OT A to Z: G is for Grading

G proved a little tougher to select a word! Thanks to @kirstyes and @clissa89 for their suggestions of goals, goal attainment scaling, and groups. But I opted to use @clissa89's suggestions of "grading" as the word to represent the OT "G," as grading is a concept that is truly inherent in OT practice regardless of the client population or setting.

What is grading? Grading is the modification of an activity to support the client's performance. Grading of activities occurs in the therapeutic process when a client is working toward a specific goal. Therefore, activities may be modified - or graded - for the purpose of making them easier or more difficult, depending on the goal. Activities can be graded in a variety of ways. A few examples include increasing or decreasing the complexity or difficulty of a task by changing the amount of steps required to complete it, the amount of time given to complete a task may be altered, or the amount of cues or assistance given to the person may be changed. Grading of activities is done for therapeutic purposes and can only be done with consideration of the client's abilities.

However, the precursor to grading of an activity is a process termed activity analysis. Activity analysis is when an OT analyzes all of the complexity inherent in an activity in order to know how and in what ways to grade it. This would include things such as space requirements, the objects that must be used to complete the activity, the social or cultural requirements of the activity, the required actions to complete the activity, and the body structures and functions needed for the activity.

To illustrate this, let's think about the seemingly simple activity of making a peanut butter sandwich. As part of activity analysis we would consider demands or the requirements of the activity. This will include things like:

1. Formulate a plan to make the sandwich
2. Sequence the activity
3. The properties of the objects needed to make the sandwich such as the supplies (bread which is pliable, peanut butter which offers resistance, the knife which requires grasp)
4. Physically gather the supplies
5. Manipulate the objects - open the jar lid, open the bag of bread, hold the knife
6. Position the objects for performance of the task
7. Complete each step of the process including: get the bread out of the bag, open the jar, use the knife to get an appropriate amount of peanut butter out of the jar, put the peanut butter on the bread, spread the peanut butter on the bread without tearing the bread, put the bread together with appropriate pressure, place the sandwich on a plate, close the peanut butter jar, close the bread, wash the knife, clean the work area

First, I think we begin to recognize how even "simple" are actually complex, multi-step tasks which require multiple processes to be working effectively in parallel. After analyzing the requirements to make a peanut butter sandwich, it becomes easy to imagine how any challenge in cognitive skills, visual skills, perceptual skills, coordination, sensation, motor planning can make this activity difficult.

So how would an OT grade this activity? Depending on the goals being addressed, the OT may choose to have the supplies out already or may have the person retrieve everything from the cabinet. The OT may provide minimal or maximum cues for the planning and sequencing of the task. The OT may choose to add more items to the sandwich, or make a deli sandwich with vegetables and spread that will require numerous additional steps to complete.

In other examples of grading, if a person is having difficulty completing their morning self-care routine due to debilitation, the OT may select portions of the activity for the person to complete so they are able to do as much as possible. For instance, rather than having a person retrieve their dressing and grooming items in the room, the OT may "set-up" the activity so his or her available energy may be utilized in performing the dressing and grooming activity. As the person's endurance and safety improve, the OT may choose to grade the activity to make it more challenging, by having the person retrieve the needed items prior to dressing.

Another example of grading may be when a person is working on cognitive skills such as problem solving by developing a budget for a trip to the grocery store. To grade the activity, the number of items may be increased or decreased, the quantities of items may be changed to increase or decrease the complexity of calculations, coupons may be applied, etc.

The possibilities of grading an activity are multi-faceted, but it must be done with regard to the client's goals. OTs, because of their education and experience, have the expertise to assess the ability of the client as well as the requirements of the activity in order to achieve a therapeutic outcome.