The International Journal of Psychosocial Rehabilitation
Assisting Adolescents Experiencing Emotional and Behavioral
 Difficulties (EBD) Transition to Adulthood
 
 
Moses N. Ikiugu, Ph.D., OTR/L
Associate Professor and Director of Research
Department of Occupational Therapy
Division of Health Sciences
University of South Dakota
 
Email: moses.ikiugu@usd.edu
 
 
Elizabeth A. Ciaravino, Ph.D., OTR/L

Assistant Professor
The University of Scranton
Department of Occupational Therapy

Introduction
Adolescence is an age of transition. During this period, an individual leaves childhood and prepares to enter adulthood (Bruce & Borg, 1993). Many adolescents make this transition without serious difficulties (Haiman, Lambert, & Rodriques, 2005). However, in this stage, there is always uncertainty in that the individual is expected to act like an adult, while often being treated as a child (Haiman et al., 2005; Shannon, 1972). According to Bogin (1999) and Haiman et al. (2005), adolescents learn and practice behaviors including economic, social, and sexual activities of adults. At the same time, they are treated like children who are not expected to handle adult responsibilities (Haiman et al., 2005; Shannon, 1972). The mixed expectations from adults lead to uncertainty and turbulence which manifests as confusion, insecurity, indecision, disorganization, moodiness, and alienation. At this time, one also tends to question his/her identity.

For adolescents with signs of emotional or behavioral disturbances particularly, there is need to find ways of helping them overcome the turbulence so that their transition to adulthood is successful. This may be accomplished by helping them focus more on developing skills necessary for engagement in adult roles. One approach to maintain this focus would be by helping them formulate a philosophy to guide behavior toward a desired future (Shannon, 1972). Such a philosophy would facilitate planning for the future, with adult occupations as the goal around which the adolescent’s daily activity is organized (Haiman et al., 2005).

It is clear from available research, that adolescents with EBD need assistance to help them focus on preparation for future roles as adults (Farnworth, 2003; Masi, Mucci, & Milliepiedi, 2001; Posthuma, 2002; Sisun & Eskedal, 2005). They lack a personal philosophy to guide their transition to an adult future. The lack of philosophy makes it difficult for them to bridge the “discontinuity in a person’s life space” (Blair, 2000, p. 232) which is a natural consequence of normal adolescence as a stage of transition to adulthood. As Farnworth (2003) found, adolescent offenders (many of whom have EBD) had fragmented lives and experienced emotional and financial deprivation. This fragmentation may often be due to lack of attachment to parents and other adults, leading to a deficiency in acquisition of “social, economic and parenting skills” (Bogin, 1999, p. 393).

Occupational therapy may be an effective intervention to assist adolescents with EBD transition to adulthood and assume adult responsibilities by helping them bridge the discontinuity in their lives. According to Blair (2000) occupational therapy is best suited for this task because of its emphasis on occupation. Action through occupation integrates “feeling, thinking, and doing” (p. 231), which provides a sense of coherence in an individual’s life at this time of uncertainty. Action through occupation also facilitates change, personal development, and well-being, which makes the transition easier. The need for occupational therapy as a means of assisting adolescents with EBD transition to adulthood is further given credence by research findings indicating that such adolescents tend to participate in occupations that are significantly different from those in which typical adolescents engage (Farnworth, 2003). They tend to participate in “passive” leisure occupations such as watching television or “doing nothing” in comparison to their typical counterparts who tend to engage in “active” leisure occupations such as sports, and productive occupations such as part-time employment and school related occupations.

A review of literature reveals few occupational therapy programs established specifically to address problems of adolescents with EBD. Those that we found in the literature tend to focus on development of work/vocational skills [see for example the program described by Nochajski, Scheitzer, & Chelluri (2003)]. Other skills necessary to assume adult roles such as choosing and keeping good friends, being a spouse or parent, and participation in community organizations are often not addressed.

The purpose of the present pilot study was to provide a preliminary test of the effectiveness of a newly developed conceptual model of practice in occupational therapy as a conceptual guide to intervention to help facilitate transition of adolescents with EBD to adulthood by preparing them to assume the adult roles of worker, family member, social, and community participant. The overall research question that guided this inquiry was: Is intervention based on Instrumentalism in Occupational Therapy (IOT) conceptual model of practice (Ikiugu, 2004a, 2004b, 2004c) effective as a guide for intervention to assist adolescents with Emotional and Behavioral Disorders (EBD) transition to adulthood? The specific research questions were:

a) Did participants’ occupational performance change after intervention using IOT as a guide?

b) Were participants clearer about Desired Adult Life (DAL) and a plan of action to achieve that life after intervention?

c) Is there predictive validity of IOT as indicated by correlation between change in participants’ occupational performance after intervention and the Allen Cognitive Level Screen (Allen, 2000) scores?

d) Is there concurrent validity as indicated by correlation between participants’ performance scores as measured on IOT instruments and the Canadian Occupational Performance Measure (Law, Baptiste, Carswell, et al., 2000) scores?

Instrumentalism in Occupational Therapy (IOT)
Reviewed literature suggests that useful interventions for adolescents should aim at helping reduce their maladjustment and enhance their healthy personality development within social contexts (Ge & Conger, 1999). However, little is known about the cause of maladjustment among adolescents or how to prevent them (Ellickson, Saner, & McGuigan, 1997). It has been suggested that: “An especially vital role for occupational therapy may be in the provision and formulation of transitional services and facilitation of meeting students’ goals as they move from school to work or from adolescence to young adulthood” (Haiman et al., 2005, p. 314, emphasis original). One way that occupational therapy may fulfill this role is by helping adolescents: “Establish a personal philosophy and unique values and attitudes” that positively influence their life “in all areas of occupational performance in school, work, church, and peer group activities” (p. 301).

The researchers chose IOT to guide therapeutic interventions in this research study because this model was specifically developed to fulfill the occupational therapy role described above. It was developed as a philosophically grounded conceptual model, based on the argument that occupational therapy is based on the philosophy of pragmatism (Breines, 1986; Cutchin, 2004; Ikiugu, 2001; Ikiugu & Schultz, 2006). John Dewey’s construct of instrumentalism was operationalized as a core construct to guide development of practice guidelines of the model (Ikiugu, 2004b, 2004c). Instrumentalism is the notion that the human mind is an extension of nature and as such, is a tool that the human being uses to assist in adaptation to the environment (Dewey, 1996; Ikiugu, 2001, 2004b; Ikiugu & Schultz, 2006; Sibley, n.d.). In this view, intelligence is viewed as a tool or instrument, just like any other tool, that can be used to help solve environmental or social problems, and in that way, to fashion out the environment and to make it home. In this perspective, behavior is viewed simply as instrumental action.

In developing the IOT model, Ikiugu (2004b) derived constructs from complexity theory to formulate his view of the human being as a complex, dynamical, adaptive system, interacting adaptively with its environment. Occupation was conceptualized to be the means of that interaction. Pathology was viewed as failure of the system to be adaptive due to either hyper rigidity or hyper mobility (Schultz & Schkade, 1992; Schkade & Schultz, 1992). The role of the therapist was conceptualized as assisting individuals to become optimally adaptive systems. Based on Dewey’s construct of instrumentalism, Ikiugu (2004a) argued that in practice grounded on pragmatism, clients should be taught to use the mind in the most efficient way to help them adapt to their environment. In this sense, the therapist’s interventions would be aimed at helping individuals who have become maladaptive systems for any reason, to use their minds effectively to help them become adaptive systems once more.

Based on the above rationale, guidelines were developed for use of IOT (Ikiugu, 2004c) including three phases: belief establishment, action, and appraisal of consequences. In the belief establishment phase, a client’s beliefs that contribute to maladaptive life patterns are examined. A new set of beliefs that support desired function are established by helping the person create a mission statement specifying purpose in life. Activities are identified, whose regular performance would lead to achievement of the mission or perceived purpose in life. Self evaluation regarding performance of those activities and perceived satisfaction with performance is completed. In the action phase, goals based on identified activities and self assessment of performance of those activities are set. The client then commits to regular performance of those activities. In the consequence appraisal phase, the client and therapist collaboratively examine the consequences of performance of identified activities in terms of the extent to which established goals have been met. Depending on the consequences as experienced by the client, goals are adjusted accordingly. Therapy is guided by the Assessment and Intervention Instrument for Instrumentalism in Occupational Therapy (AIIIOT) which operationalizes the model’s guidelines (Ikiugu, 2004c). In addition to the IOT conceptual model, because of the recognized advantage of group interventions for adolescents (Haiman et al., 2005), therapy during this study was completed in a group setting using the seven step format by Cole (1998) to establish group protocols for each session.

Materials and Methods
This was a mixed design research study consisting of naturalistic, phenomenological and pre-experimental pretest-posttest designs (Depoy & Gitlin, 1998). The pre-experimental part of the study was designed to provide an indication of post-intervention changes in participants’ (clients will be referred to as participants throughout the rest of this paper to emphasize their role as research participants) clarity of DAL and participation in occupational activities that were likely to support achievement of the visualized DAL. The phenomenological portion of the design provided triangulation by generating qualitative data indicative of thematic changes of conceptualized DAL as a result of intervention. This part of the study was based on the phenomenological process of research described by Van Kaam (1959), Giorgi (1985), Paterson and Zderald (1976), Colaizzi (1978), Van Manen (1984), and Streubert (1991).

The phenomenon of interest was participants’ perceptions of DAL, and what they thought they could do to ensure its realization. The study consisted of a variety of assessments before intervention (pretest), a 15 to 30 minute interview, a five week intervention based on IOT and Cole’s (1998) group format, a repetition of the assessments after intervention (posttest), and another 15 to 30 minute interview.  

Participants
Fifteen teenagers, ages 13 through 19, both male and female, participated in this research study. They were recruited from a local day treatment center. The center consists of two programs: a school program for adolescents remanded from public school and an after-school program for adolescents remanded by the court system (the drug court). The treatment program has as its foundation the concept of relational healing for high school teenagers with learning disabilities, attention deficit/hyperactivity disorders, or serious conduct disorders (Bethesda Day Treatment Center, n.d.; Napp, 2003). As such, counseling sessions are used to help individuals understand the link between emotions, such as feeling disappointed or angry with parents, and behaviors such as acting-out. After consultation with the program director, it was decided that intervention using IOT as a conceptual model to guide therapy would add a valuable component to the overall treatment experience of the adolescents.

Instruments
Daily Activity Inventory
An activity inventory derived from Ikiugu and Rosso (2005) was used to identify occupations each participant was engaged in from 6:00 A.M. through 12:00 midnight every day for four days. This instrument is similar to diaries that have been used in time-use research (Robinson, 2003).
    
Occupational Performance Measure
This instrument (Ikiugu & Rosso, 2005) was used to rank occupational activities engaged in by the client over the four days according to importance in helping him/her achieve the visualized DAL, with the most important activity being ranked number one. The top five most important occupations were used to compute a performance score for the client using the following algorithm developed by Ikiugu and Rosso:  Pt = ∑(Pi) = ∑(F X PI), where Pt is the total performance score, Pi is the performance score for each of the five activities, F is the frequency of participation in the activity, and PI is the performance index of the activity according to rank (5 points for activity number 1, 4 for number 2, 3 for number 3, 2 for number 4, and 1 for activity number 5 respectively).

Occupational activity classification
Extensive review of literature revealed that occupations in which adolescents participate can generally be classified into three categories (Boisvert, 2004; Kuh, Hu, & Vesper, 1999; Kruppa, McLean, Eastabrook et al., 2003; Larson, 2001; Wills, Sandy, & Yaeger, 2001). These are: activities associated with health and well-being; activities not associated with health and well-being; and activities that are neutral (i.e., may enhance health and well-being or vise versa, depending on how they are used). The researchers labeled those activities active, passive, and neutral respectively. Active activities are constructive, engaging, challenging, and enhance community integration, personal development, and general quality of life, and therefore enhance health and well-being. Examples of these include academic activities, substantive peer interactions which include discussion of political, economic or social issues, finding and holding a job, etc.  

Passive activities are destructive, non-challenging, and do not encourage community participation, personal development, or overall health and well-being. These include passive leisure activities such as partying, drinking, watching television (entertainment television), interacting with friends in unstructured contexts (hanging out), etc. Neutral activities are those that can go either way depending on the context. For instance, family related occupations may be active or passive depending on how the family as a unit spends time. We are aware that this classification could be misleading if the constructs “active”, “passive”, or “neutral” are understood to refer to the level of physical effort or energy expended. For the purpose of this paper the terms are defined merely to refer to the health and wellness enhancing qualities of activities. From analysis of activity inventories, 18 occupational activities in which all participants engaged over the specified times in the research period were identified.

Using the criteria described above, each of us independently classified the activities into the three categories. Another individual who is a teacher by profession but not an occupational therapist was also requested to classify the activities. To allow comparison of classification by the three raters using Pearson moment correlation coefficients, the categories were numerically coded as follows: Passive = 0; Neutral = 1; and Active = 2. Inter-rater reliability for this instrument was very good with correlation between rater 1 and rater 2 (r=.827, p<.01), rater 2 and rater 3 (r=.869, p<.01), and rater 1 and rater 3 (r=.947, p<.01).

Occupational therapy practice framework
The occupational therapy practice framework developed by the American Occupational Therapy Association (AOTA)(2002) was used to organize activities in which participants engaged over the four days into seven occupational areas; Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), Education, Work, Play, Leisure, and Social participation (Community participation, Family related occupations, and Peer related occupations).      

Assessment and Intervention Instrument for Instrumentalism in Occupational Therapy (AIIIOT) (Ikiugu, 2004c)
This instrument is designed to guide evaluation and intervention using IOT. It consists of three sections. In section I, instructions are provided to help therapist use guided imagery to assist the client formulate a mission statement. The mission statement consists of four areas constituting the vision towards which a client should strive in order to feel that he/she is leading a meaningful life. These four areas are family, socialization, work/profession, and affiliation to a church/community organization. Section II consists of instructions that the therapist uses to guide the client in choosing two occupational activities under each of the four areas in which he/she can regularly participate in order to achieve the visualized mission in life. In section III, there are four rating scales. The client rates his/her frequency, perceived adequacy, satisfaction, and belief in ability to participate in each of the eight activities. Each of the rating scales is on a 4-point likert type scale. In each of the four scales (frequency, adequacy, satisfaction, and belief), a composite score is calculated by adding the ratings for each of the 8 occupational activities. Each activity whose rating of satisfaction is less than 4 is discussed with the client and if it is perceived to be a priority for achievement of life mission, a performance goal for the activity is set.

Allen Cognitive Level Screen [ACLS] (Allen, 2000)
This is a standardized screening tool used in occupational therapy to determine the cognitive level of functioning of clients. Since IOT is a new conceptual model whose clinical usefulness has not been established, this instrument was used to test the predictive validity of the model. Since IOT requires clients to imagine and write down a mission statement, then identify occupational activities whose regular performance would lead to achievement of that mission, it was hypothesized that the model requires a high level of cognitive functioning. Therefore, the higher a client’s level of cognitive functioning, the higher he/she would be expected to benefit from intervention based on this model. Change observed after intervention as determined by various types of measurement should therefore correlate positively with the ACLS scores.

Canadian Occupational Performance Measure (COPM)
This instrument, which is based on the Canadian Model of Occupational Performance (Law, Baptiste, Carswell et al., 2000) is used to guide a client-centered approach to therapy where the client and therapist collaboratively identify occupational performance issues and the client’s perceived ability and satisfaction with performance. The COPM was used in part to guide development of the AIIIOT (see Ikiugu, 2004c). As such, the two instruments are conceptually close in terms of underlying constructs that they are designed to measure. Since the COPM is a standardized instrument whose reliability and validity has been well established through research, it was used to test concurrent validity of the IOT in general and the AIIIOT in particular. A high correlation between the COPM and performance scores as measured on the performance measure and the AIIIOT would mean that the IOT has concurrent or convergent validity as a conceptual model of practice.

Interview guide
An interview protocol consisting of five open ended questions was used to guide the 1-on-1 interviews. The questions were: What are some of the most important things in your life right now? Why are those things so important to you? How do you see your future (Say 10 years from now) unfolding? How do you see yourself realizing that kind of future? How do you think you can act right now in order to make sure that you realize the future of your dreams? Probes were used as indicated to elicit further information. The guide was designed to help gather information about the phenomenon of interest (participants’ perceptions of DAL, and what they could do to attain it).

Interview rating scale
In a study investigating the relationship between meaning in life and indices of psychological well-being, Debats, Drost, and Hansen (1995) developed a method of quantifying qualitative experiences of meaningfulness so that they could contrast experiences of meaningfulness with meaninglessness by quantitative means. They asked participants to write down in detail an account describing an event in which they experienced a sense of meaningfulness. The text was examined using three questions to create subcategories: presence/absence of expressed meaningfulness and/or expressed meaninglessness, details of the account, and components of the experience. Using this process as a guide, we developed a quantitative method of measuring Clarity of Desired Adult Life (CDAL) as expressed in the pre and post intervention interviews. We conceptualized CDAL to be indicated by clarity of detail provided in response to one of the questions in the interview guide, “How do you see your future (Say 10 years from now) unfolding?”

Details indicating whether or not the participant was clear about the DAL included whether or not he/she was clear about desired kind of job, how much money one expected to be earning, whether or not he/she was married, had children, the kind of friends one would have, the kind of house in which one would be living, etc. In addition, we conceptualized clarity about DAL to be dependent on awareness of activities that one needed to be engaged in right now such as studying, going to college, etc., in order to achieve that future. This included how clear one was about the subjects in which he/she needed to do well in high school, major in college, etc. Content analysis of the interviews was completed looking particularly for those details. Vagueness about the details was an indicator of Lack of Clarity about Desired Adult Life (LCDAL). The rating scale was therefore on a continuum as follows:

a)    Clarity or lack of clarity about desired adult life;
b)    Clarity of plan to achieve DAL

Therefore, the scale ran on a continuum from LCDAL (0) to CDAL (4), and could be conceptualized in a linear model as follows:

LCDAL (0) (4) CDAL, where LCDAL = Lack of Clarity about Desired Adult Life, and CDAL = Clear about Desired Adult Life.

Interviews were coded with letters of the alphabet before rating so that we did not know which ones were conducted pre or post intervention. Each of us rated the interviews independently. Inter rater reliability for post intervention ratings was good as indicated by the high Pearson moment correlation coefficient (r = .606, p<.02). Our ratings of pre intervention interviews were weakly correlated (r = .258, p>.05). The overall correlation between us for all the 30 interviews (both pre and post intervention was remarkably high (r= .510, p<.01).  

Procedures
After the study proposal was approved by the University of Scranton IRB, invitations for volunteers to participate in the study were sent to the director of the day treatment center. The invitations (a letter to the parent/guardian and another one to the adolescent) were given to the case workers who distributed them to the prospective participants and their parents/guardians during their weekly home visits. Those who were interested signed consent forms, which were returned to us. It was required that all participants under 18 years of age have parental consent to participate in the study. During the first meeting, interested adolescents were informed that participation in the study was voluntary and confidential. Participants’ activities in the study were explained to them. Given that one focus of the study was to investigate use of time, they were advised that any admission of illegal activities would be reported to the program director who would deal with the issues as per the center’s policies and procedures. During this meeting, activity inventories were distributed to participants with instructions to fill out one of them every day.

In the beginning, participants were required to fill out activity inventories for seven days. However, this was found to be too demanding for some of them. Instead, they filled them out for four days, Tuesday through Friday. While they were completing activity inventories, the first author met with each of them individually at the day treatment center and administered the ACLS and the first interview. Interviews were recorded using a cassette tape recorder and later transcribed verbatim. Each interview was 15 to 20 minutes long. The second author met with them individually and administered the COPM. On Friday, one week after the first meeting with participants, they came to the Community and Health Center run by the University. Using the AIIIOT, they were guided to write mission statements. The completed activity inventories were collected during that session. The following week, the first author met with each of them individually. In collaboration with participants, occupational activities under each of the four areas (family, relationships, work/school, and affiliation to church or some other community organization) were identified whose regular performance would help the participant achieve articulated mission in life. Participants rated themselves on the four scales of AIIIOT (frequency, adequacy, satisfaction, and belief) for each occupational activity. Based on the self ratings, therapy goals for each participant were formulated.

After gathering pretest data, we conducted therapeutic interventions with the assistance of two occupational therapy students who were in their senior year. Therapy sessions were held once a week for about one and half hours, for five weeks. All sessions were conducted in groups. Individual participants’ therapy goals were used to set group goals and establish weekly group protocols (Cole, 1998). A goal that was common to most group members was used to make the group protocol for the first session, the second most popular goal the second session, and so on, until all participants’ goals were addressed. Examples of group activities included collage making as a leisure occupational activity that also helped group members reflect on the importance of participating in family oriented occupations, a reading and listening activity to help participants develop academic skills, creation of a poster to be used to teach younger children the dangers of drug abuse, etc.  After five weeks of group interventions, another set of occupational activity inventories was distributed to participants and collected after four days (Tuesday through Friday). Another interview was conducted. All assessments completed before intervention were repeated except the ACLS. Three groups of adolescents went through this process between February and December 2004. Five adolescents participated in the first group, three in the second, and seven in the third respectively.

<>Table 1
<>Example of a Group Protocol Used to Structure Intervention in one of the Sessions

Data Analysis
Statistical Analysis   
Activities in each of the participant’s inventories were organized into seven occupational areas according to the occupational therapy practice framework (AOTA, 2002): ADLs, IADLs, education, work, play, leisure, and community participation. Frequency of participation in each activity as entered in the four day inventories was noted. Each participant was requested to rank occupational activities in the list generated from the activity inventories according to perceived importance in helping him/her achieve stated mission in life. The top most important activities were used to calculate the performance score for each participant using the algorithm by Ikiugu and Rosso (2005). In addition, the occupational activities in which participants participated in the eight days as entered in the pre and post intervention activity inventories were classified into three categories (passive, active, and neutral).

Using the Statistical Package for Social Sciences (SPSS), mean performance scores, frequency of performance, COPM, AIIIOT, and CDAL scores before and after intervention were compared using paired sample t statistics. The correlation between each variable and all the other variables (age, ACL scores, and changes in COPM, performance, AIIIOT, and CDAL scores) was calculated. Finally, correlation between changes in variables after intervention was calculated to determine their interaction.
Qualitative data analysis
The pre and post intervention interviews were analyzed using the phenomenological analysis methods suggested by Colaizzi (1978), Giorgi (1985), Paterson and Zderald (1976), Streubert (1991), Van Kaam (1959), and Van Manen (1984). The analysis process consisted of the following steps:

1.    Each interview transcript was read multiple times to find out what participants had to say about the phenomenon of interest (perception of the DAL and how to achieve it). A summary of this sense of perception was written down.

2.    Each of us then immersed him/herself into the data by reading each transcript again line by line and explicating essences indicative of the phenomenon of interest. Such essences were implied by statements indicative of participants’ grasp of details of their visualized DAL and plan of action to achieve it.

3.    The identified essences were grouped according to similarity into themes and thematic descriptions were generated.

4.    Finally, a formal description of the phenomenon (participants’ perception of, and clarity of how to act now in order to achieve visualized DAL) was synthesized from the thematic descriptions.

The formal description of the phenomenon and underlying themes before and after intervention were compared to determine changes in perception and clarity of actions required to achieve the DAL after intervention.

Establishing trustworthiness of qualitative findings
The trustworthiness of the qualitative findings was assured using the criteria provided by Lincoln and Guba (1985):

Credibility was assured by triangulation of data collection methods as well as multiple designs. Methods of data collection included use of a variety of instruments to collect the same quantitative data. Qualitative and quantitative methods were used to provide triangulation of research methods. Another measure taken to ensure credibility of findings was that each of us analyzed the qualitative data separately and compared resulting themes. We debated any themes that were not consistent until we arrived at a consensus regarding interpretation of the data in question, a process known as peer debriefing.

Transferability was achieved by detailed description of the research procedures so that this research study can be easily replicated.

Dependability was achieved through reflexivity. We wrote down any biases that could have influenced our interpretation of data as such biases occurred to us. This increased probability of objectivity in our data coding.

Conformability was achieved by each of us writing memos detailing the logic leading to conceptualization of themes. These memos provided an audit trail explicating how we arrived at our findings.

Results
As mentioned earlier, 15 participants, ages 13 through 19 (mean age = 15.9 years, 6 males and 9 females), completed enough study activities for their data to be included in the analysis. Following are the study findings discussed under each of the specific research questions that the inquiry sought to answer.

Occupational Performance Change Following Intervention
The first research question was: Did participants’ occupational performance change after intervention using IOT as a conceptual guide? A paired sample t-test comparing composite frequencies of participation in activities classified in the three categories (Active, Passive, and Neutral) before and after intervention indicated that participation in occupations classified as neutral significantly decreased (t=-3.441, p<.01). There was no significant change in other categories, although participation in active occupations slightly decreased and participation in occupations classified as passive slightly increased. Results of a paired sample t-test comparing frequency of participation in specific occupations as categorized using the Occupational Therapy Practice Framework (AOTA, 2002) before and after intervention are shown in Table 2

<>Table 2
<>Comparison of Frequency of Participation in Occupations before and after Intervention (n=12).

As can be seen in table 2, there was an increase in education related occupations (t=.586, p>.05). Obviously, this change was not significant. Rather, there was a significant decrease in frequency of participation in peer related occupations (t=-1.817, p<.05) such as communication, particularly talking over the phone (t=-2.123, p<05). Community mobility also decreased (t=-2.569, p<.02). In addition, while there was no significant change in performance as measured on AIIIOT, there was a significant increase in COPM scores after intervention (t=2.075, p<.05) (not included in the table). Therefore, there was a significant change in occupational performance after intervention. Participants engaged more in education related (although this change was not statistically significant) and less in peer related occupations such as talking over the phone, and community mobility.

Clarity of Desired Adult Life (CDAL)
The second research question was: Were participants clearer about their vision of Desired Adult Life (DAL) and plan of action to achieve it after intervention? There was an increase in Clarity of visualized Desired Adult Life (CDAL) and current actions needed to achieve that future as indicated by rating scores for pre and post intervention interviews. This increase was not significant (t=1.242, p>.05). However, the change was collaborated by qualitative findings as discussed below.

Participants’ perception of future before and after intervention: A phenomenological perspective
The phenomenon of interest was participants’ perception of DAL and their ability to articulate a detailed plan to help them achieve that future.  Phenomenological analysis of pre and post intervention interviews revealed that before intervention, many participants valued family and friends because they derived a sense of security and support from them. They had a vague idea of the DAL, and could only vaguely, if at all, articulate plans to achieve the desired future. After intervention, even more participants articulated their value of family and friends. A few of them expressed values that were not articulated before intervention such as getting off the drug court, staying free of drugs, studying and attaining good grades, and doing household chores. They continued to view family and friends as a source of security. Moreover, friends were perceived as valuable confidantes. A greater number of participants expressed concern about the future, and their visualization of the DAL was clearer, even though for some, this visualization was naïve and unrealistic. The expressed concern could be understood to imply that these adolescents were thinking more about their future after than before intervention. For some of them, the plan to achieve the DAL was clearer and more logical. These perceptual changes are demonstrated by changes in phenomenological essences derived from the interview data as shown in table 3

Table 3
Number of Participants for each Essence and Theme Pre and Post Intervention

Values:
 Participants identified family as one of their values. For example, when asked what was important in his life, participant number 2 instantaneously stated: “My family”, and continued to identify his mom as the most important person in his life. Similarly, participant number 6 identified his “grandparents, my sister, and my brother” as the most important people in his life. Similarly, participant number 202 responded, “Uh, my family and my girlfriend”. Participant number 5004 answered: “parents, my grandma, my grandfather, and that’s about it. I don’t associate with my dad much or my step dad, so just usually my mom, uncle, my grandfather, and my grandmother.” It is clear from table 3 that all participants identified a value of family after intervention compared to only 80% of participants before intervention.

Also, participants identified friends as a value. In answer to the inquiry as to what was important in her life, participant number 13 answered: “School, my family, my friends”.  Similarly, participant number 201 identified his family “and my friends” as the most important. Participant number 3 responded: “My friend A and um… my other sister D”. Participant number 9 also responded; “Uh… my friends”.  More participants (73%) indicated value of friends before intervention than after intervention (69%). This is consistent with the statistical finding that after intervention, participants engaged less in peer related occupations than before intervention.

Values such as getting off the drug court, staying free of drugs, studying and attaining good grades, pets, intimate relationships, and doing household chores were articulated as values after, but not before intervention. Following are quotes from participants’ responses to the inquiry about what was important in their lives demonstrating the above finding: “My family and getting off of court” (Participant number 2). “Just staying drug-free” (Participant number 2).  “My family and my school” (Participant number 3).  “Um… my grades and school” (Participant number 202). “Oh, and my cat” (Participant number 201) (This was interpreted as value of pets by this participant).  “My family, and my friends, and my boyfriend” (Mentioning the boyfriend was interpreted to be an indication of value for intimacy by participant number 206). “Shopping” (This activity was interpreted as value of leisure by participant number 6). “and my friends are just there so I can hang out with” (Interpreted as a value of socialization by participant number 9).  “Helping mom with activities, like chores” (Participant number 202). Thus, it seems that for some participants, the value of family, getting off the drug court, staying free of drugs, school, studying and attaining good grades, pets, intimacy, and doing household chores was perceived as a value more after intervention. Interestingly, only one participant expressed a value for socialization after compared to three before intervention. This is consistent with the statistical finding that peer related occupations (which symbolize socialization) decreased after intervention.

Reasons for articulated values: Participants indicated their perception that the family was valued because it provided them with a sense of security and support. In this regard, participant number 202 stated: “My family is important to me, because without them I wouldn’t know what to do, wouldn’t be here right now.”  He saw the family as the very source of his existence, which indicated that to him, the family was a source of security. Participant number 203 further stated that his family would do “basically anything I ask” indicating that to him, they were a source of support that could be relied upon. Participant number 2 valued his family because “they are always around and when I get into trouble, they are always there for me.” Similarly, participant number 6 valued her family because “they love me.” More participants (54%) articulated security as the reason for their value of the family after intervention than did before intervention (27%).

Some of the reasons given for values after intervention were not mentioned pre intervention. These included the perceived value of friends because they were seen as a source of support and security and as confidantes, and therapeutic value of activities.  Participant number 12 for example stated that friends were valued because “they are always there for me and support me.” Participant number 203 further explained that friends were valued because a friend was seen as “someone to talk to when I need to talk.” This statement suggested that for this participant, a friend was a confidante to whom he could confide. Further, participant number 5004 articulated the idea of leisure activities being valued because they provided diversion by stating that basketball “keeps me out of trouble” because “if I don’t do that stuff, I get into trouble. You do stupid things when you aren’t busy.” So, for him, basketball (leisure activity) diverted his attention by keeping him busy and thus out of trouble. Participant number 201 further stated that her pet was valued because “I don’t know. It helps me to relax.” Helping her to relax was interpreted to mean that she perceived her interaction with the cat as a therapeutic experience.

Visualization of the future: Some participants were vague about their visualized DAL, and others were very clear regarding the kind of adult life they wanted for themselves. Vagueness about visualized future was indicated by statements such as the following in response to the inquiry about how they visualized themselves 10 years from the present: “Umm… I don’t know. Married with two kids” (Participant number 201).  The hesitation indicated that this participant was not very clear about how her life was likely to be as an adult. She probably had not thought about it very much. Similarly, participant number 204 answered the question: “I just wanna have a good life, get a good job. I don’t really know what I wanna go for yet, cause I wanna go to college. I just do not know what I wanna go for yet. So, I really don’t know anything yet.”
CDAL was indicated by statements such as: “A good life I guess. Nah, I wanna be a doctor. So, I will probably still be in college” (Participant number 206). Thus, she knew what she wanted to do in future, and could see herself in circumstances (college) that would lead to the visualized DAL (being a doctor). Similarly, participant number 5004 had no hesitation in his statement that: “I want to try and be a mechanic. So, pretty much in the mechanic route.” Fewer participants (62%) were vague about their visualized DAL after than there were before intervention (80%). Also, more participants (38%) had a clear vision of their DAL after intervention than before (27%).

Although more of the participants articulated a clear vision of the DAL, many of them tended to be unrealistic and naïve about that future (31% of the participants) after than before intervention (7%). Some of the statements indicative of this unrealistic, naïve view included a statement by participant number 6 who saw himself as having “a family of my own” at age 25, and also working as “a lawyer”. This view was rather unrealistic for a 15 year old adolescent who was still in high school and not doing very well either. Similarly, participant number 202, who was 13 years old, stated that at age 23, she would be “in college for medical school ‘cause I got my scholarship and I have a whole bunch of dogs ‘cause that’s what I wanted and I have a crocodile. Um… a tiger in my front yard ‘cause I love tigers and my mom admirers them and it would remind me of my mother if she ever passes away. And I will be getting my license for bone doctor.” As is evident from this statement, this participant seemed to be dwelling in fantasy. Although she was vivid in her description of the DAL as a 23 year old woman, this picture was not very realistic.

Some participants expressed concern about their future, which was not expressed before intervention. This concern was delineated from statements such as: “I want to do good. I want to graduate and get into college” (Participant number 206).  This desire to do good so that she could go to college indicated that she was concerned about her future. Also, some participants expressed no idea or interest about the future, which was not the case before intervention. Participant number 6 for instance stated the following in response to inquiry about how she saw herself 10 years from the present: “I have no idea”, she said. “I don’t look at the future. Just one day at a time.” In other words, following intervention, more of the participants had a clear vision of their DAL and were concerned about their future. However, for many of them, visualization of that future was rather naïve and unrealistic. Some of them appeared to lose interest in the future all together.

Plan to achieve DAL: A smaller proportion of participants (46%) were vague about plans to achieve DAL after compared to before intervention (80%). On the other hand, a larger proportion of them (23%) articulated a clear plan to achieve DAL after than before intervention (20%). An example of a vague plan of how to achieve DAL can be seen in the following answer by participant number 11 to the question of how he was going to ensure that he graduated high school and went to college. He answered: “Graduating school; Going to college; Getting good grades, In the 90s, in all subjects.” There were no details of how he was going to ensure that he got those good grades, or subjects in which he needed to do well in order to achieve his dream. His plan was therefore vague. Similarly, participant number 6 wanted to be different from his father as an adult. When asked how he would achieve that, he said: “That’s kinda hard question. I don’t know how to answer it.”

Some participants were quite clear about how they would achieve the DAL. Participant number 12 for instance was sure that in order to achieve her goals, she had to: “Um… graduate school, get a job, and I have to stay off drugs.” She also stated that she had to: “Um… following up with my parole officer. Go to my meetings, my AA meetings, and my counseling sessions.” She further stated that she needed to: “stay away from my old friends”, and “Um… stay focused.” (This could explain the reason for decreased peer related occupations after intervention. May be participants started realizing the negative influence of some of their current friends). Thus, this participant was at least aware of specific actions that she needed to take in order to get her life back on course. Similarly, participant number 206 was clear that in order to realize her visualized DAL, she had to: “do really good in school; study; pay attention, do all my work” and stop hanging out too much with her friends when she “could be sitting here studying or something”.

After intervention, some participants articulated a clear, logical plan to achieve DAL. Participant number 9, for example, decided that he wanted to be both a mechanic and a security guard. His plan to achieve that dream consisted of not doing “anything bad in school, like do what you have to do in school, study hard”, and do well in “math, science, and history” because, “you have to work a lot with numbers, so, you need good math, history so I could know like when stuff was made, so you know how old stuff is, and science so you know all the scientific stuff about mechanics and um security guards”. This participant, as can be seen in the above statement, demonstrates clear thinking, and provides a logical rationale for his proposed plan of how to achieve his goals. After intervention, at least one participant (number 3) demonstrated increased general awareness of what she needed to do in order to achieve her visualized future, even though she did not have a detailed plan. She stated that she needed to: “Show that I am doing what I am supposed to be doing, behaving.” She elaborated: “Like not having any curse words, and come to school every day, get good grades.” It is therefore evident that following intervention, a larger proportion of participants was less vague, and therefore clearer, about plans to achieve the DAL. Their plans were more logical, and they developed increased awareness of what they needed to do to achieve their goals.

Change: Following intervention, a number of participants seemed to experience change in their attitudes and perspectives about life and about their future. Such change included serious pondering of the future, self appraisal, change of goals, change of behavior, increased insight and awareness of the need for self reliance, development of new values, and development of a sense of responsibility. Such changes were indicated by statements such as: “’cause when I was on drugs I was like really mean. I didn’t care what I was doing. I was really disrespectful to my parents.”  This statement by participant number 2 indicated his increased awareness of the consequences of his behavior, which was a sign of increased insight. This interpretation was further supported by his statement that: “and I don’t want to go back that way”. Participant number 9 demonstrated change by adding being a security guard to his original goal to be a mechanic. Now, he wanted to be both a mechanic and a security guard. Participant number 202 indicated his change of behavior in the statement that: “Because I want to pass this year and know I am doing it and go on the trip, ‘cause I am behaving more this year than last year ‘cause I got suspended like every two days. So, now, I wasn’t suspended once this year, well, may be once ‘cause I, but not ‘cause I got free of it ‘cause it wasn’t on school property.”

Perception of therapy:
 The majority of participants saw therapeutic activities used in this study as both useful and fun.  Participant number 2 valued the pizza cooking activity because “I never cooked a pizza before.” For participant number 3, the valued activity was: “May be when we went to that lady’s computer class [referring to the session where the group visited career services department at the University] to help find out information about jobs and stuff.” The reason she valued this activity was: “Because I don’t have a computer or anything so I can look online, see what I have, what sites I have to go to and stuff, see what I wanna do.” Participant number 9 valued most the activity where the group worked on: “Study habits. By knowing how to study ‘cause before I didn’t know how to study and now I do got a little better idea.” Finally, for participant number 206, her perspective regarding all therapeutic activities was simple: “It was fun.”

The above analysis indicates that the finding of increased CDAL from the quantitative data, though not statistically significant, was supported by results of the qualitative data. Furthermore, use of IOT as a conceptual guide for therapeutic interventions led to therapeutic activities that were perceived by majority of participants to be valuable and fun.                  

Interaction between Variables
Correlation between change in beliefs, perceived adequacy, performance, and satisfaction

The relationships between belief in ability, perceived adequacy, frequency, and satisfaction with performance are shown in table 4.
 
Table 4
Correlation between Changes in Performance Variables as Indicated by Pearson r Correlation Coefficients (n=12).

 
Notes: * Significant at p<.05, 1 tailed; ** Significant at p<.05, 2 tailed.


Pearson r coefficients indicate that increased COPM scores was correlated with increased frequency of participation in occupations categorized as neutral (r=.686, p<.02). This suggests that change in frequency of participation in neutral occupations accounted for observed significant change in COPM scores.

Another statistically significant interaction was that clarity of participants’ visualized CDAL was correlated with decreased participation in occupations identified as important to achievement of life mission as identified during pretest using the AIIIOT (r=-.529, p<.05). This negative correlation could be because of change in participants’ perception of what was important due to increased insight following intervention. This would support our hypothesis that the reason for lack of significant change in AIIIOT scores post-intervention is that we did not account for change in prioritization of occupations with increased insight. Since the same occupations identified as important for achievement of life mission during pretest were evaluated on the four scales of AIIIOT during post-test, if participants changed their perceptions of the importance of these occupations due to increased insight following intervention, their scores on AIIIOT would decrease. This explanation would be consistent with the finding from qualitative data that some participants changed their goals and therefore their perception of what was important in their lives after intervention.

Correlation between changes in participation in specific occupations

Table 5
Correlation between Changes in Participation in Specific Occupations Following Intervention (n=12).

 
Notes: ** Significant at p<.05, 2 tailed; * Significant at p<.05, 1 tailed.

As can be seen in table 5, the more participation in peer related occupations increased, the more participants tended to attend to self care occupations such as bathing and grooming (r=.592, p<.05), and the more they tended to engage in activities related to intimacy such as spending time with boyfriend or girlfriend (r=.673, p<.02) and to be involved in joy rides (r=.673, p<.02).

The more engagement in homemaking occupations increased, the more participation in peer related, intimacy related, and joy ride activities decreased (r=-.633, p<.05, r=-.519, p<.05, and r=-.519, p<.05 respectively). Also, the more participation in education related occupations increased, the more the frequency of participation in occupations classified as passive decreased (r=-.639, p<.05).

Validity of IOT as a Conceptual Model of Practice
Research question number 3 was: Is there predictive validity as indicated by correlation between change in occupational performance post intervention and the ACLS scores? No significant relationship was found between these two variables. However, it was found that the older the participants, the more their frequency of participation in occupations classified as passive increased after intervention (r=.510, p<.05). Thus, a participant’s age seemed to be related to the type of change likely to result from therapeutic intervention using the conceptual model. The final question was: Is there concurrent validity of IOT as indicated by correlation between participants’ performance as measured on IOT instruments and the COPM scores? In answer to this question, a strong correlation was found between changes in COPM scores following intervention and changes in performance scores as calculated using the formula Pt=∑(Pi) (r=.786, p<.02).  

Discussion
The main finding in this study is that there was significant change in participation in occupations perceived by self and others as important, as measured on the COPM. This change, did not correspond to changes in the frequency, efficacy, satisfaction, and belief in ability to engage in occupations perceived to be important for attainment of personal mission in life as measured on AIIIOT, as was predicted. This finding puts in question the criterion validity of IOT as a conceptual model of practice, since its development was partly based on the COPM (see Ikiugu, 2004c).  However, a correlation was found between the COPM and performance scores, which were calculated based on the importance of identified occupations to attainment of life mission (see description in the procedures section).

We propose that this discrepancy may be explained by the fact that perception of occupations that were important for achievement of life mission and, therefore, personal future goals changed after intervention. This change in perspective would explain the lack of significance found in the change in AIIIOT scores. After intervention, we measured participants’ perception of frequency, adequacy, satisfaction, and belief in ability to perform occupations based on activities that were identified as important for achievement of life mission during pretest. We failed to capture the change in priorities and, therefore, change of perception of what was important following intervention. This interpretation of the above results would be consistent with the other finding that as participants’ visualized future as adults became clearer (as indicated by CDAL scores), their likelihood of participating in occupations identified as important to attainment of life mission (as indicated by AIIIOT scores) decreased. In other words, as participants’ view