Thursday, March 30, 2006

The role of occupational therapy in family reunification

For background information, you may first choose to reference this entry:
An analysis of foster care policy and its impact on occupational therapy


Children are placed in temporary foster homes when their parents are unable to care for them; foster care is generally designed as a temporary service for children and families who are experiencing a crisis. Children in foster care are more likely to experience psychological and developmental problems (Simms, Dubowitz, & Szilagyi, 2000); therefore, there is an increased likelihood that they attend early intervention and preschool programs where occupational therapists provide services.

Occupational therapy education programs have been successful in increasing therapists’ knowledge and skills in working with parents of children who have disabilities (Hinojosa, Sproat, Mankhetwit, & Anderson, 2002). However, little has been written about occupational therapist’s interactions within the foster care system, particularly as it relates to parent training programs for families that are going through reunification.

Research indicates that 57% of the children in foster care are reunified with their birth parents, although in recent years, reunification rates have declined (Department of Health and Human Services, 2003). Additionally, some studies show that reunification efforts are not always successful for the long term. Terling (1999) states that reentry into foster care due to additional maltreatment occurs too frequently, and that 37% of the children reunited with their families reenter the system within 3 1/2 years.


This data indicates that there is an acute need for parental training programs that are effective and that will support the occupational performance of both children and parents. Hanna and Rodger (2002) reviewed the occupational therapy literature and identified that the available evidence regarding the efficacy of occupational therapy intervention for parent training and collaboration is limited. From a broader perspective, several studies have been commissioned by the Assistant Secretary for Planning and Evaluation of the U.S. Department of Health and Human Services (1992, 1995) and they indicate that few states have programs that address the reunification problem, and those that do address the issue do so from the perspective of placement prevention. Currently, there is very little evidence to guide the participation of occupational therapy in parent training programs.

The most specific parent training program that is described in the literature is Eyberg’s Parent Child Interaction Therapy (1988). This technique involves specific training in real-time by providing feedback on parenting during a play session with a child. Although this is described primarily as a counseling intervention, it is very functionally oriented and related to direct parenting occupations. Articles that describe this intervention were included as they related to emotional problems of the child (Johnson, Franklin, Hall, Prieto, 2000) as well as coping problems of the parent (Borrego, Urquiza, Rasmussen, & Zebell, 1999).

Another interesting perspective on parenting training involves an assessment of speech and communication patterns between mothers and their children who have cerebral palsy (Pennington & McConachie, 2001). This study indicated that a multitude of developmental factors can have an influence on interaction and communication between parents and children. Again, as many children in the foster care system have multiple developmental difficulties, this article identifies a myriad of issues that are important to consider when providing intervention for this population.

Finally, two occupational therapy articles (Ganadaki, & Magill-Evans, 2003; Nakamura, Stewart, & Tatarka, 2000) are included in the review, but both of these have significant methodological problems. Both studies used the Nursing Child Assessment Teaching Scale which is normed for mothers only. These studies both attempted to document the participation of fathers in parenting. Use of a standardized tool that is normed on mothers leads to questions regarding the appropriateness of use for measuring father performance. Additionally, in the Nakamura, Stewart, & Taturka study, there was a very small sample size and they had many problems with data collection; in the end they found no difference between intervention and non-intervention groups. Other studies (Pennington & McConachie, 2001) specifically excluded fathers from their research because of known and accepted differences in parenting interactions between mothers and fathers.

An interesting article describes therapists’ qualitative perceptions of parent-child relationships in therapy (Mayer, White, Ward, & Barnaby, 2002). The authors identify several themes of interest that may help provide guidance for future research on specific therapist interactions in parent education.

In summary, there is a notable lack of research and identification of methodologies for occupational therapists to provide parent training programs. This lack of information is troubling in consideration of the high frequency of contact between occupational therapists and families that are in the foster care system.

Case Study


Sam is a 35 month old child who was initially referred for occupational therapy when he was 26 months old. He has been seen for direct occupational therapy twice weekly for thirty minute sessions since the time of his initial referral. Sam is now splitting his time between his foster parents and his biological parents. Because of previously identified interaction and bonding problems with the biological parents, all occupational therapy intervention is now being provided in the biological parent’s home.

All previous observations about the parent-child interactions were qualitative. Quantitative data could provide different information that might guide intervention more specifically and promote parenting skills of the biological parents. For the purposes of this case study my initial plan was to administer the Parenting Stress Index (Abidin, 1995). Unfortunately, I experienced some logistical problems with obtaining the instrument due to qualification requirements that are strictly enforced by the current test publisher. Instead, I administered the Parental Stress Scale (Berry & Jones, 1995).

The Parental Stress Scale is a very brief self-report scale that contains 18 items representing positive and negative themes of parenthood. Parents read statements and either agree or disagree with them in terms of their typical relationship with their child. The parents rate each item on a five-point Likert scale with higher scores on the scale indicating greater stress.

The Parental Stress Scale demonstrated good internal and test-retest reliability. Additionally, it had good concurrent validity with other tests such as the Parenting Stress Index. Factor analysis was completed and a four factor solution was identified by the researchers but these specific factors were not labeled.

Both of Sam’s parents willingly participated in the assessment and they filled out the Parental Stress Scale independent of each other. Sam’s father scored a 36 and his mother scored an 18. There is no normative data to compare their scores to, but the pattern of their responses provides useful clinical data.

Statements that Sam’s father agreed with on the Scale included: “Caring for my children sometimes takes more time and energy than I have to give,” “I sometimes worry whether I am doing enough for my children,” and “Having children leaves little time and flexibility in my life.” These statements are completely consistent with other statements he has made and reflects his anxiety regarding the sudden addition of having to care for Sam again. He felt undecided about statements including “The major source of stress in my life is my children,” “It is difficult to balance different responsibilities because of my children,” and “Having children has meant having too few choices and too little control over my life.” I believe that these statements are more difficult to answer affirmatively to, but the father’s undecided response indicates that this may be a concern for him on some level.

Sam’s mother had a score of 18; she responded to every question in a way that indicates she perceives no stress at all with regard to Sam and her parenting responsibilities. Based upon my observations in the home, the apparent lack of bonding and interaction that she has with Sam, and the simple reality of having three more children to care for, I don’t believe that this is a valid measure of her parental stress. Rather, it is likely that issues relating to social desirability strongly influenced her responses. This is not completely unexpected given her passive traits and the experiences she has had of having her children removed from her by the Child Protection Services system.

Sam’s father is willing to admit to stressors that he experiences, and this assessment provides some direction into how his confidence could be increased with his parenting skills. He requires modeling of appropriate limit setting and interactive play participation, and then additionally requires positive feedback on interactions that he has that are beneficial. He may benefit from a program that incorporates elements of Parent Child Interaction Therapy.

Sam’s mother will require a different approach in terms of facilitating her parenting skills. First, she has to develop some trust with the people providing intervention. It is understandable that this will be a significant obstacle based on her previous experiences that the roles of outside professionals were primarily punitive (from her perspective), despite her own admissions that “young age and stupidity” caused her to lose custody of Sam. After some greater degree of trust is established, it might be useful to re-administer the Parental Stress Scale so that targeted areas for intervention could be determined.


The high rate of recidivism for children within the foster care system is an indicator that families and children would benefit from specific and well-designed programs that facilitate parenting skills. Although this concept is nearly universally accepted, very little research has been done that identifies what interventions are most helpful in promoting positive parenting skills and concomitantly, supporting typical child development. Occupational therapists interact with children in foster care frequently and they require more knowledge of what kinds of parenting interventions are best to use in clinical practice. Literature review substantiates that there is little knowledge available to promote program development for these children and families.

Occupational therapists working with this population of children and families should explore areas for program development and document intervention strategies that support parental skill development. Although the children in the foster care system will demonstrate significant developmental delays in multiple areas, it is critical to also address the larger issues of children’s adapting to reunification and promoting positive parenting practices that support child development.


Abidin, R. (1995). Parenting stress index (PSI) 3rd ed. Odessa, FL : Psychological Assessment Resources, Inc.

Berry, J. O., & Jones, W. H. (1995). The Parental Stress Scale: Initial psychometric evidence. Journal of Social and Personal Relationships, 12, 463-472.

Borrego, Jr., J., Urquiza, A.J., Rasmussen, R.A., & Zebell, N. (1999). Parent-Child Interaction Therapy with a family at high-risk for physical abuse. Child Maltreatment, 4(4), 331-342

Eyberg, S. (1988). Parent Child Interaction Therapy: Integration of Traditional and Behavioral Concerns. Child and Family Behavior Therapy, 10(1), 33-45.

Ganadaki, E. & Magill-Evans, J. (2003). , Mothers' and fathers' interactions with children with motor delays. American Journal of Occupational Therapy, 57, 463-467.

Hanna, K. & Rodger, S. (2002) Towards family-centred practice in paediatric occupational therapy: A review of the literature on parent-therapist collaboration. Australian Occupational Therapy Journal 49 (1), 14-24.

Hinojosa, J., Sproat, C., Mankhetwit, S., & Anderson, J. (2002). Shifts in Parent-therapist Partnerships: Twelve Years of Change. American Journal of Occupational Therapy, 56, 556-563.

Johnson, B. D., Franklin, L. C., Hall, K., & Prieto, L. R. (2000). Parent training through play: Parent-Child Interaction Therapy with a hyperactive child. Family Journal-Counseling & Therapy for Couples & Families, 8, 180-186.

Mayer, M. L., White, B. P., Ward, J. D., & Barnaby, E. M. (2002). Therapists’ perceptions about making a difference in parent-child relationships in early intervention occupational therapy services. American Journal of Occupational Therapy, 56, 411-421.

Nakamura, W.M., Stewart, K.B., & Tatarka, M.E. (2000). Assessing Father-Infant Interactions Using the NCAST Teaching Scale: A Pilot Study. American Journal of Occupational Therapy, 54, 44-51.

Pennington L., McConachie, H. (2001). Predicting patterns of interaction between children with cerebral palsy and their mothers. Developmental Medicine and Child Neurology, 43, 83-90.

Simms, M.D., Dubowitz, H., Szilagyi, M.A. (2000). Health care needs of children in the foster care system. Pediatrics. 106, 909-918.

Terling, T. (1999). The efficacy of family reunification practices: Reentry rates and correlates of reentry for abused and neglected children reunited with their families. Child Abuse & Neglect. 23, 1359-1370.

U.S. Department of Health and Human Services (1992). Intensive foster care reunification programs, Executive Summary. Retrieved March 13, 2004 from

U.S. Department of Health and Human Services (1995). A review of family preservation and family reunification programs. Retrieved March 13, 2004 from

U.S. Department of Health and Human Services. (2003). The AFCARS report: FY 1999, FY 2000, FY 2001 and FY 2002 Foster Care: Entries, Exits, and In Care on the Last Day. Retrieved March 3, 2004, from entryexit2002.htm.

1 comment:

Lisa said...

I just linked to your posting on my blog...

As a former foster child and current child advocate, I am concerned about the recidivism factor in reunification and the risks of further abuse to that child.

Thank you for your time and thoughtfulness in posting this information!