Michael is an 8-year old boy, who has been referred to OT by his teacher, because he has difficulty with math, printing, and following classroom routines. He is often distracted, and therefore seems out of step with the class and with his classmates. He exhibits clumsiness in his daily activities, struggles with Physical Education classes, and tends to be isolated on the playground.
The first issue that arises is the legitimacy of the child’s viewpoint as a reliable informant on his own occupational performance and problems. Some would challenge the ability of a child to report with a suitable level of reliability and validity on the problems that will form the basis for the therapeutic relationship. This issue goes to the heart of the client-centred approach, which is the basis of the COPM. The client-centred approach takes as its basic assumption the primacy of the client’s perspective in identifying the issues that are the focus of therapy. Thus, having the client’s perspective is fundamentally important.
Arguably, very young children are not capable of self-evaluating and reporting problems. It is often assumed that young children are not capable of self-assessment, however, recent research is questioning that assumption (Missiuna & Pollock, 2000). While it is true that young children may not be capable of highly abstract processes, the difficulty may rest with the methods used to elicit their input, rather than with the child’s ability to self-evaluate. Curtin (2001) notes “Though occupational therapists tend to be skilled at giving children a voice in treatment activities, involving children in defining the purpose of therapy is more challenging.” (p. 301).
At the root of this issue is the definition of “client”. For the COPM, the client is not necessarily the person whose name is on the referral for occupational therapy, but rather the person who seeks to change his or her occupational performance. In this instance, it is the child, Michael, who is expected to work toward change, therefore he must be considered the client. That means that his perception of the problems and his agenda must govern the therapeutic approach, within a client-centred relationship.
Imagine, on the other hand, that Michael was an infant of 9 months, whose parents were worried about his development. Then we might construe the parents as the clients, since they are the ones who are seeking to make a change, and indicating a willingness to alter their own occupation to afford more enriching developmental opportunities for their baby. It is difficult to imagine a client-centred relationship with a baby, since the process depends so heavily on the direction of the client.
A second issue in using the COPM with children is the possible inclusion of other key stakeholders as informants in the assessment process. For example, parents and teachers are often pivotal players in the therapeutic process of a child, and will undoubtedly have issues and ideas that they wish to have considered. It is important in this instance to be clear that they are not necessarily clients, since it is still Michael’s occupational performance that is the focus of assessment and therapy. However they may have important information to contribute to our understanding of Michael’s context. Therapists have told us of instances where they have completed the COPM independently with the client/child, with his or her parents, and with the teacher, and found significantly different problems identified on all three forms. This then calls for a meeting to reconcile perspectives and to set a therapeutic agenda in which all can invest and participate. The enhanced understanding among stakeholders achieved using the COPM in a process like this can be a therapeutic success in itself, to say nothing of the improved cooperation that is sure to ensue when all stakeholders feel they have been heard and given an opportunity to influence the process of therapy.
For the very ambitious therapist in this situation, it is possible to nominate all three stakeholders as clients, if time and resources permit. This broadens the therapeutic focus to include the occupational performance of all three, and makes it appropriate to expect occupational change in all three in order to improve the overall situation. In this instance, each completes the COPM from his or her own perspective, reflecting the occupational changes that he or she would like to make. Presumably in the parents’ case, this would involve changes in the parenting role; in the teacher’s case, it would involve changes in the way she meets her professional role expectations; and in the case of Michael, it would involve changes in his school behaviour and perhaps also his occupation at home.
A third issue in using the COPM with children is the possible need to modify the interviewing approach, the language of the assessment or the scoring system to accommodate the child’s developmental level and ability to deal with abstract concepts. An experienced pediatric therapist would tell us that these kinds of developmental adaptations are second-nature, however, for the uninitiated, it may be important to think through strategies for communicating more effectively with child clients on the COPM. In a review of self-report assessments used with children, Sturgess, Rodger & Ozanne (2002) identified several instruments that are valid and reliable when used with children as young as 4 years of age. Careful attention to the language used in the questions, the addition of concrete stimuli such a s pictures, the clarity of response options and the context for the assessment can improve the validity of the results. As an example, one therapist told us how she modified the scoring cards to show happy and sad faces on the extremes of the scoring continua, in place of the words that are currently there.
Finally, on a similar note, it is essential to take account of developmental issues when assessing children with the COPM, as it is with any other measure. Further, it may be necessary to supplement the COPM with commonly used and recognized developmental assessments, in order to ensure the developmental appropriateness of problems identified and therapeutic challenges offered.