Occupational therapy in the wider healthcare system in the NHS - allied health professionals
Allied Health Professionals (AHPs) are health care professionals distinct from nursing, medicine, and pharmacy [
9]. They are the third largest workforce in the NHS. In the main they are degree level professions and are professionally autonomous practitioners. Presently, 13 of the 14 AHPs are regulated by the Health and Care Professions Council (HCPC) with Osteopaths regulated by the General Osteopathic Council (GOC). Among other roles they are involved with the delivery of health or related services pertaining to the identification, evaluation and prevention of diseases and disorders, dietary and nutrition services, rehabilitation and health systems management.
A recent strategy developed to inform and inspire the healthcare system about how AHPs can be best utilised to support key healthcare transformation initiatives [
10] suggest they can be impactful by 1. improving the health and wellbeing of people and populations 2. supporting and providing solutions to general practice and urgent and emergency services to address demand 3. supporting integration, addressing historical service boundaries to reduce duplication and fragmentation 4. delivering evidence based practice to address unexplained variances in service quality and efficiency.
To deliver this work, the AHPs have entered into four commitments (to the individual, to keep care closer to home, to the health and wellbeing of population and to care for those who care) and four priorities (to lead change, further develop their skills, utilise information and technology and evaluate, improve and evidence the impact of their contribution). Occupational Therapists are essential members of AHP group and committed to support the strategic objectives and priorities so their impact and contribution in the wider healthcare system is enhanced.
Occupational therapy practice and adult ADHD
The ability to synthesise and apply occupational concepts is what uniquely distinguishes occupational therapy from other health professions [
11,
12]. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by working with people and communities to enhance their ability to engage in the occupations they want to, need to, or are expected to do, or by modifying the occupation or the environment to better support their occupational engagement [
13]. There now a renewed understanding of how engagement in occupation is therapy and fundamental to health and wellbeing [
14].
Occupational therapy practice emphasises the occupational nature of humans and the importance of occupational identity [
15]. It provides practical support to empower people to facilitate recovery and overcome barriers preventing them from doing the activities (or occupations) that matter to them and also utilises occupation to maintain health or prevent deterioration.
This support increases people’s independence and satisfaction in all aspects of life. “Occupation” as a term refers to practical and purposeful activities that allow people to live independently and have a sense of identity [
16,
17]. This could be essential day-to-day tasks such as self-care, work or leisure.
Occupations are central to a person’s identity and sense of competence and have particular meaning and value to that individual. Occupational therapists are skilled in evaluating all aspects of the domain, their interrelationships, and the client within his or her contexts and environments (Table
1). Originally founded on humanistic values, occupational therapy emphasised occupation as the positive engagement between the person and the environment to influence overall well-being [
11,
18] whilst other definitions followed and can add to an understanding of this core concept [
14,
19,
20]. Occupations occur in context and are influenced by the interplay among factors of the individual, performance skills, and performance patterns. Occupations occur over time; have purpose, meaning, and perceived utility to the client; and can be observed by others (e.g., preparing a meal) or be known only to the person involved (e.g., learning through reading a textbook). Occupations can involve the execution of multiple activities for completion and can result in various outcomes.
Table 1
Aspects of the domain of occupational therapy. All aspects of the domain transact to support engagement, participation and health
Activities of daily living (ADLs)a Instrumental activities of daily living (IADLs): Rest and sleep, Education, Work, Play, Leisure, Social participation | Values, beliefs and spirituality, Body functions, Body structures | Motor skills, Process skills, Social interaction skills | Habits, Routines, Rituals Roles | Cultural, Personal, Physical, Social Temporal, Virtual |
ADHD affects all aspects of Occupational Functioning: In terms of Client Factors, people with ADHD report low self-esteem [
21] and self-efficacy [
22]. In terms of Contexts and Environments, it affects
educational functioning [
23] with studies in childhood demonstrating disruptive classroom behaviour and academic underperformance, poor grades, poor reading [
24] and overall, adverse long-term effect on academic outcomes [
24‐
26]. Similarly ADHD affects
relationships [
27] and there is evidence that these are particularly affected in the ability to provide emotional support and manage interpersonal conflict [
28] which can lead to divorce [
29] and loneliness [
30].
In terms of Performance Patterns, referring to
employment, there is evidence to imply poor performance; for example, young adults with ADHD were shown to change employment frequently, obtain fewer full time occupations and be more frequently fired [
31]. Similarly, in a follow up study of boys with ADHD aged 4–12 who were initially treated at a university medical clinic, 41% had been fired at least once and 26% were unemployed at follow-up during ages 21–23 [
32].
Another study estimated that adult ADHD was associated with a 4–5% reduction in work performance, a 2.1 relative-odds of sickness absence and a 2.0 relative-odds of workplace accidents and injuries [
33]. A survey undertaken by the World Health Organisation in 10 countries reported that 3.5% of the workers suffered from ADHD resulting in 143 million days of lost production. Workers with ADHD had an average 8.4 excess sickness absence days per year and even higher annualised average excess numbers of work days associated with reduced work quantity (21.7 days) and quality (13.6 days). In addition to this, ADHD has been associated with increased absenteeism [
34,
35], impaired organisational skills [
36] and abilities [
37] and poor time management [
38].
A possible explanation why these Contexts and Environments are affected, may be due to the cognitive impairment which has been documented in ADHD which leads to Performance Skills impairment. We know that both vigilance and sustained attention are impaired in adults with ADHD [
39] so it is expected that ADHD will interfere with task performance due to attentional deficits. Also, impairment is found in cognitive flexibility or set shifting referring to the ability to switch attention from one aspect of an object to another, or to adapt and shift one’s response based on situational demands, such as changes in the rules, schedule, or type of reinforcement in a task [
40,
41].
One of the well documented deficits in ADHD is to their executive function; this is what allows an individual to plan a series of steps necessary to achieve a desired goal, keep these steps in mind whilst acting on the goal, monitor progress through these steps, and have the cognitive flexibility to adjust or change the steps if progress is not being made toward the original goal [
42]. In adults with ADHD, deficits to these functions have been well studied [
43,
44].
Apart from deficits in attention and executive function, children [
45] and adults [
46] with ADHD also have working memory deficits which can affect performance.
Occupational therapists have skills and competencies unique in understanding and affecting change in adult ADHD which affects many domains of a person’s occupation. Although the theoretical case can be made, there is need for further research to evidence the effects for occupational therapy interventions in adult ADHD.
Occupational therapy practice models and adult ADHD
Best practice requires that therapists thoughtfully choose the models that fit their views of the purpose and focus of therapy, as well as support their ability to understand and explain the specific challenges faced by their clients [
47]. “The therapist should collaborate with the person to establish the priority occupational areas which will be the focus of occupational therapy intervention. Assessment of current performance in these occupational areas will guide appropriate intervention strategies, which may focus on compensating for the challenges, developing skills or enhancing/developing performance components.” Subsequently, the occupational therapist may draw from a range of suitable models to guide intervention Occupational therapy has a wide variety of models available to understand the people’s occupations. There is no consensus as to the single model which should be used in all circumstances. The Canadian Model of Occupational Performance (CMOP) [
48], Person-Environment-Occupation-Performance Model (PEOP) [
49,
50] and Model of Human Occupation (MOHO) [
51] models are all acceptable in practice although a unified and flexible approach is recommended for people with Adult ADHD. A therapist who begins with an occupation-focused model as the organising model of practice will have gathered essential information about occupational roles and priorities up front and will be reminded to ensure that therapy sessions reflect client-centred goals and interests. This client-centred therapy focus fits well with the recent emphasis on patient-centred measures of satisfaction in healthcare [
52].
Occupational therapy approaches and adult ADHD
Interventions for ADHD are mainly focused on how symptom reduction can be achieved with either Medicines or Psychological Interventions [
5]. However although useful, these do not provide guidance on how interventions can be structured to deliver ‘real life’ benefits beyond symptom reduction or increase participation, bearing in mind that symptom reduction alone does not always produce improvement in daily functioning [
53].
From previous work, we found that the framework proposed by the ADHD Star can be a useful guide to multidisciplinary interventions based on the ADHD Star domains ‘Focus and Attention’, ‘Friends and Social Life’, ‘Physical Health’, ‘How you Feel’ “Understanding your ADHD”, “Organising yourself”, “Thinking and reacting” and “Meaningful use of time” [
54]. To this framework, the Occupational Therapy Models of Practice can be deployed using the different frames of reference depending on the needs of the individual.
Interventions consider what the therapist and client identify to work on during a treatment session. Interventions are defined from the Occupational Therapy Practice Framework [
55] and include preparatory methods, purposeful activities and occupation-based interventions.
Preparatory methods are techniques that prepare a client to participate in occupations and for our purpose can be a discussion and completion of the ADHD Star.
Purposeful activities suggest that the client participate in activities that help improve skills that would enhance occupational performance, such as gardening, joining a social group, doing voluntary work etc.
Occupation-based intervention is when a client, in therapy, engages in occupations that match his or her identified goals, which may include cooking in a kitchen, getting dressed in his or her room, and travelling independently. Observations are made on how the therapist describes the interventions to the client and if they relate to the client’s goals. The Occupational therapist will use a graded approach and adapt the demands of the occupation, the environmental context or the support provided to maximise independence, skill acquisition and self-efficacy.