Including a relationship-focus in paediatric occupational therapy interventions: Introducing the PAIR Model

ABSTRACT

The importance of parent-child relationships for child developmental outcomes suggests a need to incorporate a relationship focus into early intervention programs for children with developmental delays. Nevertheless, confusion exists about the definition and application of relationship-focussed interventions, and occupational therapists remain more developmentally- and child-focussed. There is a need to operationalize relationship-focussed interventions to make these approaches clinically accessible. This report defines, and provides a rationale for, including parent-child relationship-focussed interventions in early childhood occupational therapy interventions. A new conceptual model, the “Phased Approach to Incorporating a Relationship-focus” (PAIR), is detailed for consideration in pediatric therapy settings. The PAIR model can support professional education, inform practice, and guide future research regarding relationship-focussed interventions. Research is needed to test the usefulness of this model in occupational therapy practice.

KEYWORDS:

• Parent-Child Relationship
• early intervention
• education
• training
• developmental delays

Introduction

As part of a multidisciplinary early intervention team, occupational therapists provide therapeutic services to children from birth to 6 years of age, with a focus on supporting development and assisting the child to participate in a range of daily activities (Law et al., 2011). However, the effectiveness of developmentally-orientated interventions, commonly conducted directly with the child (Case-Smith, 2013), have been questioned (Barfoot, Meredith, Ziviani, & Whittingham, 2015; Innocenti, Roggman, & Cook, 2013; Miller, Ziviani, Ware, & Boyd, 2014). Based on wide acceptance that child development occurs within the context of positive parent-child interactions (Barfoot, Meredith, Ziviani, & Whittingham, 2016; Innocenti, Roggman, & Cook, 2013; Schore & Schore, 2008), early intervention practitioners, including occupational therapists, have been called to include a parent-child relationship focus as a core component of interventions provided (Atkins-Burnett & Allen-Meares, 2000; Barfoot, Meredith, Ziviani, & Whittingham, 2015, 2016; Case-Smith, Clark, & Schlabach, 2013; Innocenti, Roggman, & Cook, 2013; Karaasalan, Diken, & Mahoney, 2011; Miller, Ziviani, Ware, & Boyd, 2014). To support this aim, relationship-focussed interventions must be operationalized for use within the context of pediatric occupational therapy practice. In this paper, the origins of parent-child relationship interventions (including attachment theory, infant mental health and emotional regulation theory) are overviewed, followed by a clear definition of these interventions. A process model and case study are then presented to support application and further empirical consideration.

Parenting and Child Development

Calls for a relationship-focus to be included in early intervention comes from recognition that parenting behaviors have a significant impact on child development (Barfoot, Meredith, Ziviani, & Whittingham, 2015; Innocenti, Roggman, & Cook, 2013; Parkes, McCullough, Madden, & McCahey, 2009; Van Zeijl et al., 2006; Zeanah & Zeanah, 2009) and occupational outcomes (Lawlor, 2003). It is now well accepted that child development occurs within the context of parent-child interactions (Barfoot, Meredith, Ziviani, & Whittingham, 2016; Innocenti, Roggman, & Cook, 2013; Schore & Schore, 2008). Positive parent-child interactions are defined as those including warmth, sensitivity, responsiveness, and adaption to the child’s needs (Mortensen & Mastergeorge, 2014). Parental sensitivity is considered especially important, as it allows parents to understand the child’s perspective and respond in ways that support the unique needs of the child (Ainsworth, Blehar, & Water, 1978).

The purpose of occupational therapy in early childhood intervention is to maximize the child’s participation in daily activities and improve functional skills and independence (Morgan et al., 2016). Traditionally, occupational therapists have been trained to be child-focussed and developmentally orientated and there is some evidence that these models still predominate in clinical practice (Case-Smith, Clark, & Schlabach, 2013). While many occupational therapists have been trained in newer approaches, such as being family-centered and occupation-focussed (Rodger, 2010), the parent-child relationship is not yet commonly targetted in pediatric settings for children with developmental delays (Alexander, Frederico, & Long, 2018; Barfoot, Meredith, Ziviani, & Whittingham, 2016). In a systematic review on motor performance, Case-Smith, Clark, and Schlabach (2013) concluded that, although a developmental frame of reference is an important foundation for pediatric occupational therapists, interventions “built solely on developmental theory have minimal effects on motor outcomes” (p. 421). Case-Smith & O’Brien (2010) concluded that interventions are more effective when social elements and family collaborations are included. Similarly, Lawlor (2003) reflected on the social nature of most occupations of very young children and their occurrence in the context of significant people in children’s lives. She advocated for occupational therapists to focus on the social construction of childhood occupations and highlighted the potential benefits of understanding the role of relational connectedness in optimizing both meaning and participation for children.

Attachment Theory

Current understanding about the importance of positive parent-child interactions for child development is largely informed by attachment theory (Bowlby, 1969/1984; Schore & Schore, 2008). Attachment theory focusses on the quality of early parental care, with particular emphasis on parental sensitivity and responsiveness (Van Zeijl et al., 2006). A foundational tenet of this theory is that infants’ needs for nourishment and protection biologically primes them to initiate signals and be in relationship with their caregivers (Bowlby, 1969/1984; Muir, Lojkasek, & Cohen, 1999; Van Zeijl et al., 2006; Weatherston, 2007). In response to signals initiated by the baby, the parental caregiving system is, in turn, biologically primed to respond sensitively (Klebanov & Travis, 2014).

Importantly, the child’s ability to initiate signals and the parents’ ability to respond and adapt to the child’s signals, contributes to the process of providing an appropriately stimulating developmental environment for the child (Klebanov & Travis, 2014). According to attachment theory, when sensitive and responsive caregiving exists for the child, a more secure attachment relationship is more likely to develop (Bowlby, 1969/1984). Where parents are not able to interact in these ways, or responses to the child are unpredictable or inconsistent, an insecure (i.e., anxious, avoidant or, more concerningly, disorganized) attachment pattern is more likely to develop (Atkinson et al., 1999; Bowlby, 1969/1984).

The attachment relationship a child develops with parents is an important consideration for occupational therapists as it has been shown to predict child developmental outcomes (Alexander, Frederico, & Long, 2018; Juffer, Bakermans-Kranenburg, & van IJzendoorn, 2014; Van Ijzendoorn, Schuengel, & Bakermans-Kranenburg, 1999; Van Zeijl et al., 2006; Zeanah & Zeanah, 2009). For the parent of a child with developmental difficulties, several factors might impact on the quality of the developing parent-child relationship. First, due to factors associated with the disability, it is more difficult for a parent to establish a sensitive pattern of interactions with a child with a neurodevelopmental disability than with a typically developing child (Barfoot, Meredith, Ziviani, & Whittingham, 2015; Chiarello & Palisano, 1998; Dolev, Oppenheim, Koren-Karie, & Nurit Yirmiya, 2009; Hanzlik, 1989). For example, a child may have more difficulty initiating and sustaining clear signals about their needs (Barfoot, Meredith, Ziviani, & Whittingham, 2015; Hanzlik, 1989; Pennington, Thomson, James, Martin, & McNally, 2009). As parent sensitivity to child cues is pivotal to the development of a secure relationship, the child’s difficulties providing clear signals can cause great frustration for the child and jeopardize attachment security. Second, for the parent, there is often grief and distress associated with the child receiving a diagnosis (Barfoot, Meredith, Ziviani, & Whittingham, 2015, 2017; Oppenheim, Koren-Karie, Dolev, & Yirmiya, 2009). This can preoccupy parents, making it more difficult for them to tune in to their child’s signals and respond sensitively, which may further jeopardize attachment security (Oppenheim, Koren-Karie, Dolev, & Yirmiya, 2009). As might be expected given these challenges, it has been shown that the prevalence of disorganized attachment is 35% for children with neurological abnormalities compared to 15% in the non-clinical population (Van Ijzendoorn, Schuengel, & Bakermans-Kranenburg, 1999).

Emotional Regulation

Another important consideration for occupational therapists is that, through positive parent-child interactions and attunement, the child learns to trust that parents will meet their emotional needs. During child-caregiver interactions, dysfunctional and disruptive parenting behaviors affect the child’s autonomic nervous system, which has implications for the child’s capacity to self-regulate emotions (Köhler-Dauner et al., 2019). When parents sensitively attune to the child’s internal state of arousal and respond to the child’s needs in a timely manner, they support the child’s development of emotional self-regulation (Drake, Belsky, & Fearon, 2014; Schore & Schore, 2008). The formation and maintenance of a secure attachment relationship therefore lays the foundation for the development of emotional regulation in children (Schore & Schore, 2008).

The parents’ and child’s ability to self-regulate is important for occupational therapists to consider as it has been associated with several child developmental outcomes, including cognition, social skills, mental health, and well-being (Housman, 2017). Furthermore, the effectiveness of early intervention for children with developmental delays appears less related to the amount or intensity of services received than to the ability of the parents to read their child’s cues and respond sensitively (Innocenti, Roggman, & Cook, 2013; Mahoney & Nam, 2011).

Attachment Security, Emotional Regulation, and Developmental Outcomes

Links between attachment security, emotional regulation, and developmental outcomes, summarized earlier, have contributed to calls for early intervention practitioners to provide interventions that include a focus on positive parent-child interactions (Atkins-Burnett & Allen-Meares, 2000; Barfoot, Meredith, Ziviani, & Whittingham, 2015; Karaasalan, Diken, & Mahoney, 2011). This suggests value in including a relationship-focus in pediatric occupational therapy interventions. Consistent with this suggestion, the national guidelines for best practice in Australia (Early Childhood Intervention Australia, 2016) recommend early childhood practitioners focus on parent responsiveness and strengthening parent-child relationships.

Defining Relationship-Focused Interventions

Despite the growing call to deliver parent-child relationship interventions, there is evidence that occupational therapists are confused about the definition of these interventions (Barfoot, Meredith, Ziviani, & Whittingham, 2022). According to Stewart (2008), the overall aim of a relationship-focused occupational therapy intervention is to promote positive parent-child interactions that meet the unique needs of children experiencing challenges. In these interventions, the parent-child relationship becomes a core focus of the intervention as well as the method through which the intervention is delivered (Atkins-Burnett & Allen-Meares, 2000; Barfoot, Meredith, Ziviani, & Whittingham, 2015; Stewart, 2008). Parents are supported to read the child’s unique cues and adapt their responses moment to moment to meet the child’s needs (Stewart, 2008). This enables the child to develop trust that the parent will support their exploration of new tasks (Ainsworth, 1979; Dujardin et al., 2016). By targeting parent-child interactions in therapy sessions, the occupational therapist can assist parents to strengthen their skills in reading and responding to the unique needs of their child while facilitating their child’s development (Barfoot, Meredith, Ziviani, & Whittingham, 2015; Heffron, 2000; Stewart, 2008). Using this approach, strengths-based, transactional paradigms are emphasized in which reciprocal parent-child interactions are supported by the occupational therapist, often with the use of video review (Barfoot, Meredith, Ziviani, & Whittingham, 2015). Prioritising a relationship-focus in the early stages of therapy may, in turn, foster a more resilient parent-child relationship, which represents a platform of attuned and collaborative interactions between the parent and the child upon which to build further developmental and goal-orientated interventions (Barfoot, Meredith, Ziviani, & Whittingham, 2015).

Outcomes from Relationship-Focused Interventions

Consistent with theoretical expectations, several studies have indicated benefits for children with developmental difficulties when there is a focus on parent-child interactions. A Cochrane Review by Oono, Honey, and McConnachie (2013) concluded that implementation of parent-mediated interventions for young children with Autism Spectrum Disorder (ASD) resulted in enhanced communication and improved management of behaviors. For children with developmental diagnoses other than ASD, it is also likely that interventions supporting parent-child interactions support their developmental outcomes. For example, there is some evidence that interventions which enhance parent-child interactions can promote developmental outcomes for children with cerebral palsy (e.g., Barfoot, Meredith, Ziviani, & Whittingham, 2015; Chiarello & Palisano, 1998; Dirks, Blauw-Hospers, Hulshof, & Hadders-Algra, 2011). In these studies, the parent-child interventions were associated with improved parenting behaviors and increased child initiations, with the latter recognized as an important foundation for skill mastery (Miller, Ziviani, Ware, & Boyd, 2014). Qualitative observations from a study investigating interactions between parents and children with cerebral palsy (Barfoot, Meredith, Ziviani, & Whittingham, 2017) also suggested that, when parents were able to implement therapeutic strategies while remaining emotionally available, children appeared better able to receive and respond to therapeutic strategies.

In an exploratory relationship-focused training study conducted in Australia by Barfoot et al. (2022), practitioners reported that, when they increased their focus on parent-child interactions, they observed positive changes for children with developmental delays. These changes included increased child exploration and engagement in sessions, improvements in communication, play, and social skill initiations, and developmental changes. This is an important finding because, as highlighted earlier, child initiations and exploration are foundations of skill mastery (Miller, Ziviani, Ware, & Boyd, 2014; Pennington, Goldbart, & Marshall, 2004). Participants also reported observing a reduction in children’s challenging behaviors and that children appeared “happier” overall. These findings are promising given that children with developmental delays are at higher risk of behavioral and emotional difficulties (Baker et al., 2003).

Occupational Therapy Practice

While occupational therapists may acknowledge the importance of the parent-child relationship within the early childhood intervention context, literature suggests they do not commonly implement a relationship-focussed approach (Alexander, Frederico, & Long, 2018). A recent Australian study indicated that, while practitioners reported that they perceived the parent-child attachment relationship as an important consideration in their work, less than half of the participants felt comfortable targeting the parent-child relationship in their interventions (Alexander, Frederico, & Long, 2018). The authors of this study noted that allied health practitioners, including occupational therapists, require support to build their knowledge, skills, and confidence in this area.

This growing literature highlights the potential benefits of incorporating relationship-focused interventions in pediatric occupational therapy practice. Currently, however, this is restricted by misunderstandings about what it means to include a relationship focus into occupational therapy practice and how relationship-focussed approaches integrate and interact with other occupational therapy approaches (Barfoot et al., 2022). As relationship-focussed approaches are not part of current undergraduate training for most allied health practitioners (Alexander, Frederico, & Long, 2018), further training supported by an intervention model may provide practitioners with a clinical framework for applying this approach in therapy. The aim of this paper is to propose a conceptual model, the “Phased Approach to Incorporating a Relationship-focus” (PAIR), as an initial step in meeting this clinical need for pediatric occupational therapists.

Constructs That Inform a New Clinical Model

With increased attention to attachment theory, early brain development, and emotional regulation, it is becoming more common for occupational therapists to use constructs from the infant mental health field in their clinical practice (Schulz-Krohn & Cara, 2000; Weatherston, Ribaudo, & Glovak, 2002). Infant mental health practice emerged in the 1970s, predominantly with the work of Fraiberg, Adelson, and Shapiro (1975). Fraiberg defined “infant” as children under three years of age, “mental” as the social, emotional, and cognitive domains, and “health” as the well-being of young children and families. The emergence of infant mental health practice resulted in a significant shift in focus in clinical practice with attention to the baby, the parent, and the early developing parent-child relationship. Specifically, within the infant mental health field there is a focus on understanding and strengthening the relationship between the child and their parents (Schulz-Krohn & Cara, 2000; Stewart, 2008; Weatherston, Ribaudo, & Glovak, 2002). This requires the clinician to build a therapeutic alliance with the parent, observe, and provide support regarding parent-child interactions, child development, and how the parent experiences the child (Stewart, 2008). For the clinician using an infant mental health framework, there are three core interventions operating simultaneously: infant – parent psychotherapy, nondidactic developmental guidance, and direct support and advocacy (Fraiberg, 1980, 1982; Fraiberg, Adelson, & Shapiro, 1975).

Fraiberg’s early work went on to inform the development of the Michigan Association for Infant Mental Health Guidelines for practice (2000) to assist practitioners to work effectively with families. Key principles from these guidelines for practice include the premise that optimal growth and development for the infant occurs within the context of nurturing relationships and that what happens in the early years affects the course of development across the life span.

Along with the guidelines for practice, The Michigan Association for Infant Mental Health also developed a list of skills required for clinicians using an infant mental health approach. These skills include: building relationships and using them as instruments of change; meeting with the infant and parent together throughout the intervention; sharing in observations of the infant’s growth and development; offering guidance to the parent that is specific to the infant; and allowing the parent to take the lead in interacting with the infant. Initially, it was more common for infant mental health practitioners to include social workers, psychologists, nurses, and psychiatrists. Historically, it has been more common for these disciplines to receive training regarding the importance of the parent-child relationship in these disciplines. In recent years, with increased attention to infancy, early relationship development, and parental mental health practitioners in other disciplines, including occupational therapy, have started using infant mental health practices.

While many occupational therapists understand the importance of the parent-child relationship, it is still common that they may not have completed training in this area or feel confident applying a relationally focussed approach in their clinical practice (Alexander et al., 2018; Barfoot, Meredith, Ziviani, & Whittingham, 2022). To this end, the guidelines and skill set described by the Michigan Infant Mental Health Association have been considered in the development of the PAIR model to assist occupational therapists working with children with developmental delays to include a relationship focussed approach in their interventions.

Proposed Clinical Model: A Phased Approach to Incorporating a Relationship-Focus

In light of the difficulties reported by pediatric occupational therapists in applying relationship-focused approaches (Alexander, Frederico, & Long, 2018; Barfoot, Meredith, Ziviani, & Whittingham, 2022), the development of a process model is an important first step in supporting practitioners to include a relationship-focus as a core component of their intervention. A process model outlines specific phases to support the translation of theory into practice (Nilsen, 2015). The Phased Approach to Incorporating a Relationship-focus (PAIR) process model (see Figure 1) systematically outlines the three phrases of this therapeutic approach, demonstrating how to determine whether a relationship-focused approach is necessary and, if so, how to implement it. This model could be employed by practitioners from a range of disciplines (including speech pathology, occupational therapy, and physiotherapy) working with children with a range of developmental difficulties.

Figure 1. Proposed process model: a phased approach to incorporating a relationship-focus (PAIR).

PAIR Phase 1: Assessment and Planning

As seen in Figure 1, Phase 1 of the PAIR model involves obtaining information from parents through the usual case history taking process, with additional case history questions about the nature of their relationship with their child. Observations of the quality of the parent-child interactions through play are also added to the initial appointment process to help determine whether there are any parent-child relationship difficulties. These additional case history questions and observations of parent-child interactions are both informed by the infant mental health field (Schulz-Krohn & Cara, 2000; Weatherston, Ribaudo, & Glovak, 2002). See Table 1.

Table 1. PAIR phase 1.

Component	Content	Method
Initial contact	What is a relationship-focussed approach Why a relationship-focussed approach assists with supporting child development How sessions are structured	Discussion: Initial phone call Parent Education: Information sheets
Introduction of service	Understanding parent expectations of service Discussing relationship-focussed approach and how this fits/is different to parent expectations	Discussion during initial appointment
Case history	Child’s birth and developmental history Important family information Parent concerns Parent-child relationship questions	Parent interview
Assessment of parent and child strengths in play	Observations of child-led play and how parent responds to child’s play cues	Observation checklist such as the PICCOLO
Goal setting to include a focus on parent-child interactions	Parents long term goals for their child and what they see as their role in actively helping child achieve these. Parents short-term goals for their child Therapist shares observations of child’s development and parent-child play and discusses how these observations link to parent goals and also parent-child interactions. Therapy goals formulated to collate parent goals with therapist observations	Completion of shared goal setting proforma Plan made with parents regarding whether a relationship-focussed approach will assist in meeting goals.

Phase 1 would feasibly commence during the initial contact with parents, at which time the intention to use a relationship-focused approach could be discussed. This is important so that parents are well informed, from the beginning, that therapy includes a focus on parent-child interactions. This is especially important if attunement difficulties are identified, but also if, as therapy progresses, attunement difficulties emerge or re-present. During this appointment, parent expectations of therapy sessions can be reviewed, and the occupational therapist can explain any differences between parent expectations and a relationship-focused approach. The therapist can also review the role of an occupational therapist in this context and the reasons that this approach is considered beneficial for this particular family. For example, the occupational therapist can explain that, when a relationship-focussed approach is used, the practitioner has more of an observer role, supporting parent sensitivity and responsiveness during child-led play.

For occupational therapists who are new to implementing a relationship-focused approach, a parent-child interaction observation tool may be useful in assessing the quality of parent-child interactions to determine whether a relationship-focus is necessary. Examples of such tools include the Home Observation for Measurement of the Environment (HOME; Totsika & Sylva, 2004), Keys to Interactive Parenting Scale (KIPS; Comfort & Gordon, 2006), and the Parenting Interactions with Children: Checklist of Observations Linked to Outcomes (PICCOLO; Innocenti, Roggman, & Cook, 2013). Developmental and/or occupational assessments could also be conducted as part of this first phase to assist in determining the child’s strengths and difficulties.

During Phase 1, practitioners would also engage in goal setting with parents; that is, determining the therapeutic priorities parents have for their child. This aligns with family-centered philosophy (Di Reeze et al., 2014). However, extending traditional family-centered practice definitions, therapists could explain that emerging evidence suggests that an initial focus on parent-child interactions is an important first step in meeting these developmental goals. For example, parents may have a goal for their child to increase play skills. The therapist could explain that, because of the child’s developmental difficulties, it can be harder to read the child’s play initiations. By focusing on parent-child interactions, initially, and encouraging the parent to wait and observe what the child initiates, these therapy sessions will assist the parent to read and respond to these signals and support the expansion of play skills (Muir, Lojkasek, & Cohen, 1999). This process of strengthening child cue initiation and parent responsiveness helps the child trust that, when initiated, a signal will be responded to. This, in turn, can motivate the child to make further play initiations. Thus, for families that need support to strengthen parent-child interactions, Phase 2 Relationship-Focussed Sessions, can be commenced. If, however, the parent-child relationship is resilient and responsive, Phase 3 Goal-Oriented Sessions, can be commenced providing targeted guidance to meet parent goals (see later sections).

PAIR Phase 2: Relationship-Focussed Sessions

If, during Phase 1, it is ascertained that the family would benefit from a relationship-focussed approach, Phase 2 is commenced. In Phase 2, the practitioner provides education about supporting the child to initiate more frequent and consistent signals to the parent. As part of this phase, the occupational therapist supports the parent to wait for and follow the child’s play initiations (Muir, Lojkasek, & Cohen, 1999). This act of waiting to see what the child initiates is often referred to as “child-led” or “child-initiated” play (Barfoot, Meredith, Ziviani, & Whittingham, 2015; Muir, Lojkasek, & Cohen, 1999). Child led play is considered an important component of supporting child development as it assists the child establish his/her effect on the environment, assists with active exploration, and promotes development of the child’s sense of self (Muir, Lojkasek, & Cohen, 1999).

This phase has been informed by the child-led play principles tested in other interventions occupational therapists commonly use, (e.g. DIR-Floortime, Watch Wait and Wonder, Early Start Denver Model, Circle of Security and Hanen’s More than Words; see Oono, Honey, & McConnachie, 2013 for a Cochrane Review of parent-mediated early interventions for young children with autism spectrum disorders). While it is not within the scope of this article to define each of these, several key aspects appear common to most (Atkins-Burnett & Allen-Meares, 2000; Earhart & Zamora, 2015). The first aspect involves focussing on positive parent-child interactions known to be associated with optimal development. For example, parents are commonly asked to wait for the child to initiate a play idea and respond to this with warmth, verbal narrative, and encouragement (Innocenti, Roggman, & Cook, 2013). Encouraging the parent to wait, and to give the child more opportunity to explore and initiate, helps parents to more accurately gauge the amount of support the child requires to participate in an activity (Oppenheim et al., 2007).

During the child-led play that occurs in a relationship-focussed session, the child may also provide signals about his/her feelings, wants, and needs. This can include signals about whether the child wants more or less of a particular sensation (e.g., a smell, a movement). When the parent reads these signals and responds to them sensitivity, this allows the child to lead the interaction, and hence to have an active role in moderating the amount of incoming sensory input (Whittingham, 2016). In addition, the child draws on the relationship with the parent during challenging times, such as when they are dysregulated emotionally, in what is known as co-regulation (Ainsworth, Bell, & Stayton, 1971; Siegel, 2004). Thus, supporting parents to tune into their child during more challenging parts of the session can, in turn, assist the child to remain more emotionally regulated and provide motivation to continue playing and learning, with positive developmental consequences (Whittingham, 2016).

Opportunities for parents’ self-reflection about their child’s actions or behaviors, and their responses to these, is another important component of a relationship-focussed approach (Siegel, 2004). Parent reflective capacity is positively associated with a secure parent-child relationship as it assists understanding the child’s perspective, supporting sensitive responses to signals (Oppenheim, Koren-Karie, Dolev, & Yirmiya, 2012). Parent self-reflection can be facilitated within a relationship-focussed approach through video review of parent-child interactions (van der Voort, Juffer, Bakermans-Kranenburg, & Barlow, 2014). The use of video review in therapy is an important component of the PAIR Model as it can assist parents to accurately observe their child’s signals and enhance parents’ reflective skills. Studies have demonstrated that relationship-focused approaches that use video review with parents were more effective than those where video review was not used (Oppenheim et al., 2007; van der Voort, Juffer, Bakermans-Kranenburg, & Barlow, 2014). Once this process of the child initiating and the parent responding is occurring more frequently, the occupational therapist can move to providing more targeted suggestions to support the developmental goal (e.g., developing fine motor play skills; Barfoot, Meredith, Ziviani, & Whittingham, 2015).

To conduct Phase 2 effectively, it is important that the practitioner has access to reflective supervision to assist their ability to use a relationship focussed approach effectively (Heffron, 2000; Mares et al., 2011). Reflective supervision assists the practitioner to learn ways to respond to parents, remain open to parental distress, and have the capacity to consider multiple perspectives (Mares et al., 2011). The practitioner also needs to be able to keep the child’s experience in mind and consider what the child may be communicating through their signals and be able to share this with parents in a respectful manner (Mares et al., 2011). Both the therapist-parent relationship and reflective supervision for the therapist are important aspects of a relationship-focussed approach.

PAIR Phase 3: Goal-Orientated Sessions

With the platform of a strengthened parent-child relationship in place, the child is more confident that their cues will be recognized and responded to. The occupational therapist can now start to provide more targeted developmental guidance to meet the family’s goals for the child. Clinical reasoning is used here to determine which strategies best meet the child’s developmental needs and stated goals. A range of strategies may be used during this phase, including COOP (Polatajko, Mandich, Miller, & Macnab, 2001), coaching (Kessler & Graham, 2015), home programs (Milton & Roe, 2017). constraint-induced movement therapy (Hoare et al., 2019), and goal directed training (Law & Darrah, 2014). During this phase, the clinician would encourage the parents to remain sensitive to the child’s signals and may focus on parent-child interactions again if attunement difficulties arise that impact on the parents’ capacity to implement developmental guidance with their child. In addition, the clinician would continue to monitor whether the interventions or other stressors interfere with parent-child interactions and provide support to address this as required. This phase has been informed by the infant mental health field where developmental guidance is still provided in a relational framework (Schulz-Krohn & Cara, 2000; Stewart, 2008; Weatherston, Ribaudo, & Glovak, 2002).

A Case Example

Including a relationship-focus in pediatric occupational therapy interventions requires practitioners to modify the way in which initial appointments, case history taking, and interventions occur. The PAIR model has been trialed in clinical practice by first author (JB) with a number of families. To demonstrate this, one case example of Florence (pseudonym) is provided.

Florence, four years, was referred to occupational therapy for assistance with daily living skills. Florence had received a diagnosis of Autism Spectrum Disorder, level 3, and was having difficulties with mealtimes, dressing, and having her teeth brushed. She was non-verbal and had difficulty engaging with others in play and everyday activities. She also sought a high level of proprioceptive input, was sensitive to tactile, auditory, and oral stimuli, and had motor planning difficulties. Her parents reported that they were particularly concerned about teeth brushing and stated that they needed to hold her down to brush her teeth. This process was observed by the occupational therapist to be distressing for both Florence and her parents. However, it was important to her parents that Florence did not obtain cavities as they wanted to prevent the risk of future dental work.

During the initial appointment (Phase 1 in the PAIR model), the occupational therapist observed Florence playing with her parents. During this observation, Florence initiated few play signals and her parents had difficulty interpreting her cues. When her parents attempted to join her play, Florence would leave the activity, apparently finding these interactions intrusive. During the case history taking stage, the occupational therapist gathered information about the parent-child relationship and asked Florence’s parents to describe their relationship with her, the moments when interactions felt easier and more connected, and the moments that were particularly difficult. Through the inclusion of these questions, the occupational therapist was able to formulate the ways that parent-child relationship difficulties were impacting on Florence’s participation in a range of daily activities. With this information, it became apparent that Florence’s signals were often so subtle and hard to read that her parents would miss them and complete activities for her, such as feeding her with a spoon, undressing and dressing her without warning, and holding her down to brush her teeth. This involvement from her parents appeared to be upsetting and dysregulating for Florence. Importantly, Florence’s parents were very invested in her and loving, and they were motivated to work out ways to support Florence’s successful engagement and participation in activities. However, they also reported feeling conflicted, as they felt that they needed to complete activities for Florence, even when she became upset.

Following the initial appointment, including case history and a video recorded parent-child play observation, the occupational therapist developed a clinical formulation that commencing the intervention with a focus on supporting child cue initiation and parent responsiveness (i.e., Phase 2 of the PAIR model) would be helpful prior to implementing specific strategies to address self-care goals (i.e., Phase 3 of the PAIR model). This involved asking Florence’s parents to wait for Florence to initiate a play signal and then follow her lead in play by either putting words to what she was doing (e.g., “You’re jumping on the tramp. Jump, jump, jump! You like that!”) or copying her (e.g., “You’re jumping on the tramp, I’m jumping too!”). The occupational therapist used her knowledge of Florence’s sensory needs and play preferences to set up the therapy space. After two months of fortnightly occupational therapy sessions, it was observed that Florence explored the room more easily, chose an activity to engage with, and initiated more play ideas. Her parents interpreted Florence’s cues more consistently and responded in ways that meant Florence allowed them to join her in the play activities.

The primary goal in Phase 2 sessions had been to strengthen parent-child interactions. Florence’s parents then asked the occupational therapist for more specific input to support toothbrushing (i.e., a more developmentally appropriate occupational goal) – Phase 3 in PAIR model. The occupational therapist worked with Florence’s parents using a graded toothbrushing program that supported them to read her cues. The occupational therapist also provided continued guidance around how to respond sensitively to Florence’s cues at each new step. Within six months of following this program, Florence’s parents reported that they were more confident and successful at reading her cues in relation to toothbrushing and Florence appeared calm throughout toothbrushing. Her parents had also been able to apply this increased attunement to other aspects of Florence’s daily life and reported that other activities, such as mealtimes, dressing, and leaving the house, were feeling easier to support. They also reported that Florence was becoming less upset during dressing, that she was able to sit at the table for mealtimes and try new foods. These other activities of daily living were not targeted directly in therapy sessions, indicating that parents were able to generalize principles of attunement and apply them to a range of occupations Florence participates in.

This case example demonstrates that supporting parents to read their child’s cues in play and daily activities, as an initial focus of the occupational therapy intervention, can facilitate the implementation and success of goal-orientated strategies. When a platform of reciprocal and resilient interactions between the parent and the child has been strengthened, the occupational therapist can then work with the family to address their developmental and occupational goals. Importantly, this case example also demonstrates that applying a relationship-focused approach can translate to increased occupational performance and engagement, and that this translated across activities without a direct focus on these activities during therapy sessions. While this case study demonstrates application of the PAIR model, the next step is to test its application with families more empirically.

Considerations

The PAIR process model is presented to address the need for occupational therapists and other health professionals delivering early intervention programs to better operationalize the use of relationship-focussed approaches in practice and improve developmental outcomes and occupational performance for young children with developmental delays. While the PAIR model is based on an extensive review of available theoretical and empirical evidence, it is a preliminary clinical model. Further professional discussion and research is needed to refine the model and test its effectiveness with: 1) clinicians to determine whether it is useful to support changes in practice; and 2) families of children with developmental delays to determine whether it contributes to improved parent-child relationships, developmental outcomes, and occupational performance.

Conclusion

There has been growing acceptance of the importance of parent-child relationships in supporting positive developmental outcomes for children. This acceptance has led to calls by those involved in early childhood intervention services to re-orient programs for children with developmental delays and increase the focus on parent-child interactions as a core component of therapy sessions provided. Evidence indicates that there are potential risks to the quality of the parent-child relationship for families of children with developmental delays, which requires a targeted approach in the early intervention process. Preliminary research suggests that adopting a relational approach within occupational therapy can be a valuable adjunct to traditional developmental approaches; however, occupational therapists need to be prepared and supported for a shift in practice to occur. The development of a new clinical process model outlining a relationship-focussed approach (the PAIR Model), alongside education of practitioners in this approach, is an important first step in re-orientating occupational therapy early interventions to include a relationship focus. It is recommended that this process model is included in training for occupational therapists and that further research is conducted to determine the efficacy of the model to support practitioners, children with developmental delays, and their families.

Key Messages

• There is a need for occupational therapists to include a focus on parent-child interactions as a core component of early intervention therapy sessions.

• To assist occupational therapists to understand relationship-focused interventions, a clear model or framework is needed that outlines specific phases to support the translation of theory into practice.

• A process model, the “Phased Approach to Incorporating a Relationship-focus” (PAIR) has been proposed, which warrants testing with occupational therapists and families.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.