Using the Cognitive Orientation to Daily Occupational Performance (CO-OP) Approach with Youth with Acute Mental and Behavioral Health Needs: Part 2 – Discussing the Fit and Case Studies

This is a follow up blog on our first one, published on the ICAN website January 2004, in which we described the context of these young people and our work.

Author Bios: Lindsay Davis (MOT, OTR/L) works with patients experiencing acute psychiatric crises in inpatient pediatric behavioral health settings.
Megan McKim (MOT, OTR/L) works as a clinical manager in pediatric behavioral health, supporting quality and process improvement, program development, and clinical operations.
Lindsay and Megan both work at Nationwide Children’s Hospital in Columbus, OH.

When was CO-OP Good Fit?
We worked to carefully consider various client factors in order to identify possible candidates that could be a good candidate for the CO-OP approach as well as candidates that may not be an ideal fit for the approach.
CO-OP was further considered for patients who met the criteria below.

  • Patients were required to have an anticipated length of stay of at least 6 days. In order to be able to adequately learn the goal, plan, do, check (GPDC) approach and have sufficient time to develop a plan, practice a plan, and make any necessary modifications to a plan, this was the minimum amount of time deemed necessary by the team.
  • Patients needed to present with some degree of intrinsic/extrinsic motivation that was able to be identified during their initial goal-setting process.
  • Patients required adequate cognitive and language skills in order to engage in a metacognitive reflective process.
  • Patients who would best benefit from a top-down approach vs. a bottom-up, remediation-style approach were targeted.
  • An adequate degree of caregiver involvement was required in order to facilitate homework and reinforce the identified plan for carryover.
  • There needed to be an opportunity, to “do” or practice the goal while admitted to the inpatient psychiatric program. The following graphics detail examples of targets for which the CO-OP approach was deemed applicable vs. not applicable:

Outcomes & Conclusion:
After trialing the CO-OP approach to intervention with patients deemed appropriate for several months, therapists involved in the trial agreed that they found utility in further considering applications of the CO-OP approach within our patient populations. All patients that engaged in the CO-OP approach during this initial trial period demonstrated improvements in DPA self-ratings and expressed improved confidence and abilities post intervention as it related to the functional skills and daily occupations targeted.

Max, a first example

Background: Max is a 14-year-old transgender male who prefers to go by “Max” and he/him pronouns. Max was admitted to the inpatient adolescent unit due to suicidal ideation and behavior. Max felt that his symptoms of depression have been worsening due to his gender dysphoria. Max reported he has a difficult time completing ADL/self-care tasks due to his distress around removing his clothing and seeing his body to complete a shower daily. Max also shared that he has had decreased engagement in most of his valued occupations due to low mood/energy.

Max’s Goal: “overcome my anxiety and stress around showering and getting dressed”

Max’s Motivation:

  • wanting to feel less self-conscious
  • not wanting to worry if he smelled bad
  • wanting to look nice when he leaves the house                        

Max’s DPA Score Pre-intervention: 2/10

  • Max had been primarily using body wipes most days and showering very rarely
  • Max was using dry shampoo, washing his face, and using deodorant some days  
  • Max was reporting high levels of distress with thorough task completion


  • GoalMax’s goal “overcome my anxiety and stress around showering and getting dressed”.
  • Plan Max followed his ADL plan and routine, incorporating strategies for managing dysphoric thoughts and associated stress. Max made chart visuals to track progress.
    • Strategies used: distraction, supplementing task knowledge, task modification, relaxation
  • Do Max practiced implementing his ADL plan on the unit with new distress tolerance tools and routine.
  • Check - Max reviewed his chart to determine what strategies were helpful and continued to trial strategies to keep those that benefitted him until the plan was finalized.

Parent Education:  OT supported Max in teaching his parents his plan. Max’s parents agreed to remove the mirror from the bathroom until Max was more comfortable and confident. They purchased hygiene supplies that align with Max’s gender. In addition, his parents expressed intent to install a light dimmer for his bathroom at home.

Outcomes: Max’s DPA Score Post-intervention was 9/10. Max successfully completed his ADL plan 5/6 sessions and reported decreased perceived stress levels surrounding ADL completion. Max expressed increased confidence in his ability to perform tasks after discharge. 

Kate, our second example

Background: Kate is a 13-year-old female admitted to the inpatient adolescent unit following a suicide attempt via an intentional ingestion of medications. Kate has a history of anxiety, depression, and post-traumatic stress disorder. Kate’s trauma is in the form of exposure to domestic violence, loss of 2 siblings to gun violence, and a history of sexual abuse. She presents with decreased engagement in daily occupations and demonstrates task avoidance across home, school, and community environments. Kate’s challenges are primarily related to managing trauma responses when presented with stressors as well as poor motivation.

Kate’s Goal: “to get back to what’s most important to me”
Kate’s Motivation:

  • pass the semester
  • have more energy
  • have a better mood
  • take better care of myself

Kate’s DPA Score Pre-intervention: 3/10

  • Kate was completing a shower 1x/week
  • Kate was sleeping during most daytime hours
  • Kate was not completing any school work 


    • Goal“to get back to what’s most important to me”
    • Plan OT educated Kate on using a habit tracker of daily tasks to support behavioral activation and identified preferred distress tolerance activities to disrupt her trauma response.
      • Strategies used: distraction, relaxation, supplementing task knowledge, verbal rote script 
    • Do Kate kept track of daily tasks completed and practiced completing her daily habit tracker during hospitalization.
    • CheckKate processed and problem-solved barriers to completing her routine with her therapist and tracked her associated mood.

Parent Education:  OT supported Kate in teaching her primary caregiver about her written plan and habit tracker. Kate collaborated with her caregiver to create a nightly “check in” to help her celebrate successes, maintain progress, and problem solve barriers.

Outcomes: Kate’s DPA Score Post Intervention was 8/10. Kate was completing a thorough hygiene routine daily by time of discharge. She was observed to work on schoolwork consistently during daily education groups and was self-initiating homework. She reported feeling more confident in managing trauma-related stress and reported consistently getting at or near eight hours of sleep during appropriate times (evening hours) with fewer disruptions. 

**Above is the habit tracker utilized to process Kate’s success with her written plan for distress tolerance during functional activities. Kate would color in her performance in these activities as a motivator and to help pinpoint areas in which she still needed support in problem-solving (i.e. green – went well, was successful; yellow – went OK or partially successful; red – still difficult, need to revisit my plan). 


  1. American Occupational Therapy Association. (2016). Occupational therapy’s distinct value: Mental health promotion, prevention, and intervention across the lifespan. Bethesda, MD: AOTA Press. 
  2. Center on the Developing Child. (2017, February 14). Early childhood mental health. 
  3. Iverson, E., & Sharpe, P. (2021). Cognitive orientation to daily occupational performance (co-op) conference.  Nationwide Children’s Hospital Conference, Columbus, OH. 
  4. Katz, N., & Toglia, J. (2018). In Cognition, occupation, and participation across the lifespan: Neuroscience, neurorehabilitation, and models of intervention in occupational therapy (pp. 9–27). essay, American Occupational Therapy Association.
  5. Nationwide Children’s Hospital On Our Sleeves. (2019). On our sleeves advocacy toolkit.