DIGITAL ASSISTIVE TECHNOLOGY: THE UNIQUE CONTRIBUTION OF OCCUPATIONAL THERAPISTS

digital assistive technology      Digital technologies have become a huge part of our everyday lives. Whether we embrace or resent this fact, in Western cultures it has eaten into a big portion of our ‘doing’ time, and even some of our ‘being’ time (we can even unwind!). For people of all ages, genders, abilities and cultures, digital technology has made it possible to communicate from great distances, to interact socially and network professionally, to share relevant and irrelevant information, to watch videos, to listen to our favourite music, to be entertained, to play, to shop, to learn new things, to organise our lives, to capture good times, to remind us of essential things, to collect and categorise things, to become more productive, to relax, …  the list of functional applications is endless.

Children as young as two are confident in the use of a mobile phone or tablet, and request this on a regular basis from their parents. People in the UK spend a daily average of 2hrs and 52 mins online, with mobiles and tablets taking up to 56% of internet time (IAB & UKOM, Sept 2015).Time spent online infographic.JPG

The routine use of computers, mobile phones, tablets and other gaming devices has become part of our daily routines and we cannot easily imagine our lives without such gadgets anymore, regardless of whether we feel they are becoming more intrusive or helpful than ever.

However, in our OT roles and daily clinical practice we can over-focus on traditional activities of daily living and forget the digital field, or categorise it as an additional, non-essential occupation. How many times we hear OTs ask questions about washing & dressing, feeding, cleaning, preparing food, using public transport, managing money or anxiety when outdoors, but we rarely feel we need to hear about the person’s engagement in digital technology. ‘Can you use your mobile phone, laptop computer, kindle reader, iPad, music player, TV, Xbox…?’ ‘Is this currently an important part of your life?’ Such an essential and ubiquitous occupation is not measured by standardised assessments and rarely appears in questionnaires and initial interviews.

We set clear limitations to our clinical roles when we fail to consider that we could be helping someone access regular digital technology, and furthermore, we could use that technology to make their everyday lives easier. With the exception of services dedicated to the provision of AAC (Alternative and Augmentative Communication) devices or environmental controls, OTs can often shake any responsibility to address participation or use of digital technologies as essential tools in their interventions. Worth noting that this is not always the case, as some exceptions to this rule are available within the profession.

In this opinion piece I would like to advocate for the unique role that OTs can have in the assessment, provision and general use of digital technologies as part of their roles in any clinical areas, and why they should develop their skills in understanding and applying such technologies to their daily practice.

Unique Role of the Occupational Therapist (OT)

Through the use of digital assistive technology, OT professionals can facilitate participation in the following functional areas (some examples below):

  1. Recording, organising and categorising concepts during lessons or throughout the work day – i.e. as an alternative to handwriting, a student with movement difficulties can use ‘dictation’ software. Another person with dyslexia at work can use specific software and a laptop to assist with the mind-mapping of ideas or to organise their daily schedule.
  2. Access to educational activities – i.e. helping a persostudent and iPadn with visual impairment to read and interpret printed visual information at university through the use of a digital video magnifier or adapted laptop settings.
  3. Access to play and leisure activities – i.e. facilitating access to a gaming device such as an Xbox for an adult with a recent spinal injury.
  4. Access to communication activities (often in collaboration with Speech and Language Therapists) – i.e. assisting a student with severe dysarthria and movement difficulties to communicate verbally in a lesson through the use of adapted communication grids on an iPad.
  5. Engagement in social activities – i.e. helping an isolated elderly person to access social media to keep in touch with far-away relatives and friends; or showing a person with chronic pain how to access condition-specific online forums; or practicing social skills with a person with autism by watching online videos or making social stories on an app.
  6. Access to environmental controls – i.e. helping a person with a deteriorating condition (i.e. MND or Muscular Dystrophy) control their TV, house lights / temperature/ music through a tablet device and an adapted switch.
  7. Maintaining independence skills at home (including Telecare) – i.e. helping a person with dementia stay at home by installing sensors in the bedroom or placing regular medication reminders on their mobile phone; or assisting a young person with autism to follow visual schedules of their morning routine on an iPad app.
  8. Long-term condition management – i.e. helping a person with diabetes monitor their blood sugar levels and food intake through a specific iPad app; or assisting a person with a mental health condition to monitor their lifestyle and habits through a mobile phone app, by including their exercise routines, daily reminders, log books, mindfulness activities, etc.

Basic OT competencies in the use and provision of assistive technology have been outlined by the AOTA (2015). OT’s unique contribution to the assessment and provision of digital technology includes knowledge and expertise in the following areas:

  • Seating and positioning to encourage the best possible posture in preparation to access technology. Additionally, OTs are confident setting up and adjusting specialist seating and mounting systems to achieve an optimal environment for technology use.
  • Understanding of upper limb and hand function, and carrying out interventions to maximise this ‘access option’ first.
  • Knowledge of developmental milestones, relevant anatomy, physiology, kinesiology and medical conditions, their prognosis and occupational impact on the person. This enables an accurate assessment of physical access to technology, and accurate selection of long and short term options for the user
  • Sensory processing differences and other sensory needs (i.e. visual perceptual difficulties, auditory loss, etc.) can be identified and addressed in more complex cases, if they have an impact on the technology being tried.
  • Expertise on activity analysis to enable participation in a range of daily activities, ensuring an ergonomic fit between the technology and the specific needs of the user.
  • A holistic and client-centred view of the person, considering the best integration of the environment, the person and the occupation or activity, as part of our professional identity and practice models (see below).

PEO Model

Through our own daily interactions and experiences with digital technology we are able to understand how it can be adapted and customised to meet individual needs. At the end of the day, we often change and adapt this technology to our own personal tastes and requirements, so why not finding out more on how to adapt it to the more challenging needs of our clients?

When things become more technologically complex, an OT should never act in isolation, and other professional perspectives and support should be actively sought from local specialist teams and charities. Collaboration with these teams can increase our existing knowledge, enrich our practice and make us better prepared to meet the needs of a wider population. Many OTs are already acknowledging that we are in a privileged position to use digital technologies to our advantage, and they continue to explore options appropriate to their client groups and needs.

As ‘access experts’, enabling people to pursue and succeed in their chosen occupations, OTs should aim to get involved in all aspects that affect an individual’s participation, including their daily use of digital technologies. We should familiarise ourselves with simple and cost-effective ways of adapting these technologies to meet users with a range of needs and disabilities, the same as we familiarise ourselves with other OT techniques and approaches to maximise our professional skills in other areas of practice. This should be part of our continuous professional development.

And finally, we can use Digital Technology in OT not only because it makes things easier, but because it can make things POSSIBLE (adapted from IBM training manual, 1991).

As always, questions, comments and personal experiences with digital technology in OT clinical practice will be very welcomed.

 

References and more Information:

http://www.aota.org/About-Occupational-Therapy/Professionals/RDP/assistive-technology.aspx (Accessed January 2015)

American Occupational Therapy Association. (2010). Specialized knowledge and skills in technology and environmental interventions for occupational therapy practice. American Journal of Occupational Therapy, 64, S44–S56. doi:10.5014/ajot.2010.64S44

Terrer-Perez, P (2013). ‘Digital Assistive Technology: A Core Skill for OTs Working with Children?’. OT News, January(2): 32.

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COACHING SKILLS: ARE THEY HAVING A ‘COME BACK’ IN OCCUPATIONAL THERAPY?

                                      Coach           

While attending an interesting training day at Guy’s Hospital from Sylvia Rogers (ASD expert and best practice advocator), she drew our attention to the fact that occupational performance ‘coaching’ and other related concepts seem to be appearing again in recent OT literature generated by our colleagues.

Afterwards, I decided to persuade my team into having a whole journal club and discussion around it so that we could explore how this really works in OT clinical practice. After digging up a few recent articles (see some Refs at the end), it still looked like a reasonable idea. It brings together key longstanding OT concepts such as client/family centeredness and occupation-based practice, as well as the idea of enabling participation in the person’s natural environment.

This really got me thinking: after doing our occupation-based assessments and client-centred goal setting; are we still making our clients the passive recipients of our interventions, based on the assumption that we are professionally trained and should model the right way of doing things, or that they expect us to come up with the solutions to their problems anyway? Are there other people out there alone in a therapy clinic treating a child that does not want to be there and a mother that feels that it is your job to change her child’s difficulties into achievements?

There has to be a better way of getting families (or teachers or a wider constellation of people around our clients) invested in our interventions. We should not take whole responsibility for the success of our interventions, and, more importantly, we could even save some valuable therapy time in the long run!

Although there seems to be several approaches to coaching (i.e. solution-focused, occupational performance coaching, problem-solving interventions, etc.), they all seem to share a number of (not steps, as they do not follow a sequence) common features:

–          Joint planning and collaborative relationships are essential to make this approach work.

–          Observations of the new strategy being implemented by the parent / client/ carer.

–          Real Life practice of the ‘strategy’.

–          Reflection to gain insights into the strategies attempted.

–          Feedback from the professional related to further development of new strategies and resources.

My team also felt that there are many similarities to the CO-OP approach for children with DCD (http://www.ot.utoronto.ca/coop/about.htm ), and there is also good evidence behind this method.

Personally, I see a few gaps in the application of this model of service delivery:

–          It is heavily dependent on Language, which rules out families with poor verbal/literacy/understanding skills and possibly from other cultures.

–          Requires a good insight from the user, so it may not be appropriate for parents/clients who have difficulties to recognise their own problems and have an overly positive vision of the goals they would like to achieve.

–          The OT does not provide intervention ideas based on his/her own expertise. This can be quite limiting and potentially de-skilling for the professional: can we not give parents a little background on their child’s condition or existing good practice, to help them make better informed decisions later on when deciding on their own strategies? Can we not at least make some suggestions or model successful tried and tested methods (i.e. backward chaining, visual supports, sensory calming techniques or equipment, etc.)?

In the end, we decided that it may not be applicable to everyone, but the whole idea of ‘coaching’ to create an optimal environment that improves our client’s chances for motivation and change continues to appeal to OT practitioners and supports our core beliefs.

At this stage, we are keen to find out more. Studies on OT interventions are still in their infancy (small studies and case reports), but evidence is apparently robust in other disciplines such as education, business and psychology. Let’s not forget that ‘Life coaching’ has been around for a very long time and its popularity is not fading.

Are OTs to become the ‘new’ experts in occupational performance coaching?

What are your thoughts on this topic? Let us know if you are already using this approach in your practice.

Refs.

Aust Occup Ther J. 2009 Feb;56(1):16-23. Coaching parents to enable children’s participation: an approach for working with parents and their children. Graham F, Rodger S, Ziviani J.

Phys Occup Ther Pediatr. 2013 Apr 24. Solution-Focused Coaching in Pediatric Rehabilitation: An Integrated Model for Practice. Baldwin P, King G, Evans J, McDougall S, Tucker MA, Servais M.

Phys Occup Ther Pediatr. 2013 May;33(2):253-63. Coaching mothers of children with autism: a qualitative study for occupational therapy practice. Foster L, Dunn W, Lawson LM.

Useful OT website with more information on Occupational Performance Coaching: http://www.occupationaltherapycoaching.com/