Why this blog?

Following an in-house CO-OP Approach training in the Netherlands, the first author, a cognitive rehabilitation therapist, noted that some recent literature had applied the CO-OP Approach (Polatajko & Mandich, 2004) with children and young people with Acquired Brain Injury (ABI). There is also experience in this area in Dutch rehabilitation practice. The development of a revised Dutch Occupational Therapy Guideline for Brain Injury (Ergotherapie Nederland, 2024) and a Dutch national treatment program for children and young adults with ABI which works within a framework for diagnostics and interventions per discipline (Allonsius et al., 2023) were the reasons that the first author decided to delve further into the application of the CO-OP Approach in children with ABI.

A practice-oriented research was carried out in two parts:

1. A literature review based on the question: "How can the CO-OP Approach be used for children/young people with ABI?", within which the following sub-questions were raised: when to, when not to, for which problem, in which phase of recovery, with what degree of serious injury. Eight articles between 2009-2025 were reviewed;
2. A survey among occupational therapists in the Netherlands asking how the CO-OP Approach is currently used within paediatric rehabilitation for ABI children/young people (nb: comments from the survey are added to the text).

The purpose of this blog is to share practical suggestions that can lead to a further exchange of ideas and experiences among interested therapists.

Acquired Brain Injury (ABI)

Children and young people with Acquired Brain Injury (ABI) often experience cognitive, motor and psychosocial issues that affect their daily functioning. Commonly seen are executive function disorders, including the ability to solve problems. These issues often have a negative impact on the child's participation, at home, at school and during leisure activities (Lebrault et al., 2021). There are limited proven interventions available for rehabilitation of executive functions in children (Lebrault et al., 2024). Traditional interventions often focus on re-training specific skills, but generalizing these skills to other situations is often limited (Missiuna et al., 2010).

The power of CO-OP in ABI

The Cognitive Orientation to daily Occupational Performance (CO-OP) Approach offers innovative perspectives for this target group. This is a strategy-driven approach in which children develop their own problem-solving capacity through guided discovery. They are also encouraged to use this capacity in their own different contexts.

Although CO-OP was initially developed for children with DCD, there is growing evidence that the intervention can also be applied to children with ABI (Lebrault et al., 2024). Recent studies (Dawson et al., 2017; Jackman et al., 2018; Lebrault et al., 2021; Lebrault et al., 2024; Missiuna et al., 2010) and practical experiences from Dutch (and international) rehabilitation centres show that the CO-OP Approach:

As a colleague mentions, for example:

"Errorless learning is regularly the recommended methodology because they do not retain new information. Making mistakes no longer helps with learning, in fact, by repeatedly making the same mistake, it becomes ingrained".

Therapeutic conditions and challenges

The successful use of CO-OP requires that occupational therapists have:

• Knowledge of cognitive-behavioural approaches and learning theories, such as modelling, shaping and self-instruction (Meichenbaum; van den Houten et al., 2026).
• Skills in analysing the child’s actions during the activity performance, (dynamic performance analysis), despite limited visibility of underlying problems that occur in cognitive processes.
• A coaching attitude that focuses on discovery learning also called 'guided discovery';
• Knowledge and skills in techniques that will stimulate generalization and transfer to other activities and contexts.
• Good cooperation with parents. Significant others play a key role in embedding learned strategies in the home situation (Dietrich et al., 2024; Vezinat et al., 2025)

CO-OP Core Components (Polatajko & Mandich, 2004)

Specific applications of the CO-OP core components for children with ABI

The complexity of the cognitive problems of children with ABI requires a child specific tailor-made application of the Approach., specific suggestions include:

1. Determining the child's goal and motivation in a targeted way

In addition to using the Canadian Occupational Performance Measerment (COPM), use goalsetting with the use of pictures to clarify routines and activities. Tools like the Paediatric Card Sort (PACS) or the Dutch Photo Interview (InfOT, n.d.) can be used for children with limited communication or insight into their issues.

Choose a maximum of 2 goals for severe (executive) functional disorders to keep the focus clear.

Support children in choosing their own goals strengthening intrinsic motivation. As one colleague writes:

"It is in line with the child's sense of direction and autonomy and empowers him to come up with solutions himself"

2. Strategy use and cognitive support

Introduce and teach the global strategy "Goal, Plan, Do, Check" step by step and repeat it visually and verbally. Use this strategy iteratively during the intervention.

Stimulate learning by working with small steps in all phases of the global strategy, use the power of repetition, learning one thing at a time and visualization of what is to be learned.

Adapt the strategy’s complexity to the child's cognitive level.

Guide the child’s discovery learning by asking open-ended or more closed questions instead of giving solutions. Offer suggestions for strategies if the child gets stuck.

Don't “teach” wrong strategies. Adjust in time if errors during the 'check' are not recognized. As a colleague writes:

"This is because the reflective capacity and (limited) insight into illness is mainly only present in the moment, but quickly decreases".

3. Transfer and generalization of what has been learned

Explicitly practice and discuss how a strategy can also be used in other situations (school, home, leisure).

Invite parents and teachers actively think about application possibilities outside the therapy context.

Use videos or photos of the child in action to visually support transfer of learning to other situations and activities.

4. Involve the system (Dietrich et al., 2024)

Support parents to act more as coaches role so that they can support learning and strategy use at home.

Combine CO-OP with psycho-education about ABI so that parents understand why certain approaches are necessary.

Ensure coordination with school and other stakeholders to keep the approach consistent.

5. Session structure and timing

Schedule more sessions and shorter sessions if necessary for children with moderate to severe brain injury.

Use CO-OP after the (sub) acute phase, when the child has sufficient insight and stability.

Start each session with a brief review and end with a transfer question: "Where else could you use this?"

6. Combination with other interventions:

Combine CO-OP with compensation strategies for memory problems.

Consider behavioral management techniques for impulsivity or attention problems.

CO-OP is ideal for children with executive function disorders who benefit from strategy development and self-regulation (Lebrault et al., 2024).

The Perceive, recall, plan and perform (PRPP) system of task analysis and intervention (Chapparo et al., 2017) (PRPP) provides an in-depth analysis of cognitive processes and is widely applicable in everyday contexts.

Errorless learning (Gillen, 2009) is especially suitable for children with severe cognitive impairments or memory problems, where mistakes hinder the learning process.

CO-OP in relation to other interventions for children and young people with ABI

The Dutch Brain Injury Practice Guideline (Ergotherapie Nederland, 2024) and the Dutch national treatment program (Allonsius et al., 2023) for children and young adults with ABI recommend various interventions, including errorless learning and strategy training through Perceive, Recall, Plan & Perform (PRPP) and Cognitive Orientation to daily Occupational Performance (CO-OP). Although there may be more relevant interventions, we will limit ourselves below to a comparison between CO-OP, PRPP and errorless learning. The experience from training in the Dutch context is that occupational therapists have questions about the differences, similarities and relationships between these interventions,

What makes the CO-OP Approach unique?

The CO-OP intervention includes principles in its core elements that promote learning by children, such as make learning fun, do one thing at a time, focus on learning and not on "teaching" and make discoveries made abundantly clear. This in a pattern in which;

• The approach is child-oriented: children choose their own goals and their own way of learning is central
• Cognitive strategies are applied in practice: such as the overall strategy "Goal, Plan, Do, Check", but also specific personalized strategies that children often call their 'trick'
• The way of learning is through guided discovery: The therapist coaches and the child makes his/her own discoveries.
• And there is an explicit effort to transfer what has been learned: There is explicit attention for application in other contexts and in other activities.

CO-OP and PRPP can be considered complementary: where CO-OP focuses on self-chosen goals and strategy development via guided discovery, PRPP provides an in-depth analysis of cognitive processes (by the therapist) during task performance. Together they might form a powerful duo in the rehabilitation of children with ABI.

Conclusion and recommendations

The CO-OP Approach offers a valuable, tailor-made intervention option for children and young people with ABI. The approach promotes self-regulation, problem-solving and strategic action skills that are often limited in this target group and are hindering participation at home and at school. Although further research is needed to strengthen the evidence, practical experience in the Netherlands confirms that CO-OP can be used successfully in rehabilitation of children and young persons with ABI. What is needed is careful tailoring to the cognitive and emotional characteristics of the child and its environment. Training therapists in the CO-OP Approach and developing expertise around ABI-specific applications are important next steps for further implementation.

References