The CO-OP Approach: A transdiagnostic perspective

Abstract

Motor difficulties are widely reported in individuals with autism spectrum disorder (ASD).¹ Since the publication of the DSM-5, the dual diagnosis of ASD and developmental coordination disorder (DCD) is now recommended when criteria for both diagnoses are met. The co-occurrence of DCD is estimated at 40% of individuals with ASD, although some studies suggest that it is actually more prevalent.¹ In the presence of a dual diagnosis of DCD and ASD, should therapists consider using approaches recommended for DCD?²

The Cognitive Orientation to daily Occupational Performance (CO-OP) Approach is recommended for children with DCD due to its well documented effectiveness in the literature.² The Approach yields functional improvements in daily activities by relying on children's ability to learn to use cognitive strategies to problem-solve through their difficulties. Although initially developed specifically for children with DCD, studies have explored the effectiveness of the CO-OP Approach with various populations. A recent systematic review³ identified five studies (published between 2001 and 2022) that specifically focused on its effectiveness with children with ASD. The level of evidence from the study designs was considered low, and statistical measures of effect size (which enables clinicians to select the most effective interventions) were lacking.

Accordingly, the quasi-experimental study by Kangarani-Farahani et al.⁴ is a welcome addition to the body of evidence documenting the effectiveness of the CO-OP Approach in children with ASD and DCD. The authors measured the effect of the Approach on a variety of outcomes that targeted body-level impairments, namely motor abilities, as well as activity performance. In line with previous research on the CO-OP Approach, subjective and objective activity performance was also measured using children and families' perceived performance, as well as a blinded therapist's assessment.

Similarly to other research exploring the effectiveness of the CO-OP Approach in a pediatric population, a statistically and clinically significant change with a large effect size for subjective and objective activity performance was measured following the intervention, and this improvement was maintained at follow-up 3 months later. Interestingly, although body-level impairments are not targeted through the CO-OP Approach, a statistically significant change, with a moderate effect size, was measured following the intervention. Indeed, motor abilities improved, as measured by the Bruininks-Oseretsky Test of Motor Proficiency.

The impact of the CO-OP Approach on body-level impairments opens up interesting avenues for research into the mechanisms of action of the Approach with children with ASD. Furthermore, it offers interesting perspectives when considering an intervention with children with ASD and DCD. If the effect of the CO-OP Approach transfers to motor abilities in a group of children with ASD and DCD, could it also affect sensory processing impairments characteristic of children with ASD?

Case reports by Rodger et al.⁵ demonstrated improved tolerance to sensory stimuli following an intervention with the CO-OP Approach with children with ASD. One of the objectives chosen by children who had an aversion to the consistency of fruit with the skin left on was their ability to cut the fruit pieces to the desired size. With the contribution of the CO-OP Approach that enabled children to develop their own plan to successfully overcome their difficulties, the children were able to eat the pieces of fruit without removing the skin. The increased control given to the children with ASD through the CO-OP Approach is a strategy often used by clinicians working with children with ASD. Indeed, such increased control enhances the acceptability of activities and sensory stimuli in the environment.

In summary, the study by Kangarani-Farahani et al.⁴ clearly demonstrates that an approach originally designed for DCD can be significantly effective in improving activity performance and motor abilities in children with ASD and DCD without intellectual disability. This underscores the need to evaluate cognitive-type interventions that have been shown to be effective for other neurodevelopmental disorders and to further explore the mechanisms of action and key components that make the CO-OP Approach effective.