The occupational therapy discipline is built on several foundational theories that are fascinating, but they can also feel drawn out and extremely challenging to digest. So, we have decided to assist OT students and OT practitioners by providing summarized highlights of the OT frames of reference all in one place.
But first, let’s get past some confusing terminology. What is the difference between occupational therapy theories, models, and frames of reference?
Furthermore, what is the role of all these constructs in OT evaluation and intervention? Here is a short explanation to clear up the confusion:
A theory is a well-backed explanation of why something in the natural world is what it is or operates the way it does. For example, the PEO frame of reference is based off the theory that there is an existing interaction between person, environment, and occupation. Researchers use theories to develop and test hypotheses in hopes to further build valid and reliable constructs or models.
A model is a purposeful representation of reality in approximation to a theory. Sometimes, the terms “model” and “frame of reference” are used interchangeably in occupational therapy, which is seen in describing the Occupational Adaptation (OA) model and the Biomechanical model.
Conceptual models (such as the Intentional Relationship model) are not included in this article. In occupational therapy, the model is a mode for which therapists can use to organize their thinking, skills, and vocabulary for their profession.
A frame of reference is considered a guidance tool for practical application. Mosey (1989) defines frames of reference as “integrated collections of theoretically based information, organized in such a way that they provide guidelines for problem identification and remediation as it relates to specified elements of the profession’s domain of concern”. So, an OT would use a frame of reference as a “how-to” device for evaluation and intervention.
With that being said, we’ll proceed with the 25 occupational therapy frames of reference currently in use by our profession or that are still heavily discussed in OT school.
The overall goal of the Acquisitional Frame of Reference is the acquisition of skills and behaviors used to optimize performance within a given environment using the teaching-learning process. Children need to acquire functional behaviors in order to be successful in their environment.
Therapists use positive and negative reinforcement strategies to help children shape and achieve target skills and behaviors, and then eventually generalize the mastered skills and behaviors for everyday use. The primary example is teaching children appropriate skills and behaviors to complete activities of daily living.
Target population: Children; all disabilities
The main feature of this model is the use of behavioral modification, a technique used to shape behaviors, to increase adaptive behaviors, and to reduce maladaptive behaviors. OTs who use behavior modification in practice generally target persons who need social skills training, so children and individuals with psychiatric disorders.
This frame of reference uses elements such as stimuli (unconditioned, conditioned), reinforcement, extinction, backward chaining, systematic desensitization, and token economy as forms of intervention to achieve target behaviors that improve performance.
Target population: People across the entire age span; all disabilities
The Biomechanical Frame of Reference is a remedial approach to intervention that focuses on impairments that inhibit functional performance. Goals include using therapeutic and occupation-based activities such as ADL training to remediate existing impairments (i.e. movement-related), to prevent further deterioration (i.e contractures, muscle atrophy), and to provide compensatory/adaptive strategies for loss of movement.
Impairments that affect functional movement and joint range of motion may include reduced muscle strength or decreased muscle endurance due to multiple medication conditions (i.e. stroke, injury, etc.). From the Biomechanical frame of reference emerges assessments and interventions for muscular strengthening, passive/active range-of-motion, increasing activity tolerance, creating static and dynamic orthoses, ADL performance, and work hardening, as examples.
Target population: People across the age span; physical and neurological disabilities
The overall intent of this frame of reference is to assist the development of postural reactions in individuals who are unable to maintain typical postural alignment via automatic muscle activity. The underlying theory is that sensory stimulations develop from interaction with the environment and that autonomic motor responses, such as equilibrium, are needed for typical posture.
Intervention techniques may include gravity-eliminating activities, using external supports, and providing proximal body stability to improve distal participation with the use of prescribed assistive devices. The overall goals of intervention are to improve client’s participation in functional daily activities.
Target population: Children; disabilities which impair movement/mobility
The Cognitive-Behavioral frame of reference focuses on five interrelated aspects of life experience: behaviors, thoughts, emotion, physiological responses, and the environment (social and physical). Beck’s (1976) hierarchical levels of cognition is a unique feature of this FOR, starting from the most accessible thoughts (automatic thoughts) and moving up the cognitive to “beliefs” (conditional beliefs) and then “core schema” (absolute beliefs).
Interventions that stem from the Cognitive-Behavioral frame of reference include cognitive behavior techniques such as deep breathing, systematic desensitization, activity diaries, and graded activity scheduling for people with impacted cognitive function (i.e. anxiety, phobias, etc.). Often times, this FOR is used in conjunction with other occupation-based models to further establish details about a client’s/patient’s functional needs.
Target population: People across the age span; all disabilities
The Compensatory Frame of Reference uses just that…compensatory techniques to improve occupational performance. This includes adopting the use of assistive devices/equipment to facilitate independence despite dysfunction. This frame of reference also includes the use of environmental modifications to living areas and using splints where appropriate.
For appropriate use of this model, the therapist and patient have concluded that dysfunction is permanent and irreversible. The compensatory frame of reference does include a little snippet regarding cognitive compensation such as memory and concentration techniques. Oftentimes, educational models are used in conjunction with this model to assist the client in understanding the purpose and proper use of assistive devices and techniques to compensate for dysfunction.
Target population: People across the age span; all disabilities
The Developmental Frame of Reference suggests that human development happens in a pattern of sequence from infancy to adulthood. The underlying theory is that people are dynamic, and that individual behavior is influenced from mastery of previous stages in development (i.e. learning how to walk is dependent on mastery of static standing).
The Developmental FOR acknowledges 6 adaptive skills areas: sensory integration, cognitive skill, dyadic interaction skill, group interaction skill, self-identity skill, and sexual identity skill. Each are is mastered at age-appropriate times in lift and healthy development of all of these areas is essential to achieve healthy coping behaviors and forming relationships.
Therapists work on assisting persons to develop these skills and to master milestones at age-appropriate intervals and to prevent the development of maladaptive behaviors and skills.
Target population: People across all ages; all disabilities
This frame of reference helps therapist’s focus their examination of function in five areas of handwriting for kids: proximal posture, components (i.e. ocular motor skills, attention, and visual-perceptual skills), use of writing tools, grasp, and handwriting. Distal control (of the hand) cannot be achieved without good proximal control (the spine).
The end-goal is to produce handwriting that is readable and completed within an appropriate time interval. Therapy assessment includes inspecting legibility, spacing, and letter size for school-based handwriting.
Target population: Children; disabilities that impair handwriting
Based on key principles for the learning theory, this frame of reference focuses on helping learners acquire motor skills for functional participation. Primary terms include ability, characteristics of the task, required skills, the environment, and regulatory conditions (from which emerges the continuum between closed and open tasks).
Closed tasks are performed in environments that are stagnant with little variability such as brushing one’s hair or teeth. Open tasks are performed in environments that are in motion and that require variability in movement with each demand (i.e. competing in an athletic sport like football or basketball). Acquiring a motor skill involves active problem-solving, self-evaluation, and planning based on the therapist’s (or facilitator’s) feedback.
Target population: Children; developmental disabilities
The Neuro-Developmental Frame of Reference is used by therapists to treat posture and movement-related impairments commonly seen in cerebral palsy and post-stroke. Its intervention approaches are rooted in kinesiology and biomechanics. Key elements of the NDT frame of reference include: alignment, planes of movement, range of motion, base of support, postural control, weight shift, mobility, and muscle strength.
As opposed to compensatory ideologies, NDT postulates that impairments to function can be changed or remediated. There are no current standardized tools stemming from this frame of reference since evaluation of each person is particularly unique.
Neuro-developmental intervention strategies include therapeutic handling, graded application of manual forces, and directional cueing to promote newly learned movements. Learning new movements in therapy is for the purpose of enhancing participation in functional tasks.
Target population: People across the age span; neurological (CNS) impairments
The Brunnstrom Frame of Reference, or Movement Therapy, is considered the opposite of NDT. The approach uses primitive synergistic patterns in order to improve motor control, posing that damage to the central nervous system causes a person to regress to less mature movement patterns. Therapists teach the patient to voluntarily control motor patterns during recovery using any abnormal limb synergy patterns to their advantage.
The process of recovery includes seven stages: flaccidity, spasticity, gained voluntary control through synergies (increased spasticity), patterns outside of synergy develop (decreased spasticity), complex movement combinations form (further decreased spasticity), disappearance of spasticity, normal function in restored.
Target population: People across the age span; movement-related disorders
The Proprioceptive Neuromuscular Facilitation Frame of Reference focuses on specialized flexibility training. A combination of stretching and muscle contraction are used to increase range-of-motion (often in short-term effects) for functional performance. Therapeutic measurements include passive range of motion, active range of motion, peak torque, and muscle strength. PNF is used to increase muscle elasticity while preventing or minimizing risk for injury.
Target population: People across the age span; those with disabilities and damage to muscle
The Occupational Adaptation Model (OAM) is considered an OT frame of reference which combines the use of a self-perceived meaningful activity (occupation) and a person’s adaptive response to overcome an occupational challenge. The key term popularly referred to in therapy from this FOR is “relative mastery” or assessment of mastering a skill based on the client’s perspective.
A person’s interaction with the environment develops competency in occupations by having him/her/them overcoming environmental demands thus mastering their chosen activity. During intervention planning, clients are asked to select meaningful activities that they wish to master in consideration to their environment and roles. Despite OAM being referred to as a model, it is still technically considered an occupational therapy frame of reference.
Target population: People across the age span; all disabilities
The Occupational Adaptation Frame of Reference is not necessarily the same as the above-mentioned OAM. There is a heavier focus on the adaptation process experienced by the individual when they come across occupational barriers or challenges. Three key terms for this FOR include person, the occupational environment, and the interaction between the person and the occupational environment.
The person is comprised of sensorimotor, cognitive, and psychosocial systems. The occupational environment includes areas such as work, play, leisure, and self-maintenance. This interaction fosters the need for mastery in occupational performance. Occupational adaptation begins with the occupational challenge and how the person perceives the challenge in order gauge performance.
This FOR emphasizes the use of sub-processes within this interaction including the adaptive response generation, the adaptive response evaluation, and the adaptive response integration. All of these sub-processes lead up to creating an appropriate occupational response to the occupational performance, leading to occupational adaptation.
Target population: People across the age span; all disabilities
The Frame of Reference for Visual Perception emphasizes a top-down approach (impact on occupational performance first before identifying underlying deficit) to identify and to provide adaptive/compensatory strategies for visual perceptual deficits that limit functional occupational performance.
Rooted theories include education, developmental psychology, cognition, and Warren’s developmental hierarchy of visual-perceptual cues that include areas such as oculomotor control, visual fields, and visual acuity. However, this FOR poses that not all visual-perceptual deficits are dependent on this hierarchy and that one deficit doesn’t necessarily impact other deficits.
Visual perception can be learned from practice and life experience with the incorporation of cognitive and receptive skills. Therapists incorporate both remedial and adaptive interventions to enhance functional participation.
Target population: People across the age span; disabilities impairing visual perceptual skills
The Psychodynamic Frame of Reference has its roots in Freud’s theories of ego and its roles in developing and maintaining healthy relationships. Conflicts occur when there is a breakdown in the ego defense mechanism. Therapy focuses on two approaches: explorative and supportive.
Explorative interventions aide in surfacing conflicts from the unconscious mind to the conscious min in order to resolve the issues and to promote expression of feelings. Supportive interventions keep conflicts hidden in the unconscious while strengthening the ego defense mechanism. The goal of both approaches is to enhance typical psychosocial development and social interaction.
Target population: People across the age span; psychological/mental health disorders
Not to be confused with the Psychodynamic Frame of Reference, the Psychoanalytic Frame of Reference is based on the Vivaio model (MOVI) which emphasizes recognizing constant emotions that exist in the relationship between the patient, therapist, and “doing”. Each of these three elements communicate and effect each other to create what is referred to as a dynamic transference or unconscious connection with past or present relationships).
MOVI is comprised of seven interconnected components: Evaluation, the interaction process, the space and time settings, choice and play, materials and transformations, sensory experience and though, and nonhuman environment. OTs benefit from this FOR by using it as a means to assess the meaning of “doing” and the unconscious elements of the therapeutic relationship.
Target population: People across the age span; all disabilities
The Psychospiritual Frame of Reference focuses on spirituality and the expression of it in occupation and related behavior as it relates to health and well-being. Spirituality is considered a construct of six dimensions: becoming, meaning, being, centeredness, connectedness, and transcendence.
All dimensions are interconnected, and if there is limitations in one or more dimensions that spiritual occupation is negatively impacted (i.e. spiritual deprivation, community spiritual deprivation, spiritual latency, etc.). Activities are categorized under human occupation as “spiritual occupation” which can include examples such as meditation, prayer, scripture-reading, singing, etc.
Target population: People across the age span; all disabilities
The Rehabilitative Frame of Reference focuses on facilitating patients to fulfill meaningful activities and social roles in a competent manner. The underlying assumption for this frame of reference is that clients/patients have impairments that are not likely to be remediated or are permanent in nature, whether it’s due to physical deficits or lack of motivation for remediation on the client’s part.
The clients are encouraged to focus on abilities that remain and to attain their highest level of function through adaptation, compensation, and environmental modifications. Interventions that stem from this FOR include energy conservation, work simplification, and home modifications.
Target population: People across the age span; all disabilities
The Sensory Integration Frame of Reference, originating from the work of Dr. Jean Ayers, focuses on how individuals’ sensory systems (auditory, visual, gustatory, interoceptive, tactile, vestibular, proprioceptive) interact with and integration information from the environment. Sensory integration is broken down into abilities such as sensory modulation, sensory discrimination, sequencing, self-regulation, postural and ocular control, and praxis.
Desired outcomes of intervention include the individual successfully participating in meaningful daily tasks. SI requires a particularly structured therapeutic environment in order to grade sensory input intensity dependent on the unique needs of each client (typically children).
Target population: Children; people with sensory processing disorders
The Social Participation Frame of Reference emphasizes the power of emotion and its purpose to motivate children in social engagement. Children adoptive and regulate emotions in response to what they have learned interacting with parents and/or caregivers from an early age.
Children with disabilities may present with a decreased ability to modulate physical, physiological, and cognitive (i.e. attention) processes related to emotional regulation which affects social participation. Temperament of a child may change structured routines at home which further complicates their abilities to participate in regular social activities.
The social participation FOR has seven areas of social functioning: temperament adaptation, emotional regulation, family habits and routines, environmental supports, social participation in school, environment for peer interaction, and peer interaction.
Target population: Children; physical and mental disabilities
The Cognitive Disabilities Frame of Reference is based on Jean Piaget’s stages of cognitive development in cognitive behavioral theory. Cognitive disability is considered a limitation in sensorimotor-based actions that originate from structures of the brain that cause impairment in routine task behavior.
There is the notion that cognitive behavior is based on biological factors that can be improved or changed. Once maximum cognitive level has been accomplished, then therapists put into place compensatory techniques for biological, psychological, and environmental factors. Cognitive performance is broken down across a six-level continuum (Allen’s Cognitive Levels). Task performance involves attention, motor actions, and conscious awareness.
Target population: People across the age span; cognitive disabilities
Although it is described as model, past and current OT literature also considers the Model of Human Occupations (MOHO) a frame of reference. This makes sense since it is filled with intervention and evaluation techniques that are of the most used among occupational therapists today.
Initially based on the Occupational Behavioral Model by Mary Reilly, MOHO was further developed and introduced to the OT profession by Gary Kielhofner. Humans are considered open systems that go through growth and development through ongoing interaction with their environment.
This interaction is broken down into four phases: input, throughput, output, and feedback. Through these phases come self-maintenance and change. This open system also includes three subsystems: volition, habituation, and performance.
Target population: People across the age span; all disabilities
Rooted in learning theory, the Role Acquisition Frame of Reference addresses how individuals learn life skills that help them function within social environments. OTs address and teach clients/patients about how to learn and adopt new social roles, to transition between multiple roles, and to adapt to changes in current roles.
Learning is considered a fluid process that starts with the client’s current level of function and becomes more mastered and advanced as he/she becomes more skilled. Behavior is an adaptive response to our social, cultural, and physical environments which provides positive and negative reinforcements to shape overall behavior.
Target population: People across the age span; all disabilities
A fairly unknown concept in OT, the Spatiotemporal Adaptation Frame of Reference is considered a process by which a person discovers and absorbs new information from the environment which forms into a developmental sequence. This process involves four components: assimilation, accommodation, association, and differentiation.
The primary focus is on motor-based behaviors which assists the child in other developmental areas of his/her/their life. Through adaptation, the child can attain a higher level of function in meaningful tasks such as play, work, and self-care.
Target population: Children; physical, mental, and developmental disabilities
All of the occupational therapy frames of reference we’ve covered in this article really only showcase only a small representation of the complexity each one truly presents.
We highly recommend that both OT students and practitioners read through full descriptions of each frame of reference when you feel it is necessary. This could be in preparation for the NBCOT, refreshers for CEU credit, and for appropriate use in your own research and course and intervention development.
If we’ve missed an OT frame of reference that you would add to this list, please let us know in the comments below. If you found this article helpful, please share it with any other OT or OT student in your life that you think would benefit from it.
Mosey, A.C. (1992), updated in 2020. Partitions of Occupational Science and Occupational Therapy. American Journal of Occupational Therapy, 46: 851-853. https://doi.org/10.5014/ajot.46.9.851.
This post was originally published on April 12, 2021 and last updated on January 14, 2024.
