The Effectiveness of Client-Centered Occupational Therapy Intervention for Caregivers of Children With Cerebral Palsy
Phase: NA
Conditions: Caregiver, Occupational Balance, Occupational Performance, Occupational Satisfaction
Sponsor: Selin Başak Arslaner

The Effectiveness of Client-Centered Occupational Therapy Intervention for Caregivers 
of Children With Cerebral Palsy 
05.05.2025 
Introduction 
Cerebral palsy (CP) is defined as a lifelong but non-progressive neurological disorder resulting 
from a lesion in the immature brain (Mutch et al., 1992). The primary motor impairments seen 
in children with CP are frequently accompanied by sensory, perceptual, cognitive, and 
communicative limitations. These deficits in sensory, perceptual, and motor systems, which 
directly affect the individual's performance components, significantly limit the child's 
independence in activities of daily living (ADLs) and their occupational performance. These 
difficulties in participation necessitate a constant caregiver for the child to maintain their daily 
routines (Patel et al., 2020). 
Although caregiving is a natural part of being a parent, this role takes on a different dimension 
in the presence of functional limitations and a continuous need for support in ADLs. This 
intensive, lifelong process can cause parents to postpone their personal needs and dedicate less 
time to their interests. This situation makes it difficult for caregivers to maintain their daily life 
roles, thereby negatively affecting their occupational balance (Ahanotu et al., 2018; Hayles et 
al., 2015; Liu et al., 2023). 
Occupational balance is defined as having the right amount of occupation and sufficient variety 
among occupations of different characteristics within an individual's occupational pattern, and 
it is influenced by each individual's subjective experience. It consists of three dimensions: 
occupational areas, occupations with different characteristics, and time use (Wagman et al., 
2012). This balance is achieved through the harmonious interaction of these three dimensions 
(Duer et al., 2015). When this balance is disrupted, individuals may experience difficulties in 
organizing and maintaining their daily activities, which may in turn lead to problems in 
occupational performance (Kwon & Kim, 2023).  
Occupational performance is defined as a multidimensional concept that encompasses the 
ability to choose, organize, and perform meaningful activities appropriate for an individual's 
age and gender, as well as the satisfaction derived from these activities. Occupational 
satisfaction, on the other hand, refers to the level of fulfillment an individual derives from daily 
activities (Baum & Law, 1997). Consequently, both occupational performance issues and low 

levels of occupational satisfaction are reported among caregivers of children with CP (Ahmadi 
Kahjoogh et al., 2019). 
All these limitations and disruptions in occupational balance, performance, and satisfaction 
create an increasingly growing caregiver burden in the lives of caregivers. Caregiver burden is 
defined as the state of physical, psychological, and social pressure and burnout experienced by 
parents due to the combination of the rigorous follow-up of rehabilitation processes, the child's 
health problems, household chores, and out-of-home responsibilities (Ahanotu et al., 2018; 
Hayles et al., 2015; Liu et al., 2023). Difficulties in maintaining ADLs and the increase in 
caregiver burden can form a mutually reinforcing process. Therefore, it is crucial to support 
caregivers not only from a psychosocial perspective but also in the context of organizing and 
maintaining ADLs and the satisfaction derived from these activities. 
When intervention studies aimed at caregivers of children with neurodevelopmental conditions 
such as autism spectrum disorder, Down syndrome, and CP are examined, it is seen that various 
approaches have been developed to support caregivers' ADLs, psychosocial well-being, and 
caregiver burden (Al-Farsi et al., 2022; Watling et al., 2023). Particularly in conditions requiring 
long-term care, such as CP, it is reported that caregivers may struggle to maintain balance in 
their ADLs, and this situation is associated with their quality of life. In this context, Botella et 
al. (2025), in their occupational therapy intervention study, reported that caregivers achieved a 
more balanced distribution among activities of different characteristics in their lives, and this 
was associated with increased levels of occupational balance (Prieto-Botella et al., 2025). 
Kahjoogh et al. (2019), on the other hand, emphasized that occupation-based occupational 
therapy interventions improved caregivers' skills in organizing and maintaining activities, 
thereby increasing their occupational performance. In the same study, it was also shown that 
the intervention contributed to the strengthening of occupational satisfaction by increasing the 
fulfillment caregivers derived from daily activities (Ahmadi Kahjoogh et al., 2019). 
Furthermore, client-centered occupational therapy interventions are also reported to have 
reducing effects on the caregiver burden arising from the caregiving process (Kwon & Kim, 
2023; Prieto-Botella et al., 2025; Qaracheh et al., 2025). 
A review of the literature on intervention studies for caregivers of children with CP reveals the 
application of various intervention types, such as lifestyle redesign-based approaches, 
psychosocial support programs, education and counseling interventions, and programs aimed 
at improving stress management and coping skills (Dambi et al., 2016; Irwin et al., 2019; Sheng 

et al., 2019). However, it is noteworthy that a significant portion of these interventions is 
focused on psychosocial support and education, while client-centered and occupation-focused 
interventions directly addressing the organization of daily occupations remain limited. In 
addition, interventions explicitly structured according to the three dimensions of occupational 
balance are scarce, and existing approaches often do not systematically integrate these 
dimensions into intervention design. Accordingly, there is a need for studies examining the 
effects of client-centered occupational therapy interventions on occupational balance, 
occupational performance, occupational satisfaction, and caregiver burden among caregivers of 
children with CP. Therefore, this study aims to examine the effectiveness of a client-centered 
occupational therapy intervention, systematically structured around occupational areas, 
occupations with different characteristics, and time use, on occupational balance, occupational 
performance, occupational satisfaction, and caregiver burden among caregivers of children with 
CP. 
Method 
Study Design 
This study was a single-center, two-arm, single-blind, parallel group randomized controlled trial 
conducted among caregivers of children with CP. The study protocol was approved by local 
ethics committee. Written informed consent was obtained from all participants prior to the 
study. The study was performed between October 2024 and March 2025. 
Participants 
The sample size was calculated based on a power analysis conducted with 80% power and a 
5% error rate as 34. A total of 54 caregivers were initially assessed for eligibility; however, 12 
were excluded based on the exclusion criteria or other reasons. Consequently, 42 caregivers 
were initially included in the study. The inclusion criteria for caregivers were: (1) being the 
primary caregiver of a child with diplegic CP, (2) having access to a device with internet 
connectivity, (3) being capable of following verbal and written instructions, (4) volunteering to 
participate in the study, (5) scoring ≤5 in the Performance and Satisfaction dimensions of the 
Canadian Occupational Performance Measure (COPM) and/or scoring ≤ 16 on the 
Occupational Balance Questionnaire (OBQ11), and (6) scoring ≥ 21 on the Burden Interview 
(BI). Caregivers were excluded if they: (1) had previously received professional services or 
interventions specifically designed for caregivers, or (2) had a neurological, psychiatric, or 
chronic condition, such as multiple sclerosis, schizophrenia, or diabetes; and (3) were using 

medications (e.g., sedatives, antidepressants, or potent analgesics) that could interfere with their 
functional performance or study participation. 
The inclusion criteria for children were: (1) being between the ages of 4 and 18 years, (2) 
classification at Level IV or above on the Gross Motor Function Classification System 
(GMFCS), (3) Level III or above on the Manual Ability Classification System (MACS), (4) 
Level II or above on the Communication Function Classification System (CFCS), and (5) Level 
III or above on the Eating and Drinking Ability Classification System (EDACS). Exclusion 
criteria for children included: (1) having an additional neurological diagnosis alongside CP, 
such as hydrocephalus or epilepsy. 
The 48 eligible caregivers were randomly assigned to the intervention (n = 24) or control group 
(n = 24). Fourteen participants (7 from each group) did not complete the study, resulting in a 
final sample of 34 caregivers (17 per group). Detailed participant flow is presented in Figure 1. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
Figure 1. CONSORT Flow Diagram 
 
 
Procedure 
The intervention group received a client-centered occupational therapy program consisting of 
eight weekly individual sessions, each lasting an average of 45 minutes. The first four sessions 
were conducted online and focused on theoretical content, whereas the last four sessions were 
carried out face-to-face at the Occupational Therapy Department of a public university, 
emphasizing practical application. The control group received a single-session intervention 
focused on awareness of occupational balance and life patterns, with a mean duration of 45 
minutes. Participants in the control group did not receive ongoing follow-up during the 
Assessed for eligibility (n= 54) 
Excluded (n= 12) 
   Not meeting inclusion criteria (n=9) 
   Declined to participate (n=2) 
   Other reasons (n=1) 
Analysed  (n= 17) 
 Excluded from analysis (give reasons) (n= 3) 
 
Withdrawal of consent (n=2) 
 
Failed to attend the post-intervention 
assessment (n=1) 
 
Allocated to control (n=21) 
 Received allocated intervention (n= 20) 
 Did not receive allocated intervention (n= 4 ) 
 
Caregiver illness (n=3) 
 
 
Health issues of the child (n=1) 
 
 
Analysed  (n= 17) 
 Excluded from analysis (give reasons) (n=3) 
 
Withdrawal of consent (n=1) 
 
Failed to attend the post-intervention 
assessment (n=2) 
 
Allocated to intervention group (n= 21) 
 Received allocated intervention (n= 20) 
 Did not receive allocated intervention (give 
reasons) (n= 4 ) 
 
Technical difficulties (Online phase) 
(n=1) 
 
Transportation issues (Face-to-face 
phase) (n=3) 
Allocation 
Analysis 
Randomized (n= 42) 
Enrollment 

intervention period; however, they were offered access to the intervention after the completion 
of the study. 
All outcome assessments (pre-test and post-test) were conducted by Author 2 who was not 
involved in delivering the intervention and was blinded to group allocation. Assessments were 
conducted through face-to-face interviews. Before randomization, all participants completed 
the Sociodemographic Information Form, OBQ11-T, COPM, and BI. Following baseline 
assessments, participants were randomly assigned to the intervention and control groups using 
a computer-generated randomization sequence. Assessments were conducted at baseline (pre-
intervention) and immediately after the 8-week intervention period (post-intervention). 
 
Measurements 
Sociodemographic Information Form 
Sociodemographic data pertaining to the caregivers and children were collected using a form 
developed by the researchers. Age, gender, type of CP, level of GMFCS, MACS, CFCS, and 
EDACS were recorded for children with CP. Age, gender, marital status, educational status, 
employment status, chronic diseases, and place of residence were recorded for all caregivers. 
Occupational Balance Questionnaire 11-T (OBQ11-T) 
Wagman and Ha˚kansson (2014) developed the OBQ, a scale that measures self-rated 
occupational balance. The questionnaire had good internal consistency (Cronbach’s alpha 
0.936) and adequate test–retest reliability (Spearman’s rho¼0.926 for total score) in healthy 
adults. The OBQ was designed to analyze both at-item level and as a summed total score 
(Wagman, & Ha˚kansson, 2014). Ha˚kansson et al. (2020) reported that the OBQ had good 
reliability (0.92), model fit, and measurement invariance across age and gender groups. Test–
retest reliability of the OBQ11-T was 0.922, and Cronbach’s alpha for OBQ11-T total score 
was 0.785. The scale consists of 11 items scored on a 4-point scale from ‘strongly disagree’ 
(scored 0) to ‘strongly agree’ (scored 3). The total score is obtained by summing the individual 
items and ranges from 0 to 33. Higher scores indicate higher occupational balance. 
Canadian Occupational Performance Measure (COPM) 
It is a semi-structured scale that helps to identify problematic areas of performance experienced 
by individuals and to measure their perceived occupational performance and occupational 

satisfaction. This scale assesses the level of performance of self-care, productivity and leisure 
occupations and satisfaction with these performances as perceived by the individual. The 
importance of each occupation is measured on a 10-point scale (1 = not at all important, 
10 = very important) according to the individual’s perception. In the next step, the individual is 
asked to select five occupations that he/she considers most important and to rate separately 
his/her performance (1 = could not do it, 10 = could do it very well) and satisfaction (1 = not 
satisfied, 10 = very satisfied) in these occupations.  Cronbach’s alpha for COPM Turkish total 
score was 0.95.  
Burden Interview (BI) 
The scale was developed by Zarit, Reever, and Bach-Peterson in 1980 to assess the difficulties 
experienced by caregivers (93). It consists of 22 items, each scored on a scale from 0 to 4, 
yielding a total score ranging from 0 to 88. Scores between 0–22 indicate little or no caregiving 
burden, 21–40 indicate a moderate burden, 41–60 indicate a severe burden, and 61–88 indicate 
an excessive caregiving burden. Cronbach’s alpha reliability coefficient was reported as 0.95. 
Occupational Balance And Life Patterns Awareness Intervention 
The control group received a single-session intervention focused on occupational balance and 
life pattern awareness, with a mean duration of 45 minutes. The session consisted of a brief 
psychoeducational presentation covering the concept of occupational balance, the distribution 
of ADLs, and the role of balanced routines in well-being. Participants were encouraged to 
reflect on their own daily routines; however, no individualized intervention strategies, goal 
setting, or structured follow-up were implemented. 
Client-Centered Occupatinal Therapy Intervention 
The intervention group received an 8-week, client-centered occupational therapy program 
consisting of one 45-minute individual session per week. The online sessions were delivered 
via web-based platforms (Google Meet, Zoom, and WhatsApp) according to participant 
preference, whereas face-to-face sessions took place at the Occupational Therapy Department 
of a public university.  
The intervention's design was theoretically grounded in Wagman and Håkansson’s three 
dimensions of occupational balance and adapted from Rini and Provident’s lifestyle balance 
program. Although goals were individualized based on the COPM results, methodological 
standardization and intervention fidelity were rigorously maintained; the same therapist 

administered all individual sessions using a structured protocol. In the intervention group, each 
new session began with feedback regarding time-use patterns since the previous session. 
Intervention fidelity was supported through the use of a standardized session framework and 
consistent session delivery across participants. Detailed session contents are presented in Table 
1. 
Session 1: Introduction and Awareness 
Participants were informed about the overall structure and goals of the intervention program. 
Key concepts, including occupational balance, occupational performance, occupational 
satisfaction, and caregiver burden, were introduced in a simplified and individualized manner. 
Participants were encouraged to reflect on their daily routines and share their experiences. 
Initial awareness of imbalances in daily occupations was facilitated through guided discussion. 
Session 2: Occupational Areas 
The concepts of self-care, productivity, and leisure were explained. Based on COPM results, 
participants identified problematic occupational areas in their daily lives. Habit formation 
strategies (e.g., habit stacking, small habit approach) were introduced. The client-centered 
occupational monitoring form was introduced, and participants were asked to begin tracking 
their daily activities. 
Session 3: Occupations with Different Characteristics 
Participants explored different types of occupations, including physical, mental, social, and 
rest-related activities. Energy conservation techniques and joint protection strategies were 
introduced for physically demanding activities, while coping strategies were discussed for 
mentally demanding tasks. Participants generated individualized lists of activities under each 
category and developed a personalized “occupational menu” to support variety in daily 
occupations. 
Session 4: Time Use 
Participants were introduced to time management principles, including identifying time-
consuming activities and inefficient routines. The use of the client-centered occupational 
monitoring form was structured in this session, and participants were asked to systematically 
record their daily activities and satisfaction levels. Based on these records, participants created 
a daily or weekly timeline to better understand their time use patterns. 

Sessions 5–7: Monitoring of Client-Centered Occupational Therapy Intervention 
During these sessions, participants implemented individualized weekly plans developed in 
earlier sessions. The client-centered occupational monitoring form was reviewed in each 
session to monitor adherence, evaluate time use patterns, and identify barriers. Problem-solving 
strategies were applied collaboratively to address difficulties in implementation. Alternative 
plans were developed when needed to support sustainability and feasibility. 
Session 8: Termination and Future Planning 
The final session focused on reviewing progress, goal attainment, and changes in daily 
occupational patterns. Participants reflected on gains in occupational balance, performance, and 
satisfaction. Strategies for maintaining newly established habits were discussed, and 
participants were provided with personalized plans to support long-term sustainability. 
 
Table 1. Client-Centered Intervention Program 
Session 
Theme 
Content 
1 
Introduction 
and 
Awareness 
-Information about the overall process of the intervention program 
-A summary of the concepts of occupational balance, occupational 
performance, occupational satisfaction, and caregiver burden 
- Open discussion and sharing of feelings to clarify concepts  
2 
Occupational Areas 
-Definition of self-care, productivity and leisure occupations 
-Habit stacking strategies of occupational areas 
-Use of tiny habits method 
- Task to practice the small habits method on preferred activities in COPM 
-Open discussion and sharing of feelings to clarify concepts  
   
3 
Occupations 
of 
Different 
Characteristics 
-Joint protection and energy conservation tecniques for physical occupations 
-Coping with stress management for mental occupations 
-Individual list for social occupations 
-Brainstorming of active and passive recreational activities for resting 
occupations 
- Introduction of the client-centered occupational monitoring form for daily 
activity tracking. 
-Creation of an ‘’Occupational Menu’’ 
-Open discussion and sharing of feelings to clarify concepts  
4 
Time Use 
-Time consumer 
-5 steps of time management 
-Time planning according to COPM results 

-Creation of a timeline 
-Structured use of the client-centered occupational monitoring form 
-Open discussion and sharing of feelings to clarify concepts  
5-7 
Monitoring 
of 
Client-Centered 
Occupational 
Therapy 
Intervention 
-Monitoring implementation of the intervention program 
-Review and feedback based on the client-centered occupational monitoring 
form. 
-Alternative plans for participants who struggle with implementation 
8 
Termination 
and 
Future Planning 
- Review of gains and goal attainment 
-Receiving feedback 
 
Statistical Analysis 
Data were analyzed with IBM SPSS (Statistical Package for Social Science) version 26.0 
statistical software package program. The demographic data were analyzed using descriptive 
statistics. Normality of the data was analyzed using Shapiro-Wilk test. In the analysis of the 
pre-randomization OBQ11-T, COPM, and BI assessment results, the data were found to be 
statistically normally distributed, and parametric tests were preferred (p>0.05). An independent 
samples t-test was used to compare the groups in terms of the pre-intervention and post-
intervention results. A paired samples t-test was used to compare the pre-intervention and post-
intervention results of the control and intervention groups according to the OBQ11-T, COPM, 
and BI. A statistically significant difference was found between the COPM-Performance and 
COPM-Satisfaction dimensions in the initial assessment results of the control and intervention 
groups. Therefore, Analysis of Covariance (ANCOVA) was used to evaluate the effect of the 
intervention by controlling the differences between the pre-intervention and post-intervention 
results of the groups. Differences between the groups in terms of categorical variables were 
determined using the Fisher Exact test. Effect size was calculated using the Cohen's d test. In 
effect size (Cohen's d value) calculations, significance was achieved by calculating values less 
than 0.2 as a weak effect size, values between 0.5-0.8 as a medium effect size, and values 
greater than 0.8 as a high effect size. Statistical significance was accepted as p<0.05.