Focus on the Treatment Team: Occupational Therapy

Kate McKenna, MEd, MSEd, MS, BCBA and Kristina Gasiewski, MEd, MOTR/L, BCBA
Association for Science in Autism Treatment

History

Focus on the Treatment Team: Occupational Therapy Occupational therapy (OT) was established in 1917 by six founders of the National Society for the Promotion of Occupational Therapy (NSPOT). This Society was later renamed in 1923 and is currently known as the American Occupational Therapy Association (AOTA) (Paterson, 2011). The founders were from a variety of professional backgrounds and disciplines (i.e., psychiatrists, architects, welfare workers, teachers, nurses, and medical doctors) who came together with one strong belief that occupations hold a therapeutic value. The values and beliefs that most OTs hold today were created and shaped by the 19^th and early 20^th-century historical events such as industrialization, women’s rights, World War I, healthcare legislation, and technology (Christiansen & Haertl, 2019).

As a discipline, OT rose to prominence following WW1 as the medical professionals working with shell-shocked and wounded veterans. In their efforts to rehabilitate those suffering the effects of combat, the original practitioners of OT based their profession on the idea that real work would aid in creating a healthy body and mind (Christiansen & Haertl, 2019). As a result of their success, OT came to be recognized as a medical discipline in its own right.

By the 1960s, there were two distinct practice areas including treating those with physical disabilities and those with psychological dysfunction. Some key events that influenced the OT profession stemmed from the civil rights movement and its influence on health care and social justice, and large mental institutions closing (which affected the number of OT professionals working in longer-term mental health settings). The American Occupational Therapy Foundation (AOTF) was founded in 1965 to promote scientific development in the field of OT. At this time, there was also increased emphasis on sensorimotor therapies and neurodevelopmental theories (Christiansen & Haertl, 2019).

In the 1970s, OT was again influenced by the medical rehabilitation and treatment of war veterans. This created a shift from a holistic and occupation-based approach to a more medical, bottom-up approach with an emphasis on the source of the problem. This was a shift from the root of OT as of a top-down approach and utilizing occupations and crafts in a therapeutic manner. OT practitioners began focusing more on theory and research. Mechanical approaches were being applied to interventions such as the neuromotor and musculoskeletal systems and their relation to occupational function (Christiansen & Haertl, 2019).

With advances in science, technology, education, and health care during the 1980s and 1990s, the OT profession continued to evolve. There was a greater emphasis on research, efficacy, and defining the scope of practice. In 1986, AOTA created the American Occupational Therapy Certification Board (AOTCB), which, in 1996, was later named the National Board for Certification in Occupational Therapy (NBCOT) (Christiansen & Haertl, 2019). Regulations requiring licensure for OT became effective on July 1, 1998. Additionally, in 1999, the first edition of the American Journal of Occupational Therapy (AJOT) was published. Also, in 1997, the Individuals with Disabilities Education Act (IDEA) was passed, which ensures specialized services, including OT, are provided for children with disabilities in schools in order to improve education. This led to an increase in the number of OT practitioners working in school systems increased (Christiansen & Haertl, 2019).

Legislation and policies continue to change and heavily influence the OT profession such as increasing the quality of practice through measurable outcomes, creating goals that contain cost, and providing evidence-based research that demonstrates the effectiveness and efficacy of OT practice (Christiansen & Haertl, 2019).

Education

Occupational Therapy professionals acquire their degrees from an ACOTE (Accreditation Council for Occupational Therapy Education) accredited occupational therapy program. There are two degrees: occupational therapy assistant (OTA) and occupational therapist (OT).

An OTA may practice with an associates degree under the supervision of a licensed OT. An OT must obtain a Masters level degree to practice. However, those who acquired and have been practicing prior to 1990 may continue to practice with a bachelor’s degree. There are both post-professional master’s programs for those that hold an approved bachelor’s degree in a related field, and entry-level master’s degree programs. Additionally, there are entry-level occupational therapy doctorate (OTD) programs. At this time, the profession runs under a dual-entry point. There was a proposal to mandate a doctorate-level requirement; however, in 2019, after much debate, AOTA, who presides over ACOTE, upheld the dual point of entry policy.

Some typical courses of study may include anatomy and physiology, kinesiology, movement analysis, neuroscience, adult rehabilitation, assistive technology, occupations across the lifespan, and assessing occupational performance. Additionally, OTA and OT students must complete fieldwork consisting of two levels. Level I fieldwork typically consists of observations and shadowing OTs in multiple settings; however, there has been a bigger push to allow more hands-on opportunities during these practicums. Level II fieldwork requires a minimum of 16 weeks for OTA students and at least 24 weeks for OT students. This must occur across two different settings and requires the OT student to work directly with clients under the supervision of a licensed OT.

Standards of Practice & Guiding Documents

Once graduated, OTs and OTAs must pass the National Board for Certification in Occupational Therapy (NBCOT) exam in order to practice. Currently, all 50 states, Guam, Puerto Rico, and the District of Columbia require the NBCOT initial certification. For OTs, this test is comprised of 3 clinical simulation test items and 170 multiple-choice single-response questions. The OTA exam consists of 200 questions of both multiple-choice, single-response questions and six option multi-select questions. Passing the exam, therapists become certified and assume the following credential: OTR – Occupational Therapist Registered, or COTA – Certified Occupational Therapy Assistant. The NBCOT requires 36 units of continuing education during a three-year renewal cycle to be in good standing with the OTR NBCOT Practice Standards, the COTA NBCOT Practice Standards, and the NBCOT Code of Conduct. A list of renewal activities can be found here: NBCOT® Certification Renewal Activities.

OT professionals must be licensed per the state they work in, and state licensing requirements vary per state. It should be noted that while each state requires the initial passing of the NBCOT exam and to be registered with NBCOT, it may not be a requirement to continue this certification. Therefore, you may see two different credentials: Occupational Therapist Registered/Licensed (OTR/L) or Occupational Therapist/Licensed (OT/L).

Additionally, COTAs practice under the ongoing supervision of a licensed OT. The amount and level of supervision is guided per state regulations as well as the type of setting and insurance protocols.

As licensed professionals, OTs practice under a set of guiding documents created to guide OTs in effective and ethical provision of services, to protect consumers, and to establish a common understanding of the basic principles of the profession. Guiding OT documents include the Occupational Therapy Practice Framework (OTPF)-4 (2020), the Occupational Therapy Scope of Practice (2021), the Standards of Practice for Occupational Therapy (2021), and the Occupational Therapy Code of Ethics (2020).

Professional Organizations

There are a number of professional organizations open to membership by OTs, including the American Occupational Therapy Association (AOTA), the American Occupational Therapy Foundations (AOTF), the Canadian Association of Occupational Therapists, and the World Federation of Occupational Therapists (WFOT). Benefits of membership in these organizations include on-site access to peer-reviewed journals, attendance at conferences and webinars for professional development, and the organization’s legislative advocacy for both practitioners and clients.

Scope of Practice

A glance through the titles of some of the peer-reviewed journals published in the field of OT gives us a sense of the areas in which OTs practice. The specificity makes clear that OT is a broad field that impacts the lives of people with a range of support needs, in a variety of settings.

Published by AOTA:

AOTA members also have access to the following external journals:

Some additional occupational therapy-based journals include:

Areas of focus in OT can be categorized into two domains: Activities of Daily Living (ADLs), which include supporting competency and independence in areas such as feeding, dressing, and grooming, and Instrumental Activities of Daily Living (IADLs). IADLs are activities that bring people in contact with their environments such as shopping, managing money, traveling, work, and leisure activities. Other activities that come under the heading of IADLs revolve around independent living. Meal preparation, household chores, health management, education, and personal safety are examples (OT Scope of Practice, 2021; OTPF-4, 2020). Supporting progress in these activities may involve adapting or modifying the environment and conducting an activity analysis to pinpoint the specific skills that require work.

OTs are employed in a variety of settings such as schools, hospitals, both long-term care facilities for those with memory loss or extensive care needs and outpatient clinics, and in the home or other community settings. OT practitioners work on refining fine motor manipulation (i.e., finger dexterity, in-hand manipulation, bilateral coordination, etc.) in order to improve the overall function of skill (i.e., self-care skill, handwriting, keyboarding, etc.). OTs also have the expertise to assess core strength and develop an intervention plan for postural control that may include providing adaptive seating equipment. OT practitioners may work with an individual to improve processing skills such as organizational skills and work on improving visual perceptual and motor planning skills (Schell & Gillen, 2019).

“Occupational Therapy has a long history that is steeped in cultural and historical events. Professionals who practice OT engage in rigorous coursework and clinical practice prior to passing a certification exam and have established many professional organizations and peer-reviewed journals to form a solid foundation of scientific evidence regarding their treatments. At the heart of OT is the goal of promoting participation in meaningful occupations, which are defined by OT practitioners as any activity in which an individual engages throughout their day. The field of OT focuses on teaching individuals, across the lifespan, the skills needed to promote independence and participation in daily life activities. (Schell & Gillen, 2019).

References

American Occupational Therapy Association (2021). Occupational Therapy Scope [KG1] of Practice. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 75(Supplement_3), 7513410020. https://doi.org/10.5014/ajot.2021.75S3005

American Occupational Therapy Association. (2020). AOTA 2020 occupational therapy code of ethics. American Journal of Occupational Therapy, 74(Suppl. 3), 7413410005. https://doi.org/10.5014/ajot.2020.74S3006

American Occupational Therapy Association. (2021). Standards of practice for occupational therapy. American Journal of Occupational Therapy, 75(Suppl. 3), 7513410030. https://doi.org/10.5014/ajot.2021.75S3004

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

Christiansen, C. H., & Haertl, K. L. (2019). A contextual history of occupational therapy. In Schell, B. A. & Gillen, G. (Eds.), Willard & Spackman’s Occupational Therapy (13^th ed.). Williams & Wilkins.

Paterson, C. F. (2011). A short history of occupational therapy in psychiatry. In Cree, J. & Lougher, L. (Eds.), Occupational Therapy and Mental Health (4^th ed.). Elsevier Health Sciences UK.

Schell, B. A., & Gillen, G. (2019). Willard & Spackman’s Occupational Therapy (13^th ed.). Williams & Wilkins.

Citation for this article:

McKenna, K., & Gasiewski, K. (2022). Focus on the treatment team: Occupational therapy. Science in Autism Treatment, 19(12).

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