Annals of International Occupational Therapy

Original Research Supplemental Data

Effect of an Occupation-Based Program for Women With Intellectual and Developmental Disabilities Who Are Incarcerated

Laurie D. Stelter, PhD, OTR; Cynthia L. Evetts, PhD, OTR

Abstract

Objective:

This study evaluated the effect of an occupation-based program on the occupational performance and participation of incarcerated women with intellectual and developmental disabilities.

Methods:

A stepped wedge randomized controlled design was used to compare the number of adverse behavioral incidents among program participants with the number that occurred among participants in a delayed intervention group. The study design also included repeated measures of occupational performance and participation among program participants with the Goal Attainment Scale (GAS), the Volitional Questionnaire (VQ), the Social Profile (SP), and a relative mastery scale.

Results:

Participants who received the study intervention had significantly fewer adverse behavioral incidents compared with the delayed intervention group (N = 85; p = .02). Participants who received the intervention showed significant improvements in occupational performance and participation according to the GAS (p < .001), VQ (p < .005), and SP (p < .005).

Conclusion:

This study found that a 12-week occupational therapy program was successful in promoting occupational performance and participation of individuals with intellectual and developmental disabilities through the provision of meaningful work roles. The outcomes of this study suggest the potential utility of enhancing the rehabilitation of incarcerated individuals with intellectual and developmental disabilities and advocating for consistent inclusion of occupational therapy on service provider teams in justice-based settings. Limitations included the use of a focused sample, a short study time frame, and possible researcher bias. Future studies should allow for postintervention follow-up and replication in other settings. [Annals of International Occupational Therapy. 201X; XX(X):XX–XX.]

Abstract

Objective:

This study evaluated the effect of an occupation-based program on the occupational performance and participation of incarcerated women with intellectual and developmental disabilities.

Methods:

A stepped wedge randomized controlled design was used to compare the number of adverse behavioral incidents among program participants with the number that occurred among participants in a delayed intervention group. The study design also included repeated measures of occupational performance and participation among program participants with the Goal Attainment Scale (GAS), the Volitional Questionnaire (VQ), the Social Profile (SP), and a relative mastery scale.

Results:

Participants who received the study intervention had significantly fewer adverse behavioral incidents compared with the delayed intervention group (N = 85; p = .02). Participants who received the intervention showed significant improvements in occupational performance and participation according to the GAS (p < .001), VQ (p < .005), and SP (p < .005).

Conclusion:

This study found that a 12-week occupational therapy program was successful in promoting occupational performance and participation of individuals with intellectual and developmental disabilities through the provision of meaningful work roles. The outcomes of this study suggest the potential utility of enhancing the rehabilitation of incarcerated individuals with intellectual and developmental disabilities and advocating for consistent inclusion of occupational therapy on service provider teams in justice-based settings. Limitations included the use of a focused sample, a short study time frame, and possible researcher bias. Future studies should allow for postintervention follow-up and replication in other settings. [Annals of International Occupational Therapy. 201X; XX(X):XX–XX.]

Individuals with intellectual and developmental disabilities (IDD) constitute a growing percentage of incarcerated persons within the justice system. Worldwide, individuals with IDD represent 7% to 10% of the prison population (Hellenbach, Karatzias, & Brown, 2017), an overrepresentation compared with the global prevalence of IDD of .05% to 1.55% (McKenzie, Milton, Smith, & Oullette-Kuntz, 2016). The U.S. justice system includes a variety of settings that range from state and federal prisons to state and county jails, forensic psychiatric hospitals, and community-based programs, parole, and probation. Occupational therapy practice in justice-based settings has been more commonly focused on individuals with mental illness, but the specific application of occupational therapy to incarcerated individuals with IDD is slowly, although insufficiently, becoming more evident.

Individuals with IDD who are incarcerated are at increased risk for occupational deprivation, with few opportunities to develop skills that would better prepare them for community re-entry (Falardeau, Morin, & Bellemare, 2015). Occupational deprivation is a concept associated with an occupational justice perspective and suggests that participation in meaningful and purposeful occupations is intrinsically linked to health and well-being (Whiteford & Townsend, 2011). Women who are incarcerated also have higher risks of occupational deprivation because most justice-based programs were designed for men and do not always address the unique needs of women (Latessa, Listwan, & Koetzle, 2015). The inherent limitations of the justice environment to provide health-promoting occupations for individuals with IDD can result in the deterioration of existing skills, which can significantly affect the person's ability to meet the performance demands of current and future environments.

Three reviews have covered the use of occupational therapy within justice-based practice over the past several decades: before 2003 (Duncan, Munro, & Nicol, 2003), before 2007 (O'Connell & Farnworth, 2007), and before 2013 (Hitch, Hii, & Davey, 2016). These reviews support the need to develop and use specific outcome measures; improve the quantity and rigor of studies; create structured, theory-based programs; and build a united international response network. The distinct role of occupational therapy in this setting includes the creation of prosocial, productive environments and the use of everyday activities to promote community reintegration (O'Connell & Farnworth, 2007). Building on these literature reviews, recent surveys of justice-based practice in the United States and Canada noted that there are not enough occupational therapy practitioners working in this practice area to meet the need, and many practitioners do not identify the use of structured evaluation tools or systemized collection of outcomes (Chui et al., 2016; Muñoz, Moreton, & Sitterly, 2016). Common occupational therapy interventions include group-based formats to address vocational skills, activities of daily living, instrumental activities of daily living, social skills, problem solving skills, coping skill, and leisure engagement (Chui et al., 2016; Muñoz et al., 2016; O'Connell & Farnworth, 2007).

An extensive search of the literature to identify examples of occupational therapy practice with IDD populations in justice-based settings identified four articles. All four articles originated in the United Kingdom, used qualitative or descriptive methods, and included the primary use of work-based interventions. Interventions included a graded, work-based learning program that showed progression of social, work, literacy, and numeracy skills (Smith, Petty, Oughton, & Alexander, 2010); a comprehensive daytime routine of productive and meaningful group projects within a medium-security facility (Withers, Boulton, Morrison, & Jones, 2012); an authentic work program in which participants completed a comprehensive employment-related process, including applications and interviews (Cox et al., 2014); and the use of horticulture tasks to influence subjective health and well-being (Christie, Thomson, Miller, & Cole, 2016). All of these interventions occurred in secured settings that were designed specifically for individuals with mental health and IDD versus a secured justice setting, such as a prison, that was not designed to meet the needs of a specialized population. Because of the limited amount of literature available and the significance of the concern, additional research is needed to clarify the essential role of occupational therapy and its effectiveness in meeting the unique needs of individuals with IDD who are in justice-based settings.

The goal of this study was to evaluate systematically the effect of an occupation-based program on the occupational performance and participation of incarcerated women with IDD. This study used an occupation-based program that was grounded in overarching principles of participatory occupational justice and recognized the risks of occupational deprivation and the importance of participation in health-enhancing occupations (Whiteford & Townsend, 2011). The specific therapeutic approaches used in the program were informed by principles of occupational adaptation theory. Consistent with occupational adaptation, the outcome of occupational performance and participation is the result of the adaptive response. This outcome includes the quality and generalization of performance skill; the level of engagement or self-initiated action; and perceived efficiency, effectiveness, and satisfaction with performance (Schultz, 2014). The progress of program participants within these selected areas was anticipated to contribute to more successful community reintegration as well as improved function and quality of life within the prison environment. The goal of the research was to determine whether participation in occupation-based programming resulted in improved occupational performance and participation of women with IDD who were incarcerated. The specific research questions were as follows:

  1. How do program participants and a wait list control group differ in terms of adverse behavioral incidents?

  2. What changes in occupational performance and participation do program participants show over time?

Methods

This article describes quantitative outcomes using two design strategies of a larger mixed methods study. The first research design strategy was a stepped wedge randomized controlled design (Brown & Lilford, 2006) that compared the frequency of adverse behavioral incidents documented within facility records among participants who completed the intervention with the frequency among a control group who received delayed intervention. Those who consented to participate in the study were randomly assigned to either an immediate intervention group or a delayed intervention group using a systematic sampling method. This random sampling method involved selecting the intervention group by a predetermined interval (e.g., every fifth individual) from a randomized list of eligible participants generated during the recruitment process. One researcher enrolled participants, and a different researcher assigned participants to study groups. Random assignment was concealed from the outcome assessor.

The second strategy examined repeated measures of occupational performance and participation among program participants using the Volitional Questionnaire (VQ) (de las Heras, Geist, Kielhofner, & Li, 2007), the Goal Attainment Scale (GSA) (Kiresuk, Smith, & Cardillo, 1994), the Social Profile (SP) (Donohue, 2013), and a relative mastery rating scale. The intervention phase for each participant lasted 12 weeks, and the outcomes of this study represent approximately 6 months of data collection.

Outcome Measures

Demographic characteristics of the participants were collected from prison institutional records according to procedures approved by the institutional review board of the institution and associated state justice authorities. The measure used for comparison of the immediate and delayed intervention groups was the number of incidences of documented adverse behaviors. These officially documented adverse behaviors involved a written sanction of progressive discipline given to an incarcerated person for actions that violated prison rules. Documented adverse behaviors were selected as the measure for between-group comparison because they were anticipated to provide evidence of the effect of the intervention on behaviors outside of the direct intervention context and they were part of existing data collected by the institution.

The GAS was used to document each participant's baseline performance at a rating of −1 and the expected performance improvement standard at a rating of 0. A rating of +1 represented performance that was a little better than expected, a rating of +2 indicated performance that was much better than expected, and a rating of −2 indicated a decline from baseline performance. The occupational therapist selected one goal for each participant from a bank of possible goals developed by the principal investigator using an occupational adaptation framework. The goal was individually selected for each participant based on the results of the initial evaluation. The occupational therapist evaluated each participant's progress toward her individual performance goal using the GAS rating at the end of the intervention period. Literature has demonstrated the usefulness of the GAS as a person-centered outcome measure and the utility of framing GAS goals using a theory-driven perspective (Doig, Fleming, Kuipers, & Cornwell, 2010; Hurn, Kneebone, & Cropley, 2006).

The VQ was administered every 2 weeks. This measure used a 4-point rating scale on 14 items related to the participant's observed level of engagement or participation in session activities. This tool was designed for individuals with reduced verbal and cognitive abilities within a wide range of contexts. The VQ has been found to have acceptable construct validity, content validity, and interrater reliability (Li & Kielhofner, 2004).

A relative mastery rating scale, developed by the principal investigator and vetted by experts in occupational adaptation theory, was collected weekly throughout the intervention phase. Each participant provided a 3-point baseline relative mastery rating of 1 to 3, indicating low, moderate, and high levels, respectively, to represent her perception of efficiency, effectiveness, and satisfaction related to her own performance (Schultz, 2014). To simplify the concept for individuals with IDD, the rating was developed with pictures and simplified verbiage.

The SP was used to rate the baseline, midpoint, and ending levels of social dynamics occurring between participants. This instrument produced an average summary score, with a range of 1 to 5, based on the therapist's observations of group interactions. The SP has demonstrated reliability and validity for assessing group-level functioning during activities for adult mental health groups from the perspective that the ability to cooperate around a task promotes verbal exchanges that are less formal and that prepare the individual to re-enter community, work, and family groups (Donohue, 2007, 2013).

Participant Selection

The study was conducted at a single state prison facility in the Southwestern region of the United States. This facility has a maximal census of 100 persons and is the only prison within this state that specifically houses women with IDD. All of the participants in this study were women 18 years or older who were diagnosed with a condition affecting intellectual and/or cognitive functioning. Reasons for exclusion included (a) inability or unwillingness to consent to participation and (b) ineligibility to attend occupational therapy services because of scheduling conflicts or a security or medical status that prohibited leaving the cell/dorm. This type of restriction is typically related to a high level of aggression, elopement risk, acute illness, or self-harm behavior. Participants provided informed consent according to procedures approved by the institutional review board and associated state justice authorities.

Intervention

The intervention, identified as the OT Workshop, was implemented by an occupational therapist and an occupational therapy assistant according to a program manual developed by the principal investigator (Stelter & Whisner, 2007). The OT Workshop is a theory-driven, occupation-based approach designed to facilitate meaningful and prosocial occupational roles that are assumed to develop adaptive responses and prepare individuals for community reintegration. The OT Workshop provides a therapeutic, supported work environment to awaken capabilities and motivation through opportunities to actively participate and produce goods that contribute to the social fabric of the institution and the local community. The essential therapeutic ingredients are outlined in Table 1.

Key Therapeutic Ingredients of the OT Workshop

Table 1:

Key Therapeutic Ingredients of the OT Workshop

The OT Workshop was designed to capitalize on participants' personal interests and motivations by including them in a therapeutic work crew identified by an activity of focus. The study focused on four types of work crews: (a) the horticulture crew, (b) the craft crew, (c) the technology crew, and (d) the cooking crew. The primary activities designed to be performed in the horticulture crew were planning and maintaining garden beds. The primary activities designed to be performed in the craft crew were the planning and creation of handicrafts such as sewing, jewelry making, and repurposed items to add to the aesthetics of the immediate environment and donate to facilities or agencies in the external community. The primary activities designed for the technology crew involved basic computer operations for application to tasks such as producing a newsletter. Finally, the primary activities designed for the cooking crew were basic meal preparation and related home management tasks. These crews were selected because of their appeal to most participants, the feasibility of implementation, and the ability to provide a wide range of opportunities for building relevant adaptive skills.

After the participants crossed over from the delayed group to the intervention group, they were involved in an initial evaluation. Figure A (available in the online version of the article) shows how the assignment and intervention crossover processes occurred over the 6-month study period. The initial phase of evaluation occurred in a single group session that lasted approximately 1 hour. The focus of this session was to gain relevant information to assign each participant to the specific type of crew that best fit her interests. Once each participant was assigned to a crew, the first 2 weeks were considered a continuation of the evaluation phase to gather further observations and establish a relevant individualized performance goal using the GAS method. The occupational therapy staff administered the key therapeutic ingredients and session procedures consistently across the work crews. The ideal group size for a crew was 6 to 12 participants. The ideal group size was determined through consideration of the needs to monitor participant behavior and safety; provide necessary feedback, opportunities for social interaction, and individualized interventions; and meet demands for productivity. Each work crew met for two sessions per week for 12 weeks, with each session lasting 1.5 to 2 hours.

Stepped-wedge design. Illustration of the assignment and crossover of participants from the delayed intervention to the immediate intervention group over the time of the study along with assignment to specific crews.

Figure A.

Stepped-wedge design. Illustration of the assignment and crossover of participants from the delayed intervention to the immediate intervention group over the time of the study along with assignment to specific crews.

Data Collection

The principal investigator trained the occupational therapy staff for 3 intensive days on the implementation and documentation of the intervention. The program manual included a systemized method for gathering and recording data. Each week, the occupational therapy staff documented each participant's response to the intervention along defined elements within a database. The database included information such as the crew type, the number of sessions attended, reasons for missing sessions, primary tasks performed, relative mastery rating, and GAS, VQ, and SP scores. The principal investigator conducted on-site monitoring quarterly and had weekly e-mail or telephone contact with the occupational therapy staff to evaluate and facilitate adherence to the intervention and data collection processes.

Data Analysis

Data were de-identified, and data analysis was performed with SPSS, version 25.0. First, demographic and program data were analyzed using descriptive statistics, and the frequency of documented adverse behaviors of the delayed and intervention groups were compared with a paired t test. Second, repeated measures analysis of variance (ANOVA) was used to compare within-intervention group measures of occupational performance and participation (i.e., VQ, relative mastery rating, and SP) over the time of the intervention. A Wilcoxon signed-rank test was administered to compare GAS scores from baseline to the end of the intervention phase. Intention-to-treat analysis was adopted.

Results

All eligible individuals at the facility consented to participate (N = 85). During the 6-month data collection period, 64 participants were randomly assigned to cross over from the delayed intervention group to the immediate intervention group. Participant characteristics for the immediate and delayed intervention groups did not differ significantly; therefore, participant characteristics are shown for the combined participants in Table 2.

Participant CharacteristicsParticipant Characteristics

Table 2:

Participant Characteristics

Participants were fairly evenly represented across age (range, 22–66 years), with a mean age (42.4 years) that was slightly higher than the mean age of incarcerated women within the target state. Participants' race was predominately black (n = 43, 50.6%), followed by white (n = 25, 29.4%), which was inverse to the general population of incarcerated women in the target state. Measurement of IQ scores indicated that most participants fell into the mild intellectual disability range (55.3% of participants had IQ scores of 55–70), followed by borderline intellectual functioning (31.8% of participants had IQ scores of 71–84). Most participants had at least one other prison stay in addition to the current stay (M = 1.4 stays). Most participants (n = 53, 62.4%) were incarcerated for a violent offense (e.g., assault, homicide, sexual offenses), a finding that is consistent with state incarceration rates for violent offenses.

Descriptive Program Outcomes

The first crews implemented were a horticulture crew and two craft crews. Each of these crews enrolled eight participants (n = 24), with good completion rates (n = 22; range, 87.5%–100%) and attendance rates (range, 80.8%–92.9%). A second phase that included six crews was initiated after completion of the first phase. The second phase included a horticulture crew, two craft crews, a cooking crew, and two technology crews. Each of these crews enrolled approximately 10 participants, had completion rates of 60.0% to 80.0% (n = 45), and had attendance rates of 73.4% to 92.4%. No workshop crews required discontinuance or reorganization of members before completion. The nine crews completed a mean of 22.0 (range, 18–24) sessions. Most absences were attributed to temporary behavioral restrictions (n = 146, 30.5%) and release or transfer from the facility (n = 128, 26.7%). Very few absences occurred as a result of refusal (n = 14, 2.9%).

Stepped Wedge Randomized Controlled Trial Comparison of Adverse Behaviors

A paired samples t test showed a significant difference in the number of documented adverse behaviors within the 3-month period before the intervention (M = 0.14, SD = 0.39) and the number of these behaviors during the 3-month intervention (M = 0.02, SD = 0.13), t(63) = 2.39, p = .02. The most common types of adverse behaviors documented over a 12-month period were refusal to obey orders (including refusal to attend scheduled work) and being out of place (i.e., not in the designated area); however, these types of documented behaviors did not occur after implementation (Figure B, available in the online version of the article).

Types and frequency of documented adverse behaviors during 12-month time frame (N = 85).

Figure B.

Types and frequency of documented adverse behaviors during 12-month time frame (N = 85).

Within-Intervention Group Results

Changes in occupational performance. A Wilcoxon signed-rank test indicated that participant GAS scores at the end of the intervention phase were significantly higher than at baseline, Z = 5.72, p < .001. Table 3 shows the performance goals and those in which the participants showed significant progress. The most common area of progress was in performance behavior (n = 23, 27.1%), and the most commonly used goal was improved independence in task performance (n = 21, 24.7%). The most common level of independence achieved was complete independence, followed by indirect cueing or modeling. An example of this type of change is a participant who previously required direct cueing for each step of a moderately complex work task progressing to requiring no prompting for completion of the same task. Analysis of variance indicated no significant difference between the final GAS ratings for each intervention crew, supporting the idea that each type of crew had a comparable effect on participant outcomes, F(8, 69) = 0.51, p = .06.

Areas of Performance Progress With Goal Attainment Scale Results

Table 3:

Areas of Performance Progress With Goal Attainment Scale Results

Changes in occupational participation. Within-participants repeated measures ANOVA with a Greenhouse-Geisser correction showed a significant difference in occupational participation with VQ scores, F(3.63, 181.68) = 87.36, p < .005. The effect size value, using partial eta squared (ηp2= 0.64), suggested a large change in VQ scores over time. Post hoc analysis showed that the VQ score for occupational participation improved significantly across the six intervention measurement time points (every 2 weeks), with the exception of the final two measurement times (Figure C, available in the online version of the article). With a range of VQ scores of 14 to 56, the study outcomes indicated participant progress in occupational participation from exploratory to more consistent competency. Exploration involves basic curiosity and interest in the environment; however, competency encompasses attempts to actively engage and influence the environment. The ANOVA findings showed no significant difference between the final VQ ratings of each intervention crew, suggesting that each type of crew had comparable effects on participant outcomes, F(8, 57) = 1.14, p = .36.

Volitional Questionnaire (VQ) ratings over six times points. Higher scores represent higher levels of occupational participation.

Figure C.

Volitional Questionnaire (VQ) ratings over six times points. Higher scores represent higher levels of occupational participation.

Changes in relative mastery. Within-participants repeated measures ANOVA with a Greenhouse-Geisser correction showed no significant difference in relative mastery ratings over time, F(4.73, 80.32) = 1.25, p = .30. However, relative mastery ratings, with a scale of 3 to 9, were consistently high over time (Figure D, available in the online version of the article). For example, participants routinely documented in their journals that they were efficient, effective, and satisfied with their work in the group session. The ANOVA findings showed no significant difference among the final relative mastery ratings of the different intervention crews, F(8, 47) = 1.33, p = .25.

Mean relative mastery ratings by individual OT Workshop crew. T = technology; H = horticulture; C = craft; CO = cooking.

Figure D.

Mean relative mastery ratings by individual OT Workshop crew. T = technology; H = horticulture; C = craft; CO = cooking.

Changes in group dynamics. Within-participants repeated measures ANOVA with a Greenhouse-Geisser correction showed a significant difference in SP scores for group dynamics, F(1.23, 77.63) = 609.04, p < .005. The effect size value, using partial eta squared (ηp2 = 0.91), suggested a large change in SP scores. Post hoc analysis showed that group dynamics, or interactions among crew members, improved significantly across the three intervention measurement time points: at baseline, at 6 weeks, and at 12 weeks (M = 1.5, SD = 0.49; M = 2.4, SD = 0.35; M = 2.9, SD = 0.33, respectively). Descriptive analysis of SP ratings by individual crews showed that each crew made progress over time (Figure E, available in the online version of the article). Most of the crews improved from a parallel level of social group participation at baseline to either an associative or a basic cooperative level by the end of the intervention phase. At a parallel level, group members work side by side but do not interact. At the associative level, group members begin to interact briefly, and at a basic cooperative level, they begin to collaborate on a mutually interesting goal or project.

Social Profile (SP) ratings for each OT Workshop crew at three measurement points.

Figure E.

Social Profile (SP) ratings for each OT Workshop crew at three measurement points.

Discussion

The findings showed a significant effect on the occupational performance and participation of women with IDD who were incarcerated and who participated in brief occupational therapy interventions. The descriptive data were consistent with initial assumptions that the target population showed complexities related to cognitive impairment, diversity of ages, racial imbalance, range of criminal and social histories, records of recidivism, limited education, and occupational deprivation. Similar findings on the complexity of the characteristics and circumstances of people involved with the justice system, including occupational deprivation, are found in the justice-based occupational therapy literature (Falardeau et al., 2015; Farnworth & Muñoz, 2009).

The descriptive results of the occupational therapy intervention indicate that it is an efficient process for providing valued services to eligible individuals who are incarcerated. With the variety of uncontrollable and restrictive factors found in the prison setting (Crabtree, Ohm, Wall, & Ray, 2016), the possibility that groups would need to be dissolved or reorganized is realistic; however, all therapeutic crews were implemented to completion. Overall participant completion and attendance rates were respectably high, suggesting that the program was valued by the participants. This finding is consistent with other justice-based occupational therapy programs that were found to generally incentivize participation and support the value of occupation-based interventions (Eggers, Muñoz, Sciulli, & Crist, 2006; Fitzgerald, 2011; Völlm, Panesar, & Carley, 2014).

Generalization of Performance Skills

The finding of a significant difference in documented adverse behaviors before versus after program enrollment suggests that the occupational therapy intervention improved participants' behaviors within a relatively short time. Program participants had virtually no documented adverse behavioral incidents after they started the program. The ability and willingness of participants to maintain this level of behavioral self-regulation suggest that the program had an effect on generalization of performance skills. The generalization of an adaptive response across contexts (e.g., from the occupational therapy session to the dorm, recreation yard, or job site) is an imperative achievement for enduring behavioral change (Schultz, 2014). It appears that the opportunity to pursue meaningful and purposeful occupations can have a tempering effect on undesirable behaviors.

Adaptive Response

The significant improvements found with three of four measurement tools support the effect of the intervention on occupational performance and participation, indicating an adaptive response. Group-based interventions can present challenges related to individualizing outcomes; however, the use of the GAS captured the capacity of the interventions to promote individual progress in areas of prosocial adaptive response behaviors, relative mastery, and desire for mastery. Although occupational participation and collaborative behaviors substantially improved among participants, VQ and SP scores showed limitations in self-initiation and social dynamics. These continuing limitations are consistent with literature describing the ongoing need for support for individuals with IDD, even with improvements in independent functioning (Channon, 2014). This population seems to need a balance of opportunities for independence and necessary support for engagement (Mahoney, Roberts, Bryze, & Parker Kent, 2016). Tipping too heavily toward either independence or support for persons with IDD can result in unintended marginalization or neglect.

Although the findings for relative mastery were not significant, the ability to provide a complex population in a difficult environment with a demanding intervention that resulted in consistently high satisfaction ratings is a testament to the value attributed to the intervention. All of the therapeutic crews had a statistically similar effect, despite the varying central activities. This finding may imply that the mechanism of change was not specific to the activity of focus (i.e., craft, horticulture, technology, cooking), but the key therapeutic ingredients that were consistent across the crews (Table 1).

Limitations

This study had several limitations. First, the participants were recruited from a single facility within one state; therefore, the findings most directly represent those with similar demographic features and in a similar context. Second, in relation to the stepped wedge method, only one measure was used. With such statistically significant results, the need to consider the influence of confounding variables is indicated. Addition of another behavioral outcome measure could assist in validating the source of significant positive behavioral change. Without such measures, the influence of potentially confounding variables cannot be ruled out. Third, the evaluation of true postintervention follow-up measures, such as recidivism rates several months or years after release, was inhibited by the short time frame. This researcher's potential bias, as the program designer and evaluator, is also recognized, despite the inclusion of several valid and reliable techniques to ensure trustworthiness. A final limitation is the use of several research measures that were not specifically validated for this unique population and context; however, the VQ, GAS, and SP ratings showed valuable utility as outcome measures in this study.

Implications for Occupational Therapy Practice

This research provides a successful template for designing, implementing, and evaluating theory-driven, occupation-based occupational therapy services for individuals with IDD in a secure justice-based setting. This occupational therapy study is one of the few to specifically address the needs of people with IDD who are incarcerated (Christie et al., 2016; Cox et al., 2014; Smith et al., 2010; Withers et al., 2012). In addition, this study was specific to women (Baker & McKay, 2001) and was based in the United States. Further, this study used a rigorous research method, in contrast with some published studies of outcomes of occupational therapy and non-occupational therapy programs in justice-based settings (O'Connell & Farnworth, 2007). These findings encourage justice stake-holders to consider regular inclusion of occupational therapists on clinical provider teams and to address deficits in provider resources.

Future Research

Future research should focus on the outcomes of the occupational therapy program after a longer period of operation to capture the longer-term effect. For example, a follow-up study several years from now could show the effect of the program on recidivism rates and the capacity to generate and bridge support from the prison to the community on re-entry. The limitations of research measures suggest the need to develop ecologically valid, occupation-based measures for various justice-based populations and settings to facilitate their utility for practitioners who develop and implement programs.

Conclusion

The study findings suggest that this 12-week occupational therapy program, grounded in occupational adaptation and participatory occupational justice theories, was successful in promoting occupational performance and participation of individuals with IDD through the provision of meaningful work roles. The study found improvements in performance that were generalized beyond the intervention, an increase in self-initiated action, and improved relative mastery. This study addressed the need to evaluate manualized, theory-driven occupational therapy services within the U.S. justice system for a complex population that is occupationally deprived across multiple characteristics (e.g., incarcerated, female, IDD). When included as part of a professional care team, occupational therapy has a substantial role in addressing the participation and community reintegration needs of incarcerated individuals with IDD.

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Key Therapeutic Ingredients of the OT Workshop

Intentional opportunities to:
  Select, plan, execute, and evaluate task performance
  Create tangible products that contribute to the immediate or community environment
  Engage in graded, just-right occupational challenges
  Receive direct or indirect verbal or physical assistance only as necessary
  Receive objective, nonjudgmental feedback
  Participate in novel tasks or contexts
  Engage in a positive social environment through co-occupation
  Experience self in a prosocial role that is personally satisfying and that contributes to the physical or social environment (i.e., role-shifting experience)
Session protocol
  Practice hygiene and grooming (e.g., wash hands, brush teeth, groom hair)
  Review the progress made during the previous session and establish the task priorities for the current session
  Access and organize the necessary supplies and space
  Begin and maintain the activity while the occupational therapy staff monitors and intervenes where necessary
  Participate in hydration and music breaks as needed
  Receive a 15-minute warning that the session is ending
  Inventory supplies and clean the group space
  Review progress by identifying one's relative mastery rating, celebrate successes, and plan for the next session

Participant Characteristics

CharacteristicValue
Age, y
   M (SD)42.4 (12.6)
  Minimum–maximum22–66
Race, n (%)
  Black43 (50.6)
  White25 (29.4)
  Hispanic15 (17.6)
  Asian1 (1.2)
  Other1 (1.2)
IQ score
  55–70, n (%)47 (55.3)
  71–84, n (%)27 (31.8)
  ⩾ 85, n (%)6 (7.1)
  Unknown5 (5.9)
   M (SD)69.3 (8.4)
  Minimum–maximum55–99
Education, n (%)
  Some grade school57 (67.0)
  High school graduate or general equivalency diploma26 (30.6)
  Some college1 (1.2)
  College degree1 (1.2)
Parole projected release within 2 years, n (%)27 (31.8)
Years incarcerated
   M (SD)4.9 (5.7)
  Minimum–maximum0.1–24
Years at the facility, n (%)
  ⩽ 147 (55.3)
  2–517 (20.0)
  6–1013 (15.3)
  11–155 (5.9)
  ⩾ 163 (3.5)
Total previous prison stays, n
   M (SD)1.4 (0.8)
  Minimum–maximum0–4
Offense category, n (%)
  Violent53 (62.4)
  Property12 (14.1)
  Drug11 (12.9)
  Obstruction/other9 (10.6)

Areas of Performance Progress With Goal Attainment Scale Results

Performance goaln (%)
Prosocial adaptive response behavior
  Performance behavior/external role expectations
    Independence in task performance21 (24.7)
    Organization0 (0)
    Setting standards/leadership2 (2.4)
    Hygiene, grooming, and basic self-care0 (0)
  Social participation
    Social interaction14 (16.5)
    Communicating needs or wants/help seeking4 (4.7)
    Prosocial behavior/altruism2 (2.4)
  Problem solving and decision making
    Planning/decision making/creating12 (14.1)
    Awareness of and correction of mistakes/modifying approach8 (9.4)
  Emotional regulation and coping
    Persistence through challenges6 (7.1)
    Frustration tolerance1 (1.2)
    Generation of novel coping skills7 (8.2)
Relative mastery
  Self-esteem and competency
    Positive self-statements6 (7.1)
Desire for mastery
  Motivation
    Participation/goal-directed behavior/self-initiation2 (2.4)
Authors

Dr. Stelter is Assistant Professor, Master of Occupational Therapy Program, Texas Tech University Health Sciences Center, Lubbock, Texas. Dr. Evetts is Professor and Director, School of Occupational Therapy, Texas Woman's University, Denton, Texas.

Dr. Stelter has no relevant financial relationships to disclose. Dr. Evetts discloses that the program was funded by the Rad and Patricia Crocker Foundation. All funds were given directly to the facility for on-site staff wages and program equipment and supplies. No direct or indirect funds came to Texas Woman's University. The Foundation reimbursed travel to and from the facility for Dr. Evetts.

The authors thank Patricia Crocker and the Crocker Foundation for the visionary support and personal interest that enabled the development and implementation of the program associated with this study. They also thank Claudette Fette, OTR, PhD, and Celia Lo, PhD, for providing insight and expertise that greatly assisted this research.

Address correspondence to Laurie D. Stelter, PhD, OTR, Assistant Professor, Master of Occupational Therapy Program, Texas Tech University Health Sciences Center, 3601 4th Street, STOP 6220, Lubbock, TX 79430; e-mail: laurie.stelter@ttuhsc.edu.

Received: April 10, 2019
Accepted: July 16, 2019
Posted Online: September 20, 2019

10.3928/24761222-20190910-01

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