Mothers' experiences of engaging in Occupational

Fiona Graham,1 Sylvia Rodger, 2 and Jenny Ziviani 3 Key words: Professional–patient relations, motor skills disorders, child behaviour disorders, child, parenting, patient satisfaction.

Research

Mothers’ experiences of engaging in Occupational Performance Coaching Introduction: Occupational Performance Coaching is an intervention provided to parents, which targets their goals in occupational performance for themselves and their children. Preliminary evidence points to its effectiveness; however, little is known about parents’ experiences of engaging in Occupational Performance Coaching. Method: Within a larger mixed methods study, a purpose-designed survey comprising open and closed questions was used to explore parents’ (N = 29) experiences of engaging in Occupational Performance Coaching. The survey targeted their impressions, learning experiences, and perceptions of the impact of Occupational Performance Coaching. Numerical data were analysed descriptively; written comments were analysed using content analysis. In this case all participants were mothers. Findings: Mothers’ descriptions of Occupational Performance Coaching were largely positive. Learning experiences included gaining insights about themselves and their children alongside learning specific strategies to support their children’s occupational performance. They reported greater understanding of their children and a perception that Occupational Performance Coaching had engendered a calmer, happier emotional tone within the family. Conclusion: Mothers perceived Occupational Performance Coaching as a valuable means to support their children and themselves to attain occupational performance goals. Findings prompt greater attention to coaching approaches and, more widely, the use of transformative learning as a means to enabling occupation.

1 Senior

Lecturer, University of Otago — Medicine, Christchurch, New Zealand. 2 Director of Research and Education, Autism CRC; Honorary Professor, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia. 3 Professor, Children’s Allied Health Research, Children’s Health Queensland; School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia. Corresponding author: Dr Fiona Graham, Senior Lecturer, University of Otago, 7 Blakehall Place, Christchurch 8024, New Zealand. Email: [email protected] Reference: Graham F, Rodger S, Ziviani J (2014) Mothers’ experiences of engaging in Occupational Performance Coaching.

Introduction Occupational Performance Coaching (OPC, Graham et al 2009a) is a familycentred, strengths-based intervention for working with parents to achieve occupational performance goals for themselves and their children. Preliminary research investigating the effectiveness of OPC in assisting parents to achieve their goals for their children (such as being able to get ready for school calmly or use cutlery independently during mealtimes) has been positive (Graham et al 2013), but little is known about parents’ experiences with and perceptions of the approach. The aim of this study was to report specifically on mothers’ experiences of participating in OPC, in particular, to: (1) determine if mothers were receptive to being ‘coached’ as a means of addressing their own occupational challenges and /or those experienced by their children; (2) establish mothers’ experiences during OPC (specifically, what and how they learned); and (3) ascertain mothers’ perceptions of the impact of OPC.

British Journal of Occupational Therapy, 77(4), 189–197.

DOI: 10.4276/030802214X13968769798791 © The College of Occupational Therapists Ltd. Submitted: 10 December 2012. Accepted: 7 June 2013.

Literature review Coaching is increasingly being advocated as a means of working toward improved participation in natural environments for children and families (Baldwin et al 2013, Dunn et al 2012, Missiuna et al 2012, Palisano et al 2012). As a client-centred, performance-focused intervention, coaching utilizes

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Mothers’ experiences of engaging in Occupational Performance Coaching

cognitive-behavioural and solution-focused techniques to assist goal achievement (Grant 2003). Coaching has been proposed as a way for therapists to enact the principles of family-centred practice (Hanft et al 2004) and as a key enabling skill for occupational therapists (Townsend et al 2007a). OPC is a specific form of coaching designed to achieve parents’ goals of improved occupational performance for themselves and /or their children (Graham and Rodger 2010). Like other forms of coaching, OPC emphasises an egalitarian relationship in which the development of independent learning and decision making is a primary outcome (Stober and Grant 2006) and is performance focused and context specific (Hanft et al 2004). Uniquely, OPC addresses parent/ caregiver goals as they pertain to the performance of their own occupations and /or those of their children/dependents. It uses a collaborative performance analysis process (CPA) to support parents in their identification of solutions to occupational performance problems (see Fig. 1). During OPC, parents are guided in their problem solving of situations related to their goals. Direct instruction is intentionally minimized to encourage parents’ self-perception as the authority in their children’s lives and to enhance their capacity to problem solve independently from the therapist. Although information is provided to parents when a gap in parent knowledge is identified and when the information will assist strategy generation by the parent, OPC is not primarily an instructional or educational approach. Fig. 1. A graphical representation of the process of Collaborative Performance Analysis (CPA). Current performance ■ ■

Interpretation

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Motivation

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Learning needs

Person – Motivation – Knowledge – Ability

Preferred performance

■ Task – Steps of task – Sequence of steps – Standard expected

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Environment – Social – Physical

Parent needs

Bridges and barriers

Occupational Performance Measure (COPM, Law et al 2005) among children (F(1, 78) = 153.72, p < .001, h2 = .86) and mothers (F(1, 78) = 153.72, p < .001, h2 = .86) (Graham et al 2013). The intervention phase comprised weekly individual, face-to-face OPC sessions until goals were achieved, up to a maximum of 8 sessions (average dose = 5 sessions). Improvements were maintained at 6-week follow-up. These findings provided preliminary evidence supporting the use of OPC but also prompted further questions as to how parents perceived OPC as a way of working with therapists. A pilot study of OPC (Graham et al 2010) which included interviewing mothers (N = 3) about their experiences of the approach revealed that they generally found it to be a positive experience. The themes of ‘learning’, ‘changes at home’, and ‘a rewarding challenge’ emerged as dominant aspects of mothers’ experiences. These findings supported further investigation of OPC but raised questions about the process of learning experienced by parents. The extent to which learning featured in parents’ experience in the pilot study was intriguing as OPC is not seen to be an instructional approach. For this reason it was thought prudent to investigate parents’ experiences with a larger sample. An understanding of clients’ experiences is critical to the development of any intervention (Medical Research Council [MRC] 2008). Only when clients perceive interventions to be appropriate for addressing the concerns they raise (which is necessary for social validity) (Portney and Watkins 2000, p260) and an acceptable way of engaging with therapists can therapeutic engagement be developed. This study examined the social validity of OPC through an investigation of parents’ experiences of the approach.

Method Research design Ethical approval for this study was granted by the relevant ethics committees at the University of Queensland. The study comprised a survey component of a larger mixed methods study (Graham 2011) examining the effectiveness of OPC in enabling the occupational performance of parents and children with occupational performance difficulties. The survey was completed by parents following their completion of post intervention measures, but prior to the collection of follow-up data.

Participant recruitment Underpinning OPC is a conceptualization of performance as the product/interaction of the person, his/her environment, and the occupation in which he /she is engaged, consistent with the Person, Environment, Occupation (PEO) model (Law et al 1996). More detail on the theoretical underpinnings and process of OPC is available elsewhere (Graham et al 2010, Graham et al 2009a). A one-group time-series study investigating the effectiveness of OPC observed significant improvements in occupational performance as determined using the Canadian

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Participants were sought who were parents of children aged between 5 and 12 years and who expressed age-appropriate concerns with their children’s occupational performance in at least three areas identified through the COPM. To obtain a relatively homogenous sample, this study sought parents of children in middle childhood aged 5 to 12 years and excluded parents with intellectual disabilities or self-reported unmanaged mental health conditions. Only mothers sought inclusion in this study. Participants were recruited through a letter to those on a waiting list to attend a university occupational therapy service and through local Catholic school newsletters


Fiona Graham, Sylvia Rodger, and Jenny Ziviani

(Catholic Education is the second-largest provider of primary school education in Queensland serving families of mixed socioeconomic status [McCollow and Assad 2008]). Parents made phone contact with the first author, who initiated screening and, when appropriate, study involvement.

6.58% (n = 16) of all goals. Of these, the most common goals were ‘maintaining a calm state’ or obtaining particular skills or knowledge for assisting children with tasks identified as challenging.

Instruments Participants All parents were mothers, aged between 31 and 45 years. Family income spanned low, middle, and high income brackets for Queensland, Australia (Australian Bureau of Statistics 2006). Mothers’ education level was generally high, with 52% (n = 15) having completed postgraduate study. Most mothers were within the normal range for depression (n = 21, 72%), anxiety (n = 26, 90%), and stress (n = 22, 76%) according to Depression, Anxiety, Stress Scale normative data (DASS21, Lovibond and Lovibond 1995). Some mothers reported symptoms that indicated mild depression (n = 7, 24%) and mild stress (n = 4, 14%). Moderate or severe depression, anxiety, and stress were reported by < 10% of mothers. A third to a half of mothers made reference to parenting programmes that they had previously undertaken (such as Triple P [Sanders et al 2000]) or unspecified programmes offered by children’s schools) that had not equipped them to resolve the concerns for which they sought occupational therapy.

Descriptive information about children The children for whom mothers set goals were mainly boys (n = 29, 83%), ranging in age from 5 to 11 years (mean = 7 years 4 months, SD 1.6). Most children did not have a formal medical diagnosis as reported by their mothers. Of the 17% (n = 5) of the sample who did have a medical diagnosis, these included intellectual disability (n = 2, 7%) and Asperger’s Syndrome (n = 3, 10%). Children’s adaptive skills were measured using the relevant subscales of the Adaptive Behaviour Assessment System (ABAS II, Harrison and Oakland 2003). Internal consistency of ABAS II for each skill area is high (all < 0.75; Harrison and Oakland 2003). The construct validity of the ABAS II is supported by its theoretical consistency with the American Association of Mental Retardation (AAMR) classification of skill areas for successful and independent living (as cited by Harrison and Oakland 2003). Children in this study were, on average, below population means in all relevant skill areas (communication, community use, functional academics, home living, health and safety, leisure, self-care, selfdirection, and social). Children were in excess of one standard deviation below the mean in five out of the nine skill areas.

The nature of mothers’ goals for themselves and their children Goals (N = 135, mean = 5) selected by mothers for their children described aspects of performance of everyday tasks and routines that occurred in home or community contexts. The COPM skill areas for which goals were identified included self-care (n = 61, 45%), productivity (including homework and chores) (n = 37, 27%), and play (n = 17, 13%). In addition a number of goals related to social communication (n = 20, 15%). Goals relating to mothers’ performance accounted for

A purpose-designed survey (see Table 1) identified mothers’ experiences of OPC. Survey questions were informed, in part, by findings from interviews with mothers about their experiences of OPC in the previous pilot study (Graham et al 2010). The survey was developed drawing from best practice survey design principles (Polgar and Thomas 2000), including use of generous spacing to encourage comments, a mixture of positive and negative options when prompts are given, and careful consideration of wording to maximise clarity and minimise bias. An introductory statement emphasised the exploratory focus of the survey and the value that the researcher placed on gaining mothers’ perspectives. Although interviews are more typically used to gain information about participants’ experiences, it was anticipated that a survey would adequately elicit the information required to answer the research questions and allow efficient collection and analysis of data. The survey included questions to which mothers could either respond with ‘yes’ or ‘no’, or use a 5-point Likert scale. Based on the findings of the previous pilot study in which similar questions were asked via interview, 11 response options were provided to canvas mothers’ experience of sessions along with an invitation to use their own words.

Analysis Mothers’ responses to the survey questions yielded both quantitative and qualitative data. Categorical data (yes /no responses and selected descriptive cue words) and ordinal data from the Likert scale were reported using frequencies. Text-based responses to open-ended questions were explored using content analysis (Patton 2002) resulting in themes that summarized key findings. Content analysis was appropriate because mothers’ responses were generally brief written statements with limited elaboration and related to specific questions in the survey. Hence, text data were analysed at a literal level (Carpenter and Suto 2008). Because responses were brief and pertained to each question, it was inappropriate to combine themes if they emerged from responses to more than one question. The first author completed analysis with the aim of understanding how mothers experienced OPC, and expecting that they were likely to have had a range of experiences. The second author also examined preliminary themes from qualitative data, alongside illustrative quotations, and discussed them with the first author, resulting in minor refinement of themes.

Findings Mothers’ evaluation and description of OPC All mothers who completed the intervention phase of the study responded to the survey (n = 29, 100%) however some mothers


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Table 1. Survey questions and analysis used Survey question

Analysis

Mothers’ evaluation of OPC sessions and type of data

Firstly, we would like to know whether you feel the amount of change that occurred on each of your goals was a worthwhile outcome, considering the effort you made (yes/no) ............................................................................................................................................................Frequency Did the intervention meet your expectations? (1–5 Likert scale; 1 = expectations not at all met; 2 = expectations somewhat met; 3 = expectations met to a great extent; 4 = expectations were exceeded a little; 5 = expectations were exceeded a lot)......................................Frequency Would you recommend this coaching intervention to other parents? (yes/no) ......................................................................................................Frequency Why is this? .......................................................................................................................................................................................................Content Mothers’ descriptions of OPC

Circle the words/phrases below that best fit with your experience of taking part in this intervention (Positive, Ok, Negative, Not useful, Neutral, Useful, Worth it, Not worth it, Effortful, Easy, Made me think, Other description). An example or explanation of your choice would be really helpful .................................................................................................................................................................................................Frequency Do you feel further assistance with your child is needed at the moment? (yes/no)................................................................................................Frequency Could you say a bit about this? If yes, indicate what sort of assistance you feel is required...................................................................................Content Mothers’ learning through OPC sessions

What are the key things you feel you learnt from the coaching sessions?.............................................................................................................Content Did you learn anything that surprised you or that you hadn’t really expected? (yes/no) ..........................................................................................Frequency If yes, what was this?.............................................................................................................................................................................................Content What did you already know about helping your child to learn that the sessions prompted you to focus more on?.................................................Content Mothers’ perceived impacts of OPC sessions

What have you noticed has changed since you started the coaching sessions about your child, about yourself (in relation to your child, family, or in general), in family life?........................................................................................................................................................................Content

did not respond to all questions hence the sample size reported for each question varies. All mothers reported that the change that occurred towards goal achievement was worth the effort invested and that they would recommend the intervention to other parents. The most commonly selected response options to describe sessions were ‘made me think’ (n = 27, 93%) and ‘positive’, (n = 26, 90%). The response option of ‘effortful’ was selected by approximately one third of mothers (n = 9, 31%). All positive response options and no negative response options were selected. Mothers’ explanatory comments supporting their selected descriptors ‘made them think’, ‘positive’, and ‘effortful’ are summarized below, since comments supporting selection of these descriptors were not self-evident. Quotations are referenced to specific participants using a consistent number for each participant (for instance, P14 refers to participant 14). Mothers’ elaborated that being ‘made to think’ involved both thinking about concrete actions as well as deeper thinking about what motivated their actions with their children. Examples of concrete actions included: Made me think more about how Mila works; how he can be more involved in some of the decision making about his goals. Also how he needs a little more time on occasion to process instructions (P3).

Deeper thinking is illustrated in this mother’s comment: I took time to consider what motivated me to act in the ‘old’ ways [pre intervention]. I realized that I might save seconds in time but the child paid the price in not having a chance to master skills (P27).

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Mothers’ elaborations on their description of sessions as ‘positive’ indicated this was primarily based on improvements observed in their children. Positive experiences also related to mothers’ reflections on their ability to support their children. For example, one mother stated: Now we feel hopeful and empowered to help him learn what he needs to (P11).

A third of mothers (n = 9, 31%) also selected the descriptor ‘effortful’. Of the mothers who expanded on this descriptive cue, several linked the effort with the extent of improvement that occurred with comments such as: I have had to look at my own behaviours towards my daughter and of course it has taken some effort to change the way I interact with her (P22).

Mothers’ learning experiences A range of themes with respect to mothers’ learning experiences during OPC emerged in relation to each of the three survey questions about learning. All themes are presented in Table 2 in relation to the specific survey question asked. Some themes emerged in responses to more than one question, hence are repeated. Two ‘key’ themes were evident in mothers’ descriptions of their key learning experiences: ‘gaining insight’ and learning ‘specific strategies’.

Mothers’ gaining insight about themselves Mothers’ insights about themselves included comments such as having learnt ‘how to parent more calmly and effectively



Table 2. Themes in mothers’ learning experiences of OPC Focus of survey questions Themes

Key learning experiences Gaining insight Specific strategies

Learning Unexpected learning experiences What worked Child’s challenges and insights Own impact on child’s performance

by adjusting my behaviours (P5)’ and ‘to trust my instincts (P14)’. While insights were generally positive, they were not always comfortable for mothers. For example, one parent commented that she learnt: … that I need to manage my emotional state before I try to parent my child. That my attitude impacts on my child’s progress. That the easier road does not have the best long-term outcomes (P15).

Insights relating to their children reflected a shift for many mothers in how they perceived and understood their children. Some mothers’ insights about their children that illustrate this: Mike is a great kid who really IS trying; to question our assumptions about what he knows or ‘should’ know; to look at difficulties through ‘planning’ glasses to see why he might be struggling (P11). … Tom is a really sweet kid and has good insights into his own abilities (P6).

Specific strategies to support performance Some mothers referred to learning ‘specific strategies’ to support performance. Strategies related to managing their own responses to situations with their children as well as supporting children’s performance directly. Strategies relating to mothers’ behaviour focused on the way they engaged with their children: for example, many mothers referred to learning to be positive, calm, and encouraging with children while also being persistent and consistent in handling situations; two mothers reported they had learned to ‘manage my emotions better when it comes to parenting (P15)’, and ‘acknowledge my child’s experience — not just my own — in order to come up with new strategies for managing problems (P25).’ Strategies relating to children’s performance included applying strategies taught to mothers during OPC sessions, such as Collaborative Problem-Solving (CPS, Greene et al 2004), teaching and learning strategies (such as backward chaining, using visual cues), and teaching children skills to support their performance (such as labelling feelings and self-monitoring arousal levels). Other strategies referred to aspects of problem-solving, such as setting clear goals and making and reviewing plans, as significant parts of their learning experience.

Unexpected learning experiences Most mothers (n = 24, 83%) reported being surprised by what they learned during the OPC sessions, in terms of ‘what worked’,

Experience of using prior knowledge What worked Child’s challenges Own impact on child’s performance

and what they learned both about their children’s challenges and insights and their own impact on their children’s performances. No mothers expressed surprise about the content or nature of sessions. The most common source of surprise to mothers was which strategies worked to improve their children’s performance, for example ‘how effective passing problem-solving on to Nigel could be (P28)’, ‘that mastering one skill gave my child the confidence to attempt other tasks (P27)’, and ‘using diagrams/stick figures as an aid to talking about feelings (P26).’ As mothers learned more about their children, some reported surprise at the nature of their children’s challenges, and also at the degree of insight children had about their challenges. For example, mothers commented that ‘Martin didn’t see the world the way I do. Sequences and groupings aren’t natural to him but now I know how to teach this (P11)’, or ‘Mike is more aware of his behaviours; why they are happening; [he is] wanting, and willing to change, and has good ideas about how to get there (P8).’ Several mothers also reported surprise on learning the extent of their impact on their children’s performance. Mothers’ insights about their impact was for some reflective while for others it was affirmative, illustrated in such comments as: ‘I was trying to do Jim’s projects for him, which wasn’t helping him learn or have confidence (P2)’; ‘I am not doing too bad a job (P9)’; and ‘I observed how much my own wellbeing (or otherwise) impacts on Mitch’s mood and behaviour (P14).’

Drawing on prior knowledge Almost all (n = 27, 93 %) mothers reported that sessions had prompted them to direct their attention to their existing knowledge about ‘what worked’ to support their children’s performance. Mothers commented that they already knew about some strategies and approaches that worked to facilitate children’s performance and that the sessions prompted them to use strategies more consistently or in a different way than they had previously. Mothers also reported that sessions reiterated what they already knew about their children’s challenges, for example saying, ‘he is “muddle headed”, which I now realize is another way of saying he has trouble planning (P11)’, or that ‘multiple, complex instructions are almost impossible for him to take in, let alone react to (P14).’ Mothers also commented that sessions reminded them of the impact of their own behaviour on children’s performance, for example, being aware of the need to be calm, consistent, and to give praise and feedback when supporting children.


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Table 3. Themes of mothers’ perceptions of the impact of OPC on their children, themselves and their families Doing better Gaining insight Way of being Skills (for example, self-regulation, Knowledge More confident organization) Child He knows that persistence is the key to success He is confident, willing to try new techniques, Less frustration, tantrums when needing to in life as I have been reinforcing this more (P15). happy to plan and think first and talks to me transition (for instance, at end of computer/ when he isn’t confident so we can plan an TV time) (P16). ‘attack’ together (P11). Mother

I am quite skilled in noticing and understanding his behaviours (P14). Better conversations, not yelling so much (P26).

He’s smarter and more complex than I noticed before (P6).

I am more confident. I am enjoying my children more, taking things less personal. I feel I am doing a good job (P13).

Family

Easier for everyone to get organized now using self-monitoring strategies (P24).

As parents we need to help him by accommodating his anxieties (if possible): for example, by giving sufficient notice about changes to our routine (P124).

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Strategies Able to relax his hand to write quicker (P2).

Awareness More awareness of social interactions and better with peers (P17).

Calmer Monica has been less emotional (not so many meltdowns) and calmer (P23). Happier, much calmer, much better socially (P28).

Parent

Stop complaining so much and action the problem. Nip the problem as soon as it arises and not wait until it escalates (P18).

That I really struggle with parenting even though I am doing it all fine on the surface (P15).

More calm and relaxed (P5). More patient, more appreciative of my child. I don’t get so exasperated (P6). Being more in control and less emotional (P7).

Family

More discipline. More planning (P4). More organised and equal attention given to each child but need to increase/greater room to improve (P7).

That I don’t want my child to inherit the co-dependence that exists on both sides of the family (P15). To pursue new choices and a more calm way of living/managing (P25).

More calm in my house as I am more calm in dealing with Tom. I expect more of him (P6). When I am calm, the family is calm (P19). Our family life is calmer (P22).

Child

Mothers’ experience of the impact of OPC Mothers’ experience of the impact of OPC is illustrated by the three themes of ‘doing better’, ‘gaining insight’, and ‘different ways of being’. All three themes emerged as relevant to the perceived impact of OPC in the areas of child, self (that is, the parent), and family. Illustrative quotes for all themes are presented in Table 3. The first theme of ‘doing better’ refers to mothers’ comments about improved occupational performance through use of specific skills and strategies. The second theme, ‘gaining insight’, refers to the impact that particular knowledge or shifts in awareness had in making previously challenging situations less stressful and more successful. The third theme, ‘different ways of being’, encapsulates mothers’ observations that a shift in the emotional tone of their children, themselves, or other family members toward being calmer, happier, and more confident had occurred following OPC intervention. Greater confidence emerged in mothers’ observations of themselves and their children, but not of the family.

Discussion and implications Mothers’ experiences of OPC were overall very positive, albeit ‘effortful’ and requiring thinking and reflection on their part.

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Mothers described learning a range of skills and strategies, as well as gaining insights that they felt had led to improvements in their children’s performance through their own interactions and actions that were relevant to other aspects of family life. Mothers also reported experiencing changes in the way they interacted with their children generally and gaining a calmer internal state in themselves. These findings are consistent with those of the mothers previously reported (Graham et al 2010) and extend our understandings of mothers’ experience of learning that can inform future use of coaching with parents. Mothers were receptive to engaging in coaching to achieve their occupational performance goals. Mothers’ comments appraising OPC were usually adjoined to comments reflecting their satisfaction with the outcomes of the intervention (that is, achievement of goals). This finding is consistent with other studies in which parents have reported that achievement of their intervention priorities was a significant factor in their positive appraisal of services (McCall and Schneck 2000, Viscardis 1998, Washington and Schwartz 1996). Learning was a predominant feature of mothers’ experiences of OPC, which may provide insights into the mechanisms that underpinned the changes observed in mothers’ and children’s performance. Mothers described learning to better understand their children and themselves in their role



as parents and facilitators of children’s performance. This was somewhat unexpected given that OPC involves goal- and performance-focused coaching conversations (rather than psycho-dynamic interactions, or an educational focus in which one might expect learning to feature highly in clients’ experience). Specific information may be provided to parents (for example, about child health conditions or development) but this is a small component of OPC and was seldom used in sessions with these mothers (Graham et al 2009b), and therefore does not explain the extent of mothers’ experience of learning. The nature of the coaching conversations, however, enabled mothers to learn about themselves and their children in a different way, gaining new insights into the impact of their ‘ways of being’ on their children’s skill acquisition and the dynamics of family interactions. In comments about their perceptions of the impact of OPC, mothers referred to insights gained about themselves or their children that went beyond the learning of practical skills and strategies, to reflect changes in their attitudes, beliefs, and assumptions in relation to their support of children. These insights went beyond ‘rational knowing’ (such as concrete problem-solving) to ‘emotional knowing’ because they related to an individual’s perception of her/his self within her / his context (Marienau and Segal 2006). Mezirow’s (2000) description of transformative learning may best describe this process. Transformative learning involves exploration of the evidence for beliefs and assumptions about a situation and is inherent in some descriptions of coaching already discussed within occupational therapy (Townsend et al 2007b). The therapist’s role in facilitating transformative learning is to pay attention to the beliefs and assumptions conveyed in the client’s narrative. Through a reflective discourse (Mezirow 2000), the therapist prompts the client to critically reflect on the evidence for her/his assumptions or values. This occurs within the ‘parent needs’ stage of CPA in which parents’ interpretations, motivations, and learning needs (in relation to implementing changes /strategies) are considered. This guided critical reflection can involve the formation of new structures of meaning (that is, core ways of making sense of the world) (Taylor 2009). The therapist’s emotional sensitivity, particularly the use of empathy, is essential to this learning process. Transformative learning has been identified as an important tool in facilitating occupational enablement (Ashe 2005, Townsend et al 2007b) and is closely linked with concepts of coaching (Ashe et al 2005). As mothers came to view situations differently it would be expected (from a transformative learning perspective) that their actions in all situations with children altered to fit the emergent perspective or new ‘frame of reference’ (Mezirow 2000). Following a transformative learning process, a generalized change in performance, beyond the situations that were directly addressed, would be expected, as occurred for this group of mothers. Further research involving in-depth interviews, specifically exploring changes in parents’ core values and meanings, is needed to better understand transformative learning processes following OPC. If transformative

learning experiences do commonly occur, OPC may be effectively delivered in small groups, given the usefulness of group process in promoting transformational learning (Langan et al 2009). In a recent qualitative study examining the experience of receiving Rush and Sheldon’s coaching model (Rush and Sheldon 2011) for mothers of children with autism (n = 10), Foster et al (2013) similarly reported changes in mothers’ understanding about their child as a predominant aspect of their experience. Unlike in this study of mothers’ experience of OPC, Foster et al observed changes in mothers’ mindfulness (understanding coupled with acceptance of insights) regarding their children. Foster et al, like us, have suggested that transformative learning processes may explain links between coaching, learning, and other intra-personal changes (for example, improved parental self-efficacy). Differences in the data gathering method (survey versus interview) may have contributed to variations in findings as well as differences between interventions.

Limitations Findings drawn from mothers in this study cannot be assumed to generalize to all parents with whom OPC might be used. The high education level of mothers in this study and the undiagnosed sample of children need to be considered. Further research examining the experience of OPC with fathers, parents with lower levels of income and education, and children with diagnosed conditions is warranted as these factors may influence parents’ experiences in different ways. Survey findings are likely to be biased toward mothers who had a predisposed preference for coaching-style interventions, given that all participants had responded to an invitation to undertake OPC and had completed all sessions. Survey questions were informed by previous research regarding mothers’ experiences and attempts were made to encourage mothers to comment on any experience they felt was relevant. However, the inevitably directive nature of a written survey is likely to have influenced the kinds of experiences mothers reported and the extent of their comments.

Conclusion OPC is a specific form of health coaching that integrates coaching techniques with occupational analysis frameworks to achieve clients’ goals. Preliminary research supports the effectiveness of OPC in assisting mothers’ achievement of occupational performance goals for themselves and their children. In this study, mothers described engaging in OPC positively and experienced learning new skills, becoming aware of what they already knew, and gaining profound insights about themselves and their children. OPC may prompt transformative learning processes for parents when core values are challenged, enabling widespread improvement in parents’ capacity to support children’s performance and manage their parenting role. Therapists’ attention to their use of empathy is essential to supporting parents with this type of learning.


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Key messages OPC is perceived as an effective way to achieve occupational performance goals. Transformative learning through OPC may enable parents’ generalization of strategies. Coaching is an appropriate tool for working with mothers of children with occupational challenges.

What the study has added Coaching mothers of children with disabilities is perceived by mothers to enhance the participation of children in valued family activities and to improve children’s skill acquisition. Coaching may facilitate transformative learning processes for mothers, prompting more empathic and accepting views of themselves as mothers and of their children.

Conflict of interest: None declared. Funding: This research received no specific grant support from any funding agency in the public, commercial, or not-for-profit sectors. Research ethics: Ethical approval for this study was granted by the relevant ethics committees at The University of Queensland (#2006000953) and Catholic Education (Brisbane; #A11.071 GR). References Ashe B, Taylor M, Dubouloz C (2005) The process of change: listening to transformation in meaning perspectives of adults in arthritis health education groups. Canadian Journal of Occupational Therapy, 72(5), 280–288. Australian Bureau of Statistics (2006) Household income and income distribution, Australia, 2011-12. Available at: http://www.abs.gov.au/ausstats/ [email protected]/Latestproducts/6523.0Main%20Features22011-12?opendocument &tabname=Summary&prodno=6523.0&issue=2011-12&num=&view=

Accessed 24.03.14. Baldwin P, King G, Evans J, McDougall S, Tucker MA, Servais M (2013) Solutionfocused coaching in pediatric rehabilitation: an integrated model for practice. Physical & Occupational Therapy in Pediatrics, 33(4), 467–483. Carpenter C, Suto M (2008) Qualitative research for occupational and physical therapists: a practical guide. Oxford: Wiley-Blackwell. Dunn W, Cox J, Foster L, Mische-Lawson L, Tanquary J (2012) Impact of a contextual intervention on child participation and parent competence among children with autism spectrum disorders: a pretest-posttest repeated measures design. American Journal of Occupational Therapy, 66(5), 520–528. Foster L, Dunn W, Lawson LM (2013) Coaching mothers of children with autism: a qualitative study for occupational therapy practice. Physical & Occupational Therapy in Pediatrics, 33(2), 253–263. Graham F (2011) Occupational performance coaching: an approach to enabling performance with children and parents. (Unpublished doctoral dissertation). University of Queensland: Brisbane. Graham F, Rodger S (2010) Occupational performance coaching: enabling children’s and parents’ occupational performance. In: Rodger S, ed. Occupation-centred practice with children: a practical guide for occupational therapists. Oxford: Wiley-Blackwell. Graham F, Rodger S, Bauer J (2009b) Occupational performance coaching: an exploration of a therapist’s strategy use. Presented at the University of Queensland School of Health and Rehabilitation Sciences Post-graduate Conference, Brisbane, QLD, Australia.

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Graham F, Rodger S, Ziviani J (2013) The effectiveness of occupational performance coaching in improving children’s and mothers’ performance and mothers’ self-competence. American Journal of Occupational Therapy, 67(1), 10–18. Graham F, Rodger S, Ziviani J (2010) Occupational performance coaching with parents of children with performance issues: three case reports. Physical & Occupational Therapy in Pediatrics, 30(1), 4–15. Graham F, Rodger S, Ziviani J (2009a) Coaching parents to enable children’s participation: an approach for working with parents and their children. Australian Occupational Therapy Journal, 56(1), 16–23. Grant AM (2003) The impact of life coaching on goal attainment, metacognition and mental health. Social Behavior and Personality, 31(3), 253–263. Greene R, Ablon J, Goring J, Raezer-Blakely L, Markey J, Monuteaux MC, … Rabbitt S (2004) Effectiveness of collaborative problem solving in affectively dysregulated children with oppositional-defiant disorder: initial findings. Journal of Consulting and Clinical Psychology, 72(6), 1157–1164. Hanft B, Rush D, Shelden M (2004) Coaching families and colleagues in early childhood. Baltimore, MA: Paul H Brookes. Harrison P, Oakland T (2003) Adaptive behavior assessment system manual. 2nd ed. San Antonio, TX: Harcourt Assessment. Langan D, Sheese R, Davidson D (2009) Constructive teaching and learning: collaboration in a sociological classroom. In: Taylor EW, Mezirow J, eds. Transformative learning in practice: insights from community, workplace, and higher education. San Francisco, CA: Jossey-Bass. Law M, Baptiste S, Carswell A, McColl MA, Polatajko H, Pollock N (2005) Canadian Occupational Performance Measure (COPM). 4th ed. Ottawa, ON: CAOT Publications ACE. Law M, Cooper B, Strong S, Stewart D, Rigby P, Letts L (1996) The PersonEnvironment Occupation Model: a transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63(1), 9–23. Lovibond SH, Lovibond PF (1995) Manual for the Depression Anxiety Stress Scales. 2nd ed. Sydney, NSW: Psychological Foundation Monograph. Marienau C, Segal J (2006) Parents as developing adult learners. Child Welfare, 85(5), 767–784. McCall SA, Schneck CM (2000) Parents’ perceptions of occupational therapy services for their children with developmental disabilities. Developmental Disabilities Special Interest Section Quarterly, 23(1), 1–4. McCollow J, Assad S (2008) Queensland schools key statistics in brief. Brisbane: Queensland Teachers Union of Employees. Medical Research Council (2008) Developing and evaluating complex interventions: new guidance. London: MRC. Available at: http://www.mrc.ac.uk/ Utilities/Documentrecord/index.htm?d=MRC004871 Accessed 16.09.13. Mezirow J (2000) Learning as transformation: critical perspectives on a theory in progress. San Fancisco, CA: Jossey-Bass. Missiuna CA, Pollock NA, Levac DE, Campbell WN, Whalen SD, Bennett SM, … Russell DJ (2012) Partnering for change: an innovative schoolbased occupational therapy service delivery model for children with developmental coordination disorder. Canadian Journal of Occupational Therapy, 79(1), 41–50. Palisano RJ, Chiarello LA, King GA, Novak I, Stoner T, Fiss A (2012) Participationbased therapy for children with physical disabilities. Disability & Rehabilitation, 34(12), 1041–1052. Patton MQ (2002) Qualitative research and evaluation methods. 3rd ed. Thousand Oaks, CA: Sage Publications, Inc. Polgar S, Thomas SA (2000) Introduction to research in the health sciences. 4th ed. London: Churchill Livingston. Portney LG, Watkins MP (2000) Foundations of clinical research: applications to practice. 2nd ed. Sydney, NSW: Prentice-Hall.



Rush DD, Sheldon ML (2011) The early childhood coaching handbook. Baltimore, MA: Paul H Brookes. Sanders MR, Markie-Dadds C, Tully LA, Bor W (2000) The triple P-positive parenting program: a comparison of enhanced, standard, and self-directed behavioral family intervention for parents of children with early onset conduct problems. Journal of Consulting and Clinical Psychology, 68(4), 624–640. Stober DR, Grant AM (2006) Evidence based coaching handbook. Hoboken, NJ: John Wiley & Sons. Taylor EW (2009) Fostering transformative learning. In: Mezirow J, Taylor EW, eds. Transformative learning in practice: insights from community, workplace and higher education. San Francisco, CA: Jossey-Bass. Townsend E, Beagan B, Kumas-Tan Z, Versnel J, Iwama M, Landry J, … Brown J (2007a) Enabling: occupational therapy’s core competency.

Book reviews The rheumatic hand. 3rd ed. English version. M Van Gulijk, T Mesman, Y Veldhuis. Amersfoort, 2012. 180pp. ISBN: 978-7296-07-2 This manual provides a practical reference guide to the therapeutic management of hand problems arising as a result of musculoskeletal conditions such as rheumatoid arthritis, osteoarthritis, and carpal tunnel syndrome. It describes treatment as it is delivered in Reade, a centre for rheumatology and rehabilitation in Amsterdam, using a ‘recipe book’ type format. There are protocols for each problem and a summary of references relevant to each diagnostic group. The final chapter offers a collection of exercises presented in photographic form. Though obviously intended as a quick reference guide, this book lacks depth. It is not intended to challenge or encourage critical thinking and further reading would be required to extend learning to a more advanced level, however the references are generally not within the text itself, making it unclear which passages they refer to. There are also some issues relating to cultural differences. The references are somewhat biased towards Dutch research and conference presentations, some of the clinical specificity in language is lost in translation, and there are also some cultural differences apparent

In: Townsend EA, Polatajko HJ, eds. Enabling occupation II: advancing and occupational therapy vision for health, well-being, and justice through occupation. Ottawa, ON: CAOT Publications ACE Townsend E, Trentham B, Clark J, Dubouloz-Wilner C, Pentland W, Doble S, Laliberte-Rudman D (2007b) Enabling individual change. In: Townsend EA, Polatajko HJ, eds. Enabling occupation II: advancing an occupational therapy vision of health, well-being, and justice through occupation. Ottawa, ON: CAOT Publications ACE. Viscardis L (1998) The family-centred approach to providing services: a parent perspective. Physical & Occupational Therapy in Pediatrics, 18(1), 41–53. Washington K, Schwartz IS (1996) Maternal perceptions of the effects of physical and occupational therapy services on caregiving competency. Physical & Occupational Therapy in Pediatrics, 16(3), 33–54.

in the delivery of care. For example, following centralization of the extensor aponeurosis, a rehabilitation schedule of 24 weeks is described, which would not be feasible in the National Health Service (NHS) or private care in the United Kingdom (UK). Furthermore, some of the rehabilitation methods used in Reade are dated when compared to UK practice: flexor tendon rehabilitation follows the Kleinert method compared with early active UK regimes, for example. As most therapy departments in the UK delivering this type of rehabilitation have agreed management approaches based on research evidence, this book may not be useful in such settings. It may, however, have value where treatment is delivered by less experienced therapists or regularly changing therapists on rotation. Sarah Bradley, Advanced Occupational Therapy Practitioner in Hand Therapy, Poole Hospital NHS Foundation Trust.

Therapeutic programs for musculoskeletal disorders. James F Wyss, Amrish D Patel, eds. Demos Medical, 2013. £63.95. 385pp. ISBN: 978-1-936287-40-6 This book includes contributions from a large number of US-based authors with backgrounds in sports medicine, physical therapy, or medicine and surgery, and is edited by US-based physiatrists (rehabilitation physicians). The mainly physiological approach taken by the authors reflects their professional backgrounds, and only four

of the contributors have a background in occupational therapy. Although the importance of patient education and motivational constructs are emphasized, functional activity as it is considered in this book mainly concerns sport. Further, the main interventions considered are manual therapies, therapeutic modalities including heat, light, and laser therapy, and therapeutic exercise. Activities of daily living (ADL) interventions, assistive devices, and orthotics are referred to but not dealt with in any great depth. Psychosocial factors are also briefly referred to, but only in relation to non-specific chronic back pain, despite the fact that, as the authors acknowledge, neck pain is the second most common complaint among the general population. Pain management techniques and the bio-psychosocial model are not mentioned at all. The contents are well laid-out and clearly arranged into 50 short chapters covering the basics of musculoskeletal rehabilitation and 43 specific musculoskeletal conditions. Osteoarthritis is included in this list but inflammatory conditions are not. This book is likely to be of most interest to undergraduate or recently qualified physiotherapists. Occupational therapists specializing in musculoskeletal disorders who want to know more about physiological treatment approaches may like to loan it from a library. Carol Coole, Research Occupational Therapist, University of Nottingham.


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