Mothers’ experience of being involved with the transfer of the CO-OP approach: A qualitative study

Abstract

Introduction

Since mothers are the best persons to facilitate transfer in their children, it is important to understand their experience with implementing the cognitive orientation to daily occupational performance approach at home. Therefore, this study aims to explore mothers’ experiences in facilitating transfer during implementing cognitive orientation to daily occupational performance approach at the home in children with specific learning disorder.

Method

A semi-structured interview was applied for mothers of children receiving cognitive orientation to daily occupational performance. The interviews were transcribed verbatim and the data were analyzed using a continuous comparison technique and inductive content analysis.

Results

Five themes emerged which described the mothers’ experiences of being involved with the transfer of cognitive orientation to daily occupational performance approach at home including (1) mothers’ feelings toward themselves; (2) supportive therapist; (3) supportive social settings; (4) multidimensional educational content; and (5) educational methods.

Conclusion

Mothers expressed that cognitive orientation to daily occupational performance approach was simple, but they needed deeper information and skills. They provided suggestions for increasing the involvement during cognitive orientation to daily occupational performance intervention to increase transfer.

Keywords

Mother involvement transfer occupational therapy qualitative method

Introduction

There has been an ongoing trend in occupational therapy practice toward family-centered care and interventions. A key element of a family-centered approach is the involvement of parents (Hanna and Rodger, 2002). In fact, parents are an integral part of therapy and the first source of support for children during intervention in both clinic and home (Power et al., 2002). Of parents, fathers are more involved in play activities with their children, while mothers spend more time on caregiving, teaching, and socializing (Strauss et al., 2013). Evidence suggests father involvement in parenting leads into better behavioral outcomes which increases self-efficacy level in the child (Keshavarz and Mounts, 2017; Lindberg et al., 2017). Despite the beneficial results of dual parental involvement, the cultural context of family structure in Iran has caused mothers to be primarily responsible for rearing their children and family life. The non–household-related responsibilities of the father limit father–child interaction and relationship opportunities, so the mother is the primary care giver. Mothers generally spent more time with their children; therefore, this brings more opportunities for their involvement (Rahkar Farshi et al., 2018). In Iranian culture, patriarchy is part of traditional structure and culture which leads to reinforce gender roles in child-rearing and prevents fathers from involvement. According to these traditional roles, the father is the sole breadwinner and provider of the family and the mother is responsible for raising children as well as household responsibilities (Keshavarz and Mounts, 2017; Zare et al., 2017).

One of the intervention approaches in occupational therapy which encompasses parent involvement as one of its key features is cognitive orientation to daily occupational performance (CO-OP) (Dawson et al., 2017). CO-OP is an approach based on problem-solving which applies cognitive strategies to solve motor-based occupational performance problems (Dawson et al., 2017; Polatajko et al., 2001). In this intervention, parents have an important role in supporting child in acquiring skills, developing cognitive strategies, generalizing and transferring strategy use into daily life (Cameron et al., 2017; Polatajko et al., 2001), by involvement in goal settings, during intervention and in the acquisition phase (Cameron et al., 2017). Parents are able to raise child’s responses and create a bridge between therapeutic settings and other real-life situations of children. They are involved and committed to implement the CO-OP approach beyond treatment settings and at home and are asked to promote the development of strategy use and its transfer into daily life (Dawson et al., 2017; Mandich and Polatajko, 2004; Polatajko et al., 2001).

In this approach, “transfer” of skills and strategies takes place when children learn how to adapt their newly acquired strategies and skills beyond intervention sessions to the requirements of new tasks encountered in everyday life (Dawson et al., 2017; Houldin et al., 2018; McKeough et al., 2013). As indicated by Polatajko et al. (2001), the CO-OP approach is mostly effective when parents are involved in the implementation of the approach out of intervention sessions (Cameron et al., 2017; Mandich and Polatajko, 2004; Polatajko et al., 2001). The therapist can enhance parent involvement by ensuring parents figure out CO-OP key features. Then, parents are encouraged to observe the first session, where global cognitive strategy is introduced to the child; thus, they can support and reinforce the use of global strategy. Parents are also encouraged to observe several sessions, so they understand how to use the guided discovery and application of enabling principles in action (Dawson et al., 2017; Mandich and Polatajko, 2004; Polatajko et al., 2001). Therefore, given the constant presence of parents in child’s life, they have a key role in situations outside therapy settings and lie in the best position to support the transfer of learned skills and strategies into child’s daily life (Dawson et al., 2017; McKeough et al., 2013).

Jackman et al. (2017) research addressed parents’ experience of CO-OP approach in a group format for children with cerebral palsy (CP). One of the important emerged themes was challenges parents faced on parenting style. For instance, parents experienced that the CO-OP approach encourages parents to step back and guide the child to carry out daily living activities and allow their child to become independent which may contradict the parents’ desire to help their child. Parents believed to participate in CO-OP sessions may facilitate this change in their parenting style. They also described that participation in therapy sessions and observing the therapist’s behaviors during sessions can teach them different ways to guide the child to discover domain-specific strategies; thus, parents can apply these to their future and new goals (Jackman et al., 2017).

To implement CO-OP at home, a deep understanding of the intervention and methods of incorporating it into the family’s routines is required (Cameron et al., 2017). Research conducted by Martini et al. (2020) indicated parents who knew about CO-OP without practicing and applying these principles under the therapist’s supervision cannot sufficiently perform it at home (Martini et al., 2020). Parents faced challenges when implementing CO-OP at home and while doing homework including difficulties in analyzing where a breakdown in activity was occurring and there was often a loss when trying to ask appropriate questions which would guide the child (Cameron et al., 2017; Capistran and Martini, 2016). Another challenge was finding time to practice in a busy family routine. Parents reported it is easier to practice tasks which are part of the daily routine of the child and family (Capistran and Martini, 2016; Martini et al., 2020).

Studies have explored parents’ experience of CO-OP in children with developmental coordination disorders (DCDs) and CP and children’s experience of the approach from parents’ perspective. Parents’ experiences, concerns, and routines vary depending on the child’s diagnosis and conditions (Martini et al., 2020; Smith et al., 2015). Children with specific learning disorder (SLD) experienced behavioral difficulties due to persistent academic failure.

Research has also indicated some parents do not experience effective involvement in the education process; and parental contact with school staff is more about the child’s problems at school than about her/his accomplishment. Parents report less satisfactory partnerships with schools; therefore, their negative experiences may limit further participation (Al-Dababneh, 2018). Thus, it is expected of parents’ experiences of children with SLD to be different compared children with CP and DCD. Due to the context of Iran, mothers generally spend more time with their children; as a result, they have more opportunities of involvement.

This research aims to explore the mothers’ own experience of involvement in the transfer. Although Martini et al. (2020) study explored parents’ experience of applying CO-OP out of therapy sessions, it provides limited insight on the mothers’ experience of involvement in the transfer and applying the approach in new and untrained tasks.

The study is the qualitative phase of a larger mixed-method research aimed to develop a guideline to increase and improve the quality of parents’ involvement in the supporting transfer of CO-OP.

Method

This qualitative research was conducted with the use of content analysis methodology to explore the mothers’ experiences of their involvement in the transfer of CO-OP approach (Hammarberg et al., 2016; Graneheim and Lundman, 2004). Content analysis provides new insights and increases researcher’s understanding of particular phenomena. It is a research technique to make replicable and valid inferences from texts to the contexts of their use (Hsieh and Shannon, 2005; Krippendorff, 2018). Conventional content analysis was used to interpret the content of the text data through the systematic classification process of coding and identifying themes. The present study was adapted from the first author’s PhD thesis and was approved by the Ethics Committee of the Iran University of Medical Sciences (IR.IUMS.REC.1398.062).

Participants

Purposive sampling was carried out with mothers of children with SLD who received CO-OP intervention. The participants were the mothers of children with SLD. All children who received CO-OP intervention had the following characteristics: (1) 7–12 years; (2) diagnosed with SLD by a pediatrician according to Diagnostic and Statistical Manual of Mental Disorders (DSM–V) criteria for SLD; (3) problems in motor-based occupational performance; and (4) without any diagnosis or symptoms of neurological or neuromuscular disease.

The intervention was delivered at the rehabilitation centers of Valiasr Rehabilitation Institute in Tehran according to the structure of sessions proposed by Polatajko (2001), S. Gh, and an occupational therapist who was already trained in the CO-OP approach. At least four months after the end of the intervention, all mothers were invited for an interview and finally eight mothers participated in the interviews. Two participants were mothers of children who had received CO-OP intervention by first author (S. Gh) who was also an interviewer, which is specified in Table 1 (the second and fourth participant’s child). Informed and written consent were obtained from mothers to participate in the research. In addition, the participants’ characteristics are shown in Table 1.

Table 1.

Demographic details of mothers of children with special learning disabilities.

Mothers	Mother 1	Mother 2	Mother 3	Mother 4	Mother 5	Mother 6	Mother 7	Mother 8
Age (years)	32	42	38	45	38	34	37	52
Education	Master’s degree	High school diploma	Bachelor’s degree	High school dropout	High school diploma	Master’s degree	Advanced diploma	Advanced diploma
Father’s job	Teacher	Employee	Self-employed	Worker	Self-employed	Employee	Self-employed	Employee/self-employed
Mother’s employment	Teacher	Unemployed	Self-employed	Unemployed	Unemployed	Unemployed	Unemployed	Unemployed
Number of children	2	3	1	3	2	2	2 (1 autistic child)	4
Child’s age (years)	9	9	9	10	8	7	8	10
Child’s gender	Boy	Boy	Girl	Girl	Boy	Girl	Girl	Boy
Child’s academic grade (primary typical school)	3	3	3	4	2	1	2	4
Time passed since intervention (months)	8	8	7	5	5	7	5	9
Someone who intervened	Trained therapist	Interviewer (S. Gh)	Trained therapist	Interviewer (S. Gh)	Trained therapist	Trained therapist	Trained therapist	Trained therapist

Note: CO-OP: cognitive orientation to daily occupational performance.

Someone who intervened: The therapist who provided the CO-OP intervention for the children.

Trained therapist: Six children received CO-OP intervention by a pediatric occupational therapist with training on the CO-OP approach.

Interviewer (S. Gh): Two children received CO-OP intervention by S. Gh who is an interviewer in this study.

All eight mothers lived with their husbands, seven of whom had more than one child. They were 32–52 years, with education levels from high school to master’s degree. One family had a child with autism spectrum disorder, and other families had no child with any kind of known disorders or diseases. All fathers were employed, and two mothers were employed outside home. Table 1 presents participants’ demographic details.

Description of the intervention

Children whose parents participated in the interview received 12 individual CO-OP sessions (45–60 min each session, two sessions per week). Eight children received the intervention by two pediatric occupational therapists who trained in the CO-OP approach. One of them was S. Gh who was the interviewer in this study and two children as specified in Table 1 (the second and fourth child participants) received CO-OP intervention by S. Gh.

Prior to the intervention, CO-OP and occupation-based interventions were verbally explained, and the importance of selecting the goals by children was explained to the mothers. Then, the therapist described to the parents the type of goals and skills the child would acquire during the intervention and parents were encouraged to have a conversation about goals with the child. Parents almost attended all sessions especially the first session as recommended in Mandich and Polatajko (2004). Parents were also encouraged to support their child to use discovered strategies and learned skills, outside the clinical setting and in the new and untrained tasks. At the end of each session, the therapist verbally explained the discovered strategies and provided a written document of domain-specific strategies to parents, which was discovered during each session.

Data collection

After obtaining written informed consent from participants, semi-structured interviews were conducted in person (seven) and on the phone (one) by the first author (S. Gh). All interviews were in Persian, completed at a location of mothers’ choice, were recorded, and transcribed verbatim by the researcher. Each interview lasted approximately for an hour, and for the purpose of confidentiality of data, participants’ names were deleted from the transcriptions.

An interview guide was used (Table 2) as a basic structure, but the interviewer followed the lead of the mothers by asking and probing questions to explore or clarify information shared and obtain supplementary information. All interviews began with an open question: “Describe your experience of receiving CO-OP intervention for your child,” “Explain how CO-OP approach works? Tell us everything you know about it?”. Then, other questions were asked within an appropriate time such as “What inhibitor and facilitators did you have in applying the intervention at home and in new tasks?”, “Tell me about your role in acquiring skills and applying CO-OP at home and new tasks,” and “Which strategies have you used enabling your child could use learnt skills and strategies in new tasks and activities?”.

Table 2.

A sample of main interview questions for parents.

1. Describe your experience of receiving CO-OP intervention for your child

2. Explain how the CO-OP approach works? Tell us everything you know about it

3. What is your experience of helping and supporting your child with the use of strategies and finding cognitive strategies in new tasks?

4. Tell me about your role in acquiring skills and applying the CO-OP approach at home and new tasks

5. What inhibitors and facilitators did you have in applying the CO-OP approach at home and in new tasks?

6. Which strategies have you used so that your child could use their learnt skills and strategies in new tasks and activities?

Note: CO-OP: cognitive orientation to daily occupational performance.

Data analysis

Inductive content analysis and continuous comparison technique were employed for data analysis (Graneheim and Lundman, 2004; Griffiths and Norman, 2012). Analysis and interpretation of data were carried out in different stages by two members of the research team (S. Gh and R. V). The recorded interviews were transcribed verbatim by S. Gh. First, all interviews were read by the authors (S. Gh and R. V) for several times to obtain an overall impression. Second, the data were divided into meaning units; then, they were labeled with codes. The concepts and codes were categorized based on differences or similarities and subcategories and categories were developed. After the process of coding and grouping the codes and obtaining underlying meanings, they were interpreted as main themes. Five themes emerged; each theme and subthemes were reviewed by first author (S. Gh) and discussed with the authors N. Sh and M. R to ensure dependability.

Then, the provisional themes and subthemes as well as the summarizing texts and codes were discussed by the authors (S. Gh/R. V/M. AF/N. Sh) in a focus group. Appropriate consistency was found between the authors’ perceptions of the primary themes and their content while minor adjustments were made in the themes. Then, the themes, subthemes and their content were translated into English and were reviewed by the two authors (D. C and H. P) and minor adjustment in themes and subthemes were made to create the final categories.

The researchers planned to improve trustworthiness through prolonged engagement with the participants, integration of data collection methods (interview and field notes), professional member check, and continuous comparison of the data. After the analysis, the full transcripts of coded interviews with a summary of the emergent themes were given to the mothers to determine the accuracy of the codes and themes attributed to their experience. For stability and reliability of data, external check was used in the form of peer check by two experts of occupational therapy with the experience of working with children and mothers and review of interview transcripts through member check (Graneheim and Lundman, 2004; Griffiths and Norman, 2012).

Results

Five themes were extracted from the interviews describing the mothers’ experiences with the transfer of CO-OP at home in new and untrained tasks: (1) Mothers’ feelings toward themselves; (2) Supportive therapist; (3) Supportive social settings; (4) Multidimensional educational content; and (5) Educational methods.

Mothers’ feelings towards themselves

One of the themes reveals that mother involvement in the transfer was perceived to be affected by mothers’ feelings toward themselves. For example, mothers felt guilty about their perfectionist attitudes and strictness on their child’s performance.

“I am very strict and sensitive to my child’s performance. It’s important to me that he does everything very well, and when he is not able to do it or it takes a while, I do it quickly or I tell him the strategy and I just blame him. And now I know this is wrong and I have to give him a chance to think and then answer but I do not. And I think he cannot do that, I’m guilty. And I bother him a lot”.

Mothers also suffered from a lack of self-confidence and attributed their lack of adequate involvement in their child’s transfer to inadequate ability and skill, and even inadequate intelligence. The statements expressed a poor sense of confidence in their ability to learn and apply the principles of CO-OP in new situations without the presence of a therapist. The mothers explained that they had to wait for the child to find a solution to the problem, and they could not wait or use different ways to guide their child to find a solution, but they believed that the therapist could do it very well.

“This treatment has a special flair and requires a certain patience to achieve that result. I don't have the patience. That’s why I think I wasn’t able to help him”.

“This therapy needs patience, which I don't have …. I don't have the knowledge or the action. When something else is added, I know no more. I think it needs some intelligence, as well”.

While referring to their problems, mothers revealed their inability to manage time and lack of supporting skills and resilience. These shortfalls adversely affected mothers’ positive involvement in the process of teaching their children.

“I do all the kids’ chores, not only this child. My daughter has her own things to do. I have no fun at all for myself. I have to do my own things very quickly, so when the kids arrive, I can start working with them on their schoolwork and homework…I did all his things. Assignments and schoolwork takes a lot of time, which leaves no time for extra practice”.

Supportive therapist

Another factor raised by mothers which increased their own motivation to take part in the process of intervention was the therapist’s type of interaction with the child and mothers.

Ongoing therapist’s support and help for mothers

Mothers mentioned sometimes they encountered challenges and frustrations during the conduct of the intervention at home and in new tasks, but the therapist encouraged them to overcome them. During the intervention and completion of homework and implement learned skills between sessions, when there were challenges, the therapist listened well to the problem and coached mothers for appropriate solutions, and this collaborative relationship was very effective in motivating mothers to participate.

“Every time his progress was sluggish, [therapist] gave me hope that I should carry on with my efforts and I would get results for sure”.

“we [I] could ask any questions, whenever we had any problems, and that she [therapist] would check if I had correctly understood and guided me; it was great”.

Therapist’s care about child’s progress

When the therapist cares about the child’s progress, follows to use acquired skills at home, and encourages the continuous use of strategies at home and in new and untrained tasks, this motivates the mothers to participate more in the intervention process.

“How can I not care when I see his therapist cares so much. It is very important to me that she follows up”.

Supportive social setting

Another theme extracted from interviewing mothers was the supportive social settings. It showed that mothers sensed important facilitating and inhibiting factors in the community around them which affected the success of their children’s training. Subcategories of this theme included supportive teacher and school staff and supportive father and relatives.

Supportive teacher and school staff

The mothers reported since the child’s time is partly spent at school and school activities, and some goals, such as handwriting, sports and games are tasks that a child mostly carries out at school. They needed the support and cooperation of the school staff and teachers to give them the opportunity to use the strategies they have discovered, especially at the beginning of learning, which is slow and requires more time to do the activities; therefore, the teacher should be educated on this approach.

“Well, when he writes at home, his handwriting is so good at home, before he can remember and apply these strategies, the teacher warns him to write sooner so that he returns and writes again as before.”

Supportive father and relatives

Mothers stressed that they would be more motivated to participate if they felt that they had support and cooperation from their husbands and relatives. They said people around do not have the necessary information about how to deal with the child, and they might interfere in this process which prevents proper implementation of strategies and causes child’s failure to cooperate with activities. For example, they helped the child when they should not and did not give them enough time to complete activities or encouraged them when there was no need.

“I’m willing to spend all my time on working with the kids, and don't want their father to be trained, I just want him to support me and not to hinder”.

“When he is trying to do something that he has learned, he gets stuck for a while and does it more slowly. Father or grandmother and other people tell me not to bother the child and they help him quickly. While I learned that I had to give him a chance to do it himself.”

Multidimensional educational content

Another theme extracted from the interviews corresponds to educational content. It generally conveys in order to make training more useful and effective, mothers, in addition to their need to acquire knowledge and skill about the treatment principles in more detail, also need education in other aspects which was unrelated to CO-OP but can be very effective; therefore, the title: “The need for multidimensional educational content” was selected for this theme which consists of such categories as the need to learn principles of CO-OP in full detail and the need to know the principles of parenting.

The need to learn CO-OP in full detail

It was evident from mothers’ narratives that some mothers had no clear understanding of CO-OP, or the therapist had not properly communicated the approach to mothers. Therefore, they were unable to use these principles for learning new tasks faced by the children. Most mothers expressed that accurate, detailed, and step-by-step teaching of the principles of CO-OP approach and discovered strategies in therapy sessions to mothers enabled them to support their children in doing learned tasks and facilitated the use of cognitive strategies at home in new and untrained tasks.

“After each session, [The therapist] told me [mother] step by step these are the ways [strategies] he has achieved [discovered] here for example for eating, he discovered that he should hold the spoon correctly in his hand, sit straight, when eating take the spoon to the mouth and not head toward the spoon, and finally, take the spoon to the mouth from the front. She [therapist] showed it to me and then asked me to remind him these things at meal times”.

“The methods [CO-OP approach] the therapist used or told us to do were very simple, but when she told me, when she was guiding my son to discover strategies for breakdown points, I wondered why it hadn't occurred to me”.

It seems that some mothers did not have a proper understanding of the problem-solving process and guided discovery; thus, this implies the mothers’ misunderstanding of the principles of CO-OP approach. This misunderstanding was evident when describing the implementation of the intervention.

“I could do the questions you were asking, but it is very difficult for me to ask the question myself.”

“I guessed the reason she could not go to the toilet was because she pushed her weight backward so much, but I didn’t know how to ask a question, so I told her straight away that you shouldn’t push your weight back, and even showed her how to sit on the toilet”.

Moreover, some mothers’ words implied that they were unable to identify performance breakdown points through performance analysis, or even find issues and their priorities.

“I only saw him spilled the food, but never understood why it spilled”.

“I practiced proper eating with her a lot before, but I never knew that she should bring the spoon from the front like you said. I did not know why she drops her food, and only saw that she drops the food, but never knew why this happened”.

The need to know the principles of parenting

Mothers said that they felt they did not know many of the things they ought to know about how to treat their child. Mothers implied that they did not know the behavioral principles and techniques or the principles of proper parenting which increase their child’s positive behaviors and reduce negative ones. For instance, they did not know how to deal with behavioral barriers they faced during training, such as the child’s stubbornness and disobedience.

“I quickly punished him when he couldn’t do the task; I mean I wouldn’t allow him to watch the program he liked”.

“We have learnt to encourage our child in this way, and when I want her to study or do her homework, I promise to buy her a doll after the class, and she got used to it, and would make me get her prize. She was like this only with me”.

Mothers stated that they did not give their child the opportunity to experience new tasks independently and mothers wanted to do everything for their child when they faced a challenge.

“Well, I wouldn’t allow [child] to eat by himself, because he makes himself and the house dirty. But, it gets on my nerves, when I’m busy and he wants to eat by himself”.

“Perhaps, I don't give him much opportunity, or much time to do anything. I don't let him arrive at the result by himself, and I quickly tell him the result”.

Educational methods

One of the themes extracted from interviews is related to the mothers’ recommendations about methods of teaching to mothers about CO-OP intervention and principles. Generally, mothers suggested ways of improving and strengthening the methods of training so as to meet their needs of the audience (i.e., mothers). The participants suggested that methods of training should have such features that provide the audience with greater, deeper, and longer-lasting learning, and it should be applicable in situations outside the therapy setting and in new tasks and activities. Subthemes extracted from data were homework–based training, considering mothers’ preference of education method, simultaneous mother education with child’s intervention, and use of behavioral motivators for mothers.

Homework–based training

Some mothers believed that the therapist should give them a specific homework and should set a model, so they could continue the program at home. Mothers believed that assignments should be given so that they directly emphasize the transfer and mothers should guide the child to discover new domain-specific strategies or to use and adapt strategies in new tasks that were unrelated to trained goals and mothers wanted an increased emphasis on homework. Considering homework, mothers applied and practiced the key features of CO-OP with the guidance and supervision of the therapist.

“You know, I rather wanted to take a model from you and implement it at home, and never tried to guide my child for solution myself, because no one had told me so. Perhaps, it would have been better if you had given us an assignment. For instance, find such and so things at home; detect the breakdown point and guide your child for discovery strategies. Then, I’d be forced to do that. I would have done it if you had forced me to”.

“We have gotten used to the method of being given homework by the therapist to do at home. Tell us exactly how many times, when, and how we should do it”.

Considering mothers’ preference of education method

Some mothers found the need for hands-on and face-to-face training important. They also mentioned other ways to ensure learning such as video clips, online teaching, or written essential information, which could be helpful to use principles and doing assignments. Furthermore, it was important that each mother could choose their own preferred methods.

“I used the video I was recording from the session, when I forgot, I used the video, and I watched it to remember”.

“The mother has to accompany her child every time [child] comes to the class. She must attend, as soon as you reach each and every outcome (result) one by one is very important. It teaches [the mother] patience that she should give her [child] a chance to reach her own results. Every session I missed, I really did not know what I had to do”.

Simultaneous mothers’ education with child’s intervention

Mothers believed that teaching principles and methods to mothers should happen concurrently with or even earlier than teaching the child. Mothers can guide their child properly when their child is challenged to use strategies in tasks or needs help to apply strategies or solutions in new tasks.

“This helps mother move forward with child and to be in-step with the child”.

“I would have liked to learn things before my child did”.

Use of behavioral motivators for mothers

One of the points raised in the mothers’ narratives was the desire mothers had for learning and increasing knowledge and acquiring new skills related to their child’s treatment. Furthermore, they expressed that they needed encouragement and motivation to fuel this desire.

“If you take footage of before and after therapy, when we see the change, both the child and we will be encouraged”.

“I like learning. How did you teach my child that she learned so fast, tell me that”.

Discussion

The findings of this qualitative study helped us to reach a better understanding of the experience of mothers’ involvement in the transfer of strategies and problem-solving skill in their child with applying CO-OP. The mothers in the present study expressed that the methods and principles used in the intervention were simple and effective, but mothers were not able to get involved in the transfer because they did not have enough practicable information about the approach and did not know how to deal with their child’s behavioral challenges in the process of using strategies at home.

The mothers’ involvement in the transfer was perceived to be affected by mothers’ feelings toward themselves. Considering assessing barriers to mother involvement in their child’s training, Hornby reported parents’ belief in their own inability to help their children and in their role in their child’s academic achievement as one of the key factors (Hornby and Lafaele, 2011). Martini et al. (2020) described parents’ lower sense of self-efficacy to implement the CO-OP approach at home was an important challenge (Martini et al., 2020). Bandura’s theory of self-efficacy noted that people with a higher sense of self-efficacy are more likely to take on a difficult task, continue it until it is completed, and strive to succeed. Parent perception of their capability to help their children to succeed and to stick with a challenging task is integral to parent deciding to become involved (Bandura, 1977). Parents are often sensitive to what they need to do for their child and they feel guilty they are unable to carry out the therapist’s suggestions (Cameron et al., 2017).

Another finding of the present study is taking the opportunity to discuss and question the problems parents encounter during home programs with the therapist, which was important for involving mothers in the transfer. Mothers also mentioned that the therapist’s following-up the child’s progress and their commitment to the child’s progress increased their motivation for conducting home intervention programs. Basically, one of the principles that should be considered in family-centered approaches is the therapist’s emotional and affective support for mothers.

Parents argued that, in several other studies, they needed more contact with the therapist, even after intervention and in daily life, so they could put forward their problems and receive guidance from the therapist (Roy et al., 2008). Parents’ need to be supported by therapists, especially in early sessions of therapy when parents are often disappointed or confused about the information they receive (Dunn et al., 2012). Therapists’ ongoing follow-up can help parents continue using the process they learned outside the therapy setting (Lin et al., 2018). Effective communication supports positive relationship between parents and therapists and is an essential part of a family-centered approach (King et al., 2000a, 2000b). Another factor raised by mothers which increased their own motivation to take part in the process of intervention was the therapist’s type of interaction with the child and mothers. Parent–therapist–child relationship can influence parents’ involvement. By more collaborative relationship between parents and therapist, parents are actively involved in learning and applying the techniques with their child (Martini et al., 2020). To help parents behavioral change process with the child when a problem arises and applying the intervention at home, it is essential the therapist identifies the problem and supports parents by maintaining open and non-judgmental communication and helping them to carry out the intervention alone at home (Cameron et al., 2017).

Another finding was that receiving feedback from the child’s progress through an objective display of changes in the child’s performance by videotaping their performance before and after the intervention may motivate mothers to be more involved in the process of transfer. One of the enabling principles of CO-OP is so-called “Make it Obvious!”, which can also be used to provide feedback (Mandich and Polatajko, 2004; Polatajko et al., 2001). Mothers and children can clearly and obviously observe the achievement and extent of acquisition of child’s goals.

Mothers implied that they needed the father’s support. Research indicates that the quality of father–mother relationship is important, and mothers who receive help and support from their husband are more effective at maternal parenting, and mother’s psychological well-being. According to the conducted studies, the quality of maternal parenting is affected by the quality and frequency of the parent–child relationship and the father–mother relationship (Choi and Jackson, 2011). Mothers who have quality relationship with the father have better maternal parenting and the mother can provide warmth, supportive, and cognitive stimulation at home environment for her child (Jackson, 1999; Jackson and Scheines, 2005).

Mothers did not know the behavioral principles and techniques or the proper parenting to increase their children’s positive behaviors and reduce negative ones. For instance, they did not know how to deal with behavioral barriers they faced during training, such as the child’s stubbornness and disobedience. The CO-OP approach says parents should guide children to discover solutions and carrying out tasks instead of doing everything for their child when they are struggling with problems in tasks, thus applying the approach requires changing the way parents interact with their child (Cameron et al., 2017; Jackman et al., 2017). Parents in the Martini et al.’s (2020) study expressed that due to existing relationship, their child does not collaborate and engage with parents on using discovered strategies and for discovering new strategies.

Mothers identified the need for learning CO-OP principles in full details. As it turned out, some mothers had not yet properly understood the principles, therefore, could not identify their children’s performance breakdown points, and could not use the process of guided discovery with their child at home. Similarly, some studies reported that one of the barriers to parents prevented them from doing their homework was the uncertainty about the questions they were asking about their children’s task problems (Capistran and Martini, 2016; Cameron et al., 2017; Martini et al., 2020).

Czmowski et al. (2014) also believes that parents’ cooperation has a decisive role in identifying the performance breakdown points in children with Asperger’s syndrome which are not visible in clinical setting. Similar to the present study, the results of these studies also show mothers with greater knowledge and skill in each of the key principles of CO-OP can be considered as an important and effective factor in transfer of skills and strategies to their children (Czmowski et al. 2014).

One of the findings of this study was that giving information about CO-OP techniques or principles of proper parenting to mothers needs to be detailed, step by step, and face to face. Observing intervention sessions does not provide enough knowledge and is insufficient for developing higher level of confidence to implement the intervention alone at home. To implement CO-OP at home and by mothers themselves, it is necessary for the mothers to have a deep understanding of CO-OP, and therapists should guide them to integrate gradually the principles of the intervention into family routines, while therapists should supervise the conduction of the intervention at home and give feedback to the parents (Cameron et al., 2017).

Mothers mentioned their homework should be assigned to encourage them to practice in the taught principles and the application on the new tasks. Assignment should directly determine the role of mothers in identifying breakdown points of performance, guiding the child to discover new strategies, and transferring strategies in new tasks. Research conducted by Mcewen et al. (2010) suggested adults with stroke who had received CO-OP intervention believed that adding assignment to the program could provide an appropriate strategy to continue therapy exercises at home.

The mothers acknowledged a variety of teaching methods as better and preferred methods of transmitting information. One of these principles is to pay attention to the differences in learning styles of different people, which may mean they prefer educational content in the form of written text, video, face-to-face, or practical exercises. Studies conducted on training parents with disabled children and parents with normal school children found parents had preferred different teaching strategies (Darch et al., 2004; Ghashghaee et al., 2016; Hornby and Lafaele, 2011; Lin et al., 2018).

The strategies made by Law for effective communication between families and therapist within a family-centered context including sharing information with parents should be clear and brief, in an understandable language, and avoid unusual words and phrases (Law et al., 2003). One of the findings of Martini et al. (2020) and Jackman et al. (2017) study is that knowing about the CO-OP approach and observing the sessions are not sufficient. Parents need to reflect the techniques they have been trained and apply CO-OP under the therapist’s supervision. More hands-on practice in implementing strategies with the therapist coaching and showing examples of the application of strategies facilitate parents’ involvement in the intervention. Also, active involvement of parents with their child can be effective in increasing parents’ involvement (Jackman et al., 2017; Martini et al., 2020).

Limitations

This study has several limitations. First, there were a small number of participants due to the fact that only a small number of children could experience CO-OP intervention. Second, one of the therapists who provided the treatment for the children also conducted the interviews and led the data analysis. This may have influenced the information the mothers shared. Due to the father’s lack of cooperation, the mother’s experience alone was examined and the father’s experience of being involved in the transfer was not examined.

Conclusion

The present study provides a description of mothers’ experiences with the CO-OP approach in transfer of strategies. Mothers perceived that CO-OP was simple, but they needed better and deeper information about its principles and management of the child’s behavioral challenges under the supervision and support of a therapist in order to facilitate strategies to be conducted at home and in new tasks. Mothers provided ideas on how to improve and strengthen learning and suggested that the methods of training should include specific features.

Key findings

Mothers’ feelings about their ability to implement CO-OP at home can affect their involvement in the transfer.

A collaborative relationship between the therapist and mothers, therapist’s emotional and affective support from mothers, the therapist’s ongoing support for the child to gain skills, and the transfer and generalization of skills are factors which can increase the motivation of parents to participate in treatment.

Social support from the mother, including father’s emotional support, awareness and support of the teacher and school staff from the intervention, can be an important factor in increasing the mother’s involvement in implementation of the intervention at home.

Mothers’ observation of intervention sessions and knowledge about CO-OP do not suffice to apply the approach at home. Mothers need to learn the principles of the intervention in full details and practice the use of these principles under the supervision of a therapist.

To teach these details about the approach, therapists can use a variety of educational methods to ensure that the principles are well learned and applied by the mothers.

What the study has added

This study suggests that mothers are not able to get involved enough in the transfer of skills and strategies because they have experienced barriers which can affect their involvement in the transfer, and it seems that by considering these factors, ways to increase mother involvement in the transfer of skills in the CO-OP approach would be found.

Footnotes

Acknowledgements

The authors gratefully thank the parents and their children who participated in this study.

Authors’ contributions

Soraya Gharebaghy, Narges Shafaroodi, and roshanak Vameghy researched literature. Narges Shafarodi applied for ethical approval. Soraya Gharebaghy contributed to the development of the data. All authors contributed to the methodology of the project and analyzing and interpreting of data.

Soraya Gharebaghy, Roshanak Vameghy, Narges Shafaroodi, Malahat AkbarFahimi, and Mehdi Rassafiani carried out the analysis and initial interpretation of data and made themes and subthemes. Helene J. Polatajko and Debra Cameron reviewed the themes and subthemes and made adjustment in themes and to create the final categories.

Soraya Gharebaghy wrote the first draft of the manuscript and all authors reviewed and edited the manuscript and approved the final version.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received the financial support for the research from Iran University of Medical Sciences, Tehran, Iran (grant number: 98-1-6-14294).

ORCID iDs

Malahat Akbarfahimi

Narges Shafaroodi

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