CO-OP Introduction Online Course

CO-OP was initially developed for children with developmental coordination disorder (DCD), a condition that makes it challenging to learn new motor skills. CO-OP has several important components, which were developed over ten years of research comparing traditional treatment approaches to new interventions. Traditional approaches to treatment for children with motor-based problems focused on breaking down the activity and treating performance components. For example, if Anna, a child with DCD, is working on the task of printing, a therapist might set “improving fine motor skills” as a treatment goal, believing that improving fine motor skills must lead to improvements in printing. Similarly, if Jim, after having a stroke, is learning to walk confidently in a busy shopping mall, the treatment goal might be to “improve balance”. These treatment goals were based on the idea that performance would generally improve for activities once the impaired underlying components got better.

The CO-OP developers learned that these approaches did not usually improve performance. When comparing traditional approaches to contemporary treatment, one study showed that direct teaching could lead to improved performance in specific activities in children with DCD. This suggested that using a learning approach might be more successful than traditional impairment reduction approaches. Using this perspective, the CO-OP developers drew on ideas from Donald Meichenbaum, who originally coined Goal-Plan-Do-Check, to inform the development of a new global problem-solving approach. The new approach was initially called Verbal Self Guidance, but as more was learned and components were added, it became CO-OP. In 2001, a randomized control trial was published comparing CO-OP to traditional therapy in children with DCD, demonstrating a significant effect of CO-OP in skill performance. This study also showed that the problem solving skills learned during CO-OP could be applied to other activities, with different therapists and in different environments outside of therapy. Because of CO-OP’s success, the two main developers, Helene Polatajko and Angela Mandich, published a textbook (2004) detailing the theoretical foundations and key features of the approach. The textbook was specifically aimed at using CO-OP in a pediatric DCD population. Since its publication, several peer-reviewed studies have suggested the CO-OP Approach was effective in other populations, including children with Asperger’s syndrome and cerebral palsy and adults with traumatic brain injury and stroke.

 

In 2011, the International Cognitive Approaches Network (ICAN), formerly known as The CO-OP Academy, was formed by a community of researchers whose mission was to promote participation and engagement using CO-OP approach.

CO-OP timeline

Client-centred: CO-OP is founded on the philosophy of client-centred practice. Client-centredness refers to the idea that the client is an active participant in therapy, where their perspective is respected, and their goals are a priority. CO-OP requires that clients are able to identify goals that are important to them, which helps to ensure client-centredness and enhance clients’ motivation throughout therapy.

Performance-based: CO-OP’s main objective is skill acquisition (or enhancing performance), and therefore the focus of therapy is learning specific skills that are important to the client. Thus the client works directly on the specific skills that she or he wants to achieve, e.g. handwriting, rather than components, e.g. fine motor skills.

Problem-solving: Therapists guide clients to solve performance-based problems using a global cognitive strategy (Goal-Plan-Do-Check) to discover domain specific strategies that are specific to individual clients, goals, and situations. Teaching the client to use cognitive strategies independently is one of the main objectives of the approach.

CO-OP was initially developed for children with developmental coordination disorder (DCD), but since has been used with several other populations. CO-OP has demonstrated efficacy with people living with the following conditions:

• Asperger’s syndrome
• Cerebral palsy
• Acquired brain injury
• Stroke
• Developmental delays
• Older adults with self-identified cognitive impairment.

CO-OP research is ongoing with other populations, such as with children with dystonia.

CO-OP is a versatile approach with multiple applications across ages and diagnoses. Despite its versatility, it is recommended that clients have certain pre-requisite skills. These are as follows:

1. The client must be able to select occupations or activities that they would like to learn or for which they would like to improve their current performance level. The client identifies these occupations through an interview using the Canadian Occupational Performance Measure (COPM).
2. The client must have sufficient language fluency in order to discuss their performance with the therapist.
3. The client must have sufficient cognitive ability to benefit from CO-OP’s problem-solving approach. Research has demonstrated that clients with cognitive impairments can benefit from CO-OP, so sufficient cognitive ability relates to the ability to learn and remember from session to session.

CO-OP has four main objectives. These are:

CO-OP is made up of seven key features, which are all believed to contribute to CO-OP’s effectiveness.

Key Feature 1: Client-chosen goals

At the beginning of therapy, the therapist helps the client to identify three goals. Since CO-OP is a client-centred approach, the goals are set in partnership with the client and parents/significant others. If goals are personally relevant, the client is more motivated to learn and more engaged in therapy. This in turn leads to better skill generalization (learning a skill outside the therapy environment) and transfer (learning other novel skills).

In CO-OP, tools that help with the goal-setting process include:

• The Canadian Occupational Performance Measure (COPM)
• Daily Activity Logs
• Activity Card Sort and Pediatric Activity Card Sort

Key Feature 2: Dynamic Performance Analysis (DPA)

Dynamic performance analysis (DPA) is an observation-based strategy used by the therapist to identify clients’ breakdown in performance and to help the therapist begin to prioritize which performance problems to address. DPA also helps the therapists to begin thinking about strategies that will support skill acquisition and/or goal attainment. DPA differs from traditional activity analysis in that it is performance-based rather than component based. For example, if a client wants to ride a bike the therapist will look at which parts of bike riding are not successfully (client has trouble steering or is not pedaling quickly) rather than look for components that are weak (poor balance, muscle weakness).

Here is an example comparing a DPA vs. Task/Impairment Analysis:

Key Feature 3: Cognitive Strategy Use

Cognitive strategies are conscious tools that people use to support performance while a skill is being learned. In CO-OP, two types of cognitive strategies are used: a global strategy, and domain-specific strategies.

Key Feature 4: Guided Discovery

Guided discovery is a means of providing both instruction and feedback in which the therapist asks questions and provides hints and cues so the client can discover performance problems and solutions on her or his own. Self-discovering of solutions is believed to be associated with better generalization and transfer of skills.

When using guided discovery, therapists are asked to remember the following:

1. One thing at a time
2. Ask, don’t tell.
3. Coach, don’t adjust
4. Make it obvious

Key Feature 5: Enabling Principles

CO-OP is a client-centred, performance-based, problem-solving approach focused on skill acquisition through cognitive strategy use and guided discovery. Enabling principles are used throughout to support all CO-OP processes. The enabling principles are:

1. Make it fun/make it engaging. For children and adults alike, learning is more likely to occur if the process is enjoyable. For children, this may involve using games, fun challenges, or silliness. For adults, it involves encouraging their self-motivated and self-directed exploration of problem-solving solutions to their performance challenges.
2. Promote learning. Use established teaching techniques, including:
   Reinforcement
   Direct teaching
   Modeling
   Shaping
   Prompting
   Fading
   Chaining
3. Work towards independence. Similar to how learning is promoted by removing prompts, the therapist should remove their verbal and physical support as the skill improves.
4. Promote generalization and transfer. The therapist seeks opportunities to directly promote generalization and transfer, such as explicitly asking the client how their strategy will work outside the practice setting and what other skills it can be used with.

Key Feature 6: Parent or significant other involvement

Parents and significant other involvement is an important component in skill acquisition and generalization and transfer. The therapist should provide education to parents/significant others about CO-OP and its underlying principles. Parents and significant others are encouraged to participate in goal setting and attend at least three sessions to observe how CO-OP is carried out.

Key Feature 7: Intervention format

While CO-OP’s intervention format has undergone some alterations to best meet the needs of certain populations or delivery methods, the overall structure remains the same: