Re-Visioning Occupational Therapy - Dr Kondekar opens the new dimensions of learning beyond just vocational executions
Re-Visioning Occupational Therapy in Autism
From Domain-Wise Repetition to Dynamic Hierarchical Cognitive Learning
Occupational therapy has traditionally been organised around domains such as sensory integration, fine motor strengthening, and gross motor training.
While these domains provide useful structure, over-reliance on domain-wise repetition can unintentionally shift therapy toward activity execution rather than learning development.
There is a growing need to re-vision occupational therapy as a dynamic cognitive learning discipline, where motor activities are tools — not the end goal.
The Limitation of Domain-Wise Repetition
Structured repetition within domains often leads to:
Activity familiarity without cognitive expansion
Task dependence
Reduced problem solving
Limited generalisation
Plateau in communication
Children may become skilled at performing therapy tasks but show minimal growth in thinking, communication, or adaptability.
The Shift: From Activity Execution to Learning Execution
Therapy must evolve from:
đ “What activity is the child doing?”
to
đ “What new thinking is the child developing?”
This represents a shift from performance-based therapy to learning-based therapy.
Dr Kondekars Dynamic Hierarchical Cognitive-Verbal Model
A revised framework for occupational therapy should focus on structured progression through cognitive and verbal complexity.
Level 1 — Regulation and Engagement
Body organisation, attention readiness
Level 2 — Interaction and Exploration
Cause-effect learning, curiosity
Level 3 — Problem Solving
Adaptive thinking, flexibility
Level 4 — Concept Building
Understanding relationships, abstract thinking
Level 5 — Communication Integration
Using language and social interaction
Level 6 — Generalisation
Applying learning across contexts
This hierarchy ensures therapy moves forward developmentally rather than remaining static.
Motor Activities as Cognitive Tools
Fine motor and sensory activities remain valuable when used to:
Support problem solving
Encourage interaction
Introduce novelty
Promote communication
Muscle strengthening alone is not the developmental goal — cognitive engagement is.
Executing New Thoughts
True therapy success is seen when children begin to:
✔️ Generate ideas
✔️ Adapt responses
✔️ Ask questions
✔️ Show curiosity
✔️ Apply learning
This reflects execution of thought rather than execution of activity.
Progressive Concepts Over Static Tasks
Therapy sessions should introduce progressively complex ideas rather than repeating identical tasks.
Progression drives neuroplasticity and prevents rigidity.
Revised Case Studies — Through the Lens of Re-Visioned Therapy
Case 1 — From Puzzle Performance to Cognitive Flexibility
Previous model:
Repeated puzzle completion
Re-visioned approach:
Introduced problem-solving variations
Asked predictive questions
Added storytelling around tasks
Encouraged verbal reasoning
Outcome:
✅ Increased spontaneous speech
✅ Improved flexibility
✅ Better conceptual understanding
Clinical insight:
Shift from task execution to thought execution created learning.
Case 2 — From Sensory Routine to Interactive Learning
Previous model:
Daily sensory circuits
Re-visioned approach:
Sensory activities paired with problem solving
Turn taking games
Communication goals integrated
Novel challenges introduced
Outcome:
✅ Improved engagement
✅ Increased joint attention
✅ Better adaptive behaviour
Clinical insight:
Sensory input supported learning only when cognitively integrated.
Case 3 — From Comfort Zone to Developmental Progression
Previous model:
Repeated familiar tasks to maintain calm
Re-visioned approach:
Gradual hierarchy of difficulty
Predictable but varied tasks
Encouraged choice making
Introduced real-life scenarios
Outcome:
✅ Increased adaptability
✅ Reduced avoidance
✅ Greater confidence
Clinical insight:
Hierarchy enabled growth without overwhelming the child.
Case 4 — From Verbal Drill to Communication Thinking
Previous model:
Flashcard naming
Re-visioned approach:
Conversation scenarios
Open-ended questioning
Narrative building
Emotional understanding tasks
Outcome:
✅ Improved conversational ability
✅ Increased spontaneous language
✅ Better social understanding
Clinical insight:
Language develops through thinking, not memorisation.
Implications for Occupational Therapy Practice
Therapists should design sessions that:
Progress hierarchically
Integrate cognition and communication
Introduce novelty
Encourage thinking
Promote generalisation
The Future Role of Occupational Therapy
Occupational therapists are not only domain specialists — they are developmental learning designers.
Their role is to bridge motor engagement with cognitive and social development through structured progression.
Integrating With the 4 D Framework
Re-visioned therapy naturally aligns with:
Dynamicity → Changing experiences
Diversity → Varied contexts
Difficulty → Progressive challenge
Differences → Individual pathways
Dr Kondekars Perspective
When therapy shifts from strengthening muscles to strengthening thinking, the developmental trajectory changes.
Children move from performing tasks to understanding concepts.
This is where real independence begins.
Key Message
Occupational therapy should not be defined by activities performed, but by learning achieved.
References
Ayres AJ. Sensory Integration and the Child. Los Angeles: Western Psychological Services; 1979.
Ayres AJ. Sensory Integration and Learning Disorders. Los Angeles: Western Psychological Services; 1972.
Schaaf RC, Mailloux Z. Clinician’s guide for implementing Ayres Sensory Integration: promoting participation for children with autism. Bethesda: AOTA Press; 2015.
Bundy AC, Lane SJ, Murray EA, editors. Sensory Integration: Theory and Practice. 2nd ed. Philadelphia: F.A. Davis; 2002.
Iwama MK. The Kawa Model: Culturally Relevant Occupational Therapy. Edinburgh: Churchill Livingstone; 2006.
Law M, Baptiste S, Carswell A, McColl MA, Polatajko H, Pollock N. Canadian Occupational Performance Measure. 5th ed. Ottawa: CAOT Publications; 2014.
Bobath B. Adult Hemiplegia: Evaluation and Treatment. 3rd ed. Oxford: Butterworth-Heinemann; 1990.
Kielhofner G. Model of Human Occupation: Theory and Application. 4th ed. Baltimore: Lippincott Williams & Wilkins; 2008.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington DC: APA
Author Prof. Dr Santosh Kondekar MBBS, MD (Pediatrics), DNB (Pediatrics), FAIMER Fellowship in Pediatric Neurology & Epilepsy Postgraduate Diploma in Developmental Neurology Professor of Pediatrics Developmental Neuro Pediatrician TN Medical College & BYL Nair Hospital, Mumbai Director — AAKAAR Clinic Child Development Center Mumbai, India đ 9869405747 đ www.autismdoctor.in for all post links click https://speechandsenses.blogspot.com/p/httpsspeechandsenses.html
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