda, MD:
AOTA Press.
Gitlin, L. N., Corcoran, M., Winter, L., Boyce, A., & Hauck, W. W. (2001). A randomized,
controlled trial of a home environmental intervention: Effect on efficacy and upset in
caregivers and on daily function of persons with dementia. Gerontologist, 41, 4–14.
https://doi.org/10.1093/geront/41.1.4PubMed
Gitlin, L. N., Winter, L., Burke, J., Chernett, N., Dennis, M. P., & Hauck, W. W. (2008).
Tailored activities to manage neuropsychiatric behaviors in persons with dementia and
reduce caregiver burden: A randomized pilot study. American Journal of Geriatric
Psychiatry, 16, 229–239.
https://doi.org/10.1097/01.JGP.0000300629.35408.94PubMed</jrn>
Gitlin, L. N., Winter, L., Corcoran, M., Dennis, M. P., Schinfeld, S., & Hauck, W. W. (2003).
Effects of the Home Environmental Skill-Building Program on the caregiver–care recipient
dyad: 6-month outcomes from the Philadelphia REACH Initiative. Gerontologist, 43, 532–
546. https://doi.org/10.1093/geront/43.4.532PubMed
Graff, M. J., Vernooij-Dassen, M. J., Thijssen, M., Dekker, J., Hoefnagels, W. H., & Olderikkert,
M. G. (2007). Effects of community occupational therapy on quality of life, mood, and health
status in dementia patients and their caregivers: A randomized controlled trial. Journals of
Gerontology, Series A: Biological Sciences and Medical Sciences, 62, 1002–1009.
https://doi.org/10.1093/gerona/62.9.1002PubMed
Graham, F., Rodger, S., & Ziviani, J. (2013). Effectiveness of occupational performance
coaching in improving children’s and mothers’ performance and mothers’ self-competence.
American Journal of Occupational Therapy, 67, 10–18.
https://doi.org/10.5014/ajot.2013.004648PubMed</jrn>

PREPUBLICATION DRAFT. Page 37 of 96

Grajo, L. (2019). Theory of occupational adaptation. In B. A. B. Schell & G. Gillen (Eds.),
Willard and Spackman’s occupational therapy (13th ed., pp. 633–642). Philadelphia: Wolters
Kluwer.
Hall, J. (2017). Gender of friend. In T. K. Shackelford & V. A. Weekes-Shackelford (Eds.),
Encyclopedia of evolutionary psychological science. Berlin: Springer.
https://doi.org/10.1007/978-3-319-16999-6_1600-1</edb>
Hammell, K. R. W. (2013). Occupation, well-being, and culture: Theory and cultural humility
Canadian Journal of Occupational Therapy, 80(4), 224–234. doi:
10.1177/0008417413500465
Hammell, K. W. (2009). Self-care, productivity, and leisure, or dimensions of occupational
experience? Rethinking occupational “categories.” Canadian Journal of Occupational
Therapy, 76, 107–114. https://doi.org/10.1177/000841740907600208PubMed</jrn>
Hanna, K., & Rodger, S. (2002). Towards family-centred practice in paediatric occupational
therapy: A review of the literature on parent–therapist collaboration. Australian
Occupational Therapy Journal, 49, 14–24. https://doi.org/10.1046/j.0045-
0766.2001.00273.x</jrn>
Hettler, W. (1984). Wellness—The lifetime goal of a university experience. In J. D. Matarazzo,
S. M. Weiss, J. A. Herd, N. E. Miller, & S. M. Weiss (Eds.), Behavioral health: A handbook
of health enhancement and disease prevention (pp. 1117–1124). New York: Wiley.
Hildenbrand, W. C., & Lamb, A. J. (2013). Occupational therapy in prevention and wellness:
Retaining relevance in a new health care world. American Journal of Occupational Therapy,
67, 266–271. https://doi.org/10.5014/ajot.2013.673001PubMed
Hinojosa, J., & Kramer, P. (Eds.). (2014). Evaluation in occupational therapy (4th ed.).
Bethesda, MD: AOTA Press.
<edb>Hinojosa, J., Kramer, P., & Crist, P. (2014). Evaluation: Where do we begin? In J.
Hinojosa & P. Kramer (Eds.), Evaluation in occupational therapy: Obtaining and
interpreting data (4th ed., pp. 1–18). Bethesda, MD: AOTA Press.
Hinojosa, J., Kramer, P., Royeen, C. B., & Luebben, A. J. (2017). The core concept of
occupation. In J. Hinojosa, P. Kramer, & C. Royeen (Eds.), Perspectives on Human
Occupations: Theories Underlying Practice (pp.23-39). Philadelphia: FA Davis.
<edb>Hooper, B., & Wood, W. (2019). The philosophy of occupational therapy: A framework
for practice. In B. A. B. Schell & G. Gillen (Eds.), Willard and Spackman’s occupational
therapy (13th ed., pp. 43–55). Philadelphia: Lippincott Williams & Wilkins.
<edb>Humbert, T. K. (2016). Addressing spirituality in occupational therapy. In T. K. Humbert
(Ed.), Spirituality and occupational therapy: A model for practice and research. Bethesda,
MD: AOTA Press.
Individuals With Disabilities Education Improvement Act of 2004, Pub. L. 108–446, 20 U.S.C. §
1400 et seq.
The Joint Commission. (2012). Transitions of care: The need for a more effective approach to
continuing patient care (Hot Topics in Health Care). Retrieved from
https://www.jointcommission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf

PREPUBLICATION DRAFT. Page 38 of 96

The Joint Commission. (2013). Transitions of care: The need for collaboration across entire
care continuum (Hot Topics in Health Care). Retrieved from
https://www.jointcommission.org/sitecore/media-library/deprecated-unorganized/imported-
assets/tjc/system-folders/assetmanager/toc_hot_topicspdf/</eref>
Khetani, M. A., & Coster, W. (2019). Social participation. In B. A. B. Schell & G. Gillen (Eds.),
Willard and Spackman’s occupational therapy (13th ed., pp. 847–860). Philadelphia: Wolters
Kluwer.</edb>
<bok>Kielhofner, G. (2008). The Model of Human Occupation: Theory and application (4th
ed.). Philadelphia: Lippincott Williams & Wilkins.
Koome, F., Hocking, C., & Sutton, D. (2012). Why routines matter: The nature and meaning of
family routine in the context of adolescent mental illness. Journal of Occupational Science,
19, 312–325. https://doi.org/10.1080/14427591.2012.718245
<jrn>Larson, E. A., & Zemke, R. (2003). Shaping the temporal patterns of our lives: The social
coordination of [activities]. Journal of Occupational Science, 10, 80–89.
https://doi.org/10.1080/14427591.2003.9686514
Law, M., Baum, M. C., & Dunn, W. (2005). Measuring occupational performance: Supporting
best practice in occupational therapy (2nd ed.). Thorofare, NJ: Slack.
Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). Person–
Environment–Occupation Model: A transactive approach to occupational performance.
Canadian Journal of Occupational Therapy, 63, 9–23.
https://doi.org/10.1177/000841749606300103
Lynch, H., Hayes, N., & Ryan, S. (2016). Exploring socio-cultural influences on infant play
occupations in Irish home environments. Journal of Occupational Science, 23, 352–369.
https://doi.org/10.1080/14427591.2015.1080181</jrn>
Magasi, S., & Hammel, J. (2004). Social support and social network mobilization in African
American woman who have experienced strokes. Disability Studies Quarterly, 24(4).
Matuska, K., & Barrett, K. (2019). Patterns of occupations. In B. A. B. Schell & G. Gillen (Eds.),
Willard and Spackman’s occupational therapy (13th ed., pp. 212–220). Philadelphia: Wolters
Kluwer.
McElroy, T., Muyinda, H., Atim, S., Spittal, P., & Backman, C. L. (2012). War, displacement
and productive occupations in northern Uganda. Journal of Occupational Science, 19, 198–
212. https://doi.org/10.1080/14427591.2011.614681</jrn>
Merriam-Webster. (2020). Belief. Merriam-Webster.com dictionary. https://www.merriam-
webster.com/dictionary/belief<bok>
Meyer, A. (1922). The philosophy of occupational therapy. Archives of Occupational Therapy, 1,
1–10.<jrn>
<bok>Mosey, A. C. (1996). Applied scientific inquiry in the health professions: An
epistemological orientation (2nd ed.). Bethesda, MD: American Occupational Therapy
Association.

PREPUBLICATION DRAFT. Page 39 of 96

Moyers, P. A.; American Occupational Therapy Association. (1999). The guide to occupational
therapy practice. American Journal of Occupational Therapy, 53, 247–322.
https://doi.org/10.5014/ajot.53.3.247PubMed</jrn>
Moyers, P. A., & Dale, L. M. (2007). The guide to occupational therapy practice (2nd ed.).
Bethesda, MD: AOTA Press.
National Quality Forum. (n.d.). Patient-reported outcomes. Retrieved from
https://www.qualityforum.org/Projects/n-r/Patient-Reported_Outcomes/Patient-
Reported_Outcomes.aspx
Nilsson, I., & Townsend, E. (2010). Occupational justice—Bridging theory and practice.
Scandinavian Journal of Occupational Therapy, 17, 57–63.
https://doi.org/10.3109/11038120903287182PubMed</jrn>
Nurit, W., & Michal, A. B. (2003). Rest: A qualitative exploration of the phenomenon.
Occupational Therapy International, 10, 227–238.
https://doi.org/10.1002/oti.187PubMed</jrn>
<edb>Olson, J. A. (2004). Mothering co-occupations in caring for infants and young children. In
S. A. Esdaile & J. A. Olson (Eds.), Mothering occupations (pp. 28–51). Philadelphia: F. A.
Davis.
<edb>Orentlicher, M., Schefkind, S., & Gibson, R. (Eds.). (2015). Transitions across the
lifespan: An occupational therapy approach. Bethesda, MD: AOTA Press.
<edb>Parham, L. D., & Fazio, L. S. (Eds.). (1997). Play in occupational therapy for children. St.
Louis: Mosby.
Pickens, N., & Pizur-Barnekow, K. (2009). Co-occupation: Extending the dialogue. Journal of
Occupational Science, 16, 151–156. https://doi.org/10.1080/14427591.2009.9686656</jrn>
<jrn>Piersol, C. V., Canton, K., Connor, S. E., Giller, I., Lipman, S., & Sager, S. (2017).
Effectiveness of interventions for caregivers of people with Alzheimer’s disease and related
major neurocognitive disorders: A systematic review. American Journal of Occupational
Therapy, 71, 7105180020. https://doi.org/10.5014/ajot.2017.027581PubMed</jrn>
<jrn>Primeau, L. (2000). Divisions of household work, routines, and child occupations in
families. Journal of Occupational Science, 7, 19–28.
https://doi.org/10.1080/14427591.2000.9686461</jrn>
<jrn>Radomski, M. V. (1995). There is more to life than putting on your pants. American
Journal of Occupational Therapy, 49, 487–490. https://doi.org/10.5014/ajot.49.6.487PubMed
<edb>Robinson Johnson, K., & Dickie, V. (2019). What is occupation? In B. A. B. Schell & G.
Gillen (Eds.), Willard and Spackman’s occupational therapy (13th ed., pp. 320–333).
Philadelphia: Wolters Kluwer.
Rogers, A. T., Bai, G., Lavin, R. A., & Anderson, G. F. (2017). Higher hospital spending on
occupational therapy is associated with lower readmission rates. Medical Care Research and
Review, 74, 668–686. https://doi.org/10.1177/1077558716666981</eref>
Rogers, J. C., & Holm, M. B. (1994). Assessment of self-care. In B. R. Bonder & M. B. Wagner
(Eds.), Functional performance in older adults (pp. 181–202). Philadelphia: F. A. Davis.

PREPUBLICATION DRAFT. Page 40 of 96

Scaffa, M. (2019). Occupational therapy interventions for groups, communities, and populations.
In B. A. B. Schell & G. Gillen (Eds.), Willard and Spackman’s occupational therapy (13th
ed., pp. 436–447). Philadelphia: Wolters Kluwer.</edb>
Scaffa, M. E., & Reitz, S. M. (Eds.). (2014). Occupational therapy in community-based practice
settings (2nd ed.). Philadelphia: F. A. Davis.
Schell, B. A. B. (2019). Professional reasoning in practice. In B. A. B. Schell & G. Gillen (Eds.),
Willard and Spackman’s occupational therapy (13th ed., pp. 482–497). Philadelphia: Wolters
Kluwer.
Schell, B. A. B., Gillen, G., Crepeau, E., & Scaffa, M. (2019). Analyzing occupations and
activity. In B. A. B. Schell & G. Gillen (Eds.), Willard and Spackman’s occupational therapy
(13th ed., pp. 320–333). Philadelphia: Wolters Kluwer.
Schwartz, J.K., & Smith, R.O. (2017). Integration of Medication Management Into Occupational
Therapy Practice. American Journal of Occupational Therapy, 71(4).
https://doi.org/10.5014/ajot.2017.015032
Segal, R. (2004). Family routines and rituals: A context for occupational therapy interventions.
American Journal of Occupational Therapy, 58, 499–508.
https://doi.org/10.5014/ajot.58.5.499PubMed
<edb>Skard, G., & Bundy, A. (2008). Test of Playfulness. In L. D. Parham & L. Fazio (Eds.),
Play in occupational therapy for children (2nd ed., pp. 71–93). St. Louis: Mosby.
https://doi.org/10.1016/B978-032302954-4.10004-2</edb>
Slagle, E. C. (1924). A year’s development of occupational therapy in New York State hospitals.
Modern Hospital, 22, 98–104.
Snodgrass, J., & Amini, D. (2017). Occupational therapy practice guidelines for adults with
musculoskeletal conditions. Bethesda, MD: AOTA Press.
Sutton-Smith, B. (2009). The ambiguity of play. Cambridge, MA: Harvard University Press.
Taylor, R. R. (Ed.). (2017). Kielhofner’s Model of Human Occupation: Theory and application.
Philadelphia: Wolters Kluwer Health.
<edb>Taylor, R. (2019). Therapeutic relationship and client collaboration: Applying the
Intentional Relationship Model. In B. A. B. Schell & G. Gillen (Eds.), Willard and
Spackman’s occupational therapy (13th ed., pp. 527–538). Philadelphia: Lippincott Williams
& Wilkins.
Taylor, R. R. (2020). The intentional relationship: Occupational therapy and use of self.
Philadelphia: FA Davis
<edb>Taylor, R. R., & Van Puymbroeck, L. (2013). Therapeutic use of self: Applying the
Intentional Relationship Model in group therapy. In J. C. O’Brien & J. W. Solomon (Eds.),
Occupational analysis and group process (pp. 36–52). St. Louis: Elsevier.
<jrn>Townsend, E., & Wilcock, A. A. (2004). Occupational justice and client-centred practice:
A dialogue in progress. Canadian Journal of Occupational Therapy, 71, 75–87.
https://doi.org/10.1177/000841740407100203PubMed

PREPUBLICATION DRAFT. Page 41 of 96

<jrn>Trombly, C. A. (1995). Occupation: Purposefulness and meaningfulness as therapeutic
mechanisms (Eleanor Clarke Slagle Lecture). American Journal of Occupational Therapy,
49, 960–972. https://doi.org/10.5014/ajot.49.10.960PubMed
<bok>Uniform Data System for Medical Rehabilitation. (1996). Guide for the Uniform Data Set
for Medical Rehabilitation (including the FIM instrument). Buffalo, NY: Author.
Unruh, A. M. (2004). Reflections on: “So . . . what do you do?” Occupation and the construction
of identity. Canadian Journal of Occupational Therapy, 71, 290–295.
https://doi.org/10.1177/000841740407100508PubMed
<jrn>Uyeshiro Simon, A., & Collins, C. E. R. (2017). Lifestyle Redesign® for chronic pain
management: A retrospective clinical efficacy study. American Journal of Occupational
Therapy, 71, 7104190040. https://doi.org/10.5014/ajot.2017.025502PubMed
<jrn>Wagman, P., Håkansson, C., & Jonsson, H. (2015). Occupational balance: A scoping
review of current research and identified knowledge gaps. Journal of Occupational Science,
22, 160–169. https://doi.org/10.1080/14427591.2014.986512
Wilcock, A. A. (2006). An occupational perspective of health (2nd ed.). Thorofare, NJ: Slack.
Wilcock, A. A., & Townsend, E. A. (2019). Occupational justice. In B. A. B. Schell & G. Gillen
(Eds.), Willard and Spackman’s occupational therapy (13th ed., pp. 643–659). Philadelphia:
Lippincott Williams & Wilkins.
World Federation of Occupational Therapists. (2012a). About occupational therapy. Retrieved
from https://www.wfot.org/about-occupational-therapy</eref>
World Federation of Occupational Therapists. (2012b). Occupational science [Position
statement]. Retrieved from https://www.wfot.org/resources/occupational-science</eref>
World Federation of Occupational Therapists. (2019). Occupational therapy and community-
centred practice [Position statement]. Retrieved from
https://www.wfot.org/resources/occupational-therapy-and-community-centred-
practice</eref>
World Health Organization. (1986). The Ottawa Charter for Health Promotion. Retrieved from
https://www.who.int/healthpromotion/conferences/previous/ottawa/en/</eref>
World Health Organization. (2006). Constitution of the World Health Organization (45th ed.).
Retrieved from https://www.who.int/governance/eb/who_constitution_en.pdf</eref>
World Health Organization. (2008). International classification of functioning, disability and
health: ICF. Geneva: WHO Press.
Zemke, R., & Clark, F. (1996). Occupational science: An evolving discipline. Philadelphia: F. A.
Davis.

PREPUBLICATION DRAFT. Page 42 of 96

 Tables

Table 1. Examples of Clients: Persons, Groups, and Populations

Person Group Population

Health Management
Middle-school student with Group of students with diabetes All students in the school provided
diabetes interested in developing interested in problem solving the with access to food choices to meet
self-management skills to test school setting’s support for varying dietary needs and desires
blood sugar levels management of their condition

Feeding
Family of an infant with a history Families with infants experiencing Families of infants advocating for
of prematurity and difficulty feeding challenges advocating for research and development of
accepting nutrition orally the local hospital’s rehabilitation alternative nipple and bottle designs
services to develop infant feeding to address feeding challenges
classes

Community Mobility
Person with stroke who wants to Stroke support group talking with Stroke survivors advocating for
return to driving elected leaders about developing increased access to community
community mobility resources mobility options for all persons
living with mobility limitations

Social Participation
Young adult with IDD interested Young adults with IDD in a Young adults with IDD educating
in increasing social participation transition program sponsoring their community about their need for
leisure activities in which all may inclusion in community-based social
participate in valued social and leisure activities
relationships

Home Establishment and Management

Person living with SMI interested Support group for people living People living with SMI in the same
in developing skills for with SMI developing resources to region advocating for increased
independent living foster independent living housing options for independent
living

Work Participation
Older worker with difficulty Group of older workers in a factory Older workers in a national
performing some work tasks advocating for modification of corporation advocating for company-
equipment to address discomfort wide wellness support programs
when operating the same set of
machines

Note. IDD = intellectual and developmental disabilities; SMI = serious mental illness.

PREPUBLICATION DRAFT. Page 43 of 96

Table 2. Occupations
Occupations are “the everyday activities that people do as individuals, in families, and with communities to occupy
time and bring meaning and purpose to life. Occupations include things people need to, want to and are expected to
do” (World Federation of Occupational Therapists, 2012a, para. 2). Occupations are categorized as activities of daily
living, instrumental activities of daily living, health management, rest and sleep, education, work, play, leisure, and
social participation.
Occupation Description

Activities of Daily Living (ADLs)—Activities oriented toward taking care of one’s own body (adapted from
Rogers & Holm, 1994) and completed on a routine basis.
Bathing, showering Obtaining and using supplies; soaping, rinsing, and drying body parts;
maintaining bathing position; transferring to and from bathing positions
Toileting and toilet hygiene Obtaining and using toileting supplies, managing clothing, maintaining
toileting position, transferring to and from toileting position, cleaning body,
caring for menstrual and continence needs (including catheter, colostomy,
and suppository management), maintaining intentional control of bowel
movements and urination and, if necessary, using equipment or agents for
bladder control (Uniform Data System for Medical Rehabilitation, 1996, pp.
III-20, III-24)
Dressing Selecting clothing and accessories with consideration of time of day, weather,
and desired presentation; obtaining clothing from storage area; dressing and
undressing in a sequential fashion; fastening and adjusting clothing and
shoes; applying and removing personal devices, prosthetic devices, or splints
Eating and swallowing Keeping and manipulating food or fluid in the mouth, swallowing it (i.e.,
moving it from the mouth to the stomach
Feeding Setting up, arranging, and bringing food or fluid from the vessel to the mouth
(includes self-feeding and feeding others)
Functional mobility Moving from one position or place to another (during performance of
everyday activities), such as in-bed mobility, wheelchair mobility, and
transfers (e.g., wheelchair, bed, car, shower, tub, toilet, chair, floor); includes
functional ambulation and transportation of objects
Personal hygiene and grooming Obtaining and using supplies; removing body hair (e.g., using a razor or
tweezers); applying and removing cosmetics; washing, drying, combing,
styling, brushing, and trimming hair; caring for nails (hands and feet); caring
for skin, ears, eyes, and nose; applying deodorant; cleaning mouth; brushing
and flossing teeth; removing, cleaning, and reinserting dental orthotics and
prosthetics
Sexual activity Engaging in the broad possibilities of sexual expression and experiences with
self or others (e.g., hugging, kissing, foreplay, masturbation, oral sex,
intercourse)
Instrumental Activities of Daily Living (IADLs)—Activities to support daily life within the home and
community.
Care of others (including Providing care for others, arranging or supervising formal care (by paid
selection and supervision of caregivers) or informal care (by family or friends) for others
caregivers)
Care of pets and animals Providing care for pets and service animals, arranging or supervising care for
pets and service animals
Child rearing Providing care and supervision to support the developmental and
physiological needs of a child
Communication management Sending, receiving, and interpreting information using systems and
equipment such as writing tools, telephones (including smartphones),
keyboards, audiovisual recorders, computers or tablets, communication
boards, call lights, emergency systems, Braille writers, telecommunication
devices for deaf people, augmentative communication systems, and personal

PREPUBLICATION DRAFT. Page 44 of 96

 digital assistants
Driving and community mobility Planning and moving around in the community using public or private
transportation, such as driving, walking, bicycling, or accessing and riding in
buses, taxi cabs, ride shares, or other transportation systems
Financial management Using fiscal resources, including financial transaction methods (e.g., credit
card, digital banking), and planning and using finances with long-term and
short-term goals
Home establishment and Obtaining and maintaining personal and household possessions and
management environments (e.g., home, yard, garden, houseplants, appliances, vehicles),
including maintaining and repairing personal possessions (e.g., clothing,
household items) and knowing how to seek help or whom to contact
Meal preparation and cleanup Planning, preparing, and serving meals and cleaning up food and tools (e.g.,
utensils, pots, plates) after meals
Religious and spiritual Engaging in religious or spiritual activities, organizations, and practices for
expression self-fulfillment; finding meaning, religious, or spiritual value; establishing
connection with a divine power, such as is involved in attending a church,
temple, mosque, or synagogue; praying or chanting for a religious purpose;
and engaging in spiritual contemplation (WHO, 2008); may also include
giving back to others, contributing to society or a cause, and contributing to a
greater purpose
Safety and emergency Evaluating situations in advance for potential safety risks; recognizing
maintenance sudden, unexpected hazardous situations and initiating emergency action;
reducing potential threats to health and safety, including ensuring safety when
entering and exiting the home, identifying emergency contact numbers, and
replacing items such as batteries in smoke alarms and light bulbs
Shopping Preparing shopping lists (grocery and other); selecting, purchasing, and
transporting items; selecting method of payment and completing payment
transactions; managing internet shopping and related use of electronic devices
such as computers, cell phones, and tablets
Health Management—Activities related to developing, managing, and maintaining health and wellness routines,
including self-management, with the goal of improving or maintaining health to support participation in other
occupations.
Social and emotional health Identifying personal strengths and assets, managing emotions, expressing
promotion and maintenance needs effectively, seeking occupations and social engagement to support
health and wellness, developing self-identity, making choices to improve
quality of life in participation
Symptom and condition Managing physical and mental health needs, including using coping strategies
management for illness, trauma history, or societal stigma; managing pain; managing
chronic disease; recognizing symptom changes and fluctuations; developing
and using strategies for managing and regulating emotions; planning time and
establishing behavioral patterns for restorative activities (e.g., meditation);
using community and social supports; navigating and accessing the health
care system
Communication with the health Expressing and receiving verbal, written, and digital communication with
care system health care and insurance providers, including understanding and advocating
for self or others
Medication management Communicating with the physician about prescriptions, filling prescriptions at
the pharmacy, interpreting medication instructions, taking medications on a
routine basis, refilling prescriptions in a timely manner (AOTA, 2017c;
Schwartz & Smith, 2017)
Physical activity Completing cardiovascular exercise, strength training, and balance training to
improve or maintain health and decrease risk of health episodes, such as by
incorporating walks into daily routine
Nutrition management Implementing and adhering to nutrition and hydration recommendations from
the medical team, preparing meals to support health goals, participating in

PREPUBLICATION DRAFT. Page 45 of 96

 health-promoting diet routines
Personal care device Procuring, using, cleaning, and maintaining personal care devices, including
management hearing aids, contact lenses, glasses, orthotics, prosthetics, adaptive
equipment, pessaries, glucometers, and contraceptive and sexual devices
Rest and Sleep—Activities related to obtaining restorative rest and sleep to support healthy, active engagement
in other occupations.
Rest Identifying the need to relax and engaging in quiet and effortless actions that
interrupt physical and mental activity (Nurit & Michal, 2003, p. 227);
reducing involvement in taxing physical, mental, or social activities resulting
in a relaxed state; engaging in relaxation or other endeavors that restore
energy and calm and renew interest in engagement
Sleep preparation Engaging in routines that prepare the self for a comfortable rest, such as
grooming and undressing, reading or listening to music, saying goodnight to
others, and engaging in meditation or prayers; determining the time of day
and length of time desired for sleeping and the time needed to wake;
establishing sleep patterns that support growth and health (patterns are often
personally and culturally determined); preparing the physical environment for
periods of sleep, such as making the bed or space on which to sleep, ensuring
warmth or coolness and protection, setting an alarm clock, securing the home
(e.g., by locking doors or closing windows or curtains), setting up sleep-
supporting equipment (e.g., CPAP machine), and turning off electronics and
lights
Sleep participation Taking care of personal needs for sleep, such as ceasing activities to ensure
onset of sleep, napping, and dreaming; sustaining a sleep state without
disruption; meeting nighttime toileting and hydration needs, including
negotiating the needs of and interacting with others (e.g., children, partner)
within the social environment, such as providing nighttime caregiving (e.g.,
breastfeeding) and monitoring comfort and safety of others who are sleeping)
Education—Activities needed for learning and participating in the educational environment.
Formal educational participation Participating in academic (e.g., math, reading, degree coursework),
nonacademic (e.g., recess, lunchroom, hallway), extracurricular (e.g., sports,
band, cheerleading, dances), technological (e.g., online assignment
completion, distance learning), and vocational (including prevocational)
educational activities
Informal personal educational Identifying topics and methods for obtaining topic-related information or
needs or interests exploration skills
(beyond formal education)
Informal educational Participating in classes, programs, and activities that provide instruction or
participation training outside of a structured curriculum in identified areas of interest
Work—Labor or exertion related to the development, production, delivery, or management of objects or
services; benefits may be financial or nonfinancial (e.g. social connectedness, contributions to society, adding
structure and routine to daily life) (Christiansen & Townsend, 2010; Dorsey et al, 2019).
Employment interests and Identifying and selecting work opportunities consistent with personal assets,
pursuits limitations, goals, and interests (adapted from Mosey, 1996, p. 342)
Employment seeking and Advocating for oneself; completing, submitting, and reviewing application
acquisition materials; preparing for interviews; participating in interviews and following
up afterward; discussing job benefits; finalizing negotiations
Job performance and Creating, producing, and distributing products and services; maintaining
maintenance required work skills and patterns; managing time use; managing relationships
with coworkers, managers, and customers; following and providing
leadership and supervision; initiating, sustaining, and completing work;
complying with work norms and procedures; seeking and responding to
feedback on performance
Retirement preparation and Determining aptitudes, developing interests and skills, selecting vocational
adjustment pursuits, securing required resources, adjusting lifestyle in the absence of the

PREPUBLICATION DRAFT. Page 46 of 96

 worker role
Volunteer exploration Identifying and learning about community causes, organizations, and
opportunities for unpaid work consistent with personal skills, interests,
location, and time available
Volunteer participation Performing unpaid work activities for the benefit of selected people, causes,
or organizations
Play—Activities that are intrinsically motivated, internally controlled, and freely chosen and that may include
suspension of reality (e.g., fantasy; Skard & Bundy, 2008), exploration, humor, risk taking, contests, and
celebrations (Eberle, 2014; Sutton-Smith, 2009). Play is a complex and multidimensional phenomenon that is
shaped by sociocultural factors (Lynch, Hayes, & Ryan, 2016).
Play exploration Identifying play activities, including exploration play, practice play, pretend
play, games with rules, constructive play, and symbolic play (adapted from
Bergen, 1988, pp. 64–65)
Play participation Participating in play; maintaining a balance of play with other occupations;
obtaining, using, and maintaining toys, equipment, and supplies
Leisure—“Nonobligatory activity that is intrinsically motivated and engaged in during discretionary time, that is,
time not committed to obligatory occupations such as work, self-care, or sleep” (Parham & Fazio, 1997, p. 250).
Leisure exploration Identifying interests, skills, opportunities, and leisure activities
Leisure participation Planning and participating in leisure activities; maintaining a balance of
leisure activities with other occupations; obtaining, using, and maintaining
equipment and supplies
Social Participation—Activities that involve social interaction with others, including family, friends, peers, and
community members, and that support social interdependence (Bedell, 2012; Khetani & Coster, 2019; Magasi &
Hammel, 2004).
Community participation Engaging in activities that result in successful interaction at the community
level (e.g., neighborhood, organization, workplace, school, digital social
network, religious or spiritual group)
Family participation Engaging in activities that result in “interaction in specific required and/or
desired familial roles” (Mosey, 1996, p. 340)
Friendships Engaging in activities that support a relationship between two people based
on mutual liking in which partners provide support to each other in times of
need (Hall, 2017)
Peer group participation Engaging in activities with others who have similar interests, age,
background, or social status
Intimate partner relationships Engaging in activities to initiate and maintain a close relationship, including
giving and receiving affection and interacting in desired roles; intimate
partners may or may not engage in sexual activity
Note. CPAP = continuous positive airway pressure.

PREPUBLICATION DRAFT. Page 47 of 96

Table 3. Examples of Occupations for Persons, Groups, and Populations
Persons engage in occupations, and groups engage in shared occupations; populations as a whole do not engage in
shared occupations, which happen at the person or group level. Occupational therapy practitioners provide
interventions for persons, groups, and populations.
Occupation Client Type Example
Category
Activities of daily Person Older adult completing bathing with assistance from an adult child
living Group Students eating lunch during a lunch break
Instrumental Person Parent using a phone app to pay a babysitter electronically
activities of daily Group Club members using public transportation to arrive at a musical performance
living
Health management Person Patient scheduling an appointment with a specialist after referral by the primary
care doctor
Group Parent association sharing preparation of healthy foods to serve at a school-
sponsored festival
Rest and sleep Person Person turning off lights and adjusting the room temperature to 68° before sleep
Group Children engaging in nap time at a daycare center
Education Person College student taking an African-American history class online
Group Students working on a collaborative science project on robotics
Work Person Electrician turning off power before working on a power line
Group Peers volunteering for a day of action at an animal shelter
Play Person Child playing superhero dress up
Group Class playing freeze tag during recess
Leisure Person Family member knitting a sweater for a new baby
Group Friends meeting for a craft circle
Social participation Person New mother going to lunch with friends
Group Older adults gathering at a community center to wrap holiday presents for charity
distribution

PREPUBLICATION DRAFT. Page 48 of 96

 Table 4. Context: Environmental Factors
Context is the broad construct that encompasses environmental factors and personal factors. Environmental factors
are aspects of the physical, social, and attitudinal surroundings in which people live and conduct their lives.
Environmental Factor Components Examples
Natural environment and human- Physical geography • Raised flower beds in backyard
made changes to the environment: • Local stream cleanup by Boy Scouts
Animate and inanimate elements during a community service day project
of the natural or physical • Highway expansion cutting through an
environment and components of established neighborhood
that environment that have been Population: groups of people living in a • Universal access playground where
modified by people, as well as given environment who share the same children with mobility impairment can
characteristics of human pattern of environmental adaptation play
populations within the • Hearing loop installed in a synagogue
environment by congregation members with hearing
aids
• Tree-shaded, solid-surface walking path
enjoyed by older adults in a senior living
community
Flora (plants) and fauna (animals) • Nonshedding service dog
• Family-owned herd of cattle
• Community garden
Climate: meteorological features and • Sunny day requiring use of sunglasses
events, such as weather • Rain shower prompting a crew of road
workers to don rain gear
• Unusually high temperatures turning a
community ice skating pond to slush
Natural events: regular or irregular • Barometric pressure causing a headache
geographic and atmospheric changes • Flood of a local creek damaging
that cause disruption in the physical neighborhood homes
environment • Hurricane devastating a low-lying
region
Human-caused events: alterations or • High air pollution forcing a person with
disturbances in the natural environment lung disease to stay indoors
caused by humans that result in the • Accessible dock at a local river park
disruption of day-to-day life demolished to make way for a new bridge
construction project
• Derailment of a train loaded with highly
combustible chemicals leading to the
emergency total evacuation of a small
town
Light: light intensity and quality • Darkness requiring use of a reading
lamp
• Office with ample natural light
• Street lamps
Time-related changes: natural, regularly • Jet lag
occurring, or predictable change; rhythm • Quitting time at the end of a work shift
and duration of activity; time of day, • Summer solstice
week, month, season, or year; day–night
cycles; lunar cycles
Sound and vibration: heard or felt • Vibration of a cell phone indicating a
phenomena that may provide useful or text message
distracting information about the world • Bell signaling the start of the school day
• Outdoor emergency warning system on
a college campus

PREPUBLICATION DRAFT. Page 49 of 96

 Air quality: characteristics of the • Heavy perfume use by a family member
atmosphere (outside buildings) or causing an asthmatic reaction
enclosed areas of air (inside buildings) • Smoking area outside an office building
• High incidence of respiratory diseases
near an industrial district
Products and technology: Natural Food, drugs, and other products or • Preferred snack
or human-made products or substances for personal consumption • Injectable hormones for a transgender
systems of products, equipment, man
and technology that are gathered, • Grade-school cafeteria lunch
created, produced, or General products and technology for • Toothbrush
manufactured personal use in daily living (including • Household refrigerator
assistive technology and products) • Shower in a fitness or exercise facility
Personal indoor and outdoor mobility • Four-wheeled walker
and transportation equipment used by • Family car
people in activities requiring movement • Elevator in a multistory apartment
inside and outside of buildings building
Communication: activities involving • Hearing aid
sending and receiving information • Text chain via personal cell phones
• Use of emergency response system to
warn region of impending dangerous
storms
Education: processes and methods for • Textbook
acquiring knowledge, expertise, or skill • Online course
• Curriculum for workplace sexual
harassment program
Employment: paid work activities • Home office for remote work
• Assembly factory
• Internet connection for health care
workers to access electronic medical
records
Cultural, recreational, and sporting • Gaming console
activities • Instruments for a university marching
band
• Soccer stadium
Practice of religion and spirituality • Prayer rug
• Temple
• Sunday church service television
broadcast
Indoor and outdoor human-made • Home bathroom with grab bars and
environments that are planned, designed, raised toilet seat
and constructed for public and private • Accessible playground at a city park
use • Zero-grade entry to a shopping mall
Assets for economic exchange, such as • Pocket change
money, goods, property, and other • Household budget
valuables that an individual owns or has • Condominium association tax bill
rights to use
Virtual environments occurring in • Personal cell phone
simulated, real-time, and near-time • Synchronous video meeting of
situations, absent of physical contact coworkers in distant locations
• Open-source video gaming community
Support and relationships: People Immediate and extended family Spouses, partners, parents, siblings, foster
or animals that provide practical parents, adoptive grandparents.
physical or emotional support, Biological families and found/constructed
nurturing, protection, assistance, families
and relationships to other persons Friends, acquaintances, peers, • Trusted best friend

PREPUBLICATION DRAFT. Page 50 of 96

in the home, workplace, or school colleagues, neighbors, and community • Co-workers
or at play or in other aspects of members • Helpful next door neighbor
their daily activities • Substance Abuse Recovery Support
Group Sponsor
People in positions of authority and • Teacher who offers extra tutoring
those in subordinate positions • Legal Guardian for a parentless minor
• Women religious reporting to a Sister
Superior
• New employee being oriented to the job
tasks by their assigned mentor

Personal care providers and personal • Health care professionals and other
assistants providing support to professionals serving a community
individuals
Domesticated animals • Therapy dog program in a senior living
community
• Horse kept to draw a buggy for an
Amish family’s transportation.

Attitudes: Observable evidence of Individual attitudes of immediate and • Shared grief over the untimely death of
customs, practices, ideologies, extended family, friends and a sibling
values, norms, factual beliefs, and acquaintances, peers and colleagues, • Automatic trust from a patient who
religious beliefs held by people neighbors and community members, knows your father
other than the client people in positions of authority and • Reliance among members of a faith
subordinate positions, personal care community.
providers and personal assistants,
strangers, health care and other
professionals
Societal attitudes, including  Failure to acknowledge a young
discriminatory practices person who wishes to vote for the
first time.
 Racial discrimination in job hiring
processes
Social norms, practices, and ideologies No time off work allowed to observe a
that marginalize specific populations religious holy day.
Services, systems, and policies: Services designed to meet the needs of • Economic services, including Social
Benefits, structured programs, persons, groups, and populations Security income and public assistance
and regulations for operations, • Health services for preventing and
provided by institutions in various treating health problems, providing
sectors of society, designed to medical rehabilitation, and promoting
meet the needs of persons, healthy lifestyles
groups, and populations Systems established by governments at • Public utilities (e.g., water, electricity,
the local, regional, national, and sanitation)
international levels or by other • Communications (transmission and
recognized authorities exchange of information)
• Transportation systems
• Political systems related to voting,
elections, and governance
Policies constituted by rules, regulations, • Architecture, construction, open space
conventions, and standards established use, and housing policies
by governments at the local, regional, • Civil protection and legal services
national, and international levels or by • Labor and employment policies related
other recognized authorities to finding suitable work, looking for
different work, or seeking promotion

PREPUBLICATION DRAFT. Page 51 of 96

 Table 5. Context: Personal Factors
Context is the broad construct that encompasses environmental factors and personal factors. Personal factors are the
particular background of a person’s life and living and consist of the unique features of the person that are not part
of a health condition or health state.
Personal Factor Person A Person B
Age (chronological) • 48 years old • 14 years old
Sexual orientation • Attracted to men • Attracted to all genders
Gender identity • Female • Male
Race and ethnicity • Black French Caribbean • Southeast Asian Hmong
Cultural identification and cultural • Urban Black • Traditional clan structure
attitudes • Feminist • Elders are decision makers for
• Caribbean island identification community
Social background, social status, • Urban, upscale neighborhood • Family owns small home
and socioeconomic status • Friends are in the professional • Father works in a stable job in light
workforce manufacturing
• Income allows for luxury • Mother is a child care provider for
neighborhood children
Upbringing and life experiences • No siblings • Traditional
• Raised in household with grandmother • Born in a refugee camp before parents
as caregiver emigrated
• Moved from California to Boston while • Youngest of five siblings
an adolescent • Lives in a small city in the Upper
Midwest
Habits and past and current • Coffee before anything else • Organized and attentive to family
behavioral patterns • Meticulous about dress • Never misses a family meal
Individual psychological assets, • Anxious when not working • Known for being calm
including temperament, character • Extroverted • Not outgoing but friendly to all
traits, and coping styles, for • High level of confidence • Does not speak up or complain at
handling responsibilities, stress, • Readily adapts approach to and school during conflict
crises, and other psychological interactions with those who are culturally
demands (e.g., extroversion, different
agreeableness, conscientiousness,
psychic stability, openness to
experience, optimism, confidence)
Education • Master’s degree in political science • High school freshman
• Law degree • Advanced skills in the sciences
Profession and professional identity • Public interest lawyer • Public high school student
Lifestyle • High-rise apartment • Engaged in clan and community
• Likes urban nightlife and casual dating • Four older siblings live nearby
• Works long hours
Other health conditions and fitness • Treated for anorexia nervosa while an • Wears eyeglasses for astigmatism
adolescent • Sedentary at home except for assigned
• Occasional runner chores

PREPUBLICATION DRAFT. Page 52 of 96

Table 6. Performance Patterns
Performance patterns are the habits, routines, roles, and rituals that may be associated with different lifestyles and
used in the process of engaging in occupations or activities. These patterns are influenced by context and time use
and can support or hinder occupational performance.
Category Description Examples
Person
Habits “Specific, automatic behaviors • Automatically puts car keys in the same place
performed repeatedly, relatively • Spontaneously looks both ways before crossing the street
automatically, and with little • Always turns off the stove burner before removing a
variation” (Matuska & Barrett, cooking pot
2019, p. 214). Habits can be • Activates the alarm system before leaving the home
healthy or unhealthy, efficient or • Always checks smartphone for emails or text messages on
inefficient, and supportive or waking
harmful (Dunn, 2000). • Snacks when watching television
Routines Patterns of behavior that are • Follows a morning sequence to complete toileting,
observable, regular, and repetitive bathing, hygiene, and dressing
and that provide structure for • Follows the sequence of steps involved in meal
daily life. They can be satisfying, preparation
promoting, or damaging. • Manages morning routine to drop children off at school
Routines require delimited time and arrive at work on time
commitment and are embedded in
cultural and ecological contexts
(Fiese, 2007; Segal, 2004).
Roles Aspects of identity shaped by • Sibling in a family with three children
culture and context that may be • Retired military personnel
further conceptualized and • Volunteer at a local park district
defined by the client and the • Mother of an adolescent with developmental disabilities
activities and occupations one • Student with a learning disability studying computer
engages in. technology
• Corporate executive returning to part-time work after a
stroke
Rituals Symbolic actions with spiritual, • Shares a highlight from the day during evening meals with
cultural, or social meaning family
contributing to the client’s • Kisses a sacred book before opening the pages to read
identity and reinforcing values • Recites the Pledge of Allegiance before the start of the
and beliefs. Rituals have a strong school day
affective component and consist
of a collection of events (Fiese,
2007; Fiese et al., 2002; Segal,
2004).
Group and Population
Routines Patterns of behavior that are Group:
observable, regular, and repetitive • Workers attending weekly staff meetings
and that provide structure for • Students turning in homework assignments as they enter
daily life. They can be satisfying, the classroom
promoting, or damaging. Time • Exercise class attendees setting up their mats and towels
provides an organizational before class
structure or rhythm for routines
(Larson & Zemke, 2003). Population:
Routines are embedded in • Parents of young children following health practices such
cultural and ecological contexts as yearly checkups and scheduled immunizations
(Segal, 2004). • Corporations following business practices such as
providing services for disadvantaged populations (e.g.,
loans to underrepresented groups)

PREPUBLICATION DRAFT. Page 53 of 96

 • School districts following legislative procedures such as
those associated with the Individuals With Disabilities
Education Improvement Act of 2004 (Pub. L. 108-446) or
Medicare
Roles Sets of behaviors by the group or Group:
population expected by society • Nonprofit civic group providing housing for people living
and shaped by culture and context with mental illness
that may be further • Humanitarian group distributing food and clothing
conceptualized and defined by the donations to refugees
group or population. • Student organization in a university educating elementary
school children about preventing bullying

Population:
• Parents providing care for children until they become
adults
• Grandparents or older community members being
consulted before decisions are made
Rituals Shared social actions with Group:
traditional, emotional, purposive, • Employees of a company attending an annual holiday
and technological meaning celebration
contributing to values and beliefs • Members of a community agency hosting a fundraiser
within the group or population. every spring

Population:
• Citizens of a country suspending work activities in
observance of a national holiday

PREPUBLICATION DRAFT. Page 54 of 96

Table 7. Performance Skills for Persons
Performance skills are observable, goal-directed actions that result in a client’s quality of performing desired
occupations. Skills are supported by the context in which the performance occurs, including environmental and
client factors (Fisher & Marterella, 2019). Effective use of motor and process performance skills is demonstrated
when the client carries out an activity efficiently, safely, with ease, or without assistance. Effective use of social
interaction performance skills is demonstrated when the client completes interactions in a manner that matches the
demands of the social situation. Ineffective use of performance skills is demonstrated when the client routinely
requires assistance or support to perform activities or engage in social interactions.
The examples in this table are limited to descriptions of the client’s ability to use each performance skill in an
effective or ineffective manner. A client who demonstrates ineffective use of performance skills may be able to
successfully complete the entire occupation with the use of occupational or environmental adaptations. Successful
occupational performance by the client may be achieved when such adaptions are utilized.

Examples
Specific Skill Definitions
a
Effective Performance Ineffective Performanceb
Motor Skills—“Motor skills are the group of performance skills that represent small, observable actions related to
moving oneself or moving and interacting with tangible task objects (e.g., tools, utensils, clothing, food or other
supplies, digital devices, plant life) in the context of performing a personally and ecologically relevant daily life
task” (Fisher & Marterella, 2019, p. 331).

Positioning the body Washing dishes at the kitchen sink

Stabilizes—Moves through task Person moves through the Person momentarily props on the counter
environment and interacts with task kitchen without propping or to stabilize body while standing at the sink
objects without momentary propping loss of balance and washing dishes
or loss of balance
Aligns—Interacts with task objects Person washes dishes without Person persistently leans on the counter,
without evidence of persistent using the counter for support resulting in ineffective performance when
propping or leaning washing dishes
Positions—Positions self an Person places body or Person positions body or wheelchair too
effective distance from task objects wheelchair at an effective far from the sink, resulting in difficulty
and without evidence of awkward distance for washing dishes reaching for dishes in the sink
arm or body positions
Obtaining and holding objects Acquiring a game from a cabinet in preparation for a family activity
Reaches—Effectively extends arm Person reaches without effort Person reaches with excessive physical
and, when appropriate, bends trunk for the game box effort for the game box
to effectively grasp or place task
objects that are out of reach
Bends—Flexes or rotates trunk as Person bends without effort Person demonstrates excessive stiffness
appropriate when sitting down or when reaching for the game when bending to reach for the game box
when bending to grasp or place task box
objects that are out of reach
Grips—Effectively pinches or Person grips the game box Person grips the game box ineffectively,
grasps task objects such that the and game pieces, and they do and the box slips from the hand so that
objects do not slip (e.g., from not slip from the hand game pieces spill
between fingers, from between teeth,
from between hand and supporting
surface)
Manipulates—Uses dexterous Person readily manipulates Person fumbles the game pieces so that
finger movements, without evidence the game pieces with fingers some pieces fall off the game board
of fumbling, when manipulating task while setting up and playing
objects the game

PREPUBLICATION DRAFT. Page 55 of 96

 Coordinates—Uses two or more Person uses both hands to Person uses both hands to shuffle the cards
body parts together to manipulate shuffle the game cards but fumbles the deck, and the cards slip out
and hold task objects without without fumbling the cards, of the hands
evidence of fumbling or task objects and the cards do not slip from
slipping from the grasp the hands

Moving self and objects Completing janitorial tasks at a factory site

Moves—Effectively pushes or Person moves the broom Person demonstrates excessive effort to
pulls task objects along a supporting easily, pushing and pulling it move the broom across the floor when
surface, pulls to open or pushes to across the floor sweeping
close doors and drawers, or pushes
on wheels to propel a wheelchair
Lifts—Effectively raises or lifts Person easily lifts cleaning Person needs to use both hands to lift small
task objects without evidence of supplies out of the cart lightweight containers of cleaning supplies
excessive physical effort out of the cart
Walks—During task performance, Person walks steadily Person demonstrates unstable walking
ambulates on level surfaces without through the factory while performing janitorial duties or walks
shuffling feet, becoming unstable, while supporting self on the cart
propping, or using assistive devices
Transports—Carries task objects Person carries cleaning Person is unstable when transporting
from one place to another while supplies from one factory cleaning supplies throughout the factory
walking or moving in a wheelchair location to another, either by
walking or using a
wheelchair, without effort
Calibrates—Uses movements of Person uses an appropriate Person applies too little force to squeeze
appropriate force, speed, or extent amount of force to squeeze soap out of the container onto the cleaning
when interacting with task objects liquid soap onto a cleaning cloth
(e.g., does not crush task objects, cloth
pushes a door with enough force to
close it without a bang)
Flows—Uses smooth and fluid Person demonstrates fluid Person demonstrates stiff and jerky arm
arm and wrist movements when arm and wrist movements and wrist movements when wiping tables
interacting with task objects when wiping tables
Sustaining performance Bathing an older parent as caregiver
Endures—Persists and completes Person completes bathing of Person stops to rest, interrupting the task
the task without demonstrating parent without evidence of of bathing the parent
physical fatigue, pausing to rest, or physical fatigue
stopping to catch breath
Paces—Maintains a consistent and Person uses an appropriate Person sometimes rushes or delays actions
effective rate or tempo of tempo when bathing the when bathing the parent
performance throughout the entire parent
task performance
Process Skills—“Process skills are the group of performance skills that represent small, observable actions related
to selecting, interacting with, and using tangible task objects (e.g., tools, utensils, clothing, food or other supplies,
digital devices, plant life); carrying out individual actions and steps; and preventing problems of occupational
performance from occurring or reoccurring in the context of performing a personally and ecologically relevant daily
life task” (Fisher & Marterella, 2019, pp. 336–337).

Sustaining performance Writing sentences for a school assignment

Paces—Maintains a consistent and Person uses a consistent and Person rushes writing sentences, resulting
effective rate or tempo of even tempo when writing in incorrectly formed letters or misspelled
performance throughout the entire sentences words
task performance

PREPUBLICATION DRAFT. Page 56 of 96

 Attends—Does not look away Person maintains gaze on the Person looks toward another student and
from task performance, maintaining assignment and continues pauses when writing sentences
the ongoing task progression writing sentences without
pause
Heeds—Carries out and completes Person completes the Person writes fewer sentences than
the task originally agreed on or assignment, writing the required, not completing the assignment
specified by another person number of sentences required

Applying knowledge Taking prescribed medications

Chooses—Selects necessary and Person chooses specified Person chooses an incorrect medicine
appropriate type and number of medicine bottles appropriate bottle for the specific timed dose
objects for the task, including the for the specific timed dose
task objects that one chooses or is
directed to use (e.g., by a teacher)
Uses—Applies task objects as they Person uses a medicine spoon Person uses a tablespoon to take a 1-
are intended (e.g., using a pencil to take a dose of liquid teaspoon dose of liquid medicine
sharpener to sharpen a pencil but not medicine
a crayon) and in a hygienic fashion
Handles—Supports or stabilizes Person supports the medicine Person allows the medicine bottle to tip,
task objects appropriately, protecting bottle, keeping it upright and pills spill from the bottle
them from being damaged, slipping, without the bottle tipping or
moving, or falling falling
Inquires—(1) Seeks needed verbal Person reads the label on the Person asks the care provider what dose to
or written information by asking medicine bottle before taking take having already read the dose on the
questions or reading directions or the medication label
labels and (2) does not ask for
information when fully oriented to
the task and environment and
recently aware of the answer

Organizing timing Using an ATM to get cash to pay a babysitter

Initiates—Starts or begins the next Person begins each step of Person pauses before entering the PIN into
task action or task step without any ATM use without hesitation the ATM
hesitation
Continues—Performs single Person completes each step Person starts to enter the PIN, pauses, and
actions or steps without any of ATM use without delays then continues to enter the PIN
interruptions so that once an action or
task step is initiated, performance
continues without pauses or delays
until the action or step is completed
Sequences—Performs steps in an Person completes each step Person attempts to enter the PIN before
effective or logical order and with an of ATM use in logical order inserting the bank card into the card reader
absence of randomness in the
ordering and inappropriate repetition
of steps
Terminates—Brings to completion Person completes each step Person persists in entering numbers after
single actions or single steps without of ATM use in the completing the four-digit PIN
inappropriate persistence or appropriate length of time
premature cessation

Organizing space and objects Managing clerical duties for a large company

Searches/locates—Looks for and Person readily locates needed Person searches a shelf a second time to

PREPUBLICATION DRAFT. Page 57 of 96

locates task objects in a logical office supplies from shelves locate needed clerical supplies
manner and drawers
Gathers—Collects related task Person gathers required Person places required paper and pen in
objects into the same work space and clerical tools and supplies in different work spaces and then must move
regathers task objects that have the assigned work space them to the same work space
spilled, fallen, or been misplaced
Organizes—Logically positions or Person organizes required Person places books on top of papers,
spatially arranges task objects in an clerical tools and supplies resulting in a crowded work space
orderly fashion within a single work within the work space so all
space or between multiple are within reach
appropriate work spaces such that the
work space is not too spread out or
too crowded
Restores—Puts away task objects Person returns clerical tools Person puts pens and extra paper in a
in appropriate places and ensures that and supplies to their original different storage closet from where
the immediate work space is restored storage location originally found
to its original condition
Navigates—Moves body or Person moves through the Person bumps hand into the edge of the
wheelchair without bumping into office space without bumping desk when reaching for a pen from the pen
obstacles when moving through the into office furniture or holder
task environment or interacting with machines
task objects

Adapting performance Preparing a green salad for a family meal

Notices/responds—Responds Person notices the carrot Person delays noticing a rolling carrot, and
appropriately to (1) nonverbal task- rolling off the cutting board it rolls off the cutting board onto the floor
related cues (e.g., heat, movement), and catches it before it rolls
(2) the spatial arrangement and onto the floor
alignment of task objects to one
another, and (3) cupboard doors or
drawers that have been left open
during task performance
Adjusts—Overcomes problems Person readily adjusts the Person delays turning off the water tap
with ongoing task performance flow of water from the tap after washing the vegetables
effectively by (1) going to a new when washing vegetables
workspace; (2) moving task objects
out of the current workspace; or (3)
adjusting knobs, dials, switches, or
water taps
Accommodates—Prevents Person prevents problems Person does not prevent problems from
ineffective performance of all other from occurring during the occurring, such as carrots rolling off the
motor and process skills and asks for salad preparation cutting board onto the floor
assistance only when appropriate or
needed
Benefits—Prevents ineffective Person prevents problems Person retrieves the carrot from the floor
performance of all other motor and from continuing or and puts it back on the cutting board, and
process skills from recurring or reoccurring during the salad the carrot rolls off the board again
persisting preparation
Social Interaction Skills—“Social interaction skills are the group of performance skills that represent small,
observable actions related to communicating and interacting with others in the context of engaging in a personally
and ecologically relevant daily life task performance that involves social interaction with others” (Fisher &
Marterella, 2019, p. 342).

PREPUBLICATION DRAFT. Page 58 of 96

Initiating and terminating social Participating in a community support group
interaction

Approaches/starts—Approaches Person politely begins Person begins interactions with support

or initiates interaction with the social interactions with support group members by yelling at them from
partner in a manner that is socially group members across the room
appropriate
Concludes/disengages— Person politely ends a Person abruptly ends interaction with the
Effectively terminates the conversation with a support support group by walking out of the room
conversation or social interaction, group member
brings to closure the topic under
discussion, and disengages or says
goodbye

Producing social interaction Child playing in the sandbox with others to build tunnels for cars and
trucks

Produces speech—Produces Person produces clear verbal, Person mumbles when interacting with
spoken, signed, or augmentative (i.e., signed, or augmentative other children playing in the sandbox, and
computer-generated) messages that messages to communicate the other children do not understand the
are audible and clearly articulated with other children playing in message
the sandbox
Gesticulates—Uses socially Person gestures by waving or Person uses aggressive gestures when
appropriate gestures to communicate pointing while interacting with other children playing in
or support a message communicating with other the sandbox
children playing in the
sandbox
Speaks fluently—Speaks in a Person speaks, without Person hesitates or pauses when talking
fluent and continuous manner, with pausing, stuttering, or with other children playing in the sandbox
an even pace (not too fast, not too hesitating, when engaging
slow) and without pauses or delays, with other children playing in
while sending a message the sandbox

Physically supporting social Older adult in a senior residence talking with other residents during a
interaction shared mealtime

Turns toward—Actively positions Person turns body and face Person turns face away from other
or turns body and face toward the toward other residents while residents while interacting during the meal
social partner or the person who is interacting during the meal
speaking
Looks—Makes eye contact with Person makes eye contact Person looks down at own plate while
the social partner with other residents while interacting during the meal
interacting during the meal
Places self—Positions self at an Person sits an appropriate Person sits too far from other residents,
appropriate distance from the social distance from other residents interfering with interactions
partner at the table
Touches—Responds to and uses Person touches other Person reaches out, grasps another
touch or bodily contact with the residents appropriately resident’s shirt, and abruptly pulls on it
social partner in a socially during the meal during the meal
appropriate manner
Regulates—Does not demonstrate Person avoids demonstrating Person repeatedly taps the fork on the plate
irrelevant, repetitive, or impulsive irrelevant, repetitive, or while interacting during the meal
behaviors during social interaction impulsive behaviors while
interacting during the meal

PREPUBLICATION DRAFT. Page 59 of 96

Shaping content of social Serving ice cream to customers in an ice cream shop
interaction

Questions—Requests relevant Person asks customers for Person asks customers for their choice of
facts and information and asks their choice of ice cream ice cream flavor and then repeats the
questions that support the intended flavor question
purpose of the social interaction
Replies—Keeps conversation Person readily replies with Person delays in replying to customers’
going by replying appropriately to relevant answers to questions or provides irrelevant
suggestions, opinions, questions, and customers’ questions about information
comments ice cream products
Discloses—Reveals opinions, Person discloses no personal Person reveals socially inappropriate
feelings, and private information information about self or details about own family
about self or others in a socially others to customers
appropriate manner
Expresses emotions—Displays Person displays socially Person uses a sarcastic tone of voice when
affect and emotions in a socially appropriate emotions when describing ice cream flavor options
appropriate manner sending messages to
customers
Disagrees—Expresses differences Person expresses a difference Person becomes argumentative when a
of opinion in a socially appropriate of opinion about ice cream customer requests a flavor that is not
manner products in a polite way available
Thanks—Uses appropriate words Person thanks the customers Person fails to say thank you after
and gestures to acknowledge receipt for purchasing ice cream customers purchase ice cream
of services, gifts, or compliments

Maintaining flow of social Sharing suggestions with others in a support group for persons
interaction experiencing mental health challenges

Transitions—Handles transitions Person offers comments or Person abruptly changes the topic of
in the conversation or changes the suggestions that relate to the conversation to planning social activities
topic without disrupting the ongoing topic of mental health during a discussion of mental health
conversation challenges, smoothly moving challenges
the topic in a relevant
direction
Times response—Replies to social Person replies to another Person replies to another group member’s
messages without delay or hesitation group member’s question question about community supports for
and without interrupting the social about community supports mental health challenges before the other
partner for mental health challenges person finishes asking the question
after briefly considering how
best to respond
Times duration—Speaks for a Person sends messages about Person sends prolonged messages
reasonable length of time given the mental health challenges of containing extraneous details
complexity of the message an appropriate length
Takes turns—Speaks in turn and Person engages in back-and- Person does not respond to comments from
gives the social partner the freedom forth conversation with others during the group discussion
to take his or her turn others in the group

Verbally supporting social Visiting a Social Security office to obtain information relative to potential
interaction benefits

Matches language—Uses a tone of Person uses a tone of voice Person uses a loud voice and slang when
voice, dialect, and level of language and vocabulary that match interacting with the Social Security agent
that are socially appropriate and those of the Social Security

PREPUBLICATION DRAFT. Page 60 of 96

 matched to the social partner’s agent
abilities and level of understanding
Clarifies—Responds to gestures or Person rephrases the initial Person asks an unrelated question when the
verbal messages from the social question when the Social Social Security agent requests clarification
partner signaling that the social Security agent requests of the initial question
partner does not comprehend or clarification
understand a message and ensures
that the social partner is following
the conversation
Acknowledges and encourages— Person nods to indicate Person does not nod or use words to
Acknowledges receipt of messages, understanding of the acknowledge receipt of messages sent by
encourages the social partner to information shared by the the Social Security agent
continue the social interaction, and Social Security agent
encourages all social partners to
participate in the interaction
Empathizes—Expresses a Person shows empathy when Person expresses impatience when the
supportive attitude toward the social the Social Security agent Social Security agent expresses frustration
partner by agreeing with, expresses frustration with the with the slow computer system
empathizing with, or expressing slow computer system
understanding of the social partner’s
feelings and experiences

Adapting social interaction Deciding which restaurant to go to with a group of friends

Heeds—Uses goal-directed social Person maintains focus on Person makes comments unrelated to
interactions focused on carrying out deciding which restaurant to choosing a restaurant, disrupting the group
and completing the intended purpose go to decision making
of the social interaction
Accommodates—Prevents Person avoids making Person asks a question that is irrelevant to
ineffective or socially inappropriate ineffective responses to choosing a restaurant
social interaction others about restaurant
choice
Benefits—Prevents problems with Person avoids making Person persists in asking irrelevant
ineffective or socially inappropriate reoccurring ineffective questions to choosing a restaurant
social interaction from recurring or comments during the
persisting decision making
Note. ADL = activity of daily living; ATM = automated teller machine; PIN = personal identification number.
a
Effective use of motor and process performance skills is demonstrated when the client carries out an activity
efficiently, safely, with ease, or without assistance. Effective use of social interaction performance skills is
demonstrated when the client completes interactions in a manner that matches the demands of the social situation.
b
Ineffective performance skills are demonstrated when the client routinely requires assistance or support to perform
activities or engage in social interactions.
Source. From Powerful Practice: A Model for Authentic Occupational Therapy, by A. G. Fisher and A. Marterella,
2019, Fort Collins, CO: Center for Innovative OT Solutions. Copyright © 2019 by the Center for Innovative OT
Solutions. Used with permission.

PREPUBLICATION DRAFT. Page 61 of 96

Table 8. Performance Skills for Groups
To address performance skills for a group client, occupational therapy practitioners analyze the motor, process, and
social interaction skills of individual group members to identify whether ineffective performance skills may limit the
group’s collective outcome. Italicized words in the middle column are specific performance skills defined in Table
7.
Performance Skill Ineffective Performance by an Individual Impact on Group Collective Outcome
Category Group Member
Group collective outcome: Religious organization committee furnishing spaces for a preschool for member
families
Motor—Obtaining • Member reaches with excessive effort for Other members may need to take
and holding objects chairs stored in closet responsibility for obtaining and
• Member bends with stiffness or excessive holding objects to accommodate the
effort when reaching for the chairs member’s ineffective motor
• Member fumbles when gripping writing performance skills during the process
materials in preparation for recording of furnishing preschool spaces.
committee decisions for planning
• Member demonstrates limited finger
dexterity to manipulate tools for assembling
storage units for toys
• Member is unable to coordinate one hand
and trunk to stabilize self while gripping and
loading toys onto shelves
Process—Organizing • Member repeatedly asks for help when The group may need to accommodate
space and objects searching for needed furniture or locating play the member’s limitations in effectively
equipment that is organized logically in near organizing space and objects by
and distant places within the building adjusting the timing of the outcome to
• Member does not effectively gather required allow greater time to complete
play activity materials in the designated play furnishing the preschool spaces.
spaces
• Member has difficulty organizing toys or
play equipment within the various play spaces
in a logical and orderly fashion
• Member does not restore toys or play
equipment to storage spaces to return the
preschool space to an effective order
• Member bumps into play furniture when
navigating spaces to set up furniture to meet
the needs of families or groups
Social interaction— • Member communicates in whispers when The group decision-making process
Producing social producing speech to communicate with other may be hindered by the member’s
interaction members about decisions for placing play difficulty in producing social
equipment interactions. Limited communication
• Member delays in gesticulating so other during the tasks of placing furniture in
members do not receive effective messages preschool spaces may cause confusion
while arranging toys and play equipment among group members.
• Member speaks fluently but too fast when
communicating to friends, resulting in
challenges for other members in decision
making for furnishing the preschool
Source. Performance skill categories are from Powerful Practice: A Model for Authentic Occupational Therapy, by
A. G. Fisher and A. Marterella, 2019, Fort Collins, CO: Center for Innovative OT Solutions. Copyright © 2019 by
the Center for Innovative OT Solutions. Used with permission.

PREPUBLICATION DRAFT. Page 62 of 96

 Table 9. Client Factors
Client factors include (1) values, beliefs, and spirituality; (2) body functions; and (3) body structures that reside
within the client and influence the client’s performance in occupations.

■ VALUES, BELIEFS, AND SPIRITUALITY—Clients’ (a person, group, or population) perceptions,

motivations, and related meaning that influence or are influenced by engagement in occupations.

Category and Examples

Definition
Values—Acquired beliefs and Person:
commitments, derived from culture, ● Honesty with self and others
about what is good, right, and important ● Commitment to family
to do (Kielhofner, 2008) Group:
● Obligation to provide a service
● Fairness
● Inclusion
Population:
● Freedom of speech
● Equal opportunities for all
● Tolerance toward others

Beliefs—“Something that is accepted, Person:

considered to be true, or held as an ● One is powerless to influence others
opinion….” (Merriam-Webster, 2003, p. ● Hard work pays off
111). Group:
● Teaching others how to garden to decrease their reliance on
grocery stores
● Writing letters in support of a community park as part of a
neighborhood group
Population:
● Some personal rights are worth fighting for
● A new health care policy, as yet untried, will positively affect
society

Spirituality—“A deep experience of Person:

meaning brought about by engaging in ● Daily search for purpose and meaning in one’s life
occupations that involve the enacting of ● Guidance of actions by a sense of value beyond the personal
personal values and beliefs, reflection, acquisition of wealth or fame
and intention within a supportive Group:
contextual environment (Billock, 2005, p. ● Studying religious texts together
887). It is important to recognize that ● Attending a religious service
spirituality “as dynamic and often Population:
evolving” (Humbert, 2016, p. 12). ● Common search for purpose and meaning in life
● Guidance of actions by values agreed on by the collective

BODY FUNCTIONS—“The physiological functions of body systems (including psychological functions)” (WHO,
2001, p. 10). This section of the table is organized according to the classifications of the ICF; for fuller descriptions and
definitions, refer to WHO (2001).
Description Category
(not an all-inclusive list)
Mental functions

PREPUBLICATION DRAFT. Page 63 of 96

Specific mental functions
Higher-level cognitive Judgment, concept formation, metacognition, executive functions,
praxis, cognitive flexibility, in-sight
Attention Sustained shifting and divided attention, concentration,
distractibility
Memory Short-term, long-term, and working memory

Perception Discrimination of sensations (e.g., auditory, tactile, visual, olfactory,

gustatory, vestibular, proprioceptive)
Thought Control and content of thought, awareness of reality vs. delusions,
logical and coherent thought
Mental functions of sequencing complex Mental functions that regulate the speed, response, quality, and time
movement of motor production, such as restlessness, toe tapping, or hand
wringing, in response to inner tension

Emotional Regulation and range of emotions; appropriateness of emotions,

including anger, love, tension, and anxiety; lability of emotions

Experience of self and time Awareness of one’s identity (including gender identity), body, and
position in the reality of one’s environment and of time

Global mental functions

Consciousness State of awareness and alertness, including the clarity and continuity
of the wakeful state
Orientation Orientation to person, place, time, self, and others

Psychosocial General mental functions, as they develop over the life span,
required to understand and constructively integrate the mental
functions that lead to the formation of the personal and interpersonal
skills needed to establish reciprocal social interactions, in terms of
both meaning and purpose.

Temperament and personality Extroversion, introversion, agreeableness, conscientiousness,

emotional stability, openness to experience, self-control, self-
expression, confidence, motivation, impulse control, appetite

Energy and Energy level, motivation, appetite, craving, impulse

Sleep Physiological process, quality of sleep

Sensory functions
Visual functions Quality of vision, visual acuity, visual stability, and visual field
functions to promote visual awareness of environment at various
distances for functioning

Hearing functions Sound detection and discrimination; awareness of location and

distance of sounds
Vestibular functions Sensation related to position, balance, and secure movement against
gravity

PREPUBLICATION DRAFT. Page 64 of 96

 Taste functions Association of taste qualities of bitterness, sweetness, sourness, and
saltiness
Smell functions Sensing odors and smells
Proprioceptive functions Awareness of body position and space
Touch functions Feeling of being touched by others or touching various textures,
such as those of food; presence of numbness, paresthesia,
hyperesthesia
Interoception The internal detection of changes in one’s internal organs through
specific sensory receptors (to be aware of, e.g., hunger, thirst,
digestion, state of alertness)
Pain (e.g., diffuse, dull, sharp, phantom) Unpleasant feeling indicating potential or actual damage to some
body structure; sensations of generalized or localized pain (e.g.,
diffuse, dull, sharp, phantom)
Sensitivity to temperature and pressure Thermal awareness (hot and cold), sense of force applied to skin
(thermoreception)

Neuromusculoskeletal and movement-related functions

Functions of joints and bones
Joint mobility Joint ROM

Joint stability Maintenance of structural integrity of joints throughout the body;

physiological stability of joints related to structural integrity

Muscle functions
Muscle power Force generated by contraction of muscle or muscle groups
Muscle tone Degree of muscle tension (e.g., flaccidity, spasticity, fluctuation)

Muscle endurance Sustaining muscle contraction

Movement functions
Motor reflexes Involuntary contraction of muscles automatically induced by
specific stimuli (e.g., stretch, asymmetrical tonic neck,
symmetrical tonic neck)
Involuntary movement reactions Postural reactions, body adjustment reactions, supporting reactions

Control of voluntary movement Eye–hand and eye–foot coordination, bilateral integration, crossing
of the mid-line, fine and gross motor control, and oculomotor
function (e.g., saccades, pursuits, accommodation, binocularity)

Gait patterns Gait and mobility considered in relation to how they affect ability to
engage in occupations in daily life activities (e.g., walking patterns
and impairments, asymmetric gait, stiff gait)

Cardiovascular, hematological, immunological, and respiratory system functions

(Note. Occupational therapy practitioners have knowledge of these body functions and understand broadly the
interaction that occurs among these functions to support health, well-being, and participation in life through
engagement in occupation.)

PREPUBLICATION DRAFT. Page 65 of 96

Cardiovascular system functions Maintenance of blood pressure functions (hypertension,
Hematological and immunological system hypotension, postural hypotension), heart rate and rhythm
functions
Respiratory system functions Rate, rhythm, and depth of respiration
Additional functions and sensations of the Physical endurance, aerobic capacity, stamina, fatigability
cardiovascular and respiratory systems

Voice and speech functions; digestive, metabolic, and endocrine system functions; genitourinary and
reproductive functions
(Note. Occupational therapy practitioners have knowledge of these body functions and understand broadly the
interaction that occurs among these functions to support health, well-being, and participation in life through
engagement in occupation.)

Voice and speech functions Fluency and rhythm, alternative vocalization functions
Digestive, metabolic, and endocrine Digestive system functions, metabolic system, and endocrine
system functions system functions
Genitourinary and reproductive functions Genitourinary and reproductive functions
Skin and related structure functions
(Note. Occupational therapy practitioners have knowledge of these body functions and understand broadly the
interaction that occurs among these functions to support health, well-being, and participation in life through
engagement in occupation.)
Skin functions Protection (presence or absence of wounds, cuts, or abrasions),
Hair and nail functions repair (wound healing)
BODY STRUCTURES: “Anatomical parts of the body, such as organs, limbs, and their components” that support
body function (WHO, 2001, p. 10). This section of the table is organized according to the ICF classifications; for
fuller descriptions and definitions, refer to WHO (2001).

Category Examples not delineated in the “Body Structure” section of this

table
Structure of the nervous system (Note. Occupational therapy practitioners have knowledge of body
Structures related to the eyes and ears structures and understand broadly the interaction that occurs
Structures involved in voice and speech between these structures to support health, well-being, and
Structures of the cardiovascular, participation in life through engagement in occupation.)
immunological, and respiratory
systems
Structures related to the digestive,
metabolic, and endocrine systems
Structures related to the genitourinary
and reproductive systems
Structures related to movement

Note. The categorization of body functions and body structures is based on the ICF (WHO, 2001). The classification
was selected because it has received wide exposure and presents a language that is understood by external
audiences. ICF = International Classification of Function, Disability and Health; WHO = World Health
Organization.

PREPUBLICATION DRAFT. Page 66 of 96

 Table 10. Occupation and Activity Demands
Occupation and activity demands are the components of occupations and activities that occupational therapy
practitioners consider during the professional and clinical reasoning process. Depending on the context and needs
of the client, these demands can be deemed barriers to or supports for participation. Specific knowledge about the
demands of occupations and activities assists practitioners in selecting occupations for therapeutic purposes.
Type of Demand ACTIVITY DEMANDS OCCUPATIONAL DEMANDS
What is typically required to carry out What is required by the client
the activity? (person, group, or population) to
carry out the occupation?
Relevance and importance General meaning of the activity within ● Meaning the client derives from
the given culture the occupation; subjective and
personally constructed
● Symbolic, unconscious, and
metaphoric meaning attached to
the occupation
● Alignment with the client’s goals,
values, beliefs, and needs and
perceived utility
Examples: Person: Person:
Knitting can be a means to creating clothing Knitting is a way for the client to practice
items, a paid work opportunity, or a leisure mindfulness strategies for anxiety
activity

Group: Group:
Cooking a family meal can be for nutrition, Preparing a holiday meal with family
fulfilment of a role at home, connects members to each other and to
or leisure their culture and traditions

Population: Population:
Presence of accessible restrooms in public Creation of new accessible and all-
spaces for compliance with federal law gender restrooms symbolizes a
community’s commitment to safety and
inclusion of their disability and
LGBTQ+ populations

PREPUBLICATION DRAFT. Page 67 of 96

Objects used and their Tools, supplies, equipment, and resources required in the process of carrying
properties: out the activity or occupation and their inherent properties
• Tools (e.g., scissors, dishes, shoes, volleyball)
• Supplies (e.g., paints, milk, lipstick)
• Equipment (e.g., workbench, stove, basketball hoop)
• Resources (e.g. money, transportation)
• Inherent properties (e.g., heavy, rough, sharp, colorful, loud, bitter tasting)

Person:
Computer workstation that includes computer, keyboard, mouse, desk, and chair
Examples: Group:
Amount of money needed and transportation needs for a group of friends to attend
a concert
Population:
Planning for equipment, tools, and supplies needed to assist with flood relief efforts
to ensure safety of people with disabilities

Space demands (related to Physical environmental requirements of the activity or occupation (e.g., size,
the physical environment): arrangement, surface, lighting, temperature, noise, humidity, ventilation)

Examples: Person:
Desk arrangement in an elementary school classroom
Group:
Accessible meeting space to run a fall prevention workshop
Population:
Noise, lighting, arrangement, and temperature controls for a sensory friendly museum

Social demands (related to Elements of the social and attitudinal environments that may be required by the
the social and attitudinal activity or occupation
environment):

Examples:
Person:
Rules of engagement for a child at recess
Group:
Expectations of travelers when in an airport (e.g. waiting in line, following cues from
the staff and others, asking questions when needed)
Population:
Understanding of the social and political climate of a geographical region

Sequencing and timing Process required to carry out the activity or occupation (e.g., specific steps, sequence
demands: of steps, timing requirements)

Examples: Person:
Client’s preferred sequence and timing of morning routine to result in affirmation of
their social, cultural, and gender identity.
Group:
Steps that a class of students take in preparation to start the school day
Population:
Public Train schedules

PREPUBLICATION DRAFT. Page 68 of 96

Required actions and Actions (performance skills—motor, process, and social interaction) required that
performance skills: are an inherent part of the activity or occupation

Examples: Person:
Determining how to move body to drive a car
Group and Population:
See “Performance Skills” section for discussion related to groups and population

Required body functions: “Physiological functions of body systems (including psychological functions)”
(WHO, 2001, p . 10) required to support the actions used to perform the activity
or occupation

Examples: Person:
Cognitive level required for a child to play a game
Group and Population:
See “Client Factors” section for discussion of required body functions related to
groups and populations

Required body structures: “Anatomical parts of the body such as organs, limbs, and their components” that
support body functions (WHO, 2001, p. 10) and are required to perform the
activity or occupation

Examples: Person:
Presence of upper limb(s) to play catch
Group and Population:
See “Client Factors” section for discussion of required body structures related to groups
and populations

Note. WHO = World Health Organization.

PREPUBLICATION DRAFT. Page 69 of 96

Table 11. Occupational Therapy Process for Persons, Groups, and Populations
The occupational therapy process applies to work with persons, groups, and populations. The process for groups and
populations mirrors that for persons. The process for populations includes public health approaches, and the process
for groups may include both person and population methods to address occupational performance (Scaffa & Reitz,
2014).
Process Component Process Step, by Client Type

Person Group Population

Evaluation Consultation and Consultation and screening, Environmental scan, trend
screening: environmental scan: analysis, preplanning:
• Review client history • Identify collective need on • Collect data to inform
• Consult with the basis of available data design of intervention
interprofessional team • For each individual in the program by identifying
• Administer standardized group, information needs
screening tools ◦ Review history • Identify health trends in
◦ Administer standardized targeted population and
screening tools their potential positive and
◦ Consult with negative impacts on
interprofessional team occupational performance
Occupational profile: Occupational profile or Needs assessment,
• Interview client and community profile: community profile:
caregiver • Interview persons who • Engage with persons
make up the group within the population to
• Engage with persons in the determine their interests,
group to determine their needs, and opportunity for
interests, needs, and collaboration
priorities • Identify priorities through
◦ Surveys
◦ Interviews
◦ Group discussions or
forums
Analysis of occupational Analysis of occupational Needs assessment, review
performance: performance: of secondary data:
• Assess occupational • Conduct occupational and • Evaluate existing
performance activity analysis quantitative data, which
• Conduct occupational and • Assess group context may include
activity analysis • Assess the following for ◦ Public health records
• Assess contexts individual group members: ◦ Prevalence of disease
• Assess performance skills ◦ Occupational or disability
and patterns performance ◦ Demographic data
• Assess client factors ◦ Performance skills and ◦ Economic data
patterns
◦ Client factors
• Analyze impact of
individual performance on
the group

PREPUBLICATION DRAFT. Page 70 of 96

 Synthesis of evaluation Synthesis of evaluation Data analysis and
process: process: interpretation:
• Review and consolidate • Review and consolidate • Review and consolidate
information to select information to select information to support
occupational outcomes and collective occupational need for the program and
determine impact of outcomes identify any missing data
performance patterns and • Review and consolidate
client factors on information regarding each
occupation member’s performance and
its impact on the group and
the group’s occupational
performance as a whole
Intervention Development of the Development of the Program planning:
intervention plan: intervention plan or • Identify short-term
• Identify client goals program: program objectives
• Identify intervention • Identify collective group • Identify long-term
outcomes goals program goals
• Select outcome measures • Identify intervention • Select outcome measures
• Select methods for outcomes for the group to be used in program
service delivery, including • Select outcome measures evaluation
theoretical framework • Select methods for service • Select strategies for
delivery, including service delivery, including
theoretical framework theoretical framework
Intervention Intervention or program Program implementation:
implementation: implementation: • Carry out program or
• Carry out occupational • Carry out occupational advocacy action to address
therapy intervention to therapy intervention or identified occupational
address specific program to address the needs
occupations, contexts, and group’s specific
performance patterns and occupations, contexts, and
skills affecting performance patterns and
performance skills affecting group
performance
Intervention review: Intervention review or Program evaluation:
• Reevaluate and review program evaluation: • Gather information on
client’s response to • Reevaluate and review program implementation
intervention individual members’ and the • Measure the impact of the
• Review progress toward group’s response to program
goals and outcomes intervention • Evaluate efficiency of
• Modify plan as needed • Review progress toward program
goals and outcomes • Evaluate achievement of
• Modify plan as needed determined objectives
• Evaluate efficiency of
program
• Evaluate achievement of
determined objectives
Outcomes Outcomes: Outcomes: Outcomes:
• Use measures to assess • Use measures to assess • Use measures to assess
progress toward outcomes progress toward outcomes progress toward long-term
• Identify change in • Identify change in program goals
occupational participation occupational performance of • Identify change in
individual members and the occupational performance
group as a whole of targeted population
Transition: Transition: Sustainability plan:
• Facilitate client’s move • group members’ move • Develop action plan to
from one life role or from one life role or maintain program

PREPUBLICATION DRAFT. Page 71 of 96

 experience to another, such experience to another, such • Identify sources of
as as funding
◦ Moving to a new level ◦ Moving to a new level of • Build community
of care care capacity and support
◦ Transitioning between ◦ Transitioning between relationships to continue
providers providers program
◦ Moving into a new ◦ Moving into a new
setting or program setting or program
Discontinuation: Discontinuation: Dissemination plan:
• Discontinue care after • Discontinue care after the • Share results with
short- and long-term goals group’s short- and long- participants, stakeholders,
have been achieved or term goals have been and community members
client chooses to no longer achieved • Implement sustainability
participate • Implement discharge plan plan
• Implement discharge plan to support performance after
to support performance discontinuation of services
after discontinuation of
services

PREPUBLICATION DRAFT. Page 72 of 96

Table 12. Types of Occupational Therapy Interventions
Occupational therapy intervention types include occupations and activities, interventions to support occupations,
education and training, advocacy, group interventions, and virtual interventions. Occupational therapy interventions
facilitate engagement in occupation to enable persons, groups, and populations to achieve health, well-being, and
participation in life.
The examples provided illustrate the types of interventions that clients engage in (denoted as “client”) and that
occupational therapy practitioners provide (denoted as “practitioner”) and are not intended to be all-inclusive.
Intervention Type Description Examples
Occupations and Activities—Occupations and activities selected as interventions for specific clients are
designed to meet therapeutic goals and address the underlying needs of the client’s mind, body, and spirit. To use
occupations and activities therapeutically, the practitioner considers activity demands and client factors in relation
to the client’s therapeutic goals and contexts.
Occupations Broad and specific daily life events that Person:
are personalized and meaningful to the Client completes morning dressing and
client. hygiene using adaptive devices

Group:
Client plays a group game of tag on the
playground to improve social participation

Population:
Practitioner creates an app to improve access
for people with autism spectrum disorder
using metropolitan paratransit systems
Activities Components of occupations that are Person:
objective and separate from the client’s Client selects clothing and manipulates
engagement or contexts. Activities as clothing fasteners in advance of dressing
interventions are actions selected and
designed to support the development of Group:
performance skills and performance Group members separate into two teams for a
patterns to enhance occupational game of tag
engagement.
Population:
Client establishes parent volunteer
committees at their children’s school
Interventions to Support Occupations—Methods and tasks that prepare the client for occupational performance
are used as part of a treatment session in preparation for or concurrently with occupations and activities or
provided to a client as a home-based engagement to support daily occupational performance.
PAMs and mechanical Modalities, devices, and techniques to Person:
modalities prepare the client for occupational Practitioner administers PAMs to decrease
performance. Such approaches should pain, assist with wound healing or edema
be part of a broader plan and not used control, or prepare muscles for movement to
exclusively. enhance occupational performance

Group:
Practitioner develops a reference manual on
post mastectomy manual lymphatic drainage
techniques for implementation at an
outpatient facility
Orthotics and Construction of devices to mobilize, Person:
prosthetics immobilize, or support body structures Practitioner fabricates and issues a wrist
to enhance participation in occupations. orthosis to facilitate movement and enhance
participation in household activities

PREPUBLICATION DRAFT. Page 73 of 96

 Group:
Group members participate in a basketball
game with veterans using prosthetics after
amputation
Assistive technology Assessment, selection, provision, and Person:
and environmental education and training in use of high- Practitioner recommends using a visual
modifications and low-tech assistive technology; support (e.g., social story) to guide behavior
application of universal design
principles; and recommendations for
changes to the environment or activity Group:
to support the client’s ability to engage Practitioner uses a smart board with speaker
in occupations. system during a social skills group session to
improve participants’ attention

Population:
Practitioner recommends that a large health
care group paint exits in their facilities to
resemble bookshelves to deter patients with
dementia from eloping
Wheeled mobility Products and technologies that facilitate Person:
a client’s ability to maneuver through Practitioner recommends, in conjunction
space, including seating and with the wheelchair team, a sip-and-puff
positioning; improve mobility to switch to allow the client to maneuver the
enhance participation in desired daily power wheelchair independently and
occupations; and reduce risk for interface with an environmental control unit
complications such as skin breakdown in the home
or limb contractures.
Group:
Group of wheelchair users in the same town
host an educational peer support event
Self-regulation Actions the client performs to target Person:
specific client factors or performance Client participates in a fabricated sensory
skills. Intervention approaches may environment (e.g., through movement, tactile
address sensory processing to promote sensations, scents) to promote alertness
emotional stability in preparation for before engaging in a school-based activity
social participation or work or leisure
activities or executive functioning to Group:
support engagement in occupation and Practitioner instructs a classroom teacher to
meaningful activities. Such approaches implement mindfulness techniques, visual
involve active participation of the client imagery, and rhythmic breathing after recess
and sometimes use of materials to to enhance students’ success in classroom
simulate components of occupations. activities

Population:
Practitioner consults with businesses and
community sites to establish sensory-friendly
environments for people with sensory
processing deficits
Education and Training
Education Imparting of knowledge and Person:
information about occupation, health, Practitioner provides education regarding
well-being, and participation to enable home and activity modifications to the
the client to acquire helpful behaviors, spouse or family member of a person with
habits, and routines. dementia to support maximum independence

Group:

PREPUBLICATION DRAFT. Page 74 of 96

 Practitioner participates in a team care
planning meeting to educate the family and
team members on a patient’s condition and
level of function and establish a plan of care

Population:
Practitioner educates town officials about the
value of and strategies for constructing
walking and biking paths accessible to
people who use mobility devices
Training Facilitation of the acquisition of Person:
concrete skills for meeting specific Practitioner instructs the client in the use of
goals in a real-life, applied situation. In coping skills such as deep breathing to
this case, skills refers to measurable address anxiety symptoms before engaging
components of function that enable in social interaction
mastery. Training is differentiated from
education by its goal of enhanced Group:
performance as opposed to enhanced Practitioner provides an in-service on
understanding, although these goals applying new reimbursement and practice
often go hand in hand (Collins & standards adopted by a facility
O’Brien, 2003).
Population:
Practitioner develops a training program to
support practice guidelines addressing
occupational deprivation and cultural
competency for practitioners working with
refugees
Advocacy—Efforts directed toward promoting occupational justice and empowering clients to seek and obtain
resources to support health, well-being, and occupational participation.
Advocacy Advocacy efforts undertaken by the Person:
practitioner. Practitioner collaborates with a client to
procure reasonable accommodations at a
work site

Group:
Practitioner collaborates with and educates
teachers in an elementary school about
inclusive classroom design

Population:
Practitioner serves on the policy board of an
organization to procure supportive housing
accommodations for people with disabilities
Self-advocacy Advocacy efforts undertaken by the Person:
client with support by the practitioner. Client requests reasonable accommodations,
such as audio textbooks, to support their
learning disability

Group:
Client participates in an employee meeting to
request and procure adjustable chairs to
improve comfort at computer workstations

Population:
Client participates on a student committee
partnering with school administration to

PREPUBLICATION DRAFT. Page 75 of 96

 develop cyberbullying prevention programs
in their district
Group Interventions—Use of distinct knowledge of the dynamics of group and social interaction and leadership
techniques to facilitate learning and skill acquisition across the life span. Groups are used as a method of service
delivery.
Functional groups, Groups used in health care settings, Person:
activity groups, task within the community, or within Client participates in a group for adults with
groups, social groups, organizations that allow clients to traumatic brain injury focused on individual
and other groups explore and develop skills for goals for reentering the community after
participation, including basic social inpatient treatment
interaction skills and tools for self-
regulation, goal setting, and positive Group:
choice making. Group of older adults participates in
volunteer days to maintain participation in
the community through shared goals

Population:
Practitioner works with middle school
teachers in a district on approaches to
address issues of self-efficacy and self-
esteem as the basis for creating resiliency in
children at risk for being bullied
Virtual Interventions—Use of simulated, real-time, and near-time technologies for service delivery absent of
physical contact, such as telehealth or mobile health (mHealth)
Telehealth Use of technology such as video Person:
(telecommunication conferencing, teleconferencing, or Practitioner performs a telehealth therapy
and information mobile telephone application session with a client living in a rural area
technology) and technology to plan, implement, and
mHealth (mobile evaluate occupational therapy Group:
telephone application intervention, education, and Client participates in an initial online support
technology) consultation. group session to establish group protocols,
procedures, and roles

Population:
Practitioner develops methods and standards
for mHealth in community occupational
therapy practice
Note. PAMs = physical agent modalities.

PREPUBLICATION DRAFT. Page 76 of 96

Table 13. Approaches to Intervention
Approaches to intervention are specific strategies selected to direct the evaluation and intervention processes on the
basis of the client’s desired outcomes, evaluation data, and research evidence. Approaches inform the selection of
practice models, frames of references, and treatment theories.
Approach Description Examples
Create, promote (health An intervention approach that does not Person:
promotion) assume a disability is present or that any Develop a fatigue management program for a
aspect would interfere with performance. client recently diagnosed with multiple sclerosis
This approach designed to provide enriched
contextual and activity experiences that will Group:
enhance performance for all people in the Create a resource list of developmentally
natural contexts of life (adapted from Dunn appropriate toys to be distributed by staff at a
et al., 1998, p. 534). day care program

Population:
Develop a falls prevention curriculum for older
adults for trainings at senior centers and day
centers
Establish, restore Approach designed to change client Person:
(remediation, restoration) variables to establish a skill or ability that Restore a client’s upper extremity movement to
has not yet developed or to restore a skill or enable transfer of dishes from the dishwasher
ability that has been impaired (adapted from into the upper kitchen cabinets
Dunn et al., 1998, p. 533).
Collaborate with a client to help establish
morning routines needed to arrive at school or
work on time

Group:
Educate staff of a group home for clients with
serious mental illness to develop a structured
schedule, chunking tasks to decrease residents’
risk of being overwhelmed by the many
responsibilities of daily life roles

Population:
Restore access ramps to a church entrance after
a hurricane
Maintain Approach designed to provide supports that Person:
will allow clients to preserve the Provide ongoing intervention for a client with
performance capabilities that they have amyotrophic lateral sclerosis to address
regained and that continue to meet their participation in desired occupations through
occupational needs. The assumption is that provision of assistive technology
without continued maintenance
intervention, performance would decrease Group:
and occupational needs would not be met, Maintain environmental modifications at a
thereby affecting health, well-being, and group home for young adults with physical
quality of life. disabilities for continued safety and engagement
with housemates

Population:
Maintain safe and independent access for people
with low vision by increasing hallway lighting
in a community center
Modify (compensation, Approach directed at “finding ways to Person:

PREPUBLICATION DRAFT. Page 77 of 96

adaptation) revise the current context or activity Simplify task sequence to help a person with
demands to support performance in the cognitive impairments complete a morning self-
natural setting, [including] compensatory care routine
techniques . . . [such as] enhancing some
features to provide cues or reducing other Group:
features to reduce distractibility” (Dunn et Modify a college campus housing building to
al., 1998, p. 533). accommodate a group of students with mobility
impairments

Population:
Consult with architects and builders to design
homes that will support aging in place and use
universal design principles
Prevent (disability Approach designed to address the needs of Person:
prevention) clients with or without a disability who are Aid in the prevention of illicit substance use by
at risk for occupational performance introducing self-initiated routine strategies that
problems. This approach is designed to support drug-free behavior
prevent the occurrence or evolution of
barriers to performance in context. Group:
Interventions may be directed at client, Prevent social isolation of employees by
context, or activity variables (adapted from promoting participation in after-work group
Dunn et al., 1998, p. 534). activities

Population:
Consult with a hotel chain to provide an
ergonomics educational program designed to
prevent back injuries in housekeeping staff

PREPUBLICATION DRAFT. Page 78 of 96

Table 14. Outcomes
Outcomes are the end result of the occupational therapy process; they describe what clients can achieve through
occupational therapy intervention. Some outcomes are measurable and are used for intervention planning and review
and discharge planning. These outcomes reflect the attainment of treatment goals that relate to engagement in
occupation. Other outcomes are experienced by clients when they have realized the effects of engagement in
occupation and are able to return to desired habits, routines, roles, and rituals.
Adaptation is embedded in all categories of outcomes. The examples listed specify how the broad outcome of health
and participation in life may be operationalized.
Outcome Category Description Examples
Occupational performance Act of doing and accomplishing a Person
selected action (performance skill), A patient with hip precautions showers
activity, or occupation (Fisher, 2009; safely with modified independence using
Fisher & Griswold, 2019; a tub transfer bench and a long-handled
Kielhofner, 2008) that results from sponge.
the dynamic transaction among the
client, the context, and the activity. Group
Improving or enhancing skills and A group of older adults cook a holiday
patterns in occupational meal during their stay in a skilled
performance leads to engagement in nursing facility with minimal assistance
occupations or activities (adapted in from staff.
part from Law et al., 1996, p. 16).
Population
A community welcomes children with
spina bifida in public settings after a
news story featuring occupational
therapy practitioners.
Improvement Increased occupational performance Person
through adaptation when a A child with autism plays interactively
performance limitation is present. with a peer.

An older adult returns home from a

skilled nursing facility as desired.

Group
Back strain in nursing personnel
decreases as a result of an in-service
education program on body mechanics
for job duties that require bending and
lifting.

Population
Accessible playground facilities for all
children are constructed in city parks.
Enhancement Development of performance skills Person
and performance patterns that A teenage mother experiences increased
augment existing performance in life confidence and competence in parenting
occupations when a performance as a result of structured social groups and
limitation is not present. child development classes.

Group
Membership in the local senior citizen
center increases as a result of expanded
social wellness and exercise programs.

PREPUBLICATION DRAFT. Page 79 of 96

 School staff have increased ability to
address and manage school-age youth
violence as a result of conflict resolution
training to address bullying.

Population
Older adults have increased
opportunities to participate in
community activities through ride-share
programs.
Prevention Education or health promotion Person
efforts designed to identify, reduce, A child with orthopedic impairments is
or stop the onset and reduce the provided with appropriate seating and a
incidence of unhealthy conditions, play area.
risk factors, diseases, or injuries
Occupational therapy promotes a Group
healthy lifestyle at the individual, A program of leisure and educational
group, population (societal), and activities is implemented at a drop-in
government or policy level (adapted center for adults with serious mental
from AOTA, in press-a). illness.

Population
Access to occupational therapy services
is provided in underserved areas where
residents typically receive other services.
Health and wellness Health: State of physical, mental, Person
and social well-being, as well as a A person with a mental health challenge
positive concept emphasizing social participates in an empowerment and
and personal resources and physical advocacy group to improve services in
capacities (WHO, 1986). Health for the community.
groups and populations also includes
social responsibility of members to A person with attention deficit
the group or population as a whole. hyperactivity disorder demonstrates self-
management through the ability to
Wellness: “Active process through manage the various aspects of their life.
which individuals [or groups or
populations] become aware of and Group
make choices toward a more A company-wide program for employees
successful existence” (Hettler, 1984, is implemented to identify problems and
p. 1117). Wellness is more than a solutions regarding the balance among
lack of disease symptoms; it is a work, leisure, and family life.
state of mental and physical balance
and fitness (adapted from Taber’s Population
Cyclopedic Medical Dictionary, The incidence of childhood obesity
1997, p. 2110) decreases.
Quality of life Dynamic appraisal of the client’s Person
life satisfaction (perceptions of A deaf child from a hearing family
progress toward goals), hope (real or participates fully and actively during a
perceived belief that one can move recreational activity.
toward a goal through selected
pathways), self-concept (composite Group
of beliefs and feelings about A facility experiences increased
oneself), health and functioning participation of residents during outings
(e.g., health status, self-care and independent travel as a result of
capabilities), and socioeconomic independent living skills training for care
factors (e.g., vocation, education, providers.

PREPUBLICATION DRAFT. Page 80 of 96

 income; adapted from Radomski,
1995). Population
A lobby is formed to support
opportunities for social networking,
advocacy activities, and sharing of
scientific information for stroke
survivors and their families.
Participation Engagement in desired occupations Person
in ways that are personally A person recovers the ability to perform
satisfying and congruent with the essential duties of his or her job after
expectations within the culture. a flexor tendon laceration.

Group
A family enjoys a vacation spent
traveling cross-country in their adapted
van.

Population
All children within a state have access to
school sports programs.
Role competence Ability to effectively meet the Person
demands of the roles in which one A person with cerebral palsy is able to
engages. take notes and type papers to meet the
demands of the student role.

Group
A factory implements job rotation to
allow sharing of higher demand tasks so
employees can meet the demands of the
worker role.

Population
Accessibility of polling places is
improved, enabling all people with
disabilities in the community to meet the
demands of the citizen role.
Well-being Contentment with one’s health, self- Person
esteem, sense of belonging, security, A person with amyotrophic lateral
and opportunities for self- sclerosis achieves contentment with the
determination, meaning, roles, and ability to find meaning in fulfilling the
helping others (Hammell, 2009). role of parent through compensatory
Well-being is “a general term strategies and environmental
encompassing the total universe of modifications.
human life domains, including
physical, mental, and social aspects” Group
(WHO, 2006, p. 211). Members of an outpatient depression and
anxiety support group feel secure in their
sense of group belonging and ability to
help other members.

Population
Residents of a town celebrate the
groundbreaking for a school being
reconstructed after a natural disaster.
Occupational justice Access to and participation in the Person
full range of meaningful and An individual with intellectual and

PREPUBLICATION DRAFT. Page 81 of 96

 enriching occupations afforded to developmental disabilities serves on an
others, including opportunities for advisory board to establish programs to
social inclusion and resources to be offered by a community recreation
participate in occupations to satisfy center.
personal, health, and societal needs
(adapted from Townsend & Group
Wilcock, 2004). Workers have enough break time to eat
lunch with their young children in the
day care center.

Group and Population

People with persistent mental illness
experience an increased sense of
empowerment and self-advocacy skills,
enabling them to develop an antistigma
campaign promoting engagement in the
civic arena (group) and alternative
adapted housing options for older adults
to age in place (population).
Note. AOTA = American Occupational Therapy Association.

PREPUBLICATION DRAFT. Page 82 of 96

 Glossary

A
Activities
Actions designed and selected to support the development of performance skills and performance
patterns to enhance occupational engagement.

Activities of daily living (ADLs)

Activities oriented toward taking care of one’s own body (adapted from Rogers & Holm, 1994)
and are completed on a daily basis. These activities are “fundamental to living in a social world;
they enable basic survival and well-being” (Christiansen & Hammecker, 2001, p. 156; see Table
2).

Activity analysis
Generic and decontextualized analysis that seeks to develop an understanding of typical activity
demands within a given culture.

Activity demands
Aspects of an activity needed to carry it out, including relevance and importance to the client,
objects used and their properties, space demands, social demands, sequencing and timing, required
actions and performance skills, and required underlying body functions and body structures (see
Table 10).

Adaptation
The way the client effectively and efficiently responds to occupational and contextual demands
(Grajo, 2019).

Advocacy
Efforts directed toward promoting occupational justice and empowering clients to seek and obtain
resources to fully participate in their daily life occupations. Efforts undertaken by the practitioner
are considered advocacy, and those undertaken by the client are considered self-advocacy and can
be promoted and supported by the practitioner (see Table 12).

Analysis of occupational performance

The step in the evaluation process in which the client’s assets and limitations or potential
problems are more specifically determined through assessment tools designed to analyze,
measure, and inquire about factors that support or hinder occupational performance (See Exhibit
2).
Assessments

“A specific tool, instrument, or systematic interaction … used to understand a client’s occupational

profile, client factors, performance skills, performance patterns, and contextual and environ-
mental factors, as well as activity demands that influence occupational performance” (Hinojosa,
Kramer & Crist, 2014, pp. 3–4)

PREPUBLICATION DRAFT. Page 83 of 96

B
Belief
Something that is accepted, considered to be true, or held as an opinion (Merriam-Webster
Dictionary. (2003).

Body functions
“Physiological functions of body systems (including psychological functions)” (World Health
Organization [WHO], 2001, p. 10; see Table 9).

Body structures
“Anatomical parts of the body, such as organs, limbs, and their components” that support body
functions (WHO, 2001, p. 10; see Table 9).

C
Client
Persons (including those involved in care of a client), groups (a collection of individuals having
shared characteristics or common or shared purpose, e.g., family members, workers, students,
and those with similar interests or occupational challenges), and populations (aggregates of
people with common attributes such as contexts, characteristics or concerns, including health
risks, Scaffa & Reitz, 2014))

Client-centered care (client-centered practice) Approach to service that incorporates respect

for and partnership with clients as active participants in the therapy process. The approach
emphasizes clients’ knowledge and experience, strengths, capacity for choice, and overall
autonomy (Boyt Schell et al., 2014a, p. 1230).

Client factors
Specific capacities, characteristics, or beliefs that reside within the person and that influence
performance in occupations. Client factors include values, beliefs, and spirituality; body
functions; and body structures (see Table 9).

Clinical reasoning

See Professional Reasoning

Collaborative approach
Orientation in which the occupational therapy practitioner and client work in the spirit of
egalitarianism and mutual participation. Collaboration involves encouraging clients to describe
their therapeutic concerns, identify their own goals, and contribute to decisions regarding
therapeutic interventions (Boyt Schell et al., 2014a).

Community
A collection of populations that is changeable and diverse and includes various people, groups,
networks, and organizations (WFOT, 2019, Scaffa, 2019).

Context

PREPUBLICATION DRAFT. Page 84 of 96

The construct that constitutes the complete make-up of a person’s life as well as the common and
divergent factors that comprise groups and populations. Context includes environmental factors
and personal factors (see Tables 4 and 5)

Co-occupation
Occupation that implicitly involves two or more people (Boyt Schell et al., 2014a, p. 1232).

Cornerstones
Something of significance on which everything else depends

D
Domain
Profession’s purview and areas in which its members have an established body of knowledge and
expertise.

E
Education
• As an occupation: Activities involved in learning and participating in the educational
environment (see Table 2).
• As an environmental factor of context: processes and methods for acquisition of knowledge,
expertise, or skills (see Table 4)
• As an intervention: Activities that impart knowledge and information about occupation, health,
well-being, and participation, resulting in acquisition by the client of helpful behaviors, habits,
and routines that may or may not require application at the time of the intervention session (see
Table 12).

Empathy
The emotional exchange between occupational therapy practitioners and clients that allows more
open communication, ensuring that practitioners connect with clients at an emotional level to assist
them with their current life situation

Engagement in occupation
Performance of occupations as the result of choice, motivation, and meaning within a supportive
context and environment.

Environmental Factors
The physical, social, and attitudinal environment in which people live and conduct their lives.

Evaluation
“The comprehensive process of obtaining and interpreting the data necessary to understand the
person, system, or situation. . . . Evaluation requires synthesis of all data obtained, analytic
interpretation of that data, reflective clinical reasoning, and consideration of occupational
performance and contextual factors” (Hinojosa, Kramer & Crist, 2014, p. 3).

G
Goal

PREPUBLICATION DRAFT. Page 85 of 96

Measurable and meaningful, occupation-based, long- term or short-term aim directly related to the
client’s ability and need to engage in desired occupations (AOTA, 2013a, p. S35).

Group
A collection of individuals having shared characteristics and/or common or shared purpose (e.g.,
family members, workers, students, and those with similar occupational interests or occupational
challenges).

Group intervention
Use of distinct knowledge and leadership techniques to facilitate learning and skill acquisition
across the lifespan through the dynamics of group and social interaction. Groups may be used as
a method of service delivery (see Table 12).

H
Habilitation
Health care services that help a person keep, learn or improve skills and functioning for daily
living. Examples include therapy for a child who isn’t walking or talking at the expected age.
These services may include physical and occupational therapy, speech-language pathology, and
other services for people with disabilities in a variety of inpatient and/or outpatient settings.
(Provision of EHB, 45 C.F.R. §156.115(a)(5)(i) (2015).

Habits
Specific, automatic behaviors performed repeatedly, relatively automatically, and with little
variation” (Matuska & Barrett, 2019, p.214). Habits can be healthy or unhealthy, efficient or
inefficient, supportive or harmful (Dunn, 2000).

Health
“State of complete physical, mental, and social well- being, and not merely the absence of disease
or infirmity” (WHO, 2006, p. 1).

Health management
Developing, managing, and maintaining routines for health and wellness by engaging in self-care
with the goal of improving or maintaining health, including self-management, to allow for
participation in other occupations. See Table 2.

Health promotion
“Process of enabling people to increase control over, and to improve, their health. To reach a state
of complete physical, mental, and social well-being, an individual or group must be able to
identify and realize aspirations, to satisfy needs, and to change or cope with the environment”
(WHO, 1986).

Hope
Real or perceived belief that one can move toward a goal through selected pathways

I
Independence

PREPUBLICATION DRAFT. Page 86 of 96

 “Self-directed state of being characterized by an individual’s ability to participate in necessary
and preferred occupations in a satisfying manner irrespective of the amount or kind of external
assistance desired or required” (AOTA, 2002a, p. 660).

Instrumental activities of daily living (IADLs) Activities that support daily life within the
home and community and that often require more complex inter- actions than those used in
ADLs (see Table 2).

Interdependence
“Reliance that people have on one another as a natural consequence of group living” (Christiansen
& Townsend, 2010, p. 419). “Interdependence engenders a spirit of social inclusion, mutual aid,
and a moral commitment and responsibility to recognize and support difference” (Christiansen &
Townsend, 2010, p. 187).

Interests
“What one finds enjoyable or satisfying to do” (Kielhofner, 2008, p. 42).

Intervention
“Process and skilled actions taken by occupational therapy practitioners in collaboration with the
client to facilitate engagement in occupation related to health and participation. The intervention
process includes the plan, implementation, and review” (AOTA, 2010, p. S107; see Table 12).

Intervention approaches
Specific strategies selected to direct the process of interventions on the basis of the client’s desired
outcomes, evaluation data, and evidence (see Table 13).

Interventions to support occupations

Methods and tasks that prepare the client for occupational performance, used as part of a treatment
session in preparation for or concurrently with occupations and activities or provided to a client as
a home-based engagement to support daily occupational performance. See Table 12.

L
Leisure
“Nonobligatory activity that is intrinsically motivated and engaged in during discretionary time,
that is, time not committed to obligatory occupations such as work, self-care, or sleep” (Parham
& Fazio, 1997, p. 250; see Table 2).

M
Motor skills
the group of performance skills that represent small, observable actions related to moving
oneself or moving and interacting with tangible task objects (e.g., tools, utensils, clothing, food
or other supplies, digital devices, plant life) in the context of performing a personally and
ecologically relevant daily life task. They are commonly named in terms of type of task being
performed (e.g., ADL motor skills, school motor skills, work motor skills)” (Fisher &
Marterella, 2019, p. 331). See Table 7.

PREPUBLICATION DRAFT. Page 87 of 96

 O
Occupation
The everyday personalized activities that people do as individuals, in families, and with
communities to occupy time and bring meaning and purpose to life Occupations can involve the
execution of multiple activities for completion and can result in various outcomes. The
Framework identifies a broad range of occupations categorized as activities of daily living,
instrumental activities of daily living, health management, rest and sleep, education, work, play,
leisure, and social participation (see Table 2).

Occupational science
Occupational science provides a way of thinking that enables an understanding of occupation,
the occupational nature of humans, the relationship between occupation, health and wellbeing,
and the influences that shape occupation” World Federation of Occupational Therapists
[WFOT], 2012b, p. 2P.4

Occupation-based
The best practice method used in occupational therapy, which involves the practitioner using an
evaluation process and types of interventions that actively engage the client in occupation (Fisher
& Marterella, 2019)

Occupational analysis
Analysis that is performed with an understanding of “the specific situation of the client and
therefore must understand the specific occupations the client wants or needs to do in the actual
context in which these occupations are performed” (Schell et al., 2019, p. 322).
Occupational demands
Aspects of an activity needed to carry it out, including relevance and importance to the client,
objects used and their properties, space demands, social demands, sequencing and timing, required
actions and performance skills, and required underlying body functions and body structures (see
Table 10).

Occupational identity
“Composite sense of who one is and wishes to become as an occupational being generated from
one’s history of occupational participation” (Boyt Schell et al., 2014a, p. 1238).

Occupational justice
“A justice that recognizes occupational rights to inclusive participation in everyday occupations
for all persons in society, regardless of age, ability, gender, social class, or other differences”
(Nilsson & Townsend, 2010, p. 58). Access to and participation in the full range of meaningful
and enriching occupations afforded to others, including opportunities for social inclusion and the
re- sources to participate in occupations to satisfy personal, health, and societal needs (adapted
from Townsend & Wilcock, 2004).

Occupational performance
The accomplishment of the selected occupation resulting from the dynamic transaction among
the client, their context, and the occupation.

PREPUBLICATION DRAFT. Page 88 of 96

 Occupational profile
Summary of the client’s occupational history and experiences, patterns of daily living, interests,
values, needs, and relevant contexts (see Exhibit 2).

Occupational therapy
The therapeutic use of everyday life occupations with persons, groups or poulations (i.e. the
client) for the purpose of enhancing or enabling participation. Occupational therapy practitioners
use their knowledge of the transactional relationship among the person, their engagement in
valued occupations, and the context to design occupation-based intervention plans. Occupational
therapy services are provided for habilitation, rehabilitation, and promotion of health and wellness
for clients with disability- and non-disability-related needs. The services include acquisition and
preservation of occupational identity for those who have or are at risk for developing an illness,
injury, disease, disorder, condition, impairment, disability, activity limitation, or participation
restriction (adapted from AOTA, 2011).

Organization
Entity composed of individuals with a common purpose or enterprise, such as a business,
industry, or agency.

Outcome
Emerge from the occupational therapy process; what clients can achieve through occupational
therapy intervention (see Table 14).

P
Participation
“Involvement in a life situation” (WHO, 2001, p. 10).

Performance patterns
Habits, routines, roles, and rituals that may be associated with different lifestyles and used in the
process of engaging in occupations or activities. These patterns are influenced by context and
time and can support or hinder occupational performance (see Table 6).

Performance skills
The observable, goal-directed actions that result in a client’s quality of performing desired
occupations. Skills are supported by the context in which the performance occurred and by
underlying client factors (Fisher & Marterella, 2019).

Person
Individual, including family member, caregiver, teacher, employee, or relevant other.

Personal Factors
The particular background of a person’s life and living and comprise the unique features of the
person that are not part of a health condition or health states. Personal factors are generally

PREPUBLICATION DRAFT. Page 89 of 96

considered to be enduring, stable attributes of the person, although some personal factors may
change over time. See Table 5
Play
Play involves active engagement in an activity which is intrinsically motivated, internally
controlled, freely chosen, and may include the suspension of reality (Skard & Bundy, 2008). Play
includes participation in a broad range of experiences including but not limited to exploration,
humor, fantasy, risk, contest, and celebrations (Sutton-Smith, 2009; Eberle, 2014). Play is a
complex and multidimensional phenomenon that is shaped by sociocultural factors (Lynch,
Hayes, & Ryan, 2016). See Table 2.

Population
Aggregates of people with common attribute(s) such as contexts, characteristics or concerns
including health risks

Prevention
Education or health promotion efforts designed to identify, reduce, or prevent the onset and
reduce the incidence of unhealthy conditions, risk factors, diseases, or injuries (AOTA, 2013b).

Process
Way in which occupational therapy practitioners operationalize their expertise to provide services
to clients. The occupational therapy process includes evaluation, intervention, and targeted
outcomes; occurs within the purview of the occupational therapy domain; and involves
collaboration among the occupational therapist, occupational therapy assistant, and client.

Process skills
The group of performance skills that represent small, observable actions related to selecting,
interacting with, and using tangible task objects (e.g., tools, utensils, clothing, food or other
supplies, digital devices, plant life); carrying out individual actions and steps; and preventing
problems of occupational performance from occurring or reoccurring in the context of performing
a personally and ecologically relevant daily life task. They are commonly named in terms of type
of task being performed (e.g., ADL process skills, school process skills, work process skills)”
(Fisher & Marterella, 2019, pp. 336-337). See Table 7

Professional Reasoning
“The process that practitioners use to plan, direct, perform, and reflect on client care” (Schell,
2019, p.482)
Q
Quality of life
Dynamic appraisal of life satisfaction (perception of progress toward identifying goals), self-
concept (beliefs and feelings about oneself), health and functioning (e.g., health status, self-care
capabilities), and socioeconomic factors (e.g., vocation, education, income; adapted from
Radomski, 1995).

R
Reevaluation

PREPUBLICATION DRAFT. Page 90 of 96

Reappraisal of the client’s performance and goals to determine the type and amount of change that
has taken place.

Rehabilitation
Rehabilitation services are provided to persons experiencing deficits in key areas of physical and
other types of function or limitations in participation in daily life activities. Interventions are
designed to enable the achievement and maintenance of optimal physical, sensory, intellectual,
psychological, and social functional levels. Rehabilitation services provide tools and techniques
needed to attain desired levels of independence and self-determination.

Rituals
For persons: Sets of symbolic actions with spiritual, cultural, or social meaning contributing to the
client’s identity and reinforcing values and beliefs. Rituals have a strong affective component
(Fiese, 2007; Fiese et al., 2002; Segal, 2004; see Table 6).

For groups and populations

Shared social actions with traditional, emotional, purposive, and technological meaning
contributing to values and beliefs within the group or population. See Table 6
Roles
For persons: Sets of behaviors expected by society and shaped by culture and context that may be
further conceptualized and defined by the client (see Table 6).

For groups and populations

Sets of behaviors by the group or population expected by society and shaped by culture and
context that may be further conceptualized and defined by the group or population. See Table 6
Routines
For persons, groups, and populations: Patterns of behavior that are observable, regular, and
repetitive and that provide structure for daily life. They can be satisfying and promoting or
damaging. Routines require momentary time commitment and are embedded in cultural and
ecological contexts (Fiese et al., 2002; Segal, 2004; see Table 6).

S
Screening
“The process of reviewing available data, observing a client, or administering screening
instruments to identify a person’s (or a population’s) potential strengths and limitations and the
need for further assessment” (Hinojosa, Kramer & Crist, 2014, p. 3).

Self-Advocacy
Advocating for oneself, including making one’s own decisions about life, learning how to obtain
information to gain an understanding about issues of personal interest or importance, developing
a network of support, knowing one’s rights and responsibilities, reaching out to others when in
need of assistance, and learning about self-determination.

Service delivery
Set of approaches and methods for providing services to or on behalf of clients.

PREPUBLICATION DRAFT. Page 91 of 96

Skilled services
To be covered as skilled therapy, the services must require the skills of a qualified occupational
therapy practitioner and must be reasonable and necessary for the treatment of the patient’s
condition, illness, or injury. Skilled therapy services may be necessary to improve a patient’s
current condition, to maintain the patient’s current condition, or to prevent or slow further
deterioration of the patient’s condition. Practitioners should check their payer policies in order to
meet payer definitions and comply with payer requirements.

Social interaction skills

The group of performance skills that represent small, observable actions related to
communicating and interacting with others in the context of engaging in a personally and
ecologically relevant daily life task performance that involves social interaction with others”
(Fisher & Marterella, 2019, p. 342).

Social participation
“Interweaving of occupations to support desired engagement in community and family activities
as well as those involving peers and friends” (Gillen & Boyt Schell, 2014, 607); involvement in
a subset of activities that involve social situations with others (Bedell, 2012) and that support
social interdependence (Magasi & Hammel, 2004). (see Table 2).

Spirituality
“A deep experience of meaning brought about by engaging in occupations that involve the
enacting of personal values and beliefs, reflection, and intention within a supportive
contextual environment (Billock, 2005, p. 887). It is important to recognize that spirituality
“as dynamic and often evolving” (Humbert, 2016, p. 12).
T
Time management
The manner in which a person, group, or population organizes, schedules, and prioritizes certain
activities

Transaction
Process that involves two or more individuals or elements that reciprocally and continually
influence and affect one another through the ongoing relationship (Dickie, Cutchin, & Humphry,
2006).

V
Values
Acquired beliefs and commitments, derived from culture, about what is good, right, and important
to do (Kielhofner, 2008)

W
Well-being
“General term encompassing the total universe of human life domains, including physical,
mental, and social aspects” (WHO, 2006, p. 211).

PREPUBLICATION DRAFT. Page 92 of 96

Wellness
“Perception of and responsibility for psychological and physical well-being as these contribute
to overall satisfaction with one’s life situation” (Boyt Schell et al., 2014a, p. 1243).

Work
Labor or exertion related to the development, production, delivery, or management of objects or
services; benefits may be financial or nonfinancial (e.g. social connectedness, contributions to
society, adding structure and routine to daily life) (Christiansen & Townsend, 2010; Dorsey et al,
2019).

PREPUBLICATION DRAFT. Page 93 of 96