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Therapeutic Strategies to Help Children with Executive Functioning Difficulties

By Jenny L. Clark, OTR/L

on February 15, 2022

Categories: Occupational Therapy , Pediatrics

Executive functions (EF) are a set of cognitive skills required for self-regulation and are comprised of skills such as working memory, self-control, and mental flexibility. Children who struggle with executive functioning often have low self-esteem and feel like they are failing in daily activities at home and school.

As therapists, we must support a child’s confidence through therapeutic interventions that address these essential skills. The interventions we use should be targeted to build on the child’s strengths, and help them identify what they enjoy doing to help them grow their EF skills so they can flourish at home and school.

The Role of Executive Functioning Skills

EF skills play an essential role in children’s everyday life by enabling them to remember daily self-care routines, learn in school, and socially engage with friends. Children are not born with EF skills, but rather develop these through experience and practice, as they grow from infancy through early adulthood. Studies show that children with attention deficit hyperactivity disorder (ADHD) and children with sensory processing disorder (SPD) experience more challenges with executive functioning than typically developing children. 1,2

Real-world difficulties with executive functioning might look like:

• Problems with perseverance & initiating or completing tasks
• Difficulty maintaining focus
• Poor time management
• Disorganization
• Challenges with following directions and/or sequencing
• Decreased self-regulation

Exploring Therapeutic Interventions for Executive Functioning

A variety of interventions can be implemented into therapy practice to help facilitate EF skills while also working on a child’s foundational motor and sensory skills. Consider integrating board games into your practice. Board games are excellent tools to aid in the development of fine motor skills, social skills, turn-taking, as well as important EF skills.

Different board games address different skill sets in the following ways:

• Strategic board games develop problem-solving skills
• Chess develops focusing skills
• Spelling board games develop planning and organizing skills
• Games with timers develop time management skills
• Block games develop sequencing skills

Some common therapy activities you may already utilize in your practice, such as puzzles and crafts, can easily be used to work on EF skills.

Therapy activities can be employed to develop different executive functioning skills in the following ways:

• Crafts develop flexibility skills, as well as the ability to initiate and complete tasks
• Puzzles develop problem-solving and perseverance skills
• Card games (such as “Memory” and “Go Fish”) develop the working memory
• “Find the Hidden Picture” activities develop working memory and prioritization skills
• “Color-by-Number” activities develop focus and organization skills

Both EF skills and self-regulation skills depend on three types of brain function: working memory, mental flexibility, and self-control. These functions are highly interrelated, and the successful application of executive function skills requires them to operate in coordination with each other. 3 Helping children develop self-regulation by teaching them sensory strategies is vital to enriching EF skills.

The following strategies can be used to promote both sensory self-regulation and executive functioning skills:

• Deep relaxation breathing techniques
• Progressive muscle relaxation
• Physical activity
• Exposure to nature

The Connection Between Executive Functioning Skills and School Success

Children are dependent upon EF skills to achieve academic success in school. 4 They help children remember and follow multi-step instructions, avoid distractions, control rash responses, adjust when rules change, persist at problem-solving, and manage long-term assignments.

There are a variety of effective school accommodations and modifications that can help students who struggle with EF, such as:

• Breaking tasks down into small steps for sequencing
• Simplifying instructions for perseverance
• Providing color-coded binders for organization
• Allowing the student to get up and move to help with focus
• Using a visual timer for time management

Explore which strategies work best for each student and the environment in which they learn.

To learn more about working with children that struggle with executive functioning, particularly those with ADHD and SPD, I offer this course for pediatric occupational therapists that will help you identify executive functioning skill deficits and learn how to implement practical takeaway strategies to help children and youth with success in childhood occupations.

Jenny L. Clark, OTR/L

Jenny L. Clark, OTR/L, BCP (AOTA-board certification in pediatrics), has helped children over the past 25 years as a licensed pediatric occupational therapist working as a speaker, consultant, private practitioner at her own clinic (Jenny’s Kids, Inc.), school-based occupational therapist, independent contractor for early intervention services, author, and inventor. Her Sensory Processing Disorder Kit: Simulations and Solutions for Parents, Teachers, and Therapists (AAPC 2006) won the 2007 media in excellence video award from the Autism Society of America.

• Brown, T., Swayne, E., & Mármol, J. M. P. (2021, January 31). The relationship between children's sensory processing and executive functions: An exploratory study . Taylor & Francis. Retrieved February 23, 2022, from https://www.tandfonline.com/doi/full/10.1080/19411243.2021.1875386?scroll=top&needAccess=true
• El Wafa, H.E.A., Ghobashy, S.A.E.L. & Hamza, A.M. A comparative study of executive functions among children with attention deficit and hyperactivity disorder and those with learning disabilities.  Middle East Curr Psychiatry   27,  64 (2020). https://doi.org/10.1186/s43045-020-00071-8
• Harvard University. (2019, February 22). A guide to executive function . Center on the Developing Child . Retrieved February 15, 2022, from https://developingchild.harvard.edu/guide/a-guide-to-executive-function/
• Cortés Pascual, A., Moyano Muñoz, N., & Quílez Robres, A. (2019). The relationship between executive functions and academic performance in primary education: Review and meta-analysis. Frontiers in Psychology , 10 . https://doi.org/10.3389/fpsyg.2019.01582

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03/08/2021 by Jessica Szklut. Hi, I am an occupational therapist at South Shore Therapies. I specialize in pediatirc brain injury and stroke, but love working with all families to help kids reach their optimal potential. Our mission with SST's social media platform is to empower, educate and inspire families to take on life’s challenges while promoting an optimistic outlook and a brighter future. If you want to read more about us, visit www.southshoretherapies.com 0 Comments

Executive Functioning in Kids: Here’s How We Can Help (From Your Occupational Therapist)

Executive function is a set of mental skills that our children use every day to actively engage in daily like skills, learn, and play. Executive function is responsible for your child’s ability to sustain attention, organize and plan, initiate and complete, problem solve, and regulate emotions. There are many different ways to address breakdowns with executive functioning skills. Your therapy team works together to address ‘the whole child’ so they can perform at their best. Check out some ways in which occupational therapy can focus on improving your child’s executive functioning skills.

What are executive functioning skills?

Think of executive function as the CEO of the brain, controlling all the skills required to plan, execute, and complete tasks and projects. These skills can be divided into the broad areas of working memory, flexible thinking, and inhibitory control. When executive function is impaired, children may display difficulty with initiating tasks, memory, organization, planning, time management, emotional control, understanding the perspectives of others, and paying attention.

Many children tend to be disorganized and distracted at times, but those who are struggling with executive function may take a very long time to get dressed, pack a bag for school, and perform simple chores. Executive function disorder is common among children who are diagnosed with attention-deficit/hyperactivity disorder (ADHD).

Occupational and Speech Therapy can help your child whom is struggling with executive functioning deficits. 

5 ways occupational therapy Addresses executive functioning skills:

1.     motor planning/sequencing:.

• Motor planning  – or praxis - refers to the ability to ideate, plan, and execute a novel motor action/sequence while simultaneously making the necessary adjustments for safety and efficiency. We use motor planning for all physical activities – everything from every day tasks like brushing teeth or hand washing, to moving around your environment or playing with peers. Kids who struggle with motor planning often take longer to learn new tasks, have difficulties sequencing and completing everyday tasks, and often are unable to recall from previous experiences in order to execute a task more effectively.
• How does OT address motor planning deficits?  Well through play! Providing a multisensory environment that encourages a child to engage with a variety of equipment/activities in novel ways helps foundationally allow the child to build praxis skills. Through play we promote development of initiation and refinement of sequencing skills and with repetition can encourage motor tasks to become more automatic for the child. We love to make obstacle courses and other movement challenges with multi-steps, engaging in multistep crafts/art projects, learning new games, and cooking/baking activities.
• Learn more about motor planning HERE :

2.     Problem Solving:

• A natural adaptive skill we often take for granted is our ability to draw from past experiences, in combination with our assessment of current situation, in order to determine the best way to approach a task in order to be successful - this is called problem solving . The age old quote “If at first you don’t succeed, try try again” is great for those children whom have foundational motor planning and problem solving skills, but can be quite difficult for children with breakdowns in these areas - because for these individuals, trying again will result in the same failure over and over unless due to difficulties with feedforward and feedback needed to problem solve and adapt their approach. 
• How can OT assist with development of problem solving skills? Using the suspension equipment and various swings allows your kids to naturally find themselves in situations where problem solving is required- how do I climb on this swing? How can I throw at this target without falling? Activities like the floor is lava is often a fan favorite – having your child setup equipment to get from point A to B without touching the floor. In addition, playing games and activities can also promote development of problem solving skills. Games like Rush Hour,  Suduku, or Tangrams are great ways to promote critical thinking, planning and problem solving. Using the just right challenge in a controlled environment allows us to teach your child how to objectively assess the situation, actually change their approach, and ultimately be successful with the task at hand. In turn, we can help promote and develop self esteem and confidence for your child to carry with them each and every day!

3.     Emotional Regulation and Interception:

• We feel emotions – both negative and positive – every single day. It is important that children learn how to manage, express and cope with these emotions in a healthy way – this is called emotional regulation. Interception is a sense that provides information about the internal condition of our body – how our body is feeling on the inside. Awareness of these body sensations allow us to experience essential emotions; everything from hunger or pain to sadness or anger. However development of interception and foundational emotional regulation  can be an area of challenge for many of our kids. Tantrums or meltdowns may be a common occurrence at home for kid with difficulties with emotional regulation.
• How can OT can help with emotional regulation? OT can help with your child’s ability to identify emotions, teach and support proper responses in situation of heightened emotions, help your child answer the question ‘how do I feel?” and most importantly teach strategies that your child can use to manage these emotions. Using programs like Zones of Regulation and The Alert Program take a cognitive approach to teaching emotional regulation. Role playing can help simulate and prepare for real time scenarios. And of course, using equipment, games and activities allow for opportunities to learn about different emotions, build interception and body awareness, and develop strategies to manage emotions.

4.     Organization:

• Organization  is the thinking skills that helps you put things into order, find your stuff, , gather supplies to start a tasks and complete everyday tasks efficiently and effectively. Getting organized can help make life easier and help kids with learning and thinking. Does your child have a hard time remembering where they put their toys? Do they have a hard time finding things in their backpack? Does your child struggle to get ready in the morning? Does your child always push back when it comes to writing assignments? This can be as a result of disorganization. 
• How can OT help with organization?  We can help your child develop strategies, implement systems and create aides (visual schedules, check lists, etc) to promote independence and success across environments. 
• Learn more about organization HERE :

5.     Memory:

• Working memory  is a cognitive process that is important for reasoning and plays a direct role in decision making and behavior.  Visual memory  is the ability to remember or recall visual input – such as words or images. Deficits with memory can impact yourchild’s ability to sustain attention follow multistep directions, independently engage in daily life skills, and can impact reading and writing skills.
• How does OT address difficulties with memory?   Through different games, visual perceptual activities and challenges. Choosing games such as Let's Go To The Market, Clue, Memory Match and other board games require working memory for success. Activities like Take a Picture with your Mind, Burgermania, or Pancake Pile Up promote development of visual perceptual and visual memory skills. Teaching strategies for improved memory and recall is another way OT can help your kids be more successful.

If your child is showing signs of executive function disorder, we are here to help.

Remember, just because your child may be struggling it does not mean they are incapable of accomplishing anything they put their mind to. Through education, practice, and strategies, you can support your child to meet their optimal potential.

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ADHD and Executive Functioning

How Occupational Therapy Can Help Your Child’s Executive Functioning

Learn about how your child could be struggling with their executive functioning and how Occupational Therapy can help them.

Think about an executive of a company: They have to plan out how resources of the company will be used, decide what the priorities are and in what direction to take them, and make decisions on what to do when there is conflicting information. All of these skills are established through what we call our Executive Functioning . To be able to do these everyday tasks in adult life, we must be able to develop and foster the cognitive skills required for executive functioning as a child.

What are executive functioning skills?

Put simply, they are cognitive skills that are used to execute a task. They help us to plan, organise, make decisions, shift between situations or thoughts, control our emotions and impulsivity, and learn from past mistakes. Kids rely on their executive functions for everything from packing a backpack to handwriting and picking priorities.

Children who have poor executive functioning are more disorganised than other kids. They might take an extremely long time just to get dressed or become overwhelmed while doing simple chores around the house. Their schoolwork can become a nightmare because they regularly lose papers or start week-long assignments the night before they are due. (Sound familiar?!)

How can OTs help?

Executive functioning skills are learned by the child, and some children need more modelling and assistance than others. Occupational Therapists can help by providing the right guidance to allow these skills to emerge along with their developmental milestones. Since executive functioning skills are used across a variety of contexts, it’s important for OTs to collaborate with your child’s teacher so that learning opportunities are able to be maximised through scaffolded and systematic instructional approaches.

Skill areas an OT may work with your child on include:

• Flexible thinking:  Switching approach to a task, considering new ideas or strategies, making choices and decisions, maintaining social interaction

Strategies an OT may use to foster executive functioning skills include:

• Using visual timers and checklists to assist with time management and multitasking/prioritising.
• Goal setting:   Teaching kids to sketch out what an assignment will look like when it is completed to help identify where to start, what components are needed, and what the assignment will look like when it is finished.

Of course, it’s important to keep in mind that not one size fits all, and so although one child might have difficulty initiating a task but be a good problem solver, another might find organising their school items quite a challenge. OTs help to pinpoint the skill area(s) that your child has challenges with and develop the relevant strategies during therapy. We provide the structure children need to be successful, but also find the ‘ just right challenge’ so that natural learning opportunities can arise.

If you think your child needs help with their executive functioning, please talk to our team by emailing us or calling our head office .

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Exploring the Benefits of Pediatric Occupational Therapy

July 25, 2023 by FOKP

Pediatric occupational therapy is a specialized branch of therapy designed to help children develop the skills needed for daily life activities – both now and in the future. By addressing challenges in sensory processing, fine motor skills, and more, occupational therapy aims to empower children to reach their full potential.

In this blog, we’ll explore what pediatric occupational therapy entails, how it aids children in their development, and the numerous benefits it offers for both kids and parents.

Understanding Pediatric Occupational Therapy

Pediatric occupational therapy focuses on enabling children to participate in activities that are crucial for their growth and independence.

Occupational therapists work with children to enhance skills related to self-care, play, school tasks, and social interactions. These therapists assess individual strengths and challenges to create tailored interventions that promote a child’s physical, cognitive, and emotional development.

Reasons Your Child May Need Pediatric Occupational Therapy

There are many reasons that your child may need occupational therapy, including:

• Developmental Delays
• Autism Spectrum Disorder
• Sensory Processing Disorders
• Traumatic Injuries
• Birth Injuries or Defects
• Chronic Illnesses such as cerebral palsy, multiple sclerosis, or cancer
• Learning Difficulties
• Physical Disabilities
• Attention Deficit Hyper Activity Disorder (ADHD)
• Mental Health or Behavioural Problems
• Orthopedic Injuries

How Pediatric Occupational Therapy Helps Kids

• Fine Motor Skills Development: Occupational therapists help children refine fine motor skills like grasping objects, using utensils, and handwriting. These skills are vital for tasks such as dressing, writing, cutting, tying shoelaces, and using a keyboard.
• Sensory Processing: Children with sensory processing difficulties receive support to manage sensory sensitivities or overstimulation. Occupational therapy interventions help them better process and respond to sensory stimuli such as loud noises, bright lights, and how clothing feels on their skin.
• Gross Motor Skills Improvement: Occupational therapists aid children in enhancing gross motor skills, which are essential for activities like running, jumping, and maintaining balance. These skills contribute to their overall physical coordination and confidence.
• Self-Care Independence: Children with challenges in self-care activities like dressing, bathing, and grooming can benefit from occupational therapy. Therapy sessions target these tasks so they can create a routine and the skills they need to develop a greater level of independence.
• Cognitive and Problem: Solving Abilities: Pediatric occupational therapy engages children in activities that enhance cognitive skills, including problem-solving, planning, and decision-making. These skills are transferable to academic, professional, and everyday situations.

Benefits for Kids

• Enhanced Confidence and Self-Esteem: As children master new skills through occupational therapy, their confidence and self-esteem naturally grow. These achievements foster a positive self-image that carries into various aspects of their lives.
• Improved Social Interaction: Children learn to navigate social situations, make friends, and collaborate effectively using group activities that encourage social interaction and cooperation.
• Successful Transition to School: Occupational therapy prepares children for school by addressing skills like fine motor coordination, attention span, and following instructions. This enables a much smoother transition for the child once they start schooling.
• Empowerment for Special Needs: Children with developmental delays or conditions like autism spectrum disorder benefit from tailored interventions. Occupational therapists create strategies that empower children to engage actively in life in a way that works for the child!

Benefits for Parents

• Guidance and Education: Parents receive valuable guidance on supporting their child’s development at home. Occupational therapists educate parents on activities and strategies to reinforce therapy progress outside of sessions, making it easier for new habits to form, which will help your child grow more confident.
• Stress Reduction: Parents of children with developmental challenges often experience stress. Occupational therapy provides a support system where parents can share concerns, learn coping strategies, and celebrate milestones. The occupational therapist will work alongside you to create strategies and routines that work for your family.
• Increased Understanding: Through occupational therapy, parents gain insight into their child’s strengths, challenges, and preferred learning styles. This deeper understanding fosters effective communication, connection, and routines that reduce stress and frustrations.
• Inclusion in Therapy: In many cases, parents are actively involved in therapy sessions, allowing them to witness their child’s progress firsthand. This involvement enhances the parent-child bond and creates a collaborative approach to therapy.

Getting The Support You and Your Child Needs

Pediatric occupational therapy empowers children to overcome challenges and thrive. By targeting essential skills, improving self-confidence, and fostering independence, occupational therapy sets the stage for a brighter future.

If you have concerns about your child’s development at any age, then schedule an appointment to speak with your child’s pediatrician . They will be able to assess your child, identify any issues, and refer you to an occupational therapist.

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Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review

1 Cerebral Palsy Alliance, Discipline of Child and Adolescent Health, The University of Sydney, Camperdown North South Wales, Australia

Associated Data

Introduction.

Paediatric occupational therapy seeks to improve children's engagement and participation in life roles. A wide variety of intervention approaches exist. Our aim was to summarise the best‐available intervention evidence for children with disabilities, to assist families and therapists choose effective care.

We conducted a systematic review (SR) using the Cochrane methodology, and reported findings according to PRISMA. CINAHL, Cochrane Library, MEDLINE, OTSeeker, PEDro, PsycINFO were searched. Two independent reviewers: (i) determined whether studies met inclusion: SR or randomised controlled trial (RCT); an occupational therapy intervention for children with a disability; (ii) categorised interventions based on name, core components and diagnostic population; (iii) rated quality of evidence and determined the strength of recommendation using GRADE criteria; and (iv) made recommendations using the Evidence Alert Traffic Light System.

129 articles met inclusion ( n  = 75 (58%) SRs; n  = 54 (42%)) RCTs, measuring the effectiveness of 52 interventions, across 22 diagnoses, enabling analysis of 135 intervention indications. Thirty percent of the indications assessed ( n  = 40/135) were graded ‘do it’ (Green Go); 56% (75/135) ‘probably do it’ (Yellow Measure); 10% ( n  = 14/135) ‘probably don't do it’ (Yellow Measure); and 4% ( n  = 6/135) ‘don't do it’ (Red Stop). Green lights were: Behavioural Interventions; Bimanual; Coaching; Cognitive Cog‐Fun & CAPS; CO‐OP; CIMT; CIMT plus Bimanual; Context‐Focused; Ditto; Early Intervention (ABA, Developmental Care); Family Centred Care; Feeding interventions; Goal Directed Training; Handwriting Task‐Specific Practice; Home Programs; Joint Attention; Mental Health Interventions; occupational therapy after toxin; Kinesiotape; Pain Management; Parent Education; PECS; Positioning; Pressure Care; Social Skills Training; Treadmill Training and Weight Loss ‘Mighty Moves’.

Evidence supports 40 intervention indications, with the greatest number at the activities‐level of the International Classification of Function. Yellow light interventions should be accompanied by a sensitive outcome measure to monitor progress and red light interventions could be discontinued because effective alternatives existed.

Occupational therapy intervention for children promotes engagement and participation in children's daily life roles (Mandich & Rodger, 2006 ). Children's roles include, developing personal independence, becoming productive and participating in play or leisure pursuits (Roger et al .). Inability to participate because of disease, disability or skill deficits, can cause marginalisation, social isolation and lowered self‐esteem (Mandich & Rodger, 2006 ). Occupational therapists select interventions for children based upon an analysis of the child's performance of daily life roles, how their performance is affected by their disability, and how their environment supports or constrains their performance (Mandich & Rodger, 2006 ).

The practices of paediatric occupational therapists have evolved and changed based on research and theory (Rodger, Brown & Brown, 2005 ), such as family centred care and the World Health Organisation's (WHO) International Classification of Functioning, Disability and Health (ICF; World Health Organisation, 2001 ). These frameworks have led many occupational therapists to move away from impairment‐based interventions at the body structures and functions level aimed at remediating the child's deficits (known as ‘bottom‐up’ interventions), and instead to focus on improving functional activity performance and participation (‘top‐down’ interventions) (Weinstock‐Zlotnick & Hinojosa, 2004 ), as well as partnering with parents to deliver therapy embedded within daily life.

Clinicians will always have different expertise and preferences, but there are financial and ethical ramifications of delivering interventions. Ensuring the latest research findings are easily accessible to families and clinicians is vital. Occupational therapists positively embrace evidence‐based practice, but on the ground, implementation can lag (Flores‐Mateo & Argimon, 2007 ; Upton, Stephens, Williams & Scurlock‐Evans, 2014 ). Systematic reviews (SR) indicate that the translation of the latest evidence into routine clinical care lags 10–20 years in all countries and specialities ( Flores‐Mateo & Argimon ), which for paediatric patients is an entire childhood. Multiple paediatric occupational therapy interventions exist to address children's specific goals. In partnership with parents, it is the therapist's role to choose and tailor the intervention choices to match the child and parent's goals, preferences and potential for improvement based upon their diagnosis. Staying up‐to‐date is time‐consuming. Furthermore, appraising evidence and up skilling in new interventions requires reallocation of time and resources.

The aim of this paper is to systematically describe current intervention options available to paediatric occupational therapists across different child diagnostic populations, rating the quality and recommendations for use of each intervention, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system (Guyatt et al ., 2008 ) and the Evidence Alert Traffic Light System (Novak & McIntyre, 2010 ). The purpose of reviewing and rating the entire evidence‐base is to provide a ‘one‐stop’ access guide for clinicians and policy‐makers, allow for the easy comparison of interventions, encourage the uptake of evidence‐based interventions, to confer better outcomes for children. We sought to answer the following ‘PICOs’ question: What is the effectiveness of occupational therapy intervention for children with disabilities? P opulation = children with a disability (including arthrogyposis OR attention deficit hyperactivity disorder OR autism spectrum disorder OR behaviour disorders OR brachial plexus OR brain injury OR burns OR cerebral palsy OR cancer OR chronic pain OR developmental coordination disorder OR developmental disability OR down syndrome OR fetal alcohol spectrum disorder OR learning disability OR mental health OR muscle diseases; OR intellectual disability OR obesity OR preterm infants OR physical disability OR rheumatoid arthritis OR spina bifida); I ntervention = occupational therapy (including all specific named occupational therapy techniques); C omparison = none specified; O utcome = all outcomes accepted; and S tudy Design = SR OR randomised controlled trials (RCTs).

Study design

A SR of reviews was conducted, to provide an overview of the best available evidence. RCTs not included within the SRs were also appraised.

Search strategy

This review was carried out according to the Cochrane Collaboration methodology (Higgins & Green, 2011 ), incorporating the recommended quality features for conducting SRs of reviews (Smith, Devane, Begley & Clarke, 2011 ), and is reported according to the PRISMA statement (Moher, Liberati, Tetzlaff & Altman, 2010 ). Relevant articles were identified by searching: CINAHL (1983–2016); Cochrane Database of Systematic Reviews ( http://www.cochrane.org ); Database of Reviews of Effectiveness (DARE); EMBASE (1980–2016); ERIC; Google Scholar; MEDLINE (1956–2014); OTSeeker ( http://www.otseeker.com ); and PsycINFO (1935–2016). Searches were supplemented by hand searching and retrieval of any additional articles meeting eligibility criteria that were cited in reference lists. The search of all published studies was performed in March 2014 and updated in August 2018. Interventions and keywords for investigation were identified using the contributing authors’ knowledge.

Inclusion criteria

Published studies fulfilling the following criteria were included: (i) Type of study: All SRs and RCTs meeting inclusion criteria were appraised. SRs were preferentially sought since they provide a summary of large bodies of evidence and help to explain differences amongst studies. Plus, SRs limit bias. We also included RCTs not included within the SRs, because they are the gold standard design for measuring the effectiveness of interventions. Lower levels of evidence were only included if: the SR reviewed lower levels of evidence; (ii) Types of interventions: Studies that involved the provision of any type of occupational therapy intervention; and (iii) Types of participants: Studies that explicitly involved humans in which 100% of the participants were children of any childhood disability diagnosis.

Exclusion criteria

(i) Studies about typically developing children or adults; (ii) diagnostic studies OR prognostic studies OR about outcome measure psychometrics OR about theoretical frameworks NOT intervention; (iii) interventions that primarily fall under the skillset of another profession, for example pharmacotherapies, psychotherapy, speech therapies, etc. (iv) a second publication of the same study (Note: RCTs that met inclusion criteria but were also cited within included SRs, were treated as duplicates and not reported on twice); (v) studies were unpublished or non‐peer reviewed; and (vi) full‐text was not available in English.

Data abstraction

A data abstraction form was devised based on the Cochrane's recommendations (Higgins & Green, 2011 ). Abstracts identified from searches were screened by two independent raters. Both independent raters reviewed full‐text versions of the articles and articles were retained if they met inclusion criteria. Agreement on inclusion and exclusion assignment was unanimous. Data extracted from included studies comprised: authors and date of study; type of intervention (if named), core components and diagnostic population; who delivered the intervention; location of where the intervention was carried out; intensity of the intervention; study design and original authors’ conclusions about efficacy across study outcomes (Table  S1 ). In addition, based on intervention description and ICF definitions, reviewers assigned an ICF domain to each intervention outcome sought by study authors (World Health Organisation, 2001 ). Where multiple SRs or RCTs existed, we noted when the older research was superseded by newer evidence. Interventions with the same name and/or similar core components, and that were administered to the same diagnostic populations, were grouped together. All data required to answer the study questions were published within the papers, so no contact with authors was necessary. All the supporting data are included with Table  S1 .

Quality of the evidence

Quality ratings were assigned by two independent raters for each publication using GRADE (Guyatt et al ., 2008 ), which is endorsed by the World Health Organization. Within GRADE randomised trials are initially rated high, observational studies low; and other levels of evidence very low. However, high quality evidence is downgraded if methodological flaws exist, and low quality evidence is upgraded when high rigor and large effect sizes exist ( Guyatt et al . ). Ultimately, a high score indicates ‘further research is unlikely to change our confidence in the estimate of effect’; moderate scores indicate ‘further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate’; low scores indicate ‘further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate’; and very low scores indicate ‘any estimate of effect is very uncertain’ ( Guyatt et al . ).

Strength of recommendation

Unlike SR frameworks, the GRADE framework does not solely examine effect size to determine efficacy of intervention. Instead, effect size makes up just one component when weighing up the benefits and harms of each intervention. In line with the GRADE framework, the following factors were considered by both independent raters when evaluating the body of evidence for the intervention and arriving at a strength of recommendation for each diagnostic group: (i) methodological quality regarding likely benefits vs. likely risks; (ii) inconvenience; (iii) importance of the outcome that the intervention prevents; (iv) magnitude of intervention effect (effect size); (v) precision of estimate of effect; (vi) burdens; (vii) costs; and (viii) varying clinician and family values (Guyatt et al ., 2008 ).

The Evidence Alert Traffic Light System (Novak & McIntyre, 2010 ) was then applied based on the strength of recommendations by both independent raters. The Evidence Alert Traffic Light System is a GRADE‐complementary knowledge translation tool designed to assist clinicians and families to obtain easily readable, clinically useful answers within minutes (Campbell, Novak, McIntyre & Lord, 2013 ), because the alert uses a simple, three‐level colour coding that recommends a course of action. Green signifies ‘go’ because high quality evidence indicates effectiveness; red signifies ‘stop’ because high quality evidence indicates harm or ineffectiveness; and yellow signifies ‘measure’ because insufficient evidence exists to be certain about whether the child will benefit. Yellow can be assigned in three scenarios: (i) promising evidence (weak positive), (ii) unknown effectiveness because no research exists, or (iii) evidence suggests possibly no effect (weak negative).

Ethics and data

The study did not involve contact with humans, so the need for ethical approval was waived by the Cerebral Palsy Alliance's National Health and Medical Council Human Research Ethics Committee. This SR was not registered.

3138 citations were identified using the search strategy, of which 129 articles met the inclusion criteria for review. Of the 129 included articles, 58% ( n  = 75/129) were SRs; 42% ( n  = 54/129) were RCTs. Note, more than 54 RCTs exist in the paediatric occupational therapy evidence base, but we treated any RCT that was cited within an included SR as a duplicate. Flow of information is presented in the PRISMA diagram (Fig.  1 ).

PRISMA Flow Diagram

The results are now presented using PICO question format headings.

P opulation (Participants)

Included studies were across the following childhood disability diagnoses: arthrogyposis; attention deficit hyperactivity disorder (ADHD); autism spectrum disorder (ASD); behaviour disorders; brachial plexus injury; brain injury (BI); burns; cerebral palsy (CP); cancer; chronic pain; developmental coordination disorder (DCD); developmental disability (DD); Down syndrome; foetal alcohol spectrum disorder; learning disability (LD); mental health; intellectual disability (ID); obesity; preterm infants; physical disability; rheumatoid arthritis; and spina bifida. Some studies included samples from a variety of the aforementioned diagnoses. Consistent with childhood disability population incidence data, more research existed about ASD ( n  = 32/135; 24%), ADHD ( n  = 8/135; 6%), CP ( n  = 38/135; 28%) and DCD ( n  = 9/135; 7%), than other conditions.

Paediatric occupational therapy involves working with the child, the parent and the family unit: The child was the primary client for 87% ( n  = 45/52) of the interventions, i.e. therapy focussed on improving the child outcomes (e.g. an orthotic worn by the child to improve hand function), whereas the parent was the primary client for 13% ( n  = 7/52) for the interventions (e.g. parent education, aiming to improve knowledge, skills and confidence).

I nterventions

Included studies, researched the effectiveness of 52 occupational therapy intervention groups: (1) Acupuncture; (2) Assistive Devices; (3) Assistive Technology; (4) Behavioural Interventions including Applied Behavioural Analysis (ABA) and Positive Parenting Program (Triple P); (5) Bimanual Training; (6) Biofeedback; (7) Coaching; (8) Cognitive Interventions including CogFun, CogMed, (9) Cognitive Orientation to Occupational Performance (CO‐OP); (10) Conductive Education; (11) Constraint Induced Movement Therapy (CIMT); (12) CIMT &/or Bimanual; (13) Context Focused; (14) Ditto™ (hand held education & distraction device for burns patients); (15) Early Intervention, including a Developmental Approach, Neurodevelopmental Therapy (NDT) and Goals Activity and Motor Enrichment (GAME); (16) Electrical Stimulation (ES); (17) Family Centred Care; (18) Feeding Interventions; (19) Goal Directed Training, including Task Specific Training, Functional Training, Neuromotor Task Training (NTT) and Motor Imagery; (20) Handwriting Interventions; (21) Hippotherapy [Therapeutic Horse Riding]; (22) Home Programs; (23) Joint Attention; (24) Massage; (25) Meditation and/or Mindfulness; (26) Mental Health Interventions; (27) Neuro‐Developmental Therapy (NDT); (28) Occupational Therapy after BoNT; (29) Orthotics; (30) Pain Management; (31) Parent Counselling; (32) Parent Education/Parent Training; (33) Picture Exchange Communication System (PECS); (34) Play Therapy; (35) Positioning; (36) Pressure Care; (37) School Therapy; (38) Self‐Management; (39) Sensation Training; (40) Sensory Approach, including brushing, therapy balls, weighted vests, warm‐ups, sensory stimulation; (41) Sensory Integration, including sensory diets, swinging, brushing, therapy balls, weighted vests, body socks; (42) Skills Training via Mental Imagery; (43) Sleep Interventions; (44) Social Skills Training; (45) Stretching, including passive: self‐administered, therapist‐administered and device‐administered; (46) Treatment and Education of Autistic and Communication Handicapped Children (TEACCH); (47) Therapeutic Listening; (48) Treadmill Training; (49) Visual Motor Interventions; (50) Weight Loss; (51) Whole Body Vibration; and (52) Yoga.

Of the 12 included articles, authors measured the effectiveness of 52 occupational therapy interventions, across 22 diagnoses. From this, 136 intervention outcome indicators were identified, whereby an intervention, with an individual target outcome was administered to specific diagnostic groups. Insufficient data was available for analysis on one of these outcome indicators (number 74 in Table  S1 , where the SR authors found no publish data examining the effectiveness of hand orthotics in children with brain injury and therefore no recommendations could be made), (Jackman, Novak & Lannin, 2014 ) resulting in 135/136 intervention outcome indicators available for analysis.

Of the 135 intervention outcome indications: 30% ( n  = 40/135) were graded ‘do it’ (Green Go) (Arbesman, Bazyk & Nochajski, 2013 ; Bellows et al ., 2011 ; Bleyenheuft, Arnould, Brandao, Bleyenheuft & Gordon, 2015 ; Brown, Kimble, Rodger, Ware & Cuttle, 2014 ; Chang & Yu, 2014 ; Chen, Pope, Tyler & Warren, 2014c ; Chen et al ., 2014b ; Christmas, Sackley, Feltham & Cummins, 2018 ; Crompton et al ., 2007 ; Estes et al ., 2014 ; Fehlings et al ., 2010 ; Frolek Clark & Schlabach, 2013 ; Hechler et al ., 2014 ; Heinrichs, Kliem & Hahlweg, 2014 ; Hoare & Imms, 2004 ; Hoare, Imms, Carey & Wasiak, 2007 ; Hoare et al ., 2010 ; Hoy, Egan & Feder, 2011 ; Huang, Fetters, Hale & McBride, 2009 ; Inguaggiato, Sgandurra, Perazza, Guzzetta & Cioni, 2013 ; Kamps et al ., 2015 ; Kasari et al ., 2016 ; Kaya Kara et al ., 2015 ; Kurowski et al ., 2014 ; Lannin, Scheinberg & Clark, 2006 ; Lidman, Nachemson, Peny‐Dahlstrand & Himmelmann, 2015 ; Lin & Wuang, 2012 ; Madlinger‐Lewis et al ., 2014 ; Maeir et al ., 2014 ; Novak, 2014a ; Park, Maitra, Achon, Loyola & Rincón, 2014 ; Speth et al ., 2015 ; Spittle, Orton, Anderson, Boyd & Doyle, 2012 ; Spittle, Orton, Doyle & Boyd, 2007 ; Stavness, 2006 ; Stickles Goods, Ishijima, Chang & Kasari, 2013 ; Vroland‐Nordstrand, Eliasson, Jacobsson, Johansson & Krumlinde‐Sundholm, 2016 ; Zwaigenbaum et al ., 2015 ); 56% (75/135) were graded ‘probably do it’ (Yellow Measure) (Armstrong, 2012 ; Au et al ., 2014 ; Auld, Russo, Moseley & Johnston, 2014 ; Bialocerkowski, Kurlowicz, Vladusic & Grimmer, 2005 ; Bodison & Parham, 2018 ; Cameron et al ., 2017a , 2017b; Chacko et al ., 2014 ; Chantry & Dunford, 2010 ; Chen, Lee & Howard, 2014a ; Chiu, Ada & Lee, 2014 ; Cole, Harris, Eland & Mills, 1989 ; Copeland et al ., 2014 ; Dagenais et al ., 2009 ; De Vries, Beck, Stacey, Winslow & Meines, 2015 ; Duncan et al ., 2012 ; Fedewa, Davis & Ahn, 2015 ; Grynszpan, Weiss, Perez‐Diaz & Gal, 2014 ; Hahn‐Markowitz, Berger, Manor & Maeir, 2017 ; Hammond, Jones, Hill, Green & Male, 2014 ; Huang et al ., 2014 ; Jackman et al ., 2018 ; James, Ziviani, Ware & Boyd, 2015 ; Janeslätt, Kottorp & Granlund, 2014 ; Jones et al ., 2014 ; Krisanaprakornkit, Ngamjarus, Witoonchart & Piyavhatkul, 2010 ; Lannin, Novak & Cusick, 2007 ; Malow et al ., 2014 ; Maskell, Newcombe, Martin & Kimble, 2014 ; Mast et al ., 2014 ; Matute‐Llorente, González‐Agüero, Gómez‐Cabello, Vicente‐Rodríguez & Mallén, 2014 ; McLean et al ., 2017 ; Meany‐Walen, Bratton & Kottman, 2014 ; Miller‐Kuhaneck & Watling, 2018 ; Montero & Gómez‐Conesa, 2014 ; Morgan, Novak, Dale & Badawi, 2015 ; Morgan et al ., 2016a ; Morgan, Novak, Dale, Guzzetta & Badawi, 2016b ; Pfeiffer B & Arbesman, 2018 ; Polatajko & Cantin, 2010 ; Reeuwijk, van Schie, Becher & Kwakkel, 2006 ; Schaaf, Dumont, Arbesman & May‐Benson, 2018 ; Smith et al ., 2014 ; Snider, Majnemer & Darsaklis, 2010 ; Storebø et al ., 2011 ; Tatla et al ., 2013 ; Tatla, Sauve, Jarus, Virji‐Babul & Holsti, 2014 ; Vargas & Lucker, 2016 ; Westendorp et al ., 2014 ; Whalen & Case‐Smith, 2012 ; Xu, He, Mai, Yan & Chen, 2015 ; Zadnikar & Kastrin, 2011 ; Ziviani, Feeney, Rodger & Watter, 2010 ; Zwicker & Mayson, 2010 ); 10% ( n  = 14/130) were graded ‘probably don't do it’ (Yellow Measure) (Wallen & Gillies, 2006 ; Wells, Marquez & Wakely, 2018 ); and 4% ( n  = 6/135) were graded ‘don't do it’ (Red Stop) (Gringras et al ., 2014 ; Katalinic et al ., 2010 ).

The 40 green light ‘do it’ interventions indications included: (1) Behavioural Intervention using ABA for children with ASD; (2) Behavioural Intervention using Triple P for children behaviour disorders; (3) Behavioural Intervention using token economy contracts for children with a brain injury; (4) Bimanual Training for children with hemiplegic CP; (5) Coaching for parents of children at risk of disability to promote development; (6) Coaching for parents of children with ASD to promote function and behaviour; (7) CAPS cognitive intervention for children with brain injury to improve long term executive function; (8) Cog‐Fun intervention for children with attention deficit disorder to improve executive function; (9) CO‐OP for children with DCD for functional motor task performance; (10) CIMT for children with CP to improve hand function; (11) CIMT plus Bimanual for children with CP to improve hand function; (12) Context Focused intervention for children with CP for functional motor task performance; (13) Ditto hand held devices for children with burns to provide procedural distraction and self‐management education; (14) Early Intervention using ABA for children with ASD; (15) Early Intervention using Developmental Care for preterm infants; (16) Family Centred Care for children with brain injury or CP, to improve children's function; (17) Parent education feeding intervention for children with disability to improve feeding competency and growth; (18) Physiological feeding intervention for children with disability; (19) Goal Directed Training for children with CP, to improve functional task performance; (20) Goal Directed Training for children with DCD, to improve functional task performance; (21) Handwriting Task‐Specific Practice for children with DCD; (22) Home Programs for children with CP, to improve functional task performance; (23) Home Programs for children with ID, to improve functional task performance; (24) Joint Attention for children with ASD to improve social interactions; (25) Mental Health interventions for children with ASD; (26) Mental Health interventions for children with developmental delay; (27) Mental Health interventions for children with mental health disorders; (28) Occupational therapy after botulinum toxin injections for children with CP to promote hand function; (29) Kinesiotape for children with CP to improve hand function; (30) Pain Management for children with chronic pain secondary to physical disability and or chronic health conditions; (31) Parent Education using mindfulness for parents of children with ASD to reduce parental stress; (32) Parent Education using problem solving for parents of children with ASD to reduce parental stress; (33) Parent Education for children with disabilities to promote parenting confidence; (34) Parent Education for children with behaviour disorders to improve parent well‐being; (35) PECS for children with ASD to promote communication; (36) Positioning in NICU for preterm infants to promote normal movement development; (37) Pressure Care for children with CP using mattresses and cushions; (38) Social Skills Training mediated by peers for children with ASD; (39) Treadmill training for children with Down Syndrome to accelerate the onset of independent walking; (40) Weight loss using a family education and activity program called ‘Mighty Moves’ for children with obesity.

We assigned an ICF category to the primary and secondary intervention outcome of each intervention. Using the primary ICF level code, we mapped the profile of the paediatric OT evidence base to the ICF framework (Fig.  2 ). Green light effective interventions existed at the body structures and function ICF level ( n  = 14/74 indications (19%)), the activity level ( n  = 14/27 indications (52%)) and the environment level ( n  = 12/34 indications (35%)). When we compared the proportions of green light to yellow light to red light interventions by ICF levels, the activity level contained the largest number of green lights. At the activity level where there was 27 indications, green lights outweighed the number of yellow and red lights (Gree n  = 14/27; Yellow = 13/27; Red = 0/27), meaning the most common traffic code at the activity level was green, which we illustrated by green shading in Figure  2 . At the body structures and function ICF level, the most common traffic code was yellow, which we illustrated by yellow shading in Figure  2 . All the red lights within the evidence base existed at the body structures and function level. At the environmental level, the most common traffic code was also yellow, which we illustrated by yellow shading in Figure  2 . Two intervention's primary ICF code was at the participation level (Willis et al., 2010 ) and none at the personal level, indicating gaps in the occupational therapy evidence base, which we illustrated using grey shading in Figure  2 . The two participation codes were weak positive, but these were based on trials that used activity‐based interventions and assumed an upstream participation gain, which was not well‐supported.

Occupational Therapy Interventions and the International Classification of Function

C omparisons

In the included papers, consistent with conventional beliefs about it being unethical to withhold early intervention from children, rarely did researchers design studies where the control group received no intervention. In most studies, the controlled comparison was usual care. Some researchers carried out short duration studies using a wait‐list control design, where the control group received the experimental intervention after study completion.

CIMT for children with CP, was the only intervention comprehensively and empirically compared to other intervention options, using head‐to‐head RCT comparisons identified in our search strategy. CIMT was: (i) compared head‐to‐head with Bimanual Training showing no difference between the approaches (Sakzewski et al ., 2015 ; Tervahauta, Girolami & Øberg, 2017 ); and (ii) combined with Bimanual Training and/or Botulinum toxin A, showing no additive benefits occurred from a combined intervention approach (Hoare et al ., 2013 ). These researcher's concluded ‘intensity’ of practice was the key ingredient of these effective CP approaches ( Sakzewski et al . ; Tervahauta et al ., 2017 ).

A meta‐analysis of intervention options for children with DCD compared the relative effect of DCD motor interventions by calculating and comparing effect sizes (Smits‐Engelsman et al ., 2013 ). The authors calculated that ‘top‐down’ approaches (effect size = 0.89) were more effective than ‘bottom‐up’ approaches (effect size = 0.12).

To assist with comparative clinical decision‐making across the paediatric occupational therapy evidence base, we created bubble charts. We mapped the 52 identified paediatric occupational therapy interventions, across 22 diagnoses, spanning 135 intervention indications, which sought to provide analogous outcomes, by diagnosis, into separate bubbles. In the bubble charts, the size of the bubble indicated the volume of published evidence, which was calculated by counting the number of published studies on the topic. The location of the bubble on the y ‐axis of the graph corresponded to the GRADE system rating. The colour of the bubble denoted the Traffic Light Evidence Alert System rating (Fig.  3 ).

Bubble Charts Comparing the Effectiveness of Different Occupational Therapy Indications for Different Diagnoses

We set out to systematically summarise the current intervention options available to paediatric occupational therapists across different childhood disability populations. We found 40 interventions that received a ‘strong’ recommendation for use, indicating a high‐quality evidence base with more benefits than harms. These ‘green light’ interventions included: Behavioural Interventions (including ABA, Triple P and Token Economies); Bimanual; Coaching; Cognitive Cog‐Fun and CAPS; CO‐OP; CIMT; CIMT plus Bimanual; Context‐Focused; Ditto; Early Intervention (including ABA and Developmental Care); Family Centred Care; Feeding interventions (including coaching and physiologic); Goal Directed Training; Handwriting Task‐Specific Practice; Home Programs; Joint Attention; Mental Health Interventions; occupational therapy after BoNT; Kinesiotape; Pain Management; Parent Education; PECS; Positioning in NICU; Pressure Care; Social Skills Training Peer Mediated; Treadmill training and Weight loss ‘Mighty Moves’.

The paediatric occupational therapy evidence base is under immense growth and expansion. The SRs and trials greater than 10 years old were predominantly about CP with one study about Brachial Plexus and DD. Almost always these older studies showed that the ‘bottom‐up’ interventions were ineffective with no difference between the experimental and control groups.

Clinical Implications

Occupational therapists working with children and their parents have several evidence based interventions to choose from. The strength of this paper is that it provides a systematic, clear and concise summary of all the available interventions by diagnosis with an easy to interpret summary of efficacy. There are some important learnings:

A. Parent partnership within occupational therapist intervention is effective and worthwhile

Occupational Therapists embrace the principles of family centred care (Hanna & Rodger, 2002 ) where the parent is the decision‐maker and the expert in knowing their child and the therapist is a technical resource to the family. We found that 13% of paediatric occupational therapy interventions are directed at the parent, so parents can deliver intervention at home within daily parenting. Evidence suggests that parent‐delivered intervention is equally effective to therapist‐delivered intervention (Baker et al ., 2012 ), which is not surprising given parent's knowledge of their children's preferences and engagement style, and the volume of caregiving they carryout (Smith, Cheater & Bekker, 2015 ). In the diagnoses studied (ADHD, ASD, At risk, Behavioural Disorders, BI, CP, DD, LD, obesity), it was very clear that parents respond well to parent education and training (Antonini et al ., 2014 ; Barlow, Smailagic, Huband, Roloff & Bennett, 2012 ; Case‐Smith & Arbesman, 2008 ; Dykens, Fisher, Taylor, Lambert & Miodrag, 2014 ; Feinberg et al ., 2014 ; Hanna & Rodger, 2002 ; Howe & Wang, 2013 ; Kuhaneck, Madonna, Novak & Pearson, 2015 ; Lawler, Taylor & Shields, 2013 ; Tanner, Hand, O'toole & Lane, 2015 ; Zwi, Jones, Thorgaard, York & Dennis, 2011 ), consistent with family centred philosophy about parents’ aspirations of parenting well, to help their children (Hanna & Rodger, 2002 ). Moreover, parents and children carry out intervention effectively at home, and therefore home programs (Novak & Berry, 2014b ; Novak et al ., 2013 ; Sakzewski, Ziviani & Boyd, 2013 ; Sakzewski et al ., 2015 ; Wuang, Ho & Su, 2013 ) and self‐management programs (Lindsay, Kingsnorth, Mcdougall & Keating, 2014 ; Moola, Faulkner, White & Kirsh, 2014 ) are an effective method for increasing the intensity of therapy.

When carrying out parent education, literature tells us that parents need and want: knowledge of the condition and intervention options; help accessing support services; and advice about coping strategies, via a collaborative partnership (Smith et al ., 2015 ). Even though family centred practice has existed since the 1990s, parents still experience some resistance to their input from health professionals ( Smith et al . ). Unclear expectations about roles further elevate parental stress (Coyne, 2015 ). Occupational therapists therefore need to be mindful of parent's experiences and aim to clearly communicate information and coach parents to guide care, to optimise family outcomes ( Coyne ).

B. Activities‐based, ‘top‐down’ interventions deliver bigger gains

Numerous occupational therapy interventions exist, aiming to improve motor, behavioural and functional outcomes (Fig.  3 ), affording a lot of choice to families and clinicians. The greatest number of effective green light interventions was at the activity level of the ICF, indicating that daily life skills training using a ‘top‐down’ approach is a strength of the occupational therapy profession. Examples include: Bimanual Training; CIMT; CO‐OP; GAME; Goal‐Directed Training; Handwriting Task Training; Home Programs using Goal‐Directed Training; Social Skills Training; and Task Training. Consistent with current knowledge about the conditions for inducing neuroplasticity (Kleim & Jones, 2008 ), the green light, ‘top‐down’, activity level interventions all have the following key ingredients in common: (i) begin with the child's goal, to optimise motivation and saliency of practice; (ii) practice of real‐life activities in natural environments to optimise the child's learning and the variability of the practice; (iii) intense repetitions to activate plasticity, including home‐based practice; and (iv) scaffolded practice to the ‘just right challenge’ to enable success under self‐generated problem‐solving conditions, to optimise enjoyment.

In contrast, some of the most established paediatric occupational therapy interventions NDT/Bobath and SI were originally developed as ‘bottom‐up’ interventions. NDT/Bobath and SI originated in an era of medicine when intervention aimed to remediate the child's body structural deficits, thinking function would emerge (Rodger et al ., 2005 ; Rodger et al ., 2006). However, over time the NDT/Bobath and SI approaches have been broadened to also accommodate use of ‘top‐down’ functional training approaches. Fidelity to the original NDT/Bobath and SI approach therefore varies greatly (Mayston, 2016 ), and as such, a leading Bobath expert has recently stated that Bobath ‘no longer stands for a valid universal therapy approach’ (Mayston, 2016 , p. 994). This means that interpreting the meaning of historical NDT/Bobath and SI research evidence about efficacy within the context of contemporaneous clinical practice is challenging. The efficacy of both NDT/Bobath and SI have been critiqued within SRs (Boyd & Hays, 2001 ; Brown & Burns, 2001 ; Case‐Smith & Arbesman, 2008 ; Case‐Smith, Clark & Schlabach, 2013 ; Case‐Smith, Weaver & Fristad, 2015 ; Lang et al ., 2012 ; May‐Benson & Koomar, 2010 ; Novak et al ., 2013 ; Sakzewski, Ziviani & Boyd, 2009 ; Sakzewski et al ., 2013 ; Steultjens et al ., 2004 ; Watling & Hauer, 2015 ; Weaver, 2015 ) and these data mostly relate to older trials. SR authors have concluded that NDT/Bobath and SI rarely confer motor gains superior to no intervention, but the RCTs contain so many methodological flaws that recommendations for use or discontinuation of use within practice cannot be made with certainty (Boyd & Hays, 2001 ; Brown & Burns, 2001 ; Case‐Smith & Arbesman, 2008 ; Case‐Smith et al ., 2013 ; Case‐Smith et al ., 2014; Lang et al ., 2012 ; May‐Benson & Koomar, 2010 ; Novak et al ., 2013 ; Sakzewski et al ., 2009 , 2013 ; Steultjens et al ., 2004 ; Watling & Hauer, 2015 ; Weaver, 2015 ). Some therapists have interpreted the uncertainty of the NDT/Bobath and SI systematic evidence as justification of continuance, whereas others in the profession recommend discontinuance because of the growing body of ‘top‐down’ evidence that offer effective alternatives (Rodger et al ., 2006). A Bobath expert has recommended that the common‐sense way forward for the profession is to choose interventions that promote activity and participation outcomes (Mayston, 2016 ) and to use consistent language to describe intervention options. For example, describing interventions by clear uniform terminology (i.e. ‘splitting’) might be more helpful than ‘clumping’ interventions into expanded NDT/Bobath umbrella terms.

We analysed the breakdown of the effectiveness of motor interventions, above and below the worth it line (Fig.  3 ), in terms of ‘bottom‐up’ vs. ‘top‐down’, and a trend favouring ‘top‐down’ emerged. Of the seven motor intervention indications below the ‘worth it line’, coded on GRADE as weak negative or strong negative (red), 7/7 (100%) were ‘bottom‐up’ approaches. Of the 22 motor intervention indications above the ‘worth it line’ eight were green and 14 were yellow: 8/8 (100%) green indications (strong positive) were ‘top‐down’. A similar trend emerged in the comparative effectiveness analysis of functional interventions. Of the seven functional intervention indications above the ‘worth it line’, coded on GRADE as strong positive (green), 4/4 (100%) were ‘top‐down’. There were a small number of studies using SI and the sensory approach to improve function coded on GRADE as weak positive, but the studies had a high risk of bias and SR authors recommended interpreting the positive results with caution (Case‐Smith et al ., 2014; Case‐Smith et al ., 2015 ; Watling & Hauer, 2015 ).

Research Implications

The following areas of the evidence‐base would benefit from more research: (i) Parent Education : None of the parent education approaches were ineffective. Thus, more research is worthwhile exploring parent's preferred learning styles and levels of support required to manage the stress of raising a child with a disability. There are potential financial gains to the health system by thoroughly understanding effective parent interventions, because parent‐delivered intervention is equally effective and less expensive; (ii) Head‐to‐head comparisons : Head‐to‐head comparisons of different interventions aiming to achieve the same outcomes, in well‐controlled trials with cost‐effectiveness data, would enable determinations about best practice to be made from good evidence, and thus inform parent and policy‐maker's decision‐making; (iii) ‘Dose’ comparison studies : ‘Dose’ comparison studies using well controlled intensity trials would enable occupational therapists to better inform parents about ‘how much’ intervention is enough; and (iv) Participation Interventions : There is a clear gap in the evidence‐base about interventions that directly improve a child's participation in life and should be the focus of future RCTs and other rigorous methodologies. CIMT, Bimanual and Home Program occupational therapy interventions were measured to confirm whether or not they conferred participation gains, and the clinical trials demonstrated no between group differences (Adair, Ullenhag, Keen, Granlund & Imms, 2015 ). These results indicate that there is a clear need to develop interventions that specifically target participation, rather than anticipating activities‐based interventions will confer upstream participation gains. Changes in participation are multifactorial and involve individual factors, contextual factors, the nature of the participation activity and the environment in which the activity is being performed (Imms et al ., 2017 ). Any new participation intervention invented, will need to address all of these factors to be successful.

Limitations

Our review has several limitations. First, we only included SRs and RCTs because we aimed to analyse best‐available evidence, but means some intervention approaches will have been excluded and overlooked because no trials or reviews existed. Second, this was an analysis of secondary data sources and reporting bias and publication bias may be in operation, because positive findings have a higher chance of being published. This evidence may exist suggesting some interventions are ineffective which we were unable to review. Third, our search terms included ‘occupational therapy’ and thus will have excluded other effective interventions used by occupational therapists, but not invented or published by occupational therapists e.g. ‘Triple P’ for children with CP. Fourth, our paper was designed to provide an overview for clinicians indicating which interventions are effective, however, it does not provide enough detail about any one intervention to guide administration or training in any specific intervention. Clinicians need to refer directly to the cited article and more widely in the published literature for this information. Our findings must be interpreted within the context of our study limitations.

Conclusions

This review provides a high‐level summary of effective paediatric occupational therapy interventions. Thirty‐nine effective intervention indications exist, offering both families and clinicians many choices to match their preferences and expertise. The paediatric occupational therapy evidence base suggests a growing trend towards activities‐level, ‘top‐down’ approaches and parent education, over and above ‘bottom‐up’ approaches. There are important ethical implications of translating these effective evidence‐based occupational therapy intervention options into clinical practice to give children the best chance at achieving their goals.

Key points for occupational therapy

• Collaboration with parents is effective and worthwhile.
• Activities‐based, top‐down interventions confer larger clinical gains, than bottom‐up approaches, when aiming to improve a child's function.

All authors declare that this is original work and that they meet the criteria for authorship. Iona Novak designed the study, extracted the data, conducted the analyses and wrote the manuscript. Ingrid Honan conducted the analyses and wrote the manuscript. All authors read and approved the final manuscript.

The study was unfunded and there are no competing financial disclosures.

Conflict of interest

The authors have no conflicts of interest to disclose.

Supporting information

Table S1. Main results table.

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Executive Function Games

Colleen beck otr/l.

• by Colleen Beck OTR/L
• November 27, 2023

These executive function games are specifically selected to improve attention, organization, focus, working memory, and other executive functioning skills. Executive function is a set of cognitive skills that allows us to perform tasks.

Use this list of games and toys to help kids build and establish executive functioning skills in the home, school, or community. These are great games to use in therapy to boost executive function for improved independence, safety, and task completion.

Kids, teens, and young adults are developing executie functioning skills up through the early twenties and even early thirties in order to accomplish daily life tasks. The key to building skills in attention, focus, prioritization, etc. is practice!

Actually trying and trying again when unsuccessful is a huge strategy when it comes to practicing executive functioning skills, but games and toys are a fun way to develop these skill.

Amazon affiliate links are included in this blog post. As an Amazon Influencer, I earn from qualifying purchases.

Executive function games

There are some really fun and engaging games and toys for executive functioning skill development out there! We’ve broken down some of our top picks for building skills in distraction, planning, prioritization, self-control, and other areas of executive function.

Other tools you might like include our self-awareness games . These support executive functioning skills and overall awareness of tools that an individual might need to use.

You might want to check out our blog post on handwriting games for more ideas. Using pencil and paper games can target handwriting and executive functioning skills, which has a connection.

Head Rush (affiliate link) is a game that targets the development of mindfulness, empathy, and open communication. This is a great therapy game for helping kids develop communication tools with family and friends, especially when voicing their personal challenges and emotions.

This game would be perfect for family game night!  

Visual Brainstorms Game  (affiliate link) can help kids address executive functioning abilities by addressing problem solving, prioritizing, reasoning, logic, and abstract thinking.  

Learning Self-Control in School  (affiliate link) is a game that addresses planning, attention, and consequences to behaviors.     

The game Actions and Consequences  (affiliate link) can help kids learn that their actions have consequences! It’s a good game for younger kids.  

  The  Original Memory Game  (affiliate link) is the one that has spurred a TON of varieties of matching, memory, and concentration.   

Colleen Beck, OTR/L has been an occupational therapist since 2000, working in school-based, hand therapy, outpatient peds, EI, and SNF. Colleen created The OT Toolbox to inspire therapists, teachers, and parents with easy and fun tools to help children thrive. Read her story about going from an OT making $3/hour (after paying for kids’ childcare) to a full-time OT resource creator for millions of readers. Want to collaborate? Send an email to [email protected].

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Skills Addressed in Occupational Therapy:

Occupational therapy plays a vital role in helping children develop the skills necessary for everyday life. From fine motor skills like writing and buttoning to gross motor skills such as jumping and running, occupational therapy addresses a wide range of developmental needs. It also focuses on sensory processing, cognitive skills, and social interactions, ensuring that children can thrive both at home and in social settings. This comprehensive approach helps children achieve greater independence and confidence in their daily activities. Explore the key skills addressed in occupational therapy and learn how our dedicated therapists can support your child’s growth and development.

Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) addressed by occupational therapists include, but are not limited to:

• Putting on and taking off clothing/jacket/shoes/socks
• Grooming, such as washing and drying hands, brushing teeth, and brushing/styling hair
• Manipulating fasteners (buttons, snaps, zippers)
• Tying shoes
• Bathing/showering self
• Managing clothing and hygiene for toileting
• Utilizing utensils to feed self
• Drinking from an open mouth cup and straw
• Opening packages
• Participation in age-appropriate chores
• Managing money
• Meal preparation

Sensory Processing Skills addressed by occupational therapists include, but are not limited to:

• Supporting modulation of sight (vision), sound (auditory), touch (tactile), taste (gustatory), body position (proprioception), and movement (vestibular) input
• Eating various textures of food and tastes
• Remaining attentive/engaged within a busy/noisy environment
• Sitting and standing still as needed
• Transitioning between tasks and settings
• Tolerating unexpected or loud noises, smells, and bright light
• Allowing grooming (haircuts, washing of hair, nails being cut, brushing of teeth etc.)
• Wearing various forms of clothing (jeans) and shoes and socks
• Tolerating messy play
• Regulating activity level in order to attend

Bilateral Coordination Skills addressed by occupational therapists include, but are not limited to:

• Opening packages/containers
• Shifting/turning paper to cut with scissors
• Stringing beads/lacing
• Folding paper
• Catching a ball
• Spontaneously crossing midline

Fine Motor Skills addressed by occupational therapists include, but are not limited to:

• Establishment of a hand dominance
• Ability to isolate index finger to point
• Controlled grasp and release patterns
• Manipulating items in the hand
• Grasp on utensils in order to write, color, draw, and feed self
• Utilizing classroom tools such as scissors, glue stick, stencils, glue bottle, hole punch

Visual Motor Integration Skills addressed by occupational therapists include, but are not limited to:

• Drawing a person
• Forming pre-writing strokes and shapes
• Copying letters and numbers
• Cutting on the line of various lines and shapes
• Catching and kicking a ball

Visual Perceptual Skills addressed by occupational therapists include, but are not limited to:

• Detects similarities and differences
• Matching and sorting objects, pictures, and shapes
• Identifying shapes
• Ability to determine right versus left
• Completing puzzles
• Scanning left to right
• Tracking a moving target
• Ability to find a picture partially concealed
• Finds object in a busy background

Handwriting Skills addressed by occupational therapists include, but are not limited to:

• Writing name
• Maintaining a dynamic grasp on pencil
• Legibility, letter formation, spacing, and line orientation

Executive Functioning Skills addressed by occupational therapists include, but are not limited to:

• Getting self ready in the morning
• Managing emotions
• Initiating activities in a timely manner
• Controlling urges and impulses
• Retaining information
• Developing plans
• Bringing necessary materials to and from school
• Utilizing an organization system to track assignments, tests, and due dates
• Being aware of how behavior affects others

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How Occupational Therapy Can Help Your Child’s Cognitive, Emotional, and Social Skills

At Imagine Pediatric Therapy, we often explain that Occupational Therapy (OT) for children helps kids do the things that are meaningful to them, things like play, problem solving and social skills.

Our Occupational Therapists are not just teaching kids how to play, they are strengthening the life skills and abilities that they will need in adulthood. Our therapists are setting up our pediatric patients for success by improving their gross and fine motor skills when needed, but equally important, our therapists are helping children’s brains make important connections to improve their ability to interact with others.

Life skills in children and adolescents can be broken down into the following categories:

• Cognitive Skills: Problem Solving, Creative Thinking, Critical Thinking
• Emotional Skills: Self-Awareness, Self-Management
• Social Skills: Interpersonal Relationship Skills, Communication, Social Awareness

Cognitive Skills When you are faced with a problem that you cannot figure out, you feel your frustration mounting. With children, when there is a delay in developing cognitive skills, that frustration is present all day, every day, and it builds without a proper outlet. To diffuse this situation, OT assists the child to further develop their cognitive skills to navigate problems.

Imagine Pediatric therapists will work with your child by presenting unique problems and then talking through possible solutions. For example, while playing a game, the therapist chooses your child’s favorite marker, which of course upsets your child. Our therapist will walk through each step of finding a solution:

• Identifying the problem
• Brainstorming solutions or compromises
• Reinforcing that their feelings are valid, but they cannot always get their desired outcome – in this case, using their favorite marker
• Discussing how, although they did not get their desired outcome this time, they can still play the game and have fun, allowing them to move on with their day

It is not always as simple as this, and depending on the child, a therapist might take several sessions to get through one round of these points, and several more for the child to be able to put these ideas in effect independently. It’s important to have repetition and consistency; the more a therapist can work with your child on these issues, the sooner and more expertly your child will be able to use these problem-solving skills on their own.

Emotional Skills When you are experiencing major tantrums in public, perhaps with your child hitting you and screaming, it is easy to be angry or embarrassed. This isn’t your failure as a parent. Tantrums are your child struggling with self-awareness, emotional regulation and self-management, even though it might just seem like they are just trying to make your day more difficult!

Our occupational therapists can help your child identify their emotions and learn self-calming strategies. These strategies can range from taking deep breaths, to identifying sensory inputs that best help your child in different environments. At home, emotional regulation could be swinging in a circular motion or laying stomach-down on an exercise ball and rolling back and forth. When your child is out of the house – anywhere, such as school, at a pumpkin patch, or in the grocery store – calming exercises may include applying pressure to the body by hugging a weighted stuffed animal or squeezing a stress ball. Every child is different, so every child will have a different preferred way of helping themselves remain calm. Your child’s therapist will help identify what works best for them.

Social Skills Social skills are one of the key components to success in both personal and professional settings throughout life. Learning these skills in childhood sets children up for success in school by improving interactions with teachers and helping in the formation of friendships. These skills come easier for some kids than others. When your child is having difficulty identifying when others are experiencing emotions, such as sadness, they will have a difficult time expressing empathy for others or apologizing when they’ve accidentally hurt someone’s feelings.

Our therapists will work with your children to help them identify other’s emotions. For example, what does it mean when a brow is furrowed – is that person happy or angry? We will also work with your child on how to handle social situations, such as basic conversations when you meet someone new, what is nice to say and what should be avoided. For instance, if your child doesn’t like the shirt the person is wearing, it shouldn’t be mentioned. When needed, we’ll also work on the importance of maintaining eye contact when they need to apologize.

As adults, we sometimes take cognitive, emotional and social skills for granted. However, these are not skills we are born with; they are skills that are learned. Sometimes, children need a more active learning experience than others.

When your child is not meeting milestones, seems to have difficulty connecting with other people or cannot seem to appropriately express their emotions, call our office at 312-588-5050 or click here . We’ll schedule an evaluation and find out how our experienced, dedicated therapists can help.

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• Nov 21, 2023

Pediatric Occupational Therapy: Role of OT, Importance, and Benefits.

Updated: Jan 4

Occupational therapy (OT) is an allied healthcare profession that helps kids who have a physical, sensory, or cognitive disability learn how to do everyday things like eating, focusing on learning, putting on shoes and socks, and writing.

Occupational therapy helps the child overcome the barriers in their daily life activities and improves their performance at school, making them independent and thereby boosting their self-confidence.

Who benefits from Pediatric Occupational Therapy?

Sensory Processing Disorders

Cerebral Palsy

Down syndrome

Infantile Feeding/Latching Difficulties

Traumatic Brain Injuries

Handwriting Skills

Hand-eye Coordination

Daily living Skills

Birth injuries or birth defects

Juvenile rheumatoid arthritis

Child recovering from fracture

Spina bifida

Chronic illnesses like multiple sclerosis, scleroderma, etc.

What services does an Occupational Therapist provide?

Sensory Integration (SI)

Focused at helping individuals process sensory information from their surroundings. It is helpful for autistic children with hypersensitivity.

Fine Motor Skills Training

Involves improving skills such as handwriting, grasping objects like pencil, toys, and manipulating small items like buttoning their clothes, tying shoelaces, and picking things with tweezers.

Gross Motor Skills Training

It involves less fine movements like walking, crawling, balance, running around obstacles and jumping the rope.

Activities of Daily Living (ADL) Training

As the name suggests it is focused on daily activities such as dressing, bathing, grooming, and feeding. The therapist also helps the child develop a routine about how to go along the day. The aim is to promote independence in daily activities.

Cognitive Rehabilitation

Focuses on improving cognitive functions, such as memory, attention, problem-solving, and executive functioning.

Adaptive Equipment and Assistive Technology

Involves use of technology and various devices to help the individuals overcome their physical and cognitive limitations in day to day activities.

Hand Therapy

Specialized intervention for individuals with hand injuries or conditions, aiming to improve hand strength, coordination, and function.

Neurodevelopmental Treatment (NDT)

Focuses on improving movement and postural control, particularly for individuals with neurological conditions.

Where can your child receive occupational therapy?

Occupational therapists often work in various settings including hospitals, schools, rehabilitation centers, private clinics and mental health facilities based on the requirements of your child.

During the COVID pandemic online occupational therapy has gained a new found popularity and it has been found to be equally effective as offline Occupational therapy. The online sessions are tailor made in every aspect as per the requirements of your kid.

“ Parent-mediated OT services have the potential to significantly enhance parents' learning, empower them to implement OT strategies in their home & community settings, increase child participation in daily activities, improve communication & engagement between parents & their children.”- The Open Journal of Occupational Therapy (2023)

Why should you take online occupational therapy?

Online occupational therapy is highly practical and engaging. With online occupational therapy,

1. Your child can receive OT in the comfort of your home , you can schedule the sessions based on your convenience and save traveling time .

2. Parents become active participants and are aware of the goals, activities and exercises recommended for the child.

3. You connect with specialized therapists who may not be locally available .

4. Some autistic children and individuals feel more comfortable and perform better when they receive therapy in a familiar environment , which can enhance the therapeutic experience.

How does occupational therapy work?

Pediatric occupational therapists select interventions for children based upon their performance in daily life, how their performance is affected by their condition, and how their environment can restrict their performance.

Following the initial assessment, the occupational therapist creates a program of exercises and activities based on specific skills.

Occupational therapy can also vary based on the setting in which it is being provided, for instance, occupational therapy in school involves working on tasks like writing, hand-eye coordination. Whereas, private occupational therapy focuses on self-care routines and day to day activities.

The gist of pediatric occupational therapy to help the child develop important skills to build their confidence, which can be low when they are struggling.

Importance of early intervention in pediatric occupational therapy

Early intervention refers to occupational therapy provided to the child in early years of life. As soon as the child is diagnosed with a developmental delay, occupational therapy should commence.

Timely initiation of occupational therapy can significantly improve the child's emotional, cognitive, and physical capabilities. Early occupational therapy for babies helps them catch up with their milestones rapidly.

Occupational therapy in a school going child can help improve their academic performance thereby improving self confidence and enhancing the quality of life.

Few other benefits of early intervention occupational therapy are:

Increased independence in daily activities.

Supports Sensory Processing . Early intervention can help identify and address sensory challenges, making it easier for children to engage with their environment and learn effectively.

Social and emotional development. It can provide strategies and interventions to address these behaviors and improve overall functioning.

Prevention of secondary issues. Early intervention may reduce the likelihood of academic difficulties or emotional challenges later in life.

Family support and education. Early intervention allows families to be actively involved in their child's therapy, promoting a supportive environment for the child's development.

Cost savings. Addressing developmental challenges early may reduce the need for more intensive interventions later on.

"Early intervention through occupational therapy has been found to be beneficial in supporting children with developmental disabilities".

How can I prepare my child for occupational therapy?

For optimal results, your child needs to be as comfortable in the therapy sessions as possible. Few tips to prepare your child for their occupational therapy sessions are:-

Inform your child. Sometimes the child can experience fear before going to a new unfamiliar place, explain your child more about the online sessions and give a brief introduction of the therapist to make sure they feel comfortable and more open to therapy. Minimize distractions to help your child focus on the activities and instructions.

Ask your child about their goals. Children seem to take more interest in activities when they see what's in it for them. Ask your child if they want to be able to write faster, tie their shoelaces on their own, or even go to the beach with their friends and be able to dip their fingers in the sand?

Dress your child for active therapy . The occupational therapist will suggest various activities and exercises to the child, therefore, the child should feel comfortable in their clothes and participate willingly in these activities.

Tell your child what to expect . You can tell the child how often the sessions would be scheduled and the duration of the sessions. You can assure them that you will be present by their side throughout the sessions. They have nothing to worry about and it's going to be a fun experience for them.

Celebrate Achievements . Acknowledge and celebrate your child's achievements during and after the online OT sessions.

Share your child’s background with the therapist as it can help your therapist understand the strengths, and requirements of your child better.

Sounderic provides online speech therapy sessions for children with various communication disorders. We would love to help you. Get in touch with us on WhatsApp at +919644466635 or schedule a consultation with us at https://www.sounderic.com/booking-calendar/occupational-therapy-consultation?referral=service_list_widget

Follow us on Facebook , and Instagram or join our community of 20,000 parents from all across the world here, " Speech therapy guide for parents ".

https://www.researchgate.net/publication/332325758_Effectiveness_of_paediatric_occupational_therapy_for_children_with_disabilities_A_systematic_review

https://www.sounderic.com/online-occupational-therapy-children

https://www.sciencedirect. com/science/article/pii/S1569186114000369

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