Use of the Canadian Occupational
Performance Measure in Client-Centered
Occupational Therapy for Children With
Developmental Disabilities
Daehyuk Kang
The Graduate School
Yonsei University
Department of Rehabilitation Therapy
Use of the Canadian Occupational
Performance Measure in Client-Centered
Occupational Therapy for Children With
Developmental Disabilities
A Dissertation Submitted to the Department of Rehabilitation Therapy
and the Graduate School of Yonsei University in partial fulfillment of the
requirements for the degree of Doctor of Philosophy
Daehyuk Kang
December 2005
This certifies that the dissertation of Daehyuk Kang is approved.
Thesis Supervisor :Eunyoung Yoo
Boin Chung
Minye Jung
Kiyeon Chang
Hyeseon Jeon
The Graduate School
Yonsei University
December 2005
Acknowledgements
I would like to express my gratitude to my advisor, Dr. Eunyoung Yu, for
her professional advice and guidance. Her thorough review and feedback have
shaped the contents of this dissertation. My profound thanks go to Dr. Boin
Chung for her conscientious review of methodological content and quality of
this dissertation. I owe a debt of gratitude to Dr. Minye Jung for her critical
review of this dissertation. I would like to express sincerest thanks to Dr.
Kiyeon Chang for sharing her knowledge and valuable time. I am especially
grateful to Dr. Hyeseon Jeon for her thoughtful and helpful input. I extend a
hearty thanks to the clients and the occupational therapists who participated in
this study for sharing their time and thoughts. They all have my deepest
gratitude.
My work on this dissertation would not have been possible without my
wonderful, supportive family. Seungwon and Joonwon, my sons, have
provided inspiration along the way. And most of all, my wife, Soomi, for more
reasons than I can name.
Finally, I wish to dedicate this dissertation to my parents, who instilled
important values in life.
i
Table of Contents
List of Tables ····························································································· iv
Abstract ····································································································· v
Introduction ······························································································· 1
Methods ····································································································· 6
1. Participants························································································ 6
2. Allocation of Participants to Group A and Group B ······················· 7
3. Intervention ····················································································· 9
4. Instruments ······················································································ 11
4.1. Receptiveness to Client-Centered Approach Survey ············· 11
4.2. Canadian Occupational Performance Measure (COPM) ······ 13
4.3. Assessment of Motor and Process Skills (AMPS) ················ 15
4.4. Functional Independence Measure for Children (WeeFIM) · 17
5. Procedures ······················································································ 19
5.1. Pretest data collection phase ················································· 19
5.2. Intervention phase ································································· 20
5.3. Posttest data collection phase ················································ 20
6. Data Analysis ················································································· 21
ii
Results ······································································································ 22
1. Receptiveness to Client-Centered Approach Survey ····················· 22
2. Pretest Scores of the Occupational Performance Measures ··········· 24
3. Clients’ Perception of Occupational Performance Changes ·········· 25
3.1. Outcomes of Canadian Occupational Performance
Measure ················································································ 25
4. Therapists’ Observation of Occupational Performance Changes ··· 26
4.1. Outcomes of Assessment of Motor and Process Skills ········· 26
4.2. Outcomes of WeeFIM ··························································· 27
5. Correlations Among Occupational Performance Measures ··········· 28
5.1. Correlations in Group A ························································ 28
5.2. Correlations in Group B ························································ 30
Discussion ································································································ 31
1. Clients’ Perspective on Client-Centered Occupational
Therapy ·························································································· 31
2. Therapists’ Perspective on Client-Centered Occupational
Therapy ·························································································· 33
3. Relationship Among COPM, AMPS, and WeeFIM ······················· 35
Conclusion ······························································································· 38
References ································································································ 39
iii
Appendix ·································································································· 49
Abstract in Korean ··················································································· 52
iv
List of Tables
Table 1. Demographics of Between-Group Comparisons ························ 8
Table 2. Most Frequently Identified Goals in COPM ······························ 10
Table 3. Mean Scores of Receptiveness to Client-Centered
Approach Survey ······································································· 23
Table 4. Between-Group Comparisons of Occupational Performance
on Pretest······················································································ 24
Table 5. Within-Group Changes of Occupational Performance
on COPM ··················································································· 25
Table 6. Within-Group Changes of Occupational Performance
on AMPS ···················································································· 26
Table 7. Within-Group Changes of Occupational Performance
on WeeFIM ················································································· 27
Table 8. Spearman Rank Correlation Coefficients on Change Scores
Among COPM, AMPS, & WeeFIM in Group A ······················· 29
Table 9. Spearman Rank Correlation Coefficients on Change Scores
Among COPM, AMPS, & WeeFIM in Group B ······················· 30
v
ABSTRACT
Use of the Canadian Occupational Performance Measure in
Client-Centered Occupational Therapy for Children With
Developmental Disabilities
Daehyuk Kang
Dept. of Rehabilitation Therapy
(Occupational Therapy Major)
The Graduate School
Yonsei University
The aims of this study were to (a) investigate the effectiveness of client-
centered occupational therapy from clients’ perspective using the Canadian
Occupational Performance Measure (COPM), (b) examine the effectiveness of
client-centered occupational therapy from therapists’ perspective using the
Assessment of Motor and Process Skills (AMPS) and the Functional
Independence Measure for Children (WeeFIM), and (c) explore whether the
degree of clients’ receptiveness to client-centered occupational therapy could
influence correlations between clients’ perception and therapists’ observation
vi
of occupational performance changes. Eight girls and twenty-three boys with
developmental disabilities from 3 to 10 years of age participated in this study,
and caregivers of the children completed the Receptiveness to Client-Centered
Approach Survey after finishing initial assessment of the COPM with the
occupational therapists. The higher score of the survey represented the more
positive attitude toward client-centered occupational therapy. The top 15
participants with the score of 30 and higher were assigned to Group A, and the
bottom 16 participants with the score of 29 and lower were assigned to Group
B. During the intervention, each child received client-centered occupational
therapy that concentrated on improvement of occupational performance
identified by the clients (caregivers in this study). The results of the COPM
change scores demonstrated statistically significant improvement (p < .01) of
occupational performance in both Group A and Group B. This finding was
verified by the AMPS and the WeeFIM change scores that also showed
significant improvement (p < .01) of occupational performance. In Group A,
COPM-Satisfaction highly correlated with WeeFIM-Cognitive skills (rs = .78,
p < .01), COPM-Performance moderately correlated with AMPS-Motor skills
(rs = .64, p < .05), and COPM-Satisfaction moderately correlated with AMPS-
Process skills (rs = .62, p < .05). In Group B, no relationship was found among
the sections of the COPM, AMPS, and WeeFIM. The findings of this study
vii
suggested that usefulness of the COPM for children with developmental
disabilities was confirmed by the AMPS and the WeeFIM. Moderate to high
correlations were found in Group A indicating that clients’ perception and
therapists’ observation of occupational performance changes were concurrent.
In order to maximize the usefulness of the COPM for children with
developmental disabilities, the occupational therapists are advised to ensure
that they educate caregivers about the benefits of client-centered occupational
therapy.
Key Words: AMPS, Client-centered approach, COPM, Occupational therapy.
- 1 -
Introduction
The importance of client and family involvement in occupational therapy
has been emphasized from the 1970s (Northen, Rust, Nelson, & Watts,
1995). In treating children with developmental disabilities, the primary
caregivers’ active participation plays vital role for the positive outcome
(Pollock, 1993; VanLeit & Crowe, 2002). One way of facilitating the clients’
active participation is to introduce the client-centered approach. The client-
centered approach is defined as “an approach to service which embraces a
philosophy of respect for, and partnership with, people receiving services”
(Law, Baptiste, & Mills, 1995, p. 253). The goal of client-centered approach
is to have a client identify important tasks for her or him, establish treatment
goals, and design intervention process with the therapist (Simmons, Crepeau,
& White, 2000).
Recently, health care providers have been focusing on evidence-based
practice (EBP) that emphasizes both therapist’s observation and client’s
perception as valuable evidence (Holm, 2000; Lieberman & Scheer, 2002;
Savin-Baden & Taylor, 2001; Tickle-Degnen, 1999, 2002). Tickle-Degnen
and Bedell (2003) further argue that both therapist’s objective assessment
and client’s subjective perception have the same weight in clinical decision
making. In order to provide evidence that an occupational therapy is
- 2 -
effective, it is essential to use proper assessment tools that can detect
changes of occupational performance. However, some investigators dispute
that goals are usually set by therapists in conventional assessment tools, and
this may limit the active participation of clients in treatment (Law et al.,
1998; Pollock, 1993).
For the last decade, client-centered assessment tools such as the
Canadian Occupational Performance Measure (COPM) have been
emphasized in occupational therapy literature (Carpenter, Baker, &
Tyldesley, 2001; Ripat, Etcheverry, Cooper, & Tate, 2001). The COPM
provides an opportunity to establish client-centered goals and evaluate the
success of those goals (Law et al., 1998). This tool has been reported to
supplement conventional assessment tools since client-centered assessments
focus on individual’s unique needs in the areas of self-care, productivity, and
leisure (Law et al., 1994).
Examples of utilizing the COPM have been reported in occupational
therapy literature. Case-Smith (2003) studied occupational therapy outcomes
from 33 clients in hand rehabilitation using the COPM in measuring
functional changes. She identified that clients with upper-extremity injuries
made positive gains following client-centered occupational therapy. VanLeit
and Crowe (2002) evaluated the impact of an 8-week psychosocial
- 3 -
occupational therapy program for 38 mothers who had children with
disabilities. They reported significantly greater score increases on the COPM
satisfaction subscale in the treatment group.
Nevertheless, the authors of the COPM advised that it was not meant to
replace all other assessment tools in measuring effects of occupational
therapy because it only reflects client’s perception of occupational
performance and satisfaction (Law et al., 1998). Simmons and colleagues
(2000) used the COPM and the Functional Independence Measure (FIM) in
predicting outcomes for rehabilitation services in adult physical disabilities
settings. They found that use of the COPM in combination with the FIM
improved accuracy from 29% to 65%. Based on their findings, it was
inferred that other objective assessment tools could be used to supplement
the COPM.
Among objective assessment tools that reflect the therapist’s perspective,
the Assessment of Motor and Process Skills (AMPS) and the Functional
Independence Measure for Children (WeeFIM) have been reported to be
responsive to changes of occupational performance (Chen, Heinemann,
Bode, Granger, & Mallinson, 2004; Darragh, Sample, & Fisher, 1998;
Ottenbacher et al., 2000). Graff, Vernooij-Dassen, Hoefnagels, Dekker, and
de Witte (2003) explored the effects of occupational therapy services on the
- 4 -
performance of daily activities by 12 older adults with cognitive
impairments and on the sense of competence of their primary caregivers.
They used the COPM and the AMPS to measure changes of occupational
performance after 7 weeks of client-centered occupational therapy, and both
tools detected statistically significant changes. Also, the utility of the
WeeFIM has been reported by Ottenbacher and colleagues (2000) who
studied 174 children with developmental disabilities and Chen and
coworkers (2004) who reviewed functional gains of 814 children after
rehabilitation.
Even though the COPM and the AMPS have been widely used as
outcome measure instruments of occupational therapy programs, there is
limited research exploring their effectiveness to detect changes of
occupational performance in children with developmental disabilities. In
addition, while the importance of developing rapport between the clients and
the therapist has been emphasized in occupational therapy literature
(Peloquin, 1998; Tickle-Degnen, 2002), there was paucity of literature about
influence of the client’s receptiveness to client-centered occupational therapy.
In this study, three assessment tools (i.e., COPM, AMPS, and WeeFIM)
were used to measure the outcomes of the client-centered occupational
therapy for children with developmental disabilities. The COPM was
- 5 -
employed in evaluating the changes of occupational performance to reflect
the clients’ perspective. The AMPS and the WeeFIM were used in assessing
the changes of occupational performance to reflect the therapists’
perspective.
The specific purposes of this study were to (a) investigate the
effectiveness of client-centered occupational therapy from clients’
perspective using the COPM, (b) examine the effectiveness of client-
centered occupational therapy from therapists’ perspective using the AMPS
and the WeeFIM, and (c) explore whether the degree of clients’
receptiveness to client-centered occupational therapy could influence
correlations between clients’ perception and therapists’ observation of
occupational performance changes.
- 6 -
Methods
1. Participants
A sample of 60 children with developmental disabilities referred to
community-based occupational therapy programs or rehabilitation hospitals
were recruited from four occupational therapy clinics. The functional levels
of the children eligible to participate in this study were that they had to be
able to follow simple one step directions and initiate two of 83 standardized
AMPS tasks. The reason for choosing these criteria was that the AMPS
could not be used for those who were unwilling to participate in simple daily
tasks.
Among 60 clients, 31 completed the entire procedures. Of the 29 clients
who did not complete, 11 clients sought other occupational therapy clinics,
18 clients were lost because of therapists’ schedule conflict. Of the 31
participants, there were eight girls and twenty-three boys. The diagnoses
were mental retardation (n = 9), cerebral palsy (n = 7), developmental delay
(n = 6), attention deficit hyperactivity disorder (n = 5), and autism (n = 4) in
order. The participants’ ages ranged from 3 to 10 and mean age was 6.1
years old.
- 7 -
2. Allocation of Participants to Group A and Group B
For the purposes of this study, the participants were divided into Group
A and Group B based on the scores of the Receptiveness to Client-Centered
Approach Survey (see Appendix). Eight girls and twenty-three boys
participated in this study, and caregivers of the children completed the
Receptiveness to Client-Centered Approach Survey after initial assessment
of the COPM with the occupational therapists.
The scores of the survey for all participants ranged from 21 to 35, and
median was 29. Of the 31 participants, the top 15 participants with the score
of 30 and higher were assigned to Group A, and the bottom 16 participants
with the score of 29 and lower were assigned to Group B. Therefore, the
participants in Group A showed more positive attitude toward client-
centered occupational therapy than the participants in Group B. All
participants were distributed to two groups somewhat evenly in gender,
diagnoses, and age (Table 1).
- 8 -
Table 1. Demographics of Between-Group Comparisons (N = 31)
Group Aa
M (SD)
Group Bb
M (SD)
Mean
Difference
t p
(2-tailed)
Girls 5 3
Boys 10 13
MR 4 5
CP 4 3
DD 2 4
ADHD 3 2
Autism 2 2
Age 6.80 (2.34) 5.44 (1.55) 1.36 1.93 .06
Note. MR = mental retardation; CP = cerebral palsy; DD = developmental
delay; ADHD = attention deficit hyperactivity disorder. an = 15. bn = 16.
- 9 -
3. Intervention
Caregivers of participating children completed the COPM with their
occupational therapists, identifying and rating performance and satisfaction
in four to five tasks that they wished to improve in therapy sessions. A total
of 145 goals were identified, with an average of 4.7 goals for each individual.
Table 2 shows the most frequently mentioned goals in the areas of
education-related tasks (52%), self-care tasks (34%) and play tasks (14%).
Direct intervention was provided and recorded by the eight collaborating
occupational therapists whose clinical experience ranged from two to five
years. All of the assessment tools used in this study were administered by
occupational therapists who were trained to use respective tools. During the
intervention phase, each child received client-centered occupational therapy
that focused on enhancing occupational performance identified by the clients
(caregivers). The sessions were approximately 30 to 40 minutes per session
and specifically designed to meet the identified goals of the child.
- 10 -
Table 2. Most Frequently Identified Goals in COPM
Education % Self-care % Play %
Communication 24 Dressing 11 Play with peers 7
Listening 10 Eating 9 Block building 3
Reading 7 Toileting 8 Drawing 2
Writing 5 Grooming 3 Other 2
Speaking 3 Mobility 3
Other 3
- 11 -
4. Instruments
4.1. Receptiveness to Client-Centered Approach Survey
The Receptiveness to Client-Centered Approach Survey was developed
by the principal researcher based on the Client-Centered Practice
Questionnaire (Baptiste & Kang, 2002) to assess the degree of client’s
receptiveness to client-centered occupational therapy. The survey consisted
of seven items with 5-point Likert scale (5 = strongly agree, 4 = agree, 3 =
neutral, 2 =disagree, 1 = strongly disagree).
The degree of receptiveness to client-centered occupational therapy was
rated based on the following seven items:
1. I found the COPM easy to understand.
2. I found the COPM helpful.
3. The COPM helped me to identify current worries about my child’s
problems.
4. I felt comfortable helping the therapist plan my child’s treatment.
5. The COPM allowed me to feel respected and valued as an equal
partner in my child’s treatment.
6. I believe that a client is comfortable taking on responsibility for
treatment goals within Korean culture.
- 12 -
7. I believe that the COPM is an appropriate and effective tool in Korean
culture.
The Cronbach’s alpha was found to be .80, and this indicated strong
internal consistency of the survey items according to Portney and Watkins
(2000).
- 13 -
4.2. Canadian Occupational Performance Measure
In this study, the COPM was used as a guide to client-centered
occupational therapy. The therapists discussed about each child’s unique
needs with the caregiver and established treatment priorities and goals. In
addition, the COPM was used as an outcome measure to detect change of
occupational performance from a client’s perspective.
The COPM uses a semi-structured interview to detect what tasks in self-
care, productivity, and leisure a client wants, needs, or is expected to do on a
regular basis (Law et al., 1995, 1998). After all important tasks are identified,
the client (usually caregiver for child) rates each for degree of importance on
a scale of 1 to 10 (10 = most important). The most important tasks are then
the focus of intervention and outcome measurement. The client is then asked
to rate his or her perception of performance and satisfaction with this
performance in the selected tasks. The two scores are separately summed
and divided by the number of tasks, giving the mean for each. The client and
therapist then establish the goal of treatment together. On the completion of
program, possible changes in the client’s perceptions on the previously
identified occupational performance are recorded.
According to Law and colleagues (1998), test-retest reliability was found
to be in the acceptable range for both performance and satisfaction scores in
- 14 -
three different studies (ICC = .63 and .84; .79 and .75; .80 and .89
respectively). The construct and criterion validity has been evaluated for the
COPM and supported by recent studies (McColl, Paterson, Davies, Doubt, &
Law, 2000).
- 15 -
4.3. Assessment of Motor and Process Skills
The AMPS was employed in this study to objectively assess the changes
of occupational performance and reflect the therapist’s expertise. The AMPS
was administered before and after the intervention by trained and calibrated
occupational therapists who had attended 5-day AMPS workshop.
When scoring an AMPS observation, the calibrated rater scores 16
activities of daily living (ADL) motor items and 20 ADL process items with
a 4-point rating scale (4 = competent, 3 = questionable, 2 = ineffective, 1 =
markedly deficient). A Many-Faceted Rasch (MFR) computer program is
used to convert the ordinal data into interval data in the form of ADL ability
measures. The MFR model for the AMPS takes into account the task
challenge, rater severity, and item difficulty when estimating the final client
ADL motor and ADL process abilities (Stauffer, Fisher, & Duran, 2000).
Test-retest reliability coefficients were found to be r = .90 and r = .87 for
the AMPS motor skill scale and process skill scale, respectively. High inter-
and intrarater reliability persisted among 4,322 calibrated raters, and 95% of
the raters demonstrated goodness-of-fit statistics. This indicates acceptable
fit to the measurement model (Fisher, 2003). Concurrent validity with Scales
of Independent Behavior (SIB) was found to be r = .62 to .85 (Fisher, 2003)
and has been supported cross-culturally, across age groups, with a variety of
- 16 -
diagnoses (Darragh et al., 1998; Dickerson & Fisher, 1993). Reliability and
validity estimate have been reported in numerous studies qualifying for use
in this study (Fisher, Liu, Velozo, & Pan, 1992; Merritt & Fisher, 2003;
Nygard, Bernspang, Fisher, & Winblad, 1994).
- 17 -
4.4. Functional Independence Measure for Children
In this study, the WeeFIM was used as an occupation-based assessment
measuring functional improvement in basic activities of daily living. The
pre- and posttest scores were obtained by occupational therapists who
provided the intervention.
The WeeFIM instrument, developed by a multidisciplinary task force in
the early 1990s, was designed to measure functional outcomes of pediatric
clients receiving medical rehabilitation. It is intended for use with children
from six months to seven years of age who have acquired or congenital
disabilities. It may also be used with older children or adolescents who are
delayed in the development of functional abilities (Chen et al., 2004).
The WeeFIM contains 13 motor and 5 cognitive items encompassing
self-care, sphincter control, locomotion, communication, and social
cognition domains. It has a 7-level rating scale that assesses the extent of
assistance needed to perform functional tasks, with 1 indicating total
dependence and 7 indicating complete independence (Uniform Data Set for
Medical Rehabilitation [UDSMR], 1993). The WeeFIM focuses on
evaluating disability and determining levels of functional independence. As
a minimal essential data set, it allows pediatric, educational, and
rehabilitation professionals to describe basic performance in daily routines
- 18 -
(Ottenbacher et al., 1997). The WeeFIM can be administered either through
direct observation, interview, or both methods combined (Sperle,
Ottenbacher, Braun, Lane, & Nochajski, 1997). However, direct observation
on what the subject actually performs is preferred (UDSMR, 1993).
The WeeFIM has been found to be excellent in reliability and validity
(Chen et al., 2004; Ottenbacher et al., 1997, 2000). Ottenbacher, Hsu,
Granger, and Fidler’s study (1996) reported a median inter-rater reliability
for the total FIM of .95 and median test-retest and equivalence reliability
values of .95 and .92, respectively through meta-analysis of 11 studies.
- 19 -
5. Procedures
5.1. Pretest data collection phase
At the beginning of this study, the principal researcher educated eight
collaborating occupational therapists about the purposes of the study and
the key features of client-centered occupational therapy. The education
sessions consisted of orientation to the project, informed consent
procedures, criteria for inclusion of participants, documentation
requirements, measures, reliability in administering the measures, and
recording of data. The occupational therapists were given manuals that
explained details of all the procedures. Prior to the administration of pretest,
they explained the purposes of the study to the participants, and verbal
consent was obtained from them. The COPM and the WeeFIM were
completed by the occupational therapists after interviewing the caregivers
of the children at each clinic. The AMPS was administered by the trained
and calibrated occupational therapists including the principal researcher.
The COPM, the AMPS, and the WeeFIM were administered in the first
week when the client began to participate in client-centered occupational
therapy. After the administration of the COPM with explanation of client-
centered occupational therapy, the Receptiveness to Client-Centered
Approach Survey was completed by the primary caregiver of each child.
- 20 -
5.2. Intervention phase
The process of recruiting final 31 participants occurred four times over
10 months, and data were collected over 13 months between October 2004
and October 2005. Each child participated in 20 to 24 sessions of client-
centered occupational therapy. The site coordinators organized data
collection, selected clients who met the inclusion criteria, and compiled the
data.
5.3. Posttest data collection phase
The posttest scores were obtained in the last week after 20 to 24 sessions
of client-centered occupational therapy. Among 60 children and their
caregivers who participated in the pretest procedures, 31 participants
completed at least 20 sessions of client-centered occupational therapy and
posttest procedures. The posttest procedures of administering the COPM, the
AMPS, and the WeeFIM were the same as the pretest procedures. The
coordinators at each clinic submitted evaluation reports for each participant
to the principal researcher.
- 21 -
6. Data analysis
Data were analyzed using SPSS for Window Version 10.0. Demographic
data and test results were entered into an SPSS file. Unpaired t test was used
to examine the homogeneity between Group A and Group B on pretest of
occupational performance measures. To determine the effectiveness of
client-centered occupational therapy, paired t tests were calculated.
Spearman’s rank correlation coefficients were used to determine the
relationships among the change scores of the COPM, the AMPS, and the
WeeFIM. The alpha level of significance was set at the conventional .05 for
all analysis.
- 22 -
Results
1. Receptiveness to Client-Centered Approach Survey
The survey consisted of seven statements with 5-point Likert scale for
each item. The mean of total scores from 31 clients was 29.55. The mean
scores of the survey items ranged from 3.84 to 4.55. The item scoring the
highest mean was the item number 4. This indicated that the most clients felt
comfortable helping the therapist plan the child’s treatment. The item
scoring the lowest score was the item number 1. This suggested that the
COPM was not that easy for the clients to understand. The mean scores of
each item for Group A and Group B are shown in Table 3.
- 23 -
Table 3. Mean Scores of Receptiveness to Client-Centered Approach Survey
Mean
Items Group
Aa
Group
Bb
Totalc
1. I found the COPM easy to understand. 4.47 3.25 3.84
2. I found the COPM helpful. 4.73 3.93 4.52
3. The COPM helped me to identify current worries about
my child’s problems.
4.60 4.00 4.29
4. I felt comfortable helping the therapist plan my child’s
treatment.
4.80 4.31 4.55
5. The COPM allowed me to feel respected and valued as
an equal partner in my child’s treatment.
4.73 3.94 4.32
6. I believe that a client is comfortable taking on
responsibility for treatment goals within Korean culture.
4.67 3.93 4.29
7. I believe that the COPM is an appropriate and effective
tool in Korean culture.
4.47 3.50 3.97
Totald 32.47 26.81 29.55
Note. Responses were made on 5-point scales (1 = strongly disagree, 5 =
strongly agree). an = 15. bn = 16. cTotal is mean scores of each item for all respondents. dTotal is mean scores of all items for each group.
- 24 -
2. Pretest Scores of Occupational Performance Measures
Table 4 shows the between-group comparisons of occupational
performance on the pretests of the COPM, the AMPS, and the WeeFIM. The
differences of occupational performance between the two groups were not
statistically significant yielding homogeneity assumption.
Table 4. Between-Group Comparisons of Occupational Performance on
Pretest
Outcome
measures
Group Aa
M (SD)
Group Bb
M (SD)
Mean
Difference
t p
(2-tailed)
COPM-P 3.25 (1.34) 3.39 (0.73) - 0.14 - .34 .735
COPM-S 3.33 (1.65) 3.48 (1.27) - 0.15 - .28 .781
AMPS-M 0.36 (1.09) 0.51 (0.69) - 0.15 - .48 .632
AMPS-P - 0.40 (0.76) - 0.57 (0.60) - 0.17 - .70 .489
WeeFIM-M 67.40 (14.79) 62.50 (13.48) - 4.90 - .97 .342
WeeFIM-C 16.07 (8.34) 17.56 (7.49) - 1.49 .53 .603
Note. COPM-P = Canadian Occupational Performance Measure-
Performance; COPM-S = Canadian Occupational Performance Measure-
Satisfaction; AMPS-M = Assessment of Motor and Process Skills-Motor
skills; AMPS-P = Assessment of Motor and Process Skills-Process skills;
WeeFIM-M = WeeFIM-Motor skills; WeeFIM-C = WeeFIM-Cognitive skills. an = 15. bn = 16.
- 25 -
3. Clients’ Perception of Occupational Performance Changes
3.1. Outcomes of Canadian Occupational Performance Measure
Table 5 shows within-group changes of occupational performance on the
COPM. Both Group A and Group B demonstrated statistically significant
improvement of self-perception in the COPM-Performance and the COPM-
Satisfaction.
Table 5. Within-Group Changes of Occupational Performance on COPM
Measure and
Condition
Pretest
M (SD)
Posttest
M (SD)
Change
M (SD)
t P
(2-tailed)
COPM-P
Group Aa 3.25 (1.34) 5.57 (1.70) 2.41 (1.40) - 6.69 .000
Group Bb 3.39 (0.73) 5.39 (1.27) 2.00 (0.95) - 8.43 .000
COPM-S
Group Aa 3.33 (1.65) 5.58 (1.75) 2.24 (1.30) - 6.67 .000
Group Bb 3.48 (1.27) 5.60 (1.12) 2.12 (1.09) - 7.81 .000
Note. COPM-P = Canadian Occupational Performance Measure-
Performance; COPM-S = Canadian Occupational Performance Measure-
Satisfaction. an = 15. bn = 16.
- 26 -
4. Therapists’ Observation of Occupational Performance Changes
4.1. Outcomes of Assessment of Motor and Process Skills
Table 6 shows within-group changes of occupational performance over
time on AMPS. The improvement of motor and process skills was
statistically significant in both Group A and Group B after client-centered
occupational therapy.
Table 6. Within-Group Changes of Occupational Performance on AMPS
Measure and
Condition
Pretest
M (SD)
Posttest
M (SD)
Change
M (SD)
t P
(2-tailed)
AMPS-M
Group Aa 0.36 (1.09) 0.98 (1.10) 0.63 (0.68) - 3.55 .003
Group Bb 0.51 (0.69) 1.32 (0.86) 0.81 (0.58) - 5.57 .000
AMPS-P
Group Aa - 0.40 (0.76) 0.05 (0.69) 0.45 (0.43) - 4.11 .001
Group Bb - 0.57 (0.60) 0.07 (0.89) 0.64 (0.52) - 4.88 .000
Note. AMPS-M = Assessment of Motor and Process Skills-Motor skills;
AMPS-P = Assessment of Motor and Process Skills-Process skills. an = 15. bn = 16.
- 27 -
4.2. Outcomes of WeeFIM
The results of the WeeFIM scores on pre- and posttest are reported in
Table 7. Both Group A and Group B showed statistically significant
improvement of occupational performance after client-centered occupational
therapy.
Table 7. Within-Group Changes of Occupational Performance on WeeFIM
Measure and
Condition
Pretest
M (SD)
Posttest
M (SD)
Change
M (SD)
t P
(2-tailed)
WeeFIM-M
Group Aa 67.40 (14.79) 71.33 (14.70) 3.93 (3.79) - 4.02 .001
Group Bb 62.50 (13.48) 72.13 (9.77) 9.63 (9.11) - 4.23 .001
WeeFIM-C
Group Aa 16.07 (8.34) 18.33 (7.92) 2.27 (1.71) - 5.13 .000
Group Bb 17.56 (7.49) 20.13 (7.68) 2.57 (2.00) - 5.13 .000
Note. WeeFIM-M = WeeFIM-Motor skills; WeeFIM-C = WeeFIM-Cognitive
skills. an = 15. bn = 16.
- 28 -
5. Correlations Among Occupational Performance Measures
The participants in Group A showed more positive attitude toward client-
centered occupational therapy than the participants in Group B based on the
results of the Receptiveness to Client-Centered Approach Survey.
5.1. Correlations in Group A
Correlations among the sections of the COPM, AMPS, and WeeFIM
change scores in Group A are presented in Table 8. In Group A, COPM-
Satisfaction highly correlated with WeeFIM-Cognitive skills (rs = .78, p < .01),
COPM-Performance moderately correlated with AMPS-Motor skills (rs = .64,
p < .05), and COPM-Satisfaction moderately correlated with AMPS-Process
skills (rs = .62, p < .05).
- 29 -
Table 8. Spearman Rank Correlation Coefficients on Change Scores Among
COPM, AMPS, & WeeFIM in Group A (n = 15)
ΔCOPM-P ΔCOPM-S ΔAMPS-M ΔAMPS-P ΔWeeFIM-M
ΔCOPM-S .67**
ΔAMPS-M .64* .47
ΔAMPS-P .43 .62* .16
ΔWeeFIM-M .36 .48 .31 .05
ΔWeeFIM-C .50 .78** .34 .32 .47
Note. ΔCOPM-P = change scores in Canadian Occupational Performance
Measure-Performance; ΔCOPM-S = change scores in Canadian Occupational
Performance Measure-Satisfaction; ΔAMPS-M = change scores in
Assessment of Motor and Process Skills-Motor skills; ΔAMPS-P = change
scores in Assessment of Motor and Process Skills-Process skills; ΔWeeFIM-
M = change scores in WeeFIM-Motor skills; ΔWeeFIM-C = change scores in
WeeFIM-Cognitive skills.
*p < .05. **p < .01.
- 30 -
5.2. Correlations in Group B
Correlations among the sections of the COPM, AMPS, and WeeFIM
change scores in Group B are presented in Table 9. Unlike Group A, in Group
B, no relationship among the sections of the COPM, AMPS, and WeeFIM
change scores was found except between the sections of the same assessment
tools (i.e., COPM and AMPS).
Table 9. Spearman Rank Correlation Coefficients on Change Scores Among
COPM, AMPS, & WeeFIM in Group B (n = 16)
ΔCOPM-P ΔCOPM-S ΔAMPS-M ΔAMPS-P ΔWeeFIM-M
ΔCOPM-S .60*
ΔAMPS-M - .28 .05
ΔAMPS-P - .16 - .05 .62*
ΔWeeFIM-M - .02 - .14 .22 .41
ΔWeeFIM-C .10 - .13 .01 - .08 - .17
Note. ΔCOPM-P = change scores in Canadian Occupational Performance
Measure-Performance; ΔCOPM-S = change scores in Canadian Occupational
Performance Measure-Satisfaction; ΔAMPS-M = change scores in
Assessment of Motor and Process Skills-Motor skills; ΔAMPS-P = change
scores in Assessment of Motor and Process Skills-Process skills; ΔWeeFIM-
M = change scores in WeeFIM-Motor skills; ΔWeeFIM-C = change scores in
WeeFIM-Cognitive skills.
*p < .05.
- 31 -
Discussion
1. Clients’ Perspective on Client-Centered Occupational Therapy
The primary purpose of this study was to investigate the effectiveness of
client-centered occupational therapy for children from clients’ perspective
using the COPM. The focus of client-centered occupational therapy was
identifying occupational performance issues and prioritizing treatment plans
by establishing mutually agreed goals between the therapists and the clients
(caregivers of the children in this study). During the intervention phase, each
child received client-centered occupational therapy that concentrated on
improving occupational performance identified by the clients.
Following client-centered occupational therapy, both Group A and
Group B demonstrated statistically significant improvement of self-
perception in the COPM-Performance and the COPM-Satisfaction.
Explanations for this result can be, first, client-centered occupational therapy
was directed at the improvement of occupational performance skills
necessary for daily activities rather than on the impairment level such as
improving sensory or cognitive functions (Graff et al., 2003). Second, client-
centered occupational therapy program may have been carried over to home
environments through the COPM procedure. The procedure involved
establishing mutually agreed goals and educating caregivers on the focus of
- 32 -
client-centered occupational therapy in the clinics. These results were
concurrent with those reported in other studies (Case-Smith, 2003; Gagne &
Hoppes, 2003; Trombly, Radomski, Trexel, & Burnet-Smith, 2002; VanLeit
& Crowe, 2002).
- 33 -
2. Therapists’ Perspective on Client-Centered Occupational
Therapy
The secondary purpose of this study was to examine the effectiveness of
client-centered occupational therapy from therapists’ perspective using the
AMPS and the WeeFIM. Since the COPM only reflects client’s perspective
on changes of occupational performance, the AMPS and the WeeFIM, that
reflect objective perspective of the therapists, were used to verify the
usefulness of the COPM.
The AMPS is an occupational therapy-specific ADL assessment that can
be administered by calibrated occupational therapists. Its usefulness has
been supported across age groups with a variety of diagnoses (Darragh et al.,
1998; Dickerson & Fisher, 1993; Fingerhut, Madill, Darrah, Hodge, &
Warren, 2002). The WeeFIM measures functional independence in children.
The ratings can be obtained from direct observation by the therapists or from
reports from the caregivers. The responsiveness of the WeeFIM was
demonstrated in Ottenbacher et al.’s research (2000) who studied 174
children with developmental disabilities. After client-centered occupational
therapy, both Group A and Group B demonstrated statistically significant
improvement of occupational performance measured by the AMPS and the
WeeFIM. This finding supported usefulness of the COPM for children with
- 34 -
developmental disabilities. Based on the results from the COPM, the AMPS,
and the WeeFIM, it can be inferred that children with developmental
disabilities (such as mental retardation, attention deficit hyperactivity
disorder, autism, cerebral palsy, developmental delay) had made substantial
progress after client-centered occupational therapy.
Recent health care delivery system urges occupational therapists to provide
the clients with the best occupational therapy services based on the most
credible scientific evidence (Dubouloz, Egan, Vallerand, & von Zweck, 1999).
The definition of evidence-based medicine (EBM) which is a model of
evidence-based practice is “the conscientious, explicit, and judicious use of
current best evidence in making decisions about the care of individual
patients” (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, p.71). In
their revised EBM textbook, patient values were added onto the existing
definition as evidence (Sackett, Strauss, Richardson, Rosenberg, & Haynes,
2000). Therefore, new meaning of evidence-based practice is integrating client
values, clinician’s expertise, and the best available external clinical evidence
from systematic research. In this study, the COPM was used to reflect the
client values, and the AMPS and the WeeFIM were used to reflect clinician’s
expertise. The findings of this study provided external clinical evidence that
client-centered occupational therapy was effective.
- 35 -
3. Relationship Among COPM, AMPS, and WeeFIM
The tertiary purpose of this study was to explore whether the degree of
clients’ receptiveness to client-centered occupational therapy could influence
correlations between clients’ perception and therapists’ observation of
occupational performance changes.
For the purposes of this study, the participants were divided into Group A
and Group B based on the scores of the Receptiveness to Client-Centered
Approach Survey. The scores of the survey for all participants ranged from 21
to 35, and median was 29. Of the 31 participants, the top 15 participants with
the score of 30 and higher were assigned to Group A, and the bottom 16
participants with the score of 29 and lower were assigned to Group B.
Therefore, the participants in Group A showed more positive attitude toward
client-centered occupational therapy than the participants in Group B.
Moderate to good correlations were found among change scores of the
COPM, the AMPS, and the WeeFIM in Group A but not in Group B. This
finding emphasized the importance of developing therapeutic relationship
between clients and therapists (Peloquin, 1998). It further suggested that the
client had to understand and be receptive to the philosophy of the client-
centered occupational therapy in order to have perceptions on the changes of
occupational performance comparable with the occupational therapist. By the
- 36 -
same token, it is the occupational therapist’s responsibility to educate the
client about the benefits of client-centered occupational therapy which is
essential for establishing therapeutic relationship.
It was interesting to note that there was high correlation (rs = .78, p < .01)
between the change scores of the COPM-Satisfaction and those of the
WeeFIM-Cognitive skills in Group A. This correlation coefficient is much
higher than those of Donnelly and colleague’s study (2004) who reported fair
relationship between the FIM-Motor change scores and the COPM-
Performance (r = .35, p < .05) and the COPM-Satisfaction change scores (r
= .50, p < .05). This finding can be explained by the fact that the most
frequently identified clients’ goals and priorities using the COPM were
education-related tasks (52%) sharing some common elements with the
WeeFIM-Cognitive skill items. It should be noted here that while Case-
Smith’s study (2003) found the moderate correlations between the two
assessment tools that reflected the clients’ perception only, this study found
the moderate to good correlations among three assessment tools that reflect
both the clients’ and the therapists’ perspective.
One of the limitations in this study is that there was no mechanism to test
the degree of client’s understanding of the philosophy and concept of client-
centered occupational therapy prior to the intervention. In fact, the results of
- 37 -
Receptiveness to Client-Centered Approach Survey suggested that it was
relatively difficult for the clients to understand the COPM. The item scoring
the lowest score was the item number 1 which was “I found the COPM easy to
understand.” This suggested that it was unclear whether the client fully
understood client-centered occupational therapy or not. Therefore, in the
future study, the degree of understanding client-centered occupational therapy
can be used as one of the inclusion criteria in evaluating the effectiveness of
client-centered occupational therapy. For instance, the participants should be
educated on the philosophy and concept of client-centered occupational
therapy prior to the survey. Since the top 15 participants with the total score of
30 and higher on the survey were assigned to Group A in this study, the
inclusion criterion should also be 30 and higher in the future study.
Other limitation can be the rating process of the WeeFIM scores. Even
though the WeeFIM scores can be obtained through a combination of direct
observation and interview with a family member (Sperle et al., 1997), it is
preferred that the child should be assessed on the basis of what he or she
actually performs according to the WeeFIM guideline (UDSMR, 1993). Since
the most WeeFIM scores were obtained through interviews with the caregivers
in this study, objectivity of the WeeFIM may have been compromised.
- 38 -
Conclusion
The assessment tools used in this study appeared to be responsive to the
clients' progress, and the consistent findings across assessment tools confirmed
the effectiveness of client-centered occupational therapy. The important tasks
identified on the COPM showed statistically significant improvement which
were verified by the AMPS and the WeeFIM. Based on the findings that the
COPM, the AMPS, and the WeeFIM detected changes of occupational
performance in this study, these tools appear to have great promise in
measuring changes of occupational performance in children with
developmental disabilities. Moderate to high correlations were found in Group
A indicating that clients’ perception and therapists’ observation of
occupational performance changes were concurrent. In order to maximize the
usefulness of the COPM for children with developmental disabilities, the
occupational therapists should ensure that they educate the caregivers about
the benefits of client-centered occupational therapy.
- 39 -
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Appendix
The Receptiveness to Client-Centered Approach Survey
Therapist’s Name: Date:
What is Client-Centered Approach?
The client-centered approach is defined as “an approach to service which
embraces a philosophy of respect for, and partnership with, people receiving
services.” The key feature of the Canadian Occupational Performance
Measure is based on the notion that caregiver knows best about the child’s
strength and weakness because she or he spends most of the time with the
child. This assessment tool guides both the therapist and the client to
identify the problems and priorities, and to establish mutually agreed goals.
Through these procedures the client can expect concrete effects of
occupational therapy and evaluate them, and the therapist can prioritize the
target occupational performance for effective and efficient occupational
therapy.
Client Information
Client ID #:
Child’ Age: Child’s Gender:
Diagnosis:
- 50 -
Please respond to Each Statement by Circling the Most Appropriate
Answer
1. I found the COPM easy to understand.
5) Strongly Agree 4) Agree 3) Neutral 2) Disagree 1) Strongly
Disagree
2. I found the COPM helpful.
5) Strongly Agree 4) Agree 3) Neutral 2) Disagree 1) Strongly
Disagree
3. The COPM helped me to identify current worries about my child’s health.
5) Strongly Agree 4) Agree 3) Neutral 2) Disagree 1) Strongly
Disagree
4. I felt comfortable helping the therapist plan my child’s treatment.
5) Strongly Agree 4) Agree 3) Neutral 2) Disagree 1) Strongly
Disagree
- 51 -
5. The COPM allowed me to feel respected and valued as an equal partner in
my child’s treatment.
5) Strongly Agree 4) Agree 3) Neutral 2) Disagree 1) Strongly
Disagree
6. I believe that a client is comfortable taking on responsibility for treatment
goals within Korean culture.
5) Strongly Agree 4) Agree 3) Neutral 2) Disagree 1) Strongly
Disagree
7. I believe that the COPM is an appropriate and effective tool in Korean
culture.
5) Strongly Agree 4) Agree 3) Neutral 2) Disagree 1) Strongly
Disagree
- 52 -
국국국국 문문문문 요요요요 약약약약
발달장애아동을발달장애아동을발달장애아동을발달장애아동을 위한위한위한위한
클라이언트중심의클라이언트중심의클라이언트중심의클라이언트중심의 작업치료프로그램을작업치료프로그램을작업치료프로그램을작업치료프로그램을 실시하는데실시하는데실시하는데실시하는데 있어서있어서있어서있어서
캐나다작업수행측정캐나다작업수행측정캐나다작업수행측정캐나다작업수행측정 (COPM) (COPM) (COPM) (COPM)의의의의 유용성유용성유용성유용성
연세대학교 대학원
재활학과(작업치료학 전공)
강 대 혁
본 연구의 목적은 첫째, 발달장애 아동들을 위한 클라이언트중
심의 작업치료 효과를 캐나다작업수행측정(COPM)을 통해 클라이
언트의 관점에서 측정하고, 둘째, 그 효과를 측정한 캐나다작업수
행측정의 유용성을 운동처리기술평가(AMPS)와 소아일상생활능력
측정(WeeFIM)을 통해 작업치료사의 관점에서 검증하고, 셋째, 클
라이언트중심의 작업치료에 대한 수용도에 따라 작업수행에 대한
클라이언트의 주관적인 평가(COPM)와 작업치료사의 객관적인 평
가(AMPS, WeeFIM)간의 상관관계가 유의한 차이를 보이는지 알
아보고자 하였다. 만 3세에서 10세 사이의 발달장애아동 31명을
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대상으로 재활병원 또는 지역사회 아동발달 센터에서 20-24회에
걸쳐 클라이언트중심의 작업치료 프로그램을 실시하였다. 본 연구
의 목적을 위하여 캐나다작업수행측정의 초기 평가 후 보호자를
대상으로 클라이언트중심의 작업치료에 대한 수용도 설문조사를
실시하였다. 합계 점수 기준으로 상위 15명은 수용도가 높은 그룹
(Group A)으로, 하위 16명은 수용도가 낮은 그룹 (Group B)으로
분류하였다.
짝비교 t-검정(paired t-test)을 통해 클라이언트중심의 작업
치료 전과 후의 세 가지 평가 도구 (COPM, AMPS, WeeFIM) 점
수변화를 비교한 결과, 클라이언트중심의 작업치료에 대한 수용도
가 높은 그룹과 낮은 그룹 모두에서 통계적으로 유의한 작업수행
의 향상을 보였다 (p < .01). 스피어맨 순위상관계수(Spearman
Rank Correlation Coefficient)를 이용하여 상관관계를 알아 본 결
과, 클라이언트중심의 작업치료에 대한 수용도가 높은 그룹에서 캐
나다작업수행측정-만족도(COPM-S)와 소아일상생활능력측정-인
지기술(WeeFIM-C) (rs = .78, p < .01), 캐나다작업수행측정-수
행도(COPM-P)와 운동처리기술평가-운동기술(AMPS-M) (rs
= .64, p < .05), 캐나다작업수행측정-만족도(COPM-S)와 운동
처리기술평가-처리기술(AMPS-P) (rs = .62, p < .05) 영역 사이
에서 양호한 양의 상관관계를 보인 반면, 수용성이 낮은 그룹에서
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는 상관관계가 나타나지 않았다. 본 연구결과를 근거로 다음과 같
은 결론을 내릴 수 있다. 첫째, 발달장애 아동들을 위한 클라이언
트중심의 작업치료프로그램 효과를 COPM을 통해 클라이언트의
관점에서 확인하였고, 둘째, COPM의 유용성이 객관적인 평가도구
인 AMPS와 WeeFIM을 통해 검증되었고, 셋째, 클라이언트중심의
작업치료에 대한 수용도가 높은 그룹에서 작업수행의 변화에 대한
클라이언트의 평가와 작업치료사의 평가가 일치하는 경향을 보였
다. 따라서 발달장애 아동들을 대상으로 COPM의 유용성을 극대화
하기 위해서는 클라이언트중심의 작업치료의 장점에 대한 보다 적
극적인 보호자 교육이 요구된다고 하겠다.
핵심되는 말 : 작업치료, 클라이언트 중심접근, AMPS, COPM.