Cognitive Orientation to daily Occupational Performance (CO-OP) for children and adolescents

Last update: 8 Dec 2016

Cognitive Orientation to daily Occupational Performance (CO-OP) is used to help children and adolescents with cerebral palsy to achieve their goals1-3
The young person chooses goals that are important to them. The therapist supports the child to discover their own strategies to achieve the goals.

Who is it for?

CO-OP may be suitable for children and adolescents with cerebral palsy if they have sufficient language skills, cognitive ability and attention to:

  • Identify up to three goals they wish to achieve
  • Work with a therapist to develop strategies
  • Communicate the strategies they have developed
  • Persevere with practicing their goals

Examples of goals include improving handwriting, tying shoelaces or using a knife and fork. Leisure goals include riding a bike or playing guitar. CO-OP is a client-centred, individualised intervention.

Consider CO-OP for children and adolescents with these characteristics:

Type of cerebral palsy : Bilateral cerebral palsy, Diplegia, Hemiplegia, Quadriplegia, Triplegia, Unilateral cerebral palsy

More information about cerebral palsy is contained in the What is CP? section.


Gross Motor Function Classification System (GMFCS) – classifies severity of mobility difficulties of children and adolescents with CP.

Walks without limitations in the home and community, climbs stairs and can run and jump, difficulties with speed and coordination.

Walks with limitations, difficulties with long distances and uneven surfaces, uses a railing for climbing stairs, limited running and jumping.

Walks using a hand-held mobility device such as crutches or walking frame, may use wheeled mobility for long distances.

Usually relies on wheeled mobility with assistance, may use powered mobility, usually needs special seating and assistance with transfers.

Usually transported in a manual wheelchair, requires specialised seating and full assistance for transfers.


Manual Ability Classification System (MACS) – classifies severity of upper limb impairment: how children with cerebral palsy use their hands to handle objects in daily activities in the home, school, and community settings.

MACS Level I
Handles objects easily and successfully.

Handles most objects but with somewhat reduced quality and/or speed of achievement.

Handles objects with difficulty; needs help to prepare and/or modify activities.

Handles a limited selection of easily managed objects in adapted situations.

MACS Level V
Does not handle objects and has severely limited ability to perform even simple actions.

Communication ability : CFCS I, CFCS II

Communication Function Classification System (CFCS) – classifies severity of everyday communication of people with cerebral palsy.

CFCS Level I
Effective Sender and Receiver with unfamiliar and familiar partners.

Effective but slower paced Sender and/or Receiver with unfamiliar and/or familiar partners.

Effective Sender and Receiver with familiar partners.

Inconsistent Sender and/or Receiver with familiar partners.

CFCS Level V
Seldom effective Sender and Receiver even with familiar partners.

Movement disorder : Ataxia, Choreoathetosis, Dystonia, Hypotonia, Spasticity

More information about movement disorders can be found on our websites.

Intellectual ability : No intellectual disability, Mild intellectual disability

A person’s thinking skills – ability to understand ideas, learn and solve problems. People with intellectual disability have difficulty with intellectual functioning which may influence learning, communication, social and daily living skills. Intellectual disability may be mild to very severe.

This intervention is facilitated by a CO-OP trained allied health professional – usually an occupational therapist or physiotherapist. The therapist will use their skills to guide the child to set up their own goals for intervention. They will then support them to form their own strategies to complete these activities.

Cerebral Palsy Alliance offers a service where our occupational therapists and physiotherapists can facilitate a child or adolescent achieve their goals and help a family decide whether CO-OP is the right intervention for them.

Find a Cerebral Palsy Alliance service

Fees will apply for an assessment and intervention with a CO-OP trained therapist. The cost will depend on the service provider. Check with the provider to see if there will be additional costs to prepare a home program, write reports and travel to the sessions. Depending on the child’s goals, there may also be equipment costs.

Ask the service provider if you are eligible for funding to assist with fees and equipment. People with a disability living in Australia may also be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

The child will attend approximately 12 sessions with a therapist, once a week, for one hour. During the sessions, the therapist will work with the client to set goals, educate them and their family about using CO-OP, guide the child to develop strategies and practice goals, and provide feedback on their progress.

The therapist will usually recommend that the child practice their CO-OP strategies and goal activities between sessions - at home, school and in the community.

More about CO-OP

There are three main parts of CO-OP:

  1. Strategy - children and adolescents learn a problem-solving strategy called Goal-Plan-Do-Check
  2. Practice - they practice their goal activities using Goal-Plan-Do-Check and the problem-solving strategies they have developed for themselves
  3. Mastery – they work out how to use the strategies in different situations and then apply them to learn new skills and master different goals1-4
When interviewed, parents of children with cerebral palsy participating in a CO-OP program said they thought their children were highly motivated by developing their own goals and deciding on the strategies3. Many also felt that the opportunity for intensive practice of the goals and the chance to develop strategies which could be used in the future were important aspects.


There are two types of assessment which are necessary for undertaking CO-OP.

During the initial consultation, the therapist will guide the child and family to set goals for the intervention and observe the child completing each goal to decide how to target the intervention. Assessments to guide goal setting include:

  • Canadian Occupational Performance Measure (COPM) – helps people identify goals to work on and measures change on everyday activities that people have identified as a problem
  • Paediatric Activity Card Sort (PACS)5 – used to assist children aged five years old to 14 years old to identify their own goals for therapy
  • Perceived Efficacy and Goal Setting (PEGS)6 – used to assist children with disabilities who are aged six years old to nine years to identify their own goals for therapy

The second type of assessment is used to measure the outcome of CO-OP and ensure it has been effective. The occupational therapist, together with the child and family, will decide on the most suitable measures. Options include:

  • Canadian Occupational Performance Measure (COPM) – helps people identify goals to work on and measures change on everyday activities that people have identified as a problem.
  • Performance Quality Rating Scale (PQRS) – a therapist rates the change in the child’s ability to complete their goals, usually by assessing video recordings of the child completing the goal activity before and after their intervention7.

Best available research evidence

We searched the allied health, psychological and medical literature to find research evaluating the effects of CO-OP for children and adolescents with cerebral palsy.
We aimed to find the best available research evaluating whether CO-OP helps children to achieve self-identified functional motor goals.

We found one pilot randomised controlled trial4 which compared the outcomes of a group of children with cerebral palsy who participated in CO-OP with a group who received the same amount of typical occupational therapy (mostly directed at practicing goals).

The aim of the study was to see if CO-OP was feasible to use with children with cerebral palsy aged from seven years old to 12 years old. The children in the study had hemiplegia or spastic diplegia (one child with ataxia), were at GMFCS Levels I to III, had normal intelligence and had sufficient language to communicate with the therapist and be understood in therapy.

The study4 found that CO-OP was feasible for this group of children with cerebral palsy. Both of the interventions helped children achieve their goals. Children who participated in CO-OP were able to transfer the problem-solving strategies they learned to achieve other goals after the study.

Overall, the quality of evidence for CO-OP is low as there is only one small study4 suggesting advantages of CO-OP over typical occupational therapy. Children and adolescents with cerebral palsy and their families are encouraged to explore CO-OP with a qualified therapist to see if it matches their needs and goals. However, they should feel confident participating in an equally intensive goal directed program if a CO-OP qualified therapist is not available, or if CO-OP is not the best choice because of difficulties with attention, cognition, or language.

Date of literature searches: July 2016

This topic was completed by researchers from Cerebral Palsy Alliance in collaboration with Michelle Jackman, Occupational Therapist, John Hunter Children’s Hospital.

  1. Polatajko, H., & Mandich, A. (2004). Enabling Occupation in Children: The Cognitive Orientation to daily Occupational Performance (CO-OP) Approach. Ottawa, Ontario: CAOT Publications ACE. Purchase online
  2. Missiuna, C., Mandich, A. D., Polatajko, H. J., & Malloy-Miller, T. (2001). Cognitive Orientation to daily Occupational Performance (CO-OP): Part I – Theoretical foundations. Physical & Occupational Therapy in Pediatrics, 20(2-3), 69-81. See abstract
  3. Jackman, M., Novak, I., Lannin, N., & Froude, E. (2016). Parents’ experience of undertaking an intensive cognitive orientation to daily occupational performance (CO-OP) group for children with cerebral palsy. Disability & Rehabilitation, 1-7. doi: 10.1080/09638288.2016.1179350 See abstract
  4. Cameron, D., Craig, T., Edwards, B., Missiuna, C., Schwellnus, H., & Polatajko, H. J. (2016). Cognitive Orientation to daily Occupational Performance (CO-OP): A new approach for children with cerebral palsy. Physical and Occupational Therapy in Pediatrics, 1-16. doi: 10.1080/01942638.2016.1185500 See abstract
  5. Mandich, A., Polatajko, H., Miller, L., & Baum, C. (2004). The Pediatric Activity Card Sort (PACS). Ontario, Canada: CAOT Publications ACE.
  6. Missiuna, C., Pollock, N., Law, M., Walter, S., & Cavey, N. (2006). Examination of the Perceived Efficacy and Goal Setting System (PEGS) with children with disabilities, their parents, and teachers. American Journal of Occupational Therapy, 60(2), 204-214. See abstract
  7. Martini, R., Rios, J., Polatajko, H., Wolf, T., & McEwen, S. (2015). The performance quality rating scale (PQRS): Reliability, convergent validity, and internal responsiveness for two scoring systems. Disability and Rehabilitation, 37(3), 231-238. doi: 10.3109/09638288.2014.913702 See abstract