By Tammy Craig BSc, Trent University MSc, Rehabilitation Sciences, University of Toronto

I've spent over 15 years immersed in CO-OP, and I can tell you this: watching Guided Discovery unfold is nothing short of magic.

I started as a research assistant in Helene Polatajko's lab in 2011, and one of my primary jobs was to do PQRS ratings. The PQRS (Performance Quality Rating Scale) is the observational tool used in the CO-OP Approach to rate the quality of a participant's performance on a specific goal, such as bike riding. In the research projects I was a part of, we used the PQRS to provide a score of 1 to 10 for each goal at three distinct points: Time 1 sessions (the baseline recordings taken before any intervention occurred), Time 2 (mid-intervention), and Time 3 (post-intervention). I eventually became the PQRS master because of the sheer amount of videos I rated from different projects I was involved in at the lab.

Every PQRS scoring session took me on an emotional journey. Time 1 sessions hurt. You feel the struggle, the frustration, the weight of what seems impossible. Then comes Time 3, and suddenly you're crying tears of joy as a child rides their bike down the street, as someone writes their name clearly, as independence becomes real.

I watched hundreds of videos. Then hundreds more. I fell in love with CO-OP through those screens, witnessing hundreds of goals transform from distant hopes into tangible realities across so many different populations. I watched children beam at the camera after mastering a skill, their faces radiating something beyond pride. I watched adults button their shirts independently for the first time in years, confidence blooming with each successful clasp.

The aspect of CO-OP I've always admired most is the therapist's ability to facilitate GPDC and then work magic with Guided Discovery. Because it truly is magic. The patience required to refrain from jumping in, to hold back when someone struggles, goes against my every instinct. I'm naturally someone who thinks outside the box. I've always been praised for my creative problem-solving, for finding unique solutions to complex challenges.

Here's the paradox: one of the most critical factors in CO-OP success is also my kryptonite. Patience. Being unimpulsive. Holding space for someone to discover rather than simply telling them the answer.

"The best help you can give is to not help."
— Tammy Craig

This runs counter to every fiber of my being.

That contradiction made me the right person to research parent and guardian involvement in CO-OP for my thesis (Craig, 2016). Because parents live this same struggle. They love their children fiercely. They desperately want to help. And they must learn that the most powerful help looks like stepping back, asking questions, and letting their child's brain do the work.

This isn't intuitive. It isn't easy. And it requires a different kind of support than we often provide.

Parent involvement is foundational to CO-OP outcomes, yet the specifics of how to structure and deliver parent training remain underexplored in clinical practice. Recent research has been adding important pieces to this puzzle, clarifying both how parents influence results and practical approaches to maximize their effectiveness as home coaches (Araújo et al., 2021; Craig, 2016; Martini et al., 2021).

The Research Update: What We Now Know

Finding #1: Parent Confidence Matters More Than Compliance

My 2016 thesis (Craig, 2016) found a crucial, counter-intuitive twist. While higher parent involvement was associated with better performance on some outcomes immediately after the intervention, this finding reversed at the 3 month follow-up. At follow-up, more parent involvement was associated with poorer outcomes. This is likely because high-frequency "helping" creates dependency, preventing the child from internalizing the strategy themselves. This suggests that "more" is not "better." More low-fidelity "helping" undermines long-term generalization.

Since my thesis, the field has shifted from asking whether parents matter to understanding how to optimize their role (Araújo et al., 2021; Martini et al., 2021). Martini et al. (2021) consolidated three qualitative studies and revealed a core barrier: parents struggled with "feeling self-efficacious with the approach". Even when they understood the concepts intellectually, they lacked the confidence to apply Guided Discovery at home.

Finding #2: Why Just Watching Is Not Enough

A key finding from the Martini et al. (2021) consolidation was that 'parent observation of intervention sessions is not enough to support parents applying CO-OP at home.' Watching a therapist use Guided Discovery can be deceptive because it looks like a simple conversation. Without explicit training on the mechanics, specifically knowing exactly when to pause and how to phrase the questions, parents struggle to replicate that interaction in the complexity of their home environment.

When parents observe, their protective instincts can override their intention to use Guided Discovery. A single parental rescue can undermine the metacognitive discovery process that forms CO-OP's core (Missiuna et al., 2001; Polatajko et al., 2001).

Finding #3: It's About Quality, Not Quantity

Araújo et al. (2021) compared standard CO-OP parent involvement to standard CO-OP plus additional intensive parent coaching groups. Despite the extra support, no significant differences emerged in child outcomes between the conditions. This suggests that the standard CO-OP parental involvement protocol is sufficient on its own. Simply adding more coaching hours does not necessarily translate to better functional outcomes.

Should Parents Watch the Session? A Structural Dilemma

Based on those findings, a dual-stream model preserves the integrity of both the child's metacognitive development and the parent's skill acquisition. Given the risks of rescue behavior, the research increasingly supports the Dual-Stream model where possible.

The Parent Challenge: High-Fidelity Guided Discovery

Parents consistently identify Guided Discovery as the most challenging aspect of CO-OP implementation (Martini et al., 2021). The instinct to help by providing solutions is neurologically hardwired and requires conscious override.

Core Teaching Strategy: Explicit Contrast

Research on adult learning suggests that showing what not to do alongside what to do increases retention and application accuracy (Cameron et al., 2017).

The Wait Time Challenge

Parents typically respond to their own questions within 2-3 seconds. CO-OP requires 7-10 seconds of processing time for the child to engage metacognitively (Polatajko & Mandich, 2004).

Teaching approach: Experiential demonstration during parent training (Cameron et al., 2017). Ask the parent a question, wait 2 seconds, answer it yourself. Then repeat with 10 seconds of silence. The felt difference is more instructive than explanation.

The Human Factor: Supporting the Parent's Journey

Supporting Parents Without Overloading Families

Martini et al. (2021) found that parents whose children participated in CO-OP recognized improvements but also reported significant challenges, including difficulty incorporating CO-OP tasks into daily routines, navigating changes in the parent-child relationship, and experiencing uncertainty about their self-efficacy with the approach. These findings highlight the complexity of parent implementation.

Research on family-centered pediatric rehabilitation identifies specific principles for building parent capacity without creating additional burden (Law et al., 2003). Grandisson et al. (2023) documented perspectives from 41 parents and occupational therapists, revealing nine key principles, including:

• Being sensitive to possible negative impacts of services on families.
• Avoiding overwhelming families with information or recommendations.
• Taking the time needed for parents to process and implement strategies.
• Consistently highlighting positive aspects of the child's performance and parent efforts.
• Offering flexible conditions for service delivery.

What Drives Parent Engagement

Research on parent engagement in occupational therapy reveals that parent feelings significantly influence their participation. Parents report feeling more engaged when they experience confidence in the therapist, feel supported and validated, and sense empowerment in their role.

Conversely, feelings of hopelessness or being overwhelmed create disengagement. Notably, parents may be intellectually committed to therapy (engaged in the idea) while struggling with practical implementation (disengaged in the doing). This distinction matters.

Cultural Context Cannot Be Ignored

Families' cultures, including language, gender relations, nonverbal communication, and values placed on child independence, directly impact their ability to collaborate in therapy (Grandisson et al., 2023).

When families and therapists do not share cultural references, additional resources and adaptations are necessary to ensure collaboration respects diversity. This is particularly relevant for CO-OP, where Guided Discovery may conflict with cultural values regarding adult authority, direct instruction, or family hierarchy.

6 Practical, Research-Backed Hints for Therapists

The research points to practical strategies therapists can use to build parent confidence and make Guided Discovery stick (Cameron et al., 2017; Coelho et al., 2024; Grandisson et al., 2023; Kessler & Graham, 2015).

1.Normalize the "Awkward" Feeling

Be explicit: "This is going to feel unnatural." Research confirms that both parents and therapists feel "awkward" when first learning new interventions (Cameron et al., 2017; Coelho et al., 2024). We are asking parents to fight the "natural tendency" to rescue. Naming this validates their experience and builds trust.

2.Focus on Capacity, Not Burden

Parents are often "overwhelmed". Building family capacity means "avoid overwhelming the family with information" (Grandisson et al., 2023). Actively highlight positive moments. Point out when the parent successfully uses a Guided Discovery question. The goal is not to add more work, but to make existing interactions more effective. Coach parents that a rushed morning is not the time for Guided Discovery. This shifts the focus from "more practice" to "better practice."

3.Provide Simple, Concrete Tools

Parents often "freeze" and do not know what to say (Martini et al., 2021). The "Direct vs. Guided" contrast chart is one tool (as shown in the table above). Another is helping them create physical reminders, like cue cards with key questions ("What's the plan?", "What else could you try?") for the fridge. Having a script with 3-4 go-to phrases can be a game-changer.

4.Use "In Vivo" Feedback (Live Coaching)

Instead of only talking about Guided Discovery, have the parent try it in the session. The parent can practice coaching you (as you role-play the child) or their child directly. Research on "in vivo" feedback shows it is a powerful mechanism for skill acquisition. This provides an immediate chance to highlight what the parent is doing well ("That was a great open-ended question!") and build their confidence.

5.Bridge the "Idea vs. Doing" Gap

Research shows parents can be "engaged in the idea" (they believe in CO-OP) but "disengaged in the doing" (they struggle to use it). This is often due to low confidence, not low commitment. When a therapist hears, "I try, but it just does not work at home," the solution is usually more practice, not more information.

6.Model Patience for the Parent's Process

The "Wait Time Challenge" also applies to parents. Family-centered care highlights the need to "take the time needed for parents to process and implement strategies" (Grandisson et al., 2023). After introducing a new concept, model the same patience we ask them to show their child. Pause and ask, "What are your first thoughts on that?" Then wait. This gives them a chance to voice uncertainty, which is critical for building their confidence.

Conclusion

The research across these studies points to one practical truth for therapists. Parents do better with CO-OP when they are taught the approach directly, outside the child session, with clear examples of what Guided Discovery looks like and chances to practice it without the pressure of watching their child struggle.

Observation alone is not enough, rescue instincts interrupt the process, and confidence with the method matters as much as understanding it.

When parents understand the approach well, they can actually use it. And that is where the real magic shows up, the moment CO-OP stops living in the manual and starts living in the kitchen, the driveway, the hallway, and all the places families actually move through every day.