Importantly, occupational therapists working with children in pain are part of a team that includes other professionals, the infant or youth, and the family. Th us, other theories an d process models may inform how the team works together to assess the situation and to deve lop an intervention plan. Occupational therapists may draw upon occupation-based theory to inform their specifi c contri- bution, as well as the team \200\231s specifi c philosophy o r interdisciplinary theoretical approach. For example, collaborative teams working with chi ldren and families in health, educational, or community settings may use biopsychosocial, d evelopmental, social, and/or ecological theories of human development to ensure the needs o f the child are met. Bronfenbrenner and Ceci (1994) introduced SECTION 8 physical interventions 592 a bio-ecological model of human development to explain envi- ronmental infl uences on the i ndividual that crosses disciplinary boundaries. It has been tested, adapted, and applied to supporting children of all ages, and cited widely. Occupation-based theories are not only compatible with such approaches, but help to make the occupational therapist \200\231s role explicit to the team and to the fam- ily. Hickman and colleagues review empirical evidence on applying developmental and movement science theories to early interven- tion practices (Hickman et al., 2011). Th ey indicate the importance of transdisciplinary approaches that support collaborative goal set- ting with the child and family as both a contributor to eff ective care and a challenge to maintain in complex care settings. a comparator for later outcome evaluation to determine if goals were achieved. Th e process begins by screening for occupational performance issues \200\224there is no need for more detailed assessment procedures unless the child \200\231s health status or symptoms, includ ing pain, have an impact on or threaten occupational performance. An initial observation of an infant or an interview with the child and/or caregiver helps to identify specifi c prob lems and factors contribut- ing to those problems, as well as resources to be considered in for- mulating an intervention plan. Th e assessment process may include observation, self- report, and performance-based tests in order to document baseline performance or identify i ndividual strengths and limitations for choosing particular treatment modalities. In the pr esence of pain, it may not be appropriate or possible to conduct a complete evaluation in a single session or at all; priorities need to be established in light of the presenting cir cumstances. Although dis- cussed as a discrete step, assessment is oft en ongoing and integ rated into the intervention process. How pain a \200 ects occupation Children engage in a range of roles aligned with their dev elopmen- tal stage. For example, one of the roles of an infant is to engage in the environm ent purposefully to ensure its survival. Roles are sup- ported by occupational engagement. Pain may prevent children from engaging in the occupations that contribute to, or are essen tial for, their life roles. One way to understand the potential impact of pain is to consid er a basic occupational taxonomy (such as presented by Crepeau and Schell (2009) or Polataj ko et al. (2004)) and how pain may interfere at any level of that hierarchy (see Figure 57. 1). Infant assessment Assessing pain in infants is complex for a number of reasons, the most ob vious one being that infants are not able to self-re- port. Th us, occupational therapists must fi rst assess the context in which pain may be present (e.g. as in postoperative pain or related to a disease process) and then rely upon a combination of behavioral and physiol ogical indices shown to be the most reliable and valid measures of pain. For infants, these indices usu- ally include specifi c, anatomically defi ned facial and body move- ments, ch anges in sleep/wake states, and changes in heart rate. Many of these indices have been incl uded in a number of reli- able and valid tools available for assessing acute pain in infant s, such as the Behavioral Indicators of Infant Pain (BIIP; Holsti and Grunau, 2007b), the P remature Infant Pain Profi le (PIPP; Stevens et al., 1996), the Neonatal Facial Coding Syst em (NFCS; Grunau and Craig, 1987), the Comfort Scale (Ambuel et al., 1992) and the FLACC sc ale (face, legs, activity, cry consolability; Merkel et al., 1997). Th e psychometric prope rties of neonatal and infant pain tools have been reviewed extensively in this volume by Le e and Stevens (Chapter 35) and elsewhere (Stevens et al., 2007). Most recently, technologie s, such as near infrared spectroscopy (NIRS) and electroencephalography (EEG) are providing researchers and clinicians with important complementary information regarding evaluating p ain responses in infants at a cortical level (as reviewed by Holsti et al., 2011). Pain may inhibit an action : pinching a button; a task : buttoning a shirt; an activity : g etting dressed; an occupation : completing morning self-care. As a result, pain at any leve l of occupational performance may limit the child \200\231s roles in life; in this example, the occupational therapist is concerned with supporting the child to develop inde- pendenc e in self care because it is a natural developmental milestone, and eff ective and appropri ate dress contributes to participation in other roles, such as playing dress-up, being in u niform for a sporting team, or being dressed for school or church. Th erefore, an occupa- t ional therapy assessment will identify which aspects of occupation are aff ected by pain; t he strengths and resources the child has; and provide direction for selecting interventions that will overcome the eff ect of pain on the occupations the child needs and wants to do. Assessment Overall purpose and process Th e purpose of the assessment is to establish a bas eline that in turn informs goal setting and an intervention plan, and provides An important consideration for occupational therapists \200\231 assessment of pain is wheth er or not to use a tool that combines behavioral and physiological indices into a single sc ore (a multi- dimensional approach) or to evaluate these categories of indicators separatel y (a unidimensional approach). Th is choice is important because in both infants and in chi ldren, dissociation between behavioral and physiological indicators is common (e.g. Morison et al., 2001). Including both behavioral and physiological indices is critical; however, i f a multidimensional tool is used, and the eff ects of any applied treatments are not evalu ated as to their eff ects on both the behavioral and physiological components, caregivers a nd researchers may miss important information as to the overall effi - cacy of the treatmen t. For example, sucrose is an oral solution given to infants to reduce acute procedural pai n (Stevens et al., 2010). Although sucrose consistently reduces the behavioral component Occupation Activity [e.g., 2nd grade student, ballet dancer, baseball player] [e.g., put on a shirt, color a picture, play a game] Task [e.g., fasten a button, climb stairs, throw a ball] Action [e.g., grasp, reach, step] Figure 57.1 Th e in \202 uence of pain on childrens \200\231 occupational roles. CHAPTER 57 occupational therapy 593 of the pain response, its eff ects on physiological responses can be variable (Stevens et a l., 2010). Th is type of \200\230split \200\231 response to a treat- ment raises the conce rn that failing to reduce the physiological response leaves infants vulnerable to the desta bilizing physiological eff ects of pain. Subsequently, more detailed assessment techniques may be used to assess Elly \200\231s moto r skills, the impact of pain on performance, and environmental conditions that might help o r hinder perform- ance. For other children, the issues and ratings may be from the parent \200\231s perspective (e.g. with an infant \200\231s parents, where the issues may be feedi ng, dressing, bathing, and playing with their child). Satisfactory psychometrical propertie s were reported in a clinical trial where the COPM was used with parents/caregivers of 42 c hil- dren, ages 2 to 8, with cerebral palsy (Cusick et al., 2007), and in an interrater rel iability study with the parents of 80 children, ages 1 to 7.5, with a range of disabilities (Verkerk et al., 2006). Th e lat- ter study also found that the COPM identifi ed individua lized prob- lems that were not captured by other standardized assessment tools (Verkerk et al., 2006). Using a tool like the COPM may facilitate assessment by identifying individual, functionally relevant goals to guide intervention and provide a concurrent outcome meas- u re process. Skillfully conducted, the interview may also identify contributing factors to o ccupational performance problems that require additional assessment. It does not measure pa in, but does provide a context for assessing the impact of pain. To begin to address this issue, one study using NIRS examined the relationship between cort ical pain responses and behavioral and physiological indices (Slater et al. 2008). High cor relations were found between facial actions and cerebral blood fl ow; adding physiological indices did not improve the relationship. Although this research strategy shows promise for fi nding more accurate ways of assessing pain in infants, the fact that heart rate and oxy gen saturation had only a modest relationship with cortical blood fl ow requires further ex ploration. Th us, more work is needed to deter- mine which indices applied either in combin ation or individually will provide the most accurate refl ection of pain processing in infa nts. In addition to using standardized pain-related tools, occupational therapists can perform o bservational evaluations of the infl uence that pain may have on the infant \200\231s abili ty to engage in the environ- ment, with their caregivers, during self-care activities and d uring play (Pierce et al., 2009). For example in a home setting, formal testing can be used to evaluate function and/or development, e.g. Peabody Developmental Motor Scales-2 (Folio and Fewell, 2000), Th e Test of Playfulness (Bundy et al., 2001), and combined with it, eit her through the use of a valid scale or by using parent report or informal observation, the contribution of pain-related behaviors as potential contributors to delayed or atypical de velopment. Once the assessment is complete, goal setting with the caregivers can commence a nd treatment implemented. A fi nal example of an occupation-specifi c pain assessment tool is one which examines how pain interference impacts routine daily activities and participation. Th e Brief Pain Inven tory Pain Interference (BPI) scale (Cleeland and Ryan, 1994) is a reliable and valid scale on which children or their caregivers rate on an ordi- nal scale of 0 (no interference) to 10 (complete interference) how much their pain has interfered with general activity, mood, walk- ing ability, normal work, relations with other people, sleep, and enjoyment of life. Importantly, the BPI has been modifi ed slightly for use with youths with physical disabili ties (Tyler et al., 2002). Th e words \200\230walking ability \200\231 were changed to \200\230mobility (ability to get around) \200\231. Persons who have mobility restrictions n ot related to pain (e.g. wheel chair users) can thereby rate the impact of pain on mobility . Self-care, recreational activities, and social activities items were added to be more inc lusive of daily activities and participa- tion that could be impacted by pain. \200\230Nor mal work \200\231 was changed to \200\230school or play \200\231. Th e BPI can be helpful in determining baseline tolerance levels for specifi c occupations and participation as wel l as in evaluating outcomes before and aft er treatment (Tyler et al., 2002). In-depth disc ussion of behavioral pain assessment can be found in Section 5 of this volume (Chapters 35 \200\22341). Infants and youth One tool that assists more specifi cally with identifying occupa- tional performance issues, goal-setting, and allows for both base- line measurement and subsequent outcome evaluation, is the Canadian Occupational Performance Measure (COPM; Law et al., 20 05). Th e COPM is applicable to children of all ages; the parent or caregiver can be the in formant for children not able to speak for themselves. It consists of a semistructured inte rview and rating scale. Up to fi ve priority occupational performance issues are iden- tifi ed as intervention targets. Aft er rating an issue \200\231s importance (on a 1 to 10 scal e, 10 = extremely important), each one is rated in terms of the child \200\231s ability to perform it, and their current satisfac- tion with that level of performance, also on 1 to 1 0 scale (10 = able to do it very well; 10 = extremely satisfi ed). For example, Elly, age 6 , chose jumping rope at recess, changing into a swimsuit inde- pendently for swimming lesso ns, and printing faster at school as important occupational performance issues. With some g uidance from her mother and the occupational therapist to interpret the terms, Elly \200 \231s baseline COPM ratings (see Table 57.1). Interventions Infants Mitigating pain is vital to prevent the development of long-term chan ges in pain processing and in development associated with pain experienced in infancy. Phar macological management, along with other forms of non-pharmacological management, is covere d extensively in other chapters; thus the focus of this section will be Table 57.1 Elly \200\231s baseline COPM ratings Occupational performance issue Importance Performance Satisfaction with performance Jump rope 9 4 2 Change into swimsuit 9 5 2 Print faster 8 5 5 SECTION 8 physical interventions 594 to evaluate the effi cacy of those treatments for which occupational therapists have specia lized knowledge, including modifying the environment, positioning, feeding and play. pain management, combining sucking and ingesting oral solu- tions, whether sweetened soluti ons or the more ecologically sali- ent and potentially potent breast milk, may stimulate mu ltiple pain relieving pathways (Holsti et al., 2011). Oral sweeteners have been used for mi tigating pain in infants; however, more recent evidence suggests that they may be inducing mild sedation rather than providing analgesia (e.g. Slater et al., 2010). Some concerns hav e been noted regarding the methodology of this work (e.g. Stevens et al, 2011); therefore, these results require replication. In addition, sweeteners may have unintended negative eff ects on development when used in very immature infants over repeated events (Johnston et a l., 2002; Holsti and Grunau, 2010). For a detailed review of the use of sweet solutions, re aders are directed to Harrison et al. (Chapter 49, this volume). Further work is needed to understand the mechanisms of action of sweeteners and their eff ects long term. Occupational therapists have specifi c expertise in assessing the impact of the environment on everyday occupations (Polatajko et al., 2007). For infants undergoing procedural pain, occupational therapists can evaluate the infant \200\231s environment to ensure stimu- lati on is modifi ed to minimize pain. For example, evidence from two trials suggests that reduc ing environmental noise and lighting reduces both physiological and behavioral pain indices in preterm infants (Catelin et al., 2005; Sizun et al., 2002); however, the proce- dures e valuated in these studies were not skin-breaking, and envi- ronmental modifi cations were c ombined with other interventions. Th us, more research is needed to determine the relative contribu- tion of environmental modifi cation on pain in infants. Occupational therapists can also use positioning strategies, includ- ing swaddling and faci litated tucking for pain reduction in infants. Swaddling is a strategy whereby an infant \200\231s arms and legs are tucked inside a blanket throughout the procedure. Alternatively , facilitated tucking is done by a caregiver who contains the infant \200\231s arms and leg s with their own hands during the procedure (Figure 57.2). Breastfeeding provides reduction of pain-related behaviors in infants born full term (Shah et al., 2009), for infants born preterm who have mature feeding skills (Holsti et al., 2011 ), and for infants up to 6 months of age (Dilli et al., 2009). A clear benefi t to breast- feeding is that this treatment supports mother/infant interaction. Moreover, some have foun d breastfeeding to be more effi cacious than sucrose (Codipietro et al., 2008) and than mat ernal holding (Leite et al., 2009), reducing both behavioral and physiological pain indices . In the most recent systematic review, suffi cient evidence was found for both strategies fo r reducing pain indices in preterm infants ( \210\222 0.75: 95% confi dence interval \210 \222 1.14, \210\222 0.36; Pillai Riddell et al., 2011). Nevertheless, many of the studies evaluating these treatments did not use blind evaluators nor did they account for order eff ects in those using a cross-over design; therefore, further research is needed to determin e the benefi ts of these methods. Most recently, over fi ve blood collections, facilitated tucking did not reduce pain indices (behavioral) as eff ectively as did sucrose, but did ha ve an additive eff ect when used with sucrose; however, no diff erences in physiological in dices were found (Cignacco et al, 2012). Currently, no evidence evaluating swaddling or fac ilitated tucking for older infants is available. Th e timing of the treatment and the volume of breast milk/ feeding ingested is important f or maximizing its pain-mitigating eff ects (Holsti et al., 2011). For example, the infant m ust feed before, during and aft er the painful stimulus. If breast milk is given on its own , at least 5 ml of milk must be given in combina- tion with sucking (Upadhyay et al., 2004) . To date, no studies have compared full breastfeeding with the provision of breast milk on its own. Finally, feeding as a pain-relieving treatment should be used with caution becaus e more study is needed to examine the use of this intervention over repeated painful events , particularly in infants born preterm, and to determine the eff ects of feeding on cortica l pain processing to ensure this treatment is not acting merely as a sedative. In addition to specializing in modifying the environment and using therapeutic positioning for managing pain, occupational therapists have specialized knowledge in the development of oral motor control and feeding. Indeed, feeding is considered a pri- mary self-care relate d occupation of infants. For the purposes of Youth For youth, occupational therapists can provide a variety of treat- ments aimed at mit igating or managing pain in a variety of set- tings, such as in hospital, in clinics, and o f particular benefi t is the application of treatment in the home. Indeed, home programs ar e essential for transferring therapy skills from the clinic into the child \200\231s natura l environments. Knowing the family \200\231s goals and activities are the fi rst steps in d etermining realistic expectations for home programs. Naturally occurring routines for teach ing or reinforcing skills are sought as learning opportunities. Aft er modeling individuali zed interventions, therapists should observe the family member \200\231s skill level in per forming the therapeutic activ- ity and provide guidance as needed. Written home instruction s may increase the family \200\231s adherence with interventions. Th erapists should strive for minimal disruption of daily routines within the child \200\231s environments. Family m embers \200\231 questions and concerns must be addressed. If the occupational therapist is treating an acute problem which may persist beyond a hospital stay, referrals to community resources may be needed to ensure that follow up care is maintained (Jaff e et al., 2010). Figure 57.2 Example of a parent providing facilitated tucking. CHAPTER 57 occupational therapy 595 Energy conservation When assessment fi ndings indicate that a child experiences increased p ain with more intense or longer duration activities, or their participation in such activit ies is precluded by pain, then some collaborative problem-solving based on energy conserva- tion, joint protection, and/or ergonomic principles may be help- ful (Backman, 2011). A cr itical point is to help the child (and his/ her supporters) to apply the principles to the specifi c activities and situations that are important to them with the aim of helping to b alance activity and rest so that the child can participate as long as possible without pain and fatigue. Simply providing a list of prin- ciples and examples is generally insuffi cie nt \200\224the child needs to be encouraged to fi gure out how to apply and modify the prin ciples to situations in their own occupations. Although recommended for children (Kuchta an d Davidson, 2008), evidence in support of joint protection (including splints) and energy c onservation principles is largely limited to studies in adults (Hammond and Freeman, 2001; Steultjens et al., 2004). is another alternative. In both cases, the weight carried needs to be matched to the child \200\231s size and strength. When it comes to text- books, for those with pain, an even bet ter alternative is to avoid carrying them back and forth to school by having a set at home and another set at school. Th e occupational therapist may be able to intervene with the sc hool to justify the second set. Play/distraction Play is also a primary occupation of infants and children (Bundy, 1992). W ith respect to the pediatric pain management literature, typically, distraction is the inte rvention studied, and the context is for managing acute pain. A number of diff erent distra ction strate- gies have been studied, such as showing an infant or child a novel toy or vid eo, some being more eff ective than others. More specifi - cally, whereas showing an infant a novel toy does not appear to modify behavioral pain responses in infants and young child ren (e.g. Cramer-Berness and Friedman, 2005), parents showing a video does appear to reduce immunization pain in this same age group (Cohen et al., 2006). Th ese simple strategies re quire limited atten- tion and visual engagement of the infant or child. A comprehensive rev iew of distraction techniques by Cohen et al. can be found in Chapter 53 in this volume. Energy conservation principles include prioritizing, planning, positioning, and pacing. Pai n saps energy reserves: one may need to set clear priorities in terms of choosing the activ ities in which to engage during a day, week, or other period of time. When children feel we ll, they will engage in play and other activities that interest them (Taylor and Erlandson, 2001). Once priorities are established, plans can be made for participating in the high pr iority activities, such as ways to get there, preparing or practicing ahead of time, obtain ing appropriate equipment or assistive devices, if applicable. Positioning refers to awaren ess of body posture and positioning of the tools and equipment that support the activity or occupation. Placing frequently used items within pain-free/easy reach while working on sch ool activities, games, or craft s is one example. Setting up a computer workstation to supp ort a well-aligned pos- ture is another. Lastly, pacing refers to \200\230listening \200 \231 to how one \200\231s body responds to participation in the activity \200\224what inten sity or dura- tion is tolerable or exacerbates pain \200\224and adapting accordingly. Child ren will learn how to pace, how to adjust their involvement to accommodate their pain and t heir interest in performing an activ- ity concurrently. When the activities are related to school, gym, or social groups, there may also be a need to teach teachers, coaches, and lea ders about the intermittent nature of pain and pacing so that further pain and fatigue is p revented whenever possible. Alternatively or in addition, occupational therapists and other health care providers use t herapeutic play for managing pain in a number of settings (Bandstra et al., 2008). Play is a complex activ- ity requiring more interaction with the environment and incorpo- rating mo re complex cognitive and sensory-motor processes than simple distraction. When more engagem ent is required by the child, that is, the child actually has contact with a toy and uses i t or is immersed activity in a task, such as with virtual reality, pain is reduced (e.g. La w et al., 2011; Tanabe et al., 2002). For example, in a single-subject randomized design, M elcher-McKearnan and colleagues (2000) found that in children with burn injuries, play acti vities were more eff ective in minimizing distress behaviors, maximizing activity and fun t han were rote exercises. A more detailed discussion on the role of child life and recreatio nal thera- pies by LeBlanc and Chambers can be found in Chapter 52 in this volume. Instruction in body mechanics Back pain in youths is common (Kjaer et al., 2011). Instructi on in and rehearsal of proper body mechanics and postures that will not increase the risk o f low back injury are essential for clients experi- encing both acute and chronic back pain . Practice in using the body safely and in maximizing performance during routine tasks in n at- ural (i.e. homework, or leisure) environments is particularly impor- tant (Grangaard, 2 011; Strong, 1996). Th e child should be taught to avoid tasks or positions that do not all ow balanced posture. Joint protection principles may help prevent or reduce pain for children who have either ch ronic joint conditions, such as juve- nile arthritis, or an acute episode of pain from a mu sculoskeletal condition or injury. Joint protection principles include avoiding static post ures and using the largest/strongest joints possible to minimize stress on smaller joints ( Niedermann et al., 2011). Kuchta and Davidson (2008) off er numerous practical examples and hand- outs for children with rheumatic diseases, including strategies for managing pain (e .g. how to apply heat and cold) and modifying activities (e.g. choosing a backpack, plannin g car or plane travel, modifying gym class). Th ese and other handouts can be printed from the publisher \200\231s web site (<http://www.radcliff e-oxford.com/ rheumaticdiseases/>), and four have been included in this text as online supplementary materials. For example, ca rrying books in a messenger-style shoulder bag with the strap across the body pro- tects th e smaller joints of the hands and wrists compared to grip- ping a book bag or lunch bag. Us ing an appropriate sized backpack Adaptive equipment To assist children maintain independence in routine daily activi- ties, occupational therapists also can provide instruction for and provision of adaptive equipmen t (Howard, 2002). In particular, adaptive equipment is oft en needed for children with disa bilities and to supplement therapy. Adaptive equipment includes such things as bathtub seat s, high chairs, wheelchairs, car seats, and hydraulic lift s. Th e equipment is used to pre vent abnormal move- ment patterns, muscle tone, positioning, and postures or support SECTION 8 physical interventions 596 more independent function. Adaptive equipment also prevents or facilitates correct position ing when the child is not being han- dled. Moreover, the equipment can be used to reinforce postures and movements introduced in treatment which can then be used in home programs. Mo tor, sensory, perceptual, cognitive, and psy- chosocial development are also promoted with its use. Equipment should be restricted in its use as much as possible so as to allow the c hild \200\231s free exploration of the environment. Furthermore, any equipment should be mo nitored regularly to ensure the child \200\231s and family \200\231s needs and therapeutic goals are met (Aubert, 2008). to cover the isolette with a blanket to shade the infant \200\231s eyes. She explains how l owered lighting and noise can help stabilize the baby. She also describes how promoting fl exed positioning will support the infant \200\231s motor development, and keep the baby cal m. She shows them how they can work with their nurse to use facili- tated tucking for provi ding treatment during blood tests. She begins educating the parents regarding infant behavi oral cues which can be signs of stress and stability and how these signs are integrated int o the unit standardized pain assessment scale so they can evaluate how well their facilitat ed tucking is working. Th e following day at the school, Patricia receives a referral to see Ben, a 13-year-old st udent who has mild spastic hemiplegia cerebral palsy, but no cognitive impairment. Ben comp lains of daily, 30 to 90 min episodes of mild-to-moderate intensity leg pain exacerbated by prolonged ambulation, fatigue, and situ- ational stress. Th e pain interferes mildly with mobility, stress management, and sleep as indicated by his importance ratings on the COPM o f 8, 7, and 9 respectively. Ben rates his performance as 6 (mobility), 6 (stress management ), and 4 (sleep), moderate satisfaction in these areas. Relaxation strategies A variety of methods for inducing a relaxation response are avail- ab le for managing pain. Progressive muscle relaxation (e.g. Barsky et al., 2010) or autogenic training (Payne, 2000), whereby clients are instructed in use of silently repeating seven standardized relaxa- tion themes, are methods by which children can self-manage pain (for f urther details see Engel, 2011). Th ese strategies should be inte- grated into the youth \200\231s daily routine, and the occupational therapist can help determine when the timing of these strategies might be most eff ective. Ben received eight autogenic relaxation training sessions in his home for stress management and sleep diffi culties. Importantly, this training does not require gross motor movement or muscle contractions, both problematic for Ben. Each 45 min weekly ses- sion consisted of information on stress and relaxation rehearsal. Ben was also given a relaxation tape to gu ide him through prac- tice at home and school. Pain intensity (0 equals \200\230no pain \200\231; 10 equals \200\230pain as bad as it could be \200\231) and tension levels (0 = \200\230com- pletely relaxed \200\231; 10 equals \200\230uptight/tense as you can be \200 \231) were rated in a diary pre and post relaxation practice. Ben was weaned from relaxatio n tape use, and integration of relaxation and stress management strategies into daily routi nes emphasized. He was also instructed in strategies to promote restful sleep. Ben \200\231 s family was instructed to encourage and praise his relaxation practice. Ben reported moder ate improvement in reducing pain interfer- ence, especially with stress management and slee p. Conclusion Pain in infants and children interferes with their ability to engage in essentia l interactions with caregivers, with the acquisition of devel- opmental milestones, and wit h participation in activities related to self-care, leisure, play, school, and work. Using occupation-based theoretical models, such as the CMOP-E and the Occupational Th erapy Pract ice Framework: Domain and Process, provides a foun- dation for the provision of occupationa l therapy services to infants and youth. Th rough an iterative and continuous problem-solvi ng process, occupational therapists provide standardized assessment of the infant \200\231s or youth \200\231s performance problems and along with the integration of the child \200 \231s environmental context, develop and moni- tor the eff ects of interventions. Occupatio nal therapists use specifi c treatment strategies such as feeding, positioning, splinting, and instructing in energy conservation and joint protection strategies, and the use of adap tive equipment. While some of the eff ects of these strategies have been evaluated rigorous ly in infants and chil- dren, as happens oft en in other areas of pediatric rehabilitation, some techniques have been applied based solely upon research con- ducted in adults. Th us, much more research is needed on assessing the benefi ts of occupational therapy interventi ons for mitigating both acute and chronic pain in children. Patricia \200\231s work in these two cases was guided by a practice process of assessment, intervention, and outcome evaluation; her clinical reasoning was informed by theory. By ass essing the inter- action between the infant \200\231s developmental stage and the NICU envi ronment, with an occupation focus, Patricia \200\231s recommen- dations enable the parents to engage with their baby (parenting role, nurturing occupation). Drawing on a specifi c th eory related to infant development, Patricia \200\231s intervention plan minimizes threats to the infant \200\231s future occupational performance. Into Ben \200\231s routine at home and school, Patricia integrated spe- cifi c pain-relievi ng modalities thus facilitating his occupational roles. An outcome measure at baseline allo wed for later outcome evaluation, showing progress toward achieving Ben \200\231s goals. Case example Patricia is the consulting occupational therapist for the local hos- pital neonatal intensi ve care unit (NICU) 2 days per week and for a community school 3 days per week. At the hosp ital, a new infant is admitted overnight who has a signifi cant brain bleed and will requir e ongoing blood tests. Th e nurse asked that Patricia help teach the parents ways in which they can modify the infant \200\231s environment to support the infant \200\231s developmen t and to help with pain management. 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