Cognitive Orientation

to Daily Occupational Performance

(CO-OP):
Part III--
The Protocol in Brief
Helene J. Polatajko
Angela D. Mandich
Cheryl Missiuna
Linda T. Miller
Jennifer J. Macnab
Theresa Malloy-Miller
Elizabeth A. Kinsella
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Helene J. Polatajko, PhD, OT(C), is Professor and Chair,Department ofOccupa-

tionalTherapy;Professor,DepartmentofRehabilitationScience,FacultyofMedicine,
UniversityofToronto,Toronto,Ontario,Canada;andProfessor,FacultyofEducation,
The University of Western Ontario, London,Ontario, Canada.Angela D.Mandich,
MSc,OT(C) isdoctoral candidate,School ofKinesiology, and Instructor, School of
Occupational Therapy, The University of Western Ontario. Cheryl Missiuna,PhD,
OT(C)isAssistant Professor,SchoolofRehabilitationScience,andCo-Investigator,
CanChildCentreforChildhoodDisabilityResearch,McMasterUniversity,Hamilton,
Ontario,Canada.LindaT.Miller,PhD,isAssistant Professor,School ofOccupational
Therapy, Faculty ofHealth Sciences,The University of Western Ontario. JenniferJ.
Macnab,BA,isadoctoral candidate,Department ofEpidemiology &Biostatistics,
FacultyofMedicine,TheUniversityofWesternOntario.TheresaMalloy-Miller,M Sc,
For personal use only.

OT(C),isOccupationalTherapist,ThamesValley ChildrenCentre,London,Ontario,
Canada. All of the above authors aremembers ofthe Developmental Coordination
DisorderResearchGroup.ElizabethA.Kinsella,MAEd,OT(C)isdoctoralcandidate,
Faculty of Education, The University of Western Ontario.
Address correspondence to: Helene J. Polatajko, PhD, OT(C), Department of
Occupational Therapy, Faculty of Medicine, University of Toronto, 256 McCaul
Street, Toronto, Ontario, Canada, M5T 1W5 (E-mail: h.polatajko@utoronto.ca).
[Haworth co-indexing entry note]: ‘‘Cognitive Orientation to Daily Occupational Performance (CO-
OP): Part III--The Protocol in Brief.’’ Polatajko, Helene J. et al. Co-published simultaneously in Physical &
Occupational Therapy in Pediatrics (The Haworth Press, Inc.) Vol. 20, No. 2/3, 2001, pp. 107-123; and:
Children with Developmental Coordination Disorder: Strategies for Success (ed: Cheryl Missiuna) The
Haworth Press, Inc., 2001, pp. 107-123. Single or multiple copies of this article are available for a fee from
The Haworth Document Delivery Service [1-800-342-9678, 9:00 a.m. - 5:00 p.m. (EST). E-mail address:
getinfo@haworthpressinc.com].

E 2001 by The Haworth Press, Inc. All rights reserved. 107

 108 CHILDREN WITH DEVELOPMENTAL COORDINATION DISORDER

SUMMARY. Parts I and II of this series introduced the Cognitive

Orientation to daily Occupational Performance (CO-OP), a new ap-
proach to intervention that is based on the premise that cognition plays
an important role in the acquisition of occupational skills and the devel-
opment of occupational competency. Developed for use with children
who have occupational performance deficits, CO-OP is an individual-
ized, client-centred approach focused on strategy-based skill acquisi-
tion. This third paper in this series presents a brief description of the
actual CO-OP protocol including its objectives, prerequisites and key
features. [Article copies available for a fee from The Haworth Document
DeliveryService:1 -800-342-9678.E-maila ddress:<getinfo@haworthpressinc.
com>Website:<http://www.HaworthPress.com>E2001byTheHaworthPress,
Inc. All rights reserved.]

KEYWORDS. Cognitive approach, intervention, DCD, CO-OP

Cognitive Orientation to daily Occupational Performance (CO-

OP) is an approach to intervention that uses the power of cognition to
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drive successful performance. The CO-OP approach is based on the

premise that cognition plays an important role in the acquisition of
occupational skills and, by extension, the development of occupa-
tional competency. Created for use with children who have occupa-
tional performance deficits, the CO-OP approach can be used to
promote the acquisition of new skills and the improvement of exist-
ing skills. In CO-OP, intervention focuses on the use of cognitive
strategies to solve performance problems and to develop occupation-
al competency.
CO-OP developed as an intervention approach as a result of re-
For personal use only.

search being performed with children with Developmental Coordina-

tion Disorder (DCD).* These children (see Polatajko 1 for a descrip-
tion) appear to have difficulty with the motor aspects of performance,
particularly when a novel motor task is to be performed. Traditionally,
therapy for these children has focused on reducing the underlying
motor impairment (see Mandich, Polatajko, Macnab, & Miller, this
volume, for a description 2). These approaches, based on sensory-mo-
tor (reflex-hierarchical) models of motor development, conceptualize

*Although to dateCO-OPhasonly beenformally investigatedwith childrenwith

DCD. Early experience with other clients suggests that, like other cognitive ap-
proaches, CO-OP is likely to have applications with other populations.
 Polatajko et al. 109

the motor performance problems of these children as stemming from

some form of sensory, sensory-motor or sensory-integrative deficit
and treatment is designed to ameliorate these underlying deficits. For
the most part, these are physical approaches. During treatment, the
child is actively engaged in a large variety of activities, often develop-
mentally sequenced, that provide the sensory, sensory-motor, or sen-
sory integrative experiences that are considered to be fundamental to
motor performance. The assumption is that exposure to such activities
will foster the development of these fundamental skills and conse-
quently improve motor performance.3
CO-OP represents a different orientation to this traditional ap-
proach. In contrast with traditional approaches, CO-OP treatment is
focused directly on occupational performance issues and is a verbal
approach. During treatment, the child is actively engaged in solving
performance problems and testing out solutions. The assumption is
that performance is the result of the interaction between the child, the
environment, and the occupation 4 and that cognitive strategies can be
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used to drive performance.5

CO-OP was developed in response to a need for an alternative to
the established approaches to the treatment of children with DCD.
For the most part, the more traditional approaches were quite costly
and time-consuming, with treatments being lengthy and progress
being slow. As well, there was mounting evidence that they were
relatively ineffective.2 Based on the results of a treatment outcome
study in which the only positive effect found was for a direct skill-
teaching task,6 it was hypothesized that DCD was essentially a motor
learning disability and that treatment should be approached from a
skill acquisition or learning perspective, rather than a neuro-develop-
For personal use only.

mental perspective.7
The learning literature, in particular the cognitive behavior modifi-
cation literature, was examined in search of a new approach to the
treatment of the performance problems of children with DCD. As
well, the contemporary motor literature was searched for a potential
model of motor performance. Both bodies of literature supported the
exploration of an approach embedded in a learning paradigm. The
cognitive behavioral literature, particularly the work of Meichen-
baum,8 provided a potential framework. Verbal self-instruction, using
the global problem solving strategy used by Meichenbaum in his
cognitive behavioral approach was adopted as a cornerstone for the
new approach. This was augmented by the mediational techniques of
 110 CHILDREN WITH DEVELOPMENTAL COORDINATION DISORDER

Feuerstein and colleagues.9,10 Finally the principles of client-centred

practice espoused by the Canadian Association of Occupational Ther-
apists11 were embedded throughout. The result was the development
of a new, child-centred, cognitive oriented approach to enabling occu-
pational performance, called Cognitive Orientation to daily Occupa-
tional Performance, ‘‘CO-OP,’’ for short.
CO-OP has been under development since 1991. The initial ver-
sion, called Verbal Self-Guidance (VSG),12,13 stressed the verbal
guidance aspect of the approach. Results of this original study were
promising so it was decided to continue to develop and test the ap-
proach. Martini14-16 demonstrated that the results could be replicated
with a different therapist. Closer examination of the approach by Man-
dich 17,18 showed that verbal self-guidance was only one of the fea-
tures of this approach; that there were a number of additional cognitive
strategies used throughout the therapy. To emphasize the importance
of cognitive strategies, the name was changed to CO-OP.
Continued use of the CO-OP approach, within a research paradigm,
has reinforced the original findings and provided evidence of the
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effectiveness of the approach, with numerous children, across several

therapists.19 Experience with the training of therapists in the CO-OP
approach has resulted in the elucidation of the key features of this
approach and has allowed for the refinement of the treatment protocol.
What is presented in this third paper in the series, is a brief description
of this protocol-- it is beyond the scope of this paper to present a full, in
depth description of the protocol.*

THE CO-OP APPROACH IN BRIEF

For personal use only.

Cognitive Orientation to daily Occupational Performance (CO-

OP) is an individualized, client-centred approach focused on strate-
gy-based skill acquisition. CO-OP is essentially a cognitive approach
to solving daily occupational performance problems. While acknowl-
edging that occupational performance is a complex multivariate phe-
nomenon resulting from the interaction of person, environment and

*The reader iscautioned that,in theexperience ofthe authors,a written descrip-

tion of the approach appears to be insuficient to allowfor itsproficient use.Experi-
ence with training therapists has highlighted the extent to which this approach
represents a deviation from traditional perspectives and,therefore, requireshands-
on-training.
 Polatajko et al. 111

occupation,11,20-28 the CO-OP approach focuses on the primacy of

cognition and strategy use in skill acquisition and the development of
occupational competency. In CO-OP, a global problem-solving strat-
egy is used to frame the development of domain specific strategies
that enable successful task performance and promote skill acquisi-
tion. CO-OP is a highly verbal approach in which cognitive strategies
are mapped onto performance to facilitate and support performance.
Objectives
CO-OP has three basic objectives:

S Skill acquisition: the child learns to perform the required or de-

sired skills. In CO-OP, a client-centred approach is used to identi-
fy the skills to be learned. The Canadian Occupational Perfor-
mance Measure (COPM)24 is used with the child to identify the
three skills that he/she needs to, wants to, or is expected to do at
school, home, or play that will be the focus of treatment. The
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COPM is a self-report measure that allows children to rate both

their level of performance and satisfaction when carrying out
tasks that they need to do on a regular basis.
S Cognitive strategy development: the child learns to use a global
problem solving strategy to frame the discovery of domain spe-
cific strategies that will solve performance problems and thereby,
improve performance and promote skill acquisition.
S Generalization and transfer: the child uses the newly acquired
skills and strategies beyond the treatment session, in everyday
life, and these skills and strategies serve as a foundation for
learning related skills and strategies.
For personal use only.

Prerequisites

For the CO-OP approach to be successful, there are a number of

prerequisites for all involved: the child, his/her parents and/or caregiv-
ers and the therapist.
To benefit from the CO-OP approach, the child must:
S have sufficient cognitive and language ability to respond to the
COPM;
S be able to identify three occupational goals;
S be able to respond and attend to the therapist;
 112 CHILDREN WITH DEVELOPMENTAL COORDINATION DISORDER

S have the potential to perform the task; and

S have the motivation to learn three skills.

The approach is most successful if the parents and/or caregivers are

involved and committed to implementing the approach beyond the
treatment arena. Prior to beginning the intervention, it is ideal if thera-
pists develop a partnership with parents, such that parents are com-
mitted to participating in the therapy sessions and to implementing
CO-OP at home. It is important that parents understand the role that
they play in helping their child acquire skills, develop cognitive strate-
gies, and transfer and generalize these into everyday life.
To be able to implement the CO-OP approach successfully, the
therapist must already bring with him or her effective communication
skills, experience with the management of children with disabilities in
a child-centered framework, excellent skills in task analysis, and a
commitment to working with parents. In addition, the therapist must
become proficient in the CO-OP approach.
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KEY FEATURES OF THE CO-OP APPROACH

There are six key features to the CO-OP approach: session struc-
ture, child-chosen goals, dynamic performance analysis, cognitive
strategies, enabling principles and parent/caregiver involvement (see
Figure 1). Each is briefly described.

FIGURE 1. Key Features of CO-OP

For personal use only.

Cognitive Orientation to Daily

Occupational Performance
(CO-OP)

Parent/
Session Child Dynamic Cognitive Enabling Caregiver
Chosen Performance Strategies Principles
Structure Involvement
Goals Analysis

Domain
Global Specific
Strategy Strategies
 Polatajko et al. 113

Session Structure
In Cognitive Orientation to daily Occupational Performance (CO-
OP) the therapy sessions are offered according to a structured format
(see Figure 2). CO-OP is usually delivered over twelve, one-to-one
sessions, each of approximately one hour in length. Parents and/or
caregivers are encouraged to observe as frequently as possible, in
order to encourage generalization and transfer. The therapy process is
divided into five phases: Preparation, Assessment, Introduction, Ac-
quisition and Consolidation.
Child-Chosen Goals
CO-OP is a child-centred approach. The child’s perspective is of
central importance throughout, beginning with the process of goal
setting and continuing throughout the intervention. A child-centered
approach is used for several reasons. First it is consistent with a gener-
al trend in health care recognizing that children should have a voice in
the interventions that concern them29-31 and second it is also consis-
tent with the client-centered philosophy of occupational therapy.11
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Further, Meichenbaum8 has emphasized the importance of the child as

a collaborator in the cognitive behavioral approach. He declared, ‘‘the
children we treat have a great deal to tell us if we would only ask and
then listen’’ (p. 96). Finally having children choose their own goals
ensures ecological relevance, which promotes motivation, transfer and
generalization. A daily activity log is provided to the child in advance
of the goal-setting session. The log helps children reflect upon the
activities that they do each day. At the beginning of the assessment
phase, the COPM is used to ensure that the goals that will be focused
on during intervention are child-chosen.
For personal use only.

Dynamic Performance Analysis

The third key feature of CO-OP is dynamic performance analysis
(DPA), a dynamic and iterative process of performance analysis, as it
happens. (For a detailed discussion of DPA, please see Polatajko et
al.32) DPA was developed in concert with the CO-OP approach to
allow for continuous evaluation of performance and to structure the
problem solving process. DPA begins during the first session and
continues throughout the intervention. The purpose of DPA is to solve
performance problems by identifying where performance breaks
down, identifying possible solutions and testing them out in a trial and
error fashion.
 114 CHILDREN WITH DEVELOPMENTAL COORDINATION DISORDER

FIGURE 2. Session Structure: CO-OP Intervention Protocol

Prior to Therapy Preparation

1. Establish contact with parents
2. Orient parents to Cognitive Orientation to daily Occupational
Performance (CO-OP)
3. Contract with parents to ensure resources and support
4. Provide Daily Activity Log
5. Check for child/parent and therapist prerequisites

Session 1 Assessment
6. Review child’s completed Daily Activity Log
7. Administer Canadian Occupational Performance Measure
(COPM) and identify three goals
8. Baseline child’s performance using the Performance Quality
Rating Scale (PQRS)

Session 2 Introduction of Global Cognitive Strategy

9. Introduce Global Cognitive Strategy: Goal-Plan-Do-Check
1. Therapist introduces the puppet, Commander GoalPlan
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DoCheck
2. Therapist maps Goal-Plan-Do-Check (GPDC)
to a familiar task
3. Child maps Goal-Plan-Do-Check to a familiar task
4. Parents observe session and discuss application of
GPDC at home

Sessions 3-11 Acquisition

10. Conduct Dynamic Performance Analysis: Ongoing
11. Facilitate the child’s acquisition and application of the Global
Cognitive Strategy: Goal-Plan-Do-Check
12. Guide discovery of Domain Specific Strategies (DSS) and
mediate their application to skill acquisition
For personal use only.

13. Apply Enabling Principles

14. Teach parents/caregivers about Goal-Plan-Do-Check and
applicable Domain Specific Strategies
15. Educate parents/caregivers about their ongoing role in
facilitating cognitive strategy use to promote skill acquisition

Session 12 Consolidation
16. Re-administer COPM
17. Re-administer baseline, using PQRS
18. Probe child for generalization and transfer of Global and
Domain Specific Strategies: GPDC and DSS
19. Review and reinforce CO-OP approach, and cognitive
strategy use with parents/caregivers
 Polatajko et al. 115

Dynamic performance analysis (DPA) is based on three assump-

tions regarding occupational performance: that motivation is a neces-
sary prerequisite for successful performance; that an individual re-
quires adequate knowledge of a task before he or she can successfully
perform the task and that occupational performance is the result of the
interaction of person, occupation, and environment.

S Motivation: In the motor learning literature, it has been well docu-

mented that an individual’s motivation for participation in a task:
(a) affects learning, (b) influences the acquisition of skill, task per-
formance, and task persistence, (c) enhances the ability to deploy
existing skills and knowledge, and (d) affects the willingness to
continue when the task becomes exceedingly challenging.33 If
task motivation is not present, it will be very difficult, if not im-
possible, to carry out a valid performance analysis. In the CO-OP
approach, motivation is ensured by the child-centred approach.
S Task Knowledge: Pressley, Borkowski and Schneider5 have
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noted that a prerequisite to performance is an understanding of

the task requirements. Brown, Pressley, Van Meter and Schud-
er34 have provided evidence that task knowledge is integral to
strategy development for performance. If at least rudimentary
task knowledge is not present, it will also be difficult, if not im-
possible, to carry out a valid performance analysis. The study of
the CO-OP approach by Mandich and colleagues18 showed that
task knowledge is often inadequate to support task performance
in children with DCD, and that supplementing task knowledge
results in improved performance.
For personal use only.

S Occupational Performance: In the occupational therapy litera-

ture it is generally believed that occupational performance is the
result of the interaction between the individual, the occupation
and the environment.11,20-28 Successful performance requires
achieving a balance between the ability of the performer, and the
supports and demands of the occupation and the environment.
Competent occupational performance is considered to be the out-
come of an interaction in which performer ability is in perfect
balance with occupational and environmental supports and de-
mands.25,26 DPA focuses on identifying the specific imbalances
that prevent successful performance. In CO-OP, a problem solv-
ing approach is used to identify the source of the imbalance and
 116 CHILDREN WITH DEVELOPMENTAL COORDINATION DISORDER

potential strategies for solving the imbalance. The study by Man-

dich and colleagues18 showed that with children with DCD, strat-
egy use can solve performance problems.

Cognitive Strategies

The fourth key feature of Cognitive Orientation to daily Occupa-

tional Performance (CO-OP) is cognitive strategy use. Cognitive
strategies are cognitive operations over and above the processes that
are a natural consequence of carrying out a task.5 They are strategic
thinking processes aimed at accomplishing goals. In CO-OP, two
kinds of strategies are used: a global strategy and domain-specific
strategies.
A global strategy is a general executive strategy that focuses on
increasing metacognitive awareness and training the individual to self-
monitor and self-evaluate.35 The global strategy utilized in CO-OP,
Goal-Plan-Do-Check, is a problem solving strategy adopted from the
cognitive behavioral work of Meichenbaum.8,35 It is represented in the
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form of the mnemonic, Goal-Plan-Do-Check, developed by Camp,

Blom, Hebert, and VonDoorwick.36 The global strategy provides a
structure within which the therapist or child can talk through the
problems encountered in task performance. When using the Goal-
Plan-Do-Check framework, the child is taught to use the following
line of self-talk:

GOAL: What do I want to do?

PLAN: How am I going to do it?
DO: Do it! (carry out the plan)
For personal use only.

CHECK: How well did my plan work?

Meichenbaum35 points out that each stage of the Goal-Plan-Do-

Check strategy facilitate an aspect of metacognitive thinking. For
instance, determining the GOAL requires self-interrogation, the
PLAN requires the child to self-monitor, the DO demands self-ob-
servation, and the CHECK fuels self-evaluation and self-reinforce-
ment. Using this global framework, the child learns to talk him or
herself through the task, and to develop metacognitive problem solv-
ing skills.
The Goal-Plan-Do-Check strategy is a central feature of the CO-
OP approach to treatment. It is taught to the child during the second
 Polatajko et al. 117

intervention session, and reinforced throughout subsequent therapy

sessions. It not only provides a global problem solving strategy for
the child, but also provides a vehicle for discovering domain specific
strategies. Some type of concrete reminder of this strategy, such as a
puppet, is used throughout the intervention sessions. One example of
this, Commander GoalPlanDoCheck is depicted in Figure 3.
Domain Specific Strategies are an array of specific cognitive strate-
gies, which focus on facilitating or improving performance that are
task, child, or situation specific. Mandich and her colleagues18 identi-
fied eight domain specific strategies used in CO-OP: body position,
task specification/modification, feeling the movement, verbal motor
mnemonic, verbal rote script, verbal instruction, verbal self-instruc-
tion, and attention to doing.
During the CO-OP intervention, children are taught to talk them-
selves through occupational performance problems using the global
cognitive strategy. This strategy is then used to frame the discovery of
domain specific strategies that will enhance performance. The empha-
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FIGURE 3. Commander GoalPlanDoCheck

For personal use only.
 118 CHILDREN WITH DEVELOPMENTAL COORDINATION DISORDER

sis during intervention is on helping the child to see how he or she can
set goals, plan actions, talk him or herself through doing, and check
outcomes. In other words, the focus is on metacognitive problem
solving processes. The therapist helps the child to acquire occupation-
al performance skills, by enabling the child’s application of cognitive
strategies to task performance.

Enabling Principles of CO-OP

A number of enabling principles have been developed for use in

CO-OP to help the child learn to talk him/herself through occupational
performance problems, use cognitive strategies, develop occupational
skills and transfer and generalize learning. These have been drawn
from general principles of learning, the literature on cognitive and
mediation techniques, information about motor learning, and clinical
experience with children with DCD.
Enabling principles are an integral part of the CO-OP therapeutic
approach and are used throughout the therapeutic intervention. They
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are captured in 6 imperatives:

S Make It Fun: Experience with CO-OP indicates that therapists
who are playful in their interactions with the children have the
greatest success in getting children to use cognitive strategies and
to improve occupational performance.
S Promote Good Strategy Use: Strategies form the bridge between
abilities and skill acquisition. Pressley et al.5 note that good strat-
egy users have a number of characteristics in common. They sug-
gest that effective use of cognitive strategies involves the coor-
For personal use only.

dination of several components including: sufficient task

knowledge; a broad repertoire of strategies; and the realization
that effort and strategy use affect performance. In CO-OP the
therapist promotes good strategy use by: evaluating and supple-
menting the child’s task knowledge as required, helping the child
to develop a range of strategies, and guiding the child to see the
connection between effort, strategy use and successful perfor-
mance.
S Frame It in Goal-Plan-Do-Check: Throughout the intervention,
the global strategy Goal-Plan-Do-Check provides the framework
for solving performance problems. The therapist guides the child
through the process of articulating the performance goal, devel-
 Polatajko et al. 119

oping a plan, carrying out the plan, and checking the effective-
ness of the plan. The focus is on teaching the child to use the
global strategy to talk himself or herself through performance
problems.
S One Thing at a Time: Children learn best when one thing is pre-
sented at a time. While the therapist may identify a number of
issues that need to be addressed, it is important to keep the child
focused on only one thing and not to place excessive attentional
demands on the child.
S Work Toward Independence: The nature of the interaction be-
tween the therapist and child changes over the course of CO-OP
intervention. During the initial phases, the therapist takes the lead
role in modeling the application of the strategy. As the child be-
comes more competent in strategy use, the therapist slowly relin-
quishes the lead role so that the child can take the lead in solving
performance problems. Throughout the intervention, the child is
encouraged to apply the strategies in everyday situations. This is
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done by discussing opportunities for transfer and generalization

with the child and parents at each treatment session and by as-
signing ‘‘homework’’ to be done between sessions.
S Guided Discovery: Children remember best when they discover
something themselves. Therefore, in CO-OP the emphasis is on
child discovery of strategies to support performance. Using a
combination of Meichenbaum’s8,35 scaffolding techniques, and
the mediational techniques of Feuerstein and colleagues10,37,38
the therapist guides the child to discover the strategies that will
help him or her perform the chosen activities. The process of
guided discovery is illuminated by four catch phrases: ‘‘Ask,
For personal use only.

don’t tell,’’ ‘‘guide, don’t adjust,’’ ‘‘make it obvious,’’ and

‘‘bridge beyond.’’ The therapist also helps the child to develop
and test out plans (as part of the Goal-Plan-Do-Check strategy)
for achieving goals. The process of guided discovery is an itera-
tive one and occurs throughout the therapy.
Parent/Caregiver Involvement
Parent involvement in the CO-OP approach is crucial to promote
the child’s ongoing skill acquisition, strategy use, and generalization
and transfer of learning. The therapist can promote parental involve-
ment by ensuring that parents learn about the salient features of CO-
 120 CHILDREN WITH DEVELOPMENTAL COORDINATION DISORDER

OP and the application of enabling principles. In this way the parent

provides a critical link between the therapeutic setting and other envi-
ronments. It has been recognized for some time now that involving
parents in an intervention program promotes maintenance of learned
behaviors and facilitates generalization and transfer.39,40 Research
indicates that students can achieve better outcomes at school when
there is strong parental involvement.41 Follow-up studies of behavior
therapy have shown that children whose parents have been taught the
behavioral techniques continue to improve and demonstrate transfer
and generalization of improvement to areas that had not been specific
treatment targets.42
In CO-OP, parents are required to observe Session Two, the session
in which the global strategy is taught. They are then encouraged to
help the child to practice applying the strategy before the next session.
As well, parents are required to observe at least two additional treat-
ment sessions and are strongly encouraged to participate in as many
additional sessions as possible. Before each session begins, the thera-
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pist discusses, with the parent and child, the homework that was done.
Examples are elicited of global and domain specific strategies that
were used between sessions. Frequently parents use these opportuni-
ties to describe successes and discuss problems. At the end of each
session, the strategies which emerged during treatment are reviewed
and possible applications within the home and school environment are
discussed.

CONCLUSION
For personal use only.

CO-OP is a new approach to treatment for children with. In contrast

to traditional approaches, CO-OP focuses directly on child-identified
performance issues, and engages the child as an active problem solver
and participant in the therapy process. Congruent with many contem-
porary ideas on skill development, CO-OP fosters the notion that
performance is the result of the interaction between the child the
environment and the occupation and that cognitive strategies can be
used to drive performance. Use of the CO-OP approach, within a
research paradigm, has provided evidence of the effectiveness of the
approach with children with DCD. Further research is needed to inves-
tigate the use of CO-OP with other populations. This approach pre-
 Polatajko et al. 121

sents an alternative for therapists interested in a direct approach to the

treatment of performance problems in children with DCD.

REFERENCES
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clumsy child syndrome.In K Whitmore,H Hart,G Willems,(Eds.), ANeurodevelop-
mentalApproachtoSpecificLearningDisorders:TheClinicalNatureoftheDisorder
(pp. 119-133). London: MacKeith Press; 1999.
2.Mandich AD,Polatajko HJ, Macnab JJ, MillerLT. Treatment of children with
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