Using the Cognitive Orientation to daily Occupational Performance (CO-OP) Approach with a Child with Mild Intellectual Disability
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Evgenia-Charikleia Lazari, MSc in Clinical Neuropsychology - Cognitive Neuroscience, OT
Clinical experience with paediatric and adolescent populations in private practice. Doctoral candidate and research assistant in the Multisensory & Temporal Processing Lab. Previous research experience in experiential learning in medical education as a research fellow in the Department of Medicine, National and Kapodistrian University of Athens. Email: lazari.evgenia.charikleia@gmail.com
In this blog I will describe, following the CO-OP Approach Process, how I used CO-OP with a child with intellectual disabilities. I will reflect on the case both from an Occupational Therapy and a Neuropsychological perspective and then present some takeaways for practice.
By prioritizing the client’s goals and integrating insights from neuropsychology and cognitive science on brain development and learning, the CO-OP Approach transforms therapy into a meaningful and transformative process. It fosters confidence, independence and personal growth, empowering clients to navigate their world.
“When was the last time you witnessed a client’s eyes light up after solving a challenge independently?”
Background
Working with children who have intellectual disabilities poses unique challenges, particularly when introducing approaches that require active cognitive engagement. Recently, I had the opportunity to implement the Cognitive Orientation to daily Occupational Performance (CO-OP) Approach with a 9-year-old child diagnosed with Cornelia de Lange syndrome and mild intellectual disability (Full-Scale Intelligence Quotient (IQ) score of 52, assessed using the WISC-V). Despite some initial concerns about whether CO-OP was a suitable intervention, this experience demonstrated its potential to adapt and empower children to achieve meaningful goals.
CO-OP Implementation Process
The therapy process is described by the steps as introduced during my CO-OP Approach training:
Step 1: Introducing CO-OP
To engage the child and foster motivation, I presented the CO-OP process as a fun and empowering game, emphasizing that every activity could be approached playfully to make learning enjoyable, while “sharpening our minds”. I explained how independently solving challenges helps us grow stronger, which sparked enthusiasm and a positive response from the child.
Step 2: Goal Setting
Together, we identified three specific goals to work on, tailoring them to the child’s interests and daily functional needs. First, given their enthusiasm for arts and crafts, we collaboratively set the goal of cutting A4 paper strips in a straight-line using scissors. This falls into the Leisure domain, according to the AOTA framework (2020).
Second, the child expressed a desire to feel independent during lunch and break times without the assistance of their shadow teacher. This led to the goal of buttoning their lunch bag button, which falls under the Activities of Daily Living (ADLs) domain, fostering autonomy in self-care routines.
Finally, their love of football motivated them to strive to improve their skills. Upon further discussion, they clarified that "better at football" meant being able to score more consistently during play. Therefore, we collaboratively set a goal of scoring five goals, consecutively, with the dominant leg from a three-meter distance. This goal aligns with the Play domain, emphasizing skill development for recreational enjoyment and also supports the Social Participation domain by fostering inclusion and building confidence in team-based activities.
Step 3: Baseline Assessment and Dynamic Performance Analysis
To establish a baseline, I observed the child’s performance for each task and assessed it using the Performance Quality Rating Scale (PQRS). Initial scores were as follows: scissors (2/10), buttons (4/10) and kicks (6/10).
Dynamic Performance Analysis (DPA) was conducted to identify the specific challenges that hindered successful performance:
●Scissors Goal: The child demonstrated difficulty with proper finger placement in the scissor’s finger holes, often misaligning the scissor blades, which prevented a clean cut. Additionally, their grip lacked stability, causing the scissors to slip or fail to close fully.
●Buttoning Goal: The child applied excessive force while attempting to push the button through the hole, often resulting in misalignment and frustration.
●Kicking Goal: The child made contact with the ball, but it traveled off-target and did not move in the intended direction.
Step 4: Strategy Development
I introduced the "Goal-Plan-Do-Check" (G-P-D-C) strategy in a rhythmic and playful way, incorporating a small dance, inspired by a group of Dutch therapists. We adapted it as "What-How-Do-See”, taking into account the child’s natural language preference in their mother tongue (Greek) for "see" instead of "check", which the child found intuitive and easy to understand.
The CO-OP Reasoning Worksheet guided my professional reasoning and the problem-solving process. We focused on understanding the specific challenges and tailoring cognitive strategies to overcome them.
Goal 1: Cutting A4 Paper Strips
Possible Strategies:
●Person-Focused: Hand positioning – Internal FOA (“Feel the movement”)
●Task-Focused: Modify the activity, cutting with a different tool.
Guided Discovery:
●Internal-focused questions: “Are your fingers stable?”
●External-focused prompts: “Is this the correct tool?”
Enabling Principles:
●Provide different cutting tools.
●Use engaging music, such as the anthem of the team they support (Panathinaikos), to make the activity enjoyable.
●Demonstrate the task together through modelling.
●Encourage home practice and presentation of progress in the next session.
Goal 2: Buttoning the Lunch Bag
Possible Strategies:
●Person-Focused: Relaxation, so that less force is applied – Imagination of button passing through.
●Memory-Focused: Verbal repetition – “The button travels inside, closes its eyes and waits to go through”.
Guided Discovery:
●“Do we love the button or are we hurting it?”
●“Are your hands going fast or slow?”
●“Imagine the button as a traveller gently passing through the hole.”
●“Should we narrate the adventure of the button?”
●“Are you using your superman eyes to see success?”
Enabling Principles:
●Temporarily use an educational book with large buttons for easier practice.
●Reinforce progress through a playful button story.
●Encourage the child to practice at home and demonstrate success at school during snack time.
Goal 3: Scoring Five Goals with the Dominant Leg
Possible Strategies:
●Person-Focused: Use verbal prompts – “Imagine the ball entering the goal.”, Visual focus
●Memory-Focused: Verbal repetition – “Left-Right-Shoot!”
Guided Discovery:
●“Where should the ball go?”
●“Are your superman eyes focused on the target?”
Enabling Principles:
●Play a 1:1 football match together.
●Celebrate success with a dance every time two goals are scored.
●Provide complementary knowledge to explain the importance of visual attention alongside leg movement.
●Encourage the child to play at school with friends, reinforcing the skill through practice and positive feedback.
Step 5: Strategy Generalization and Transfer
In the third session, when I asked the child if the conventional scissors they were using were the appropriate tool; they responded that they were not. I followed up with, "What will you do about that?" to which they enthusiastically replied, "I’ll bring and check out the other scissors!". I encouraged them by saying, "Of course, that’s a perfect idea!" After examining and testing various pairs of scissors, they selected a tool without finger holes (loop scissors). Using this tool, they successfully cut the paper strips, taped them together and created a wonderful bracelet.
Another breakthrough occurred during the fifth session, when the child transferred the “superman eyes” strategy from buttoning to shooting goals. In this session, they independently managed to fasten the button on the lunch bag, while singing the buttoning song. Overjoyed, they told me they “checked it with their superman eyes” and declared that they were now ready for football. Initially, their excitement caused them to rush through the steps. However, they quickly adapted and performed exceptionally well, successfully scoring three consecutive goals into the net.
This demonstrated the child’s ability to generalize learned strategies (superman eyes) across activities—an essential principle of the CO-OP Approach.
Step 6: Measuring Change – Post-Intervention Assessment
Following the intervention, the child demonstrated significant progress across all targeted goals:
●Scissors: Improved to 8/10, with slight difficulty maintaining consistently straight lines.
●Buttons: Achieved 9/10, successfully completing the task, though it remained somewhat challenging and tiring.
●Kicks: Reached 8/10, scoring three consecutive goals, short of the five-goal objective.
These outcomes underscore the effectiveness of the CO-OP Approach in facilitating skill acquisition, enhancing independence and empowering the child to overcome task-specific challenges.
Reflections and Insights
This case exemplifies the adaptability of CO-OP for children with mild intellectual disabilities, despite initial doubts about its suitability. By making the process engaging and aligning strategies with the child’s strengths, we were able to empower them to achieve their goals.
Takeaways for Practice
One of the most profound takeaways is the importance of client-defined goals. Skills are developed within the context of meaningful occupations and must reflect the client’s values, goals and personal realities. Goals that emerge from the client’s own interests—whether it’s cutting paper, buttoning a lunch bag or scoring football goals—create an intrinsic sense of purpose and ownership, making learning both engaging and empowering. The empowerment that comes from solving a problem independently is not just about mastering a task—it fosters a sense of autonomy and belief in one’s abilities to act and succeed. As occupational therapists, we have the capacity to create environments where this empowerment can thrive. By encouraging clients to take ownership of their goals and strategies, we are not just teaching skills but nurturing lifelong problem-solving abilities and resilient minds.
Neuropsychological perspective
From a neuropsychological perspective, solving problems independently strengthens executive functions, including planning, decision-making and self-monitoring. Research shows that actively solving a task—not merely following instructions—leads to deeper learning and better retention by engaging cognitive and neural mechanisms associated with active learning. Unlike direct instruction, where knowledge is passively transferred, active learning fosters opportunities for learners to explore, manipulate and apply content individually or collaboratively, increasing the "value" of the knowledge gained through one’s own effort (Deslauriers et al., 2019; Freeman et al., 2014). Specifically, active learning engages reinforcement learning (RL) circuits that assign greater neural and cognitive value to experiences that involve decision-making and evaluation (for a review see Dubinsky & Hamid, 2024).
Active learning environments, such as those created in CO-OP Approach interventions, stimulate neural reward-learning systems and episodic memory by presenting learners with high uncertainty, which drives attention and memory formation. In contrast, direct instruction primarily activates working memory (WM) systems in the frontal-parietal network, supporting rapid, but surface-level encoding of low-cognitive-load information (Collins et al., 2017; Monosov, 2020). While direct teaching can facilitate quick learning in low-uncertainty environments, it lacks the deeper encoding processes needed for long-term retention. Active learning, however, requires learners to navigate uncertainty and resolve challenges independently. This process strengthens synaptic plasticity and promotes generalization, ensuring adaptability (Rouhani et al., 2018; Collins & Frank, 2018).
In occupational therapy and other applied fields, these cognitive neuroscience insights underscore the importance of designing ecologically valid interventions that allow clients to actively problem-solve. By allowing clients to confront and overcome uncertainty, therapists can create environments that align with the neurobiological foundations of learning, ensuring not only skill acquisition, but also generalization, transfer and long-term retention. Therefore, the neuroscience of active learning reinforces the critical role of client-centered approaches, empowering individuals through their active participation in the therapeutic process. Evidently, the CO-OP Approach perfectly aligns with these cognitive neuroscience principles, providing a framework that supports both cognitive and emotional development.
Occupational Therapy perspective
Moreover, fundamentally at the heart of our profession as occupational therapists, we are not simply skill-trainers—we are advocates for participation, independence and meaningful engagement. Our role is to empower clients to problem-solve and engage in life’s activities, not to impose rigid task-driven methods. Therefore, we must challenge assumptions and avoid underestimating our clients’ capabilities. Preconceived notions about who may or may not benefit from cognitive strategies risk imposing limitations. This subtle form of ableism undermines the potential for growth and independence. Instead, we must first try, meeting each client where they are, creatively adapting strategies to their level of understanding and ability. Our clinical reasoning must remain dynamic and responsive, shaped by the client—not the other way around.
By prioritizing the client’s goals and integrating insights from neuropsychology and cognitive science on brain development and learning, the CO-OP Approach transforms therapy into a meaningful and transformative process. It fosters confidence, independence and personal growth, empowering clients to navigate their world.
Let’s continue to promote occupation-centered, empowering practices like CO-OP!
Acknowledgments
I had the privilege of completing my CO-OP training with Petros Meladakis, MSc, OT and Jolien van den Houten, MHPE, OT under the auspices of the Panhellenic Association of Occupational Therapists. This training was instrumental in helping me bridge my background in cognitive neuroscience with my clinical practice, enhancing both my theoretical understanding and practical application of the approach. I extend my heartfelt gratitude to them for this impactful learning experience and its profound influence on my personal and professional growth.
References
American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Supplement_2), 7412410010p1–7412410010p87.
Collins, A. G. E., & Frank, M. J. (2018). Within- and across-trial dynamics of human EEG reveal cooperative interplay between reinforcement learning and working memory. Proceedings of the National Academy of Sciences, 115(10), 2502–2507. https://doi.org/10.1073/pnas.1712333115
Deslauriers, L., McCarty, L. S., Miller, K., Callaghan, K., & Kestin, G. (2019). Measuring actual learning versus feeling of learning in response to being actively engaged in the classroom. Proceedings of the National Academy of Sciences, 116(39), 19251–19257. https://doi.org/10.1073/pnas.1821936116
Dubinsky, J. M., & Hamid, A. A. (2024). The neuroscience of active learning and direct instruction. Neuroscience and Biobehavioral Reviews, 163, 105737. https://doi.org/10.1016/j.neubiorev.2024.105737
Freeman, S., Eddy, S. L., McDonough, M., Smith, M. K., Okoroafor, N., Jordt, H., & Wenderoth, M. P. (2014). Active learning increases student performance in science, engineering, and mathematics. Proceedings of the National Academy of Sciences, 111(23), 8410–8415. https://doi.org/10.1073/pnas.1319030111
Monosov, I. E. (2020). How outcome uncertainty mediates attention, learning, and decision-making. Trends in Neurosciences, 43(10), 673–687. https://doi.org/10.1016/j.tins.2020.06.007
Rouhani, N., & Niv, Y. (2018). Signed and unsigned reward prediction errors dynamically enhance learning and memory. eLife, 7, e31752. https://doi.org/10.7554/eLife.31752