The Jo Benetton’s theoretical-methodological framework in occupational therapy with children: a scoping review

Abstract

Introduction

The Brazilian theoretical-methodological framework constructed by Jô Benetton, now called the Dynamic Occupational Therapy Method, supports the practice of occupational therapy with different populations, including children. There is a vast production of articles that require systematization to understand their scope.

Objective

Summarize and describe productions that use this framework with children and identify gaps in the literature.

Methodology

Scope review, with selection of studies in libraries and digital databases (VHL; CAPES Periodical Portal, SciELO), websites (Google Scholar) and search tools for national journals in the area; manual search in CETO Magazine, and complementary strategies. Peer-reviewed articles, gray literature, without deadline, in Portuguese or English were included. Descriptive data were analyzed using simple statistics and qualitative data received thematic analysis.

Results

2,152 studies were identified, 106 selected after reading the title/abstract, 56 of which were duplicates. Of the 50 studies read in full, 26 were for final analysis. The majority were characterized by experience reports published in Revista CETO, in the 2000s, in Portuguese. The five identified themes explain the studies' adherence to the Occupational Therapy Paradigm, analyzing the needs of children situationally, with free and dynamic interventions centered on the triadic relationship, including relevant people from the children's daily lives, and with the still timid use of activity analysis by the children.

Conclusion

This study contributes to giving visibility to a body of theoretical-practical knowledge built in the Brazilian reality, congruent with the main evidence that aims to increase the engagement and participation of children with different problems in everyday activities.

Keywords:
Occupational Therapy; Childhood; Childcare; Professional Practice; Social Participation

Resumo

Introdução

O referencial teórico-metodológico brasileiro construído por Jô Benetton, atualmente chamado de Método Terapia Ocupacional Dinâmica, sustenta a prática de terapia ocupacional com diversas populações, inclusive crianças. Há vasta produção de artigos que demandam sistematização para compreender seu escopo.

Objetivo

Resumir e descrever as produções que utilizam este referencial com crianças e identificar lacunas na literatura.

Metodologia

Revisão de escopo, com seleção de estudos em bibliotecas e bases digitais (BVS; Portal de Periódicos CAPES, SciELO), sites (Google Acadêmico) e ferramentas de buscas de revistas nacionais da área; busca manual na Revista CETO, e estratégias complementares. Foram incluídos artigos revisados ​​por pares, literatura cinzenta, sem data limite, em português ou inglês. Dados descritivos foram analisados por estatística simples e dados qualitativos receberam análise temática.

Resultados

Identificaram-se 2.152 estudos, selecionados 106 após leitura de título/resumo, sendo 56 duplicados. Dos 50 estudos lidos na íntegra, 26 foram para análise final. A maioria caracterizou-se por relatos de experiência publicados na Revista CETO, na década de 2000, em português. Os cinco temas identificados explicitam adesão dos estudos ao Paradigma da Terapia Ocupacional, analisando as necessidades das crianças situacionalmente, com intervenções livres e dinâmicas centradas na relação triádica, incluindo pessoas relevantes do cotidiano das crianças, e com uso ainda tímido da análise de atividades pelas crianças.

Conclusão

Este estudo contribui para dar visibilidade a um corpo de conhecimento teórico-prático construído na realidade brasileira congruente com as principais evidências que visam ampliar o engajamento e a participação de crianças com diferentes problemáticas nas atividades do cotidiano.

Palavras-chave:
Terapia Ocupacional; Infância; Cuidado da Criança; Prática Profissional; Participação Social

Introduction

Occupational therapy has been moving towards a strong paradigmatic change, with repercussions in the field of childhood (Novak & Honan, 2019). Interventions more focused on the search for the normativity of the body and child development are giving way to interventions based on everyday reality (Kreider et al., 2014; Calheiros et al., 2019; Novak & Honan, 2019; Fernandes et al., 2019; Ferreira et al., 2022; O’Brien & Kuhaneck, 2019). Recent reviews in the field of childhood indicate that to improve engagement and social participation, occupational therapy interventions that encompass work with the family, in the child's real context, involving school and community, are those with the best evidence (Guerzoni et al., 2008; Brooks & Bannigan, 2018; O’Brien & Kuhaneck, 2019.

In Brazil, Jô Benetton, since the 1970s, has been pointing out risks of practices aimed at social normativity instead of promoting transformations that allow people to participate in society while respecting diversities and singularities (Marcolino et al., 2020).

This author has been conducting the oldest research venture in Brazilian occupational therapy, which culminated in the Dynamic Occupational Therapy Method (DOTM), a theoretical-methodological framework built putting the practice as an object of study (Benetton, 1994; Marcolino et al.,). Her own practice (mainly with adults) was placed under investigation and, after 1980, when she founded, in partnership with Sonia Ferrari, an institution for teaching, research and assistance in occupational therapy, CETO¹ , the practice of its students and collaborators was also included in this process – expanding the investigation to multiple fields of practice and target populations (Benetton et al., 2021).

Marcolino & Fantinatti (2014) present three phases in the construction of the theoretical-methodological framework proposed by Jô Benetton. The first phase includes publications from 1984 to 1993, heavily influenced by psychoanalysis. In the second phase, from 1994 to 1999, concepts and procedures were outlined, in addition to the organization of the DOTM. In the third phase, starting in 2000, the DOTM was finalized, placing it as belonging to the occupational therapy paradigm (Marcolino et al., 2020).

Interventions in the DOTM occur through continuous and non-sequential processes (Araújo, 2022). To understand the needs and desires of the target person, a continuous descriptive and analytical process is developed, made up of aspects relating to the target person, the other people in their environment and information coming from the broad perception of the occupational therapist in the triadic relationship, called the construction of situational diagnostic (Marcolino et al., 2020; Benetton et al., 2021). Interventions in the DOTM are carried out in a dynamic process that seeks to establish and manage the action and reaction movements of the three terms of the triadic relationship (occupational therapist, target person and activities), in a setting that supports such a relationship. The educational action is central to the therapeutic function, supported by the positive transference of the occupational therapist to establish the person`s affection and desire to learn and develop (Benetton, 1994; Benetton et al., 2021).

To evaluate the intervention, dialogical processes of construction of new meanings are used – which seek to transform the usually established meanings that the person cannot, does not do, is not able to do – based on the involvement of the target person in the analysis of their situation, activities and decision-making. The Associative Path technique is the most representative example of this process, from which associations are triggered by the analysis of the activities carried out, grouped by the target person, allowing dialogue and reflection to recognize themselves and their skills, capabilities, and limits. The construction of new meanings occurs through the establishment of a space of historicity, in which the target subject can tell their story and envision their future, no longer tied to normative social expectations (Benetton, 1994; Mello et al., 2020). In DOTM, a continuous process of expanding health, everyday life and social insertion is envisaged. The expansion of health spaces results from experimentation in the triadic relationship and unique qualification of what is healthy and brings well-being, which becomes part of their everyday lives, expanding their participation and social insertion. When necessary, fourth terms (people from the target person's social world) are associated with the triadic relationship, so that the person can be recognized by others in their real potentials and limits (Benetton et al., 2021).

The DOTM, as a theoretical-methodological framework for occupational therapy practice, can be used with any target population (Benetton et al., 2021). Children are one of the populations that most require occupational therapy interventions due to various problems that interfere with occupations and social participation (Novak & Honan, 2019). Considering that the literature in the area calls for the overcoming of practices exclusively focused on normative standards, which is consistent with the framework constructed by Jô Benetton, this article proposes to summarize and describe the bibliographical production in occupational therapy that uses Jô Benetton's framework in interventions with children, in addition to identifying questions for future research.

Methodology

A scoping review was carried out (Peters et al., 2020), a model suitable for little explored themes and which allows the use of studies with different methodological designs, including gray literature. It is characterized by an iterative process of selecting relevant studies, which allows refining the most appropriate databases and sources to answer the research question (Peters et al., 2020).

This study followed the methodological guidelines of Peters et al. (2020) and PRISMA-ScR, an extension of PRISMA for scoping reviews (Tricco et al., 2018).

Review questions

Main question: What has been produced in Brazilian occupational therapy using the theoretical-methodological framework constructed by Jô Benetton in interventions with children? As this is a first review on the topic, the emphasis will be on analyzing texts that describe practices carried out in Brazil, by Brazilian occupational therapists, even if published in other countries or with foreign co-authors.

Secondary questions: 1. What is the scope of applicability of this framework with children? 2. How are the different continuous and non-sequential DOTM processes specific to childcare? 3. What could be potential research questions to expand knowledge in DOTM?

Inclusion criteria

The inclusion criteria include bibliographic publications from published or gray literature that explicitly present the use of Jô Benetton's theoretical-methodological framework discussing occupational therapy with children (0-11 years), in any context, published in: articles from various types (theoretical, theoretical-practical, primary research, case/experience reports), peer-reviewed; theses and dissertations; books and book chapters; publications in annals; editorials; and unpublished texts; without deadline, in Portuguese or English. The exclusion criteria cover videos and posts on social media.

Search strategy

This review used a variety of search strategies, considering that: (1) the development of the theoretical-methodological framework proposed by Jô Benetton took place over 50 years and mostly with the adult population (Marcolino & Fantinatti, 2014); and (2) most of her work and that of her collaborators and students was published in Revista CETO (not indexed in databases) or in a period in which scientific journals in the area in Brazil were not indexed in databases.

Therefore, for the selection of studies, in the period between May and June 2022, searches were carried out independently in the virtual libraries: Biblioteca Virtual em Saúde (BVS) and CAPES Periodicals Portal, and in the SciELO-Brasil database, using the strings: “occupational therapy AND childhood OR child”, “occupational therapy AND Benetton”, “Jô Benetton AND child OR childhood”, “psychodynamic occupational therapy AND childhood OR child” and “dynamic occupational therapy method” and “dynamic occupational therapy method AND childhood OR child” and their respective terms in English. As this is a review on a topic little explored in research, it was decided to leave the descriptors broad, and work with a greater number of studies in the screening and selection stage.

For searches in Brazilian journals, the same strings were used in the internal search tools on each website. The following periodicals were selected, with online editions: Revista de Terapia Ocupacional da Universidade de São Paulo (2002 to 2022), Cadernos de Terapia Ocupacional da UFSCar, from 2017, Brazilian Journal of Occupational Therapy (1990 to 2022) and Brazilian Interinstitutional Journal of Occupational Therapy (2017 to 2022). As the CETO magazine website does not have a search tool, a manual search was carried out in its 13 editions (1995 to 2012).

To expand the search and access studies also belonging to gray literature, the same strings were used, including the first ten pages of Google Scholar results (in tests, carried out, some strings did not exceed five pages. To iteratively complement the search: a) after identifying the authors in the previously described selection, we searched for bibliographical production in their CVs, on the Lattes Platform²; b) in November 2022, an electronic message was also sent to CETO, requesting various publications aimed at children.

The search results were organized in a spreadsheet. All procedures were documented.

Study selection

Search terms were identified in titles, abstracts, and keywords. In case of doubt, the studies were read in full. The final consolidation of the sample took place in discussion meetings with the research team. The selection process and the number of articles selected are found in the results.

Data extraction

Data were extracted using a spreadsheet containing: title, authors, date of publication, location/service, Brazilian geopolitical region, type of study, characterization of participants, objectives. Qualitative data were organized using NVivo software (version 12.7.0).

Data analysis

Simple numerical and statistical descriptions were used for descriptive data and thematic analysis for qualitative data, carried out independently. After skimming the material, analysis was carried out section by section, seeking to identify similar cores of meaning. Similar excerpts were aggregated into emerging categories (Minayo, 2014). This preliminary analysis occurred inductively. Subsequently, the emerging themes were deductively organized in light of the DOTM processes, in addition to identifying potential questions for future studies.

Results

Descriptive results

Table 1 presents the number of studies from each search strategy, highlighting the origin of gray literature. Figure 1 shows the flowchart of the path taken to select and include studies, following PRISMA-ScR (Tricco et al., 2018). In this figure, you can see a large number of excluded studies (2046 studies) after reading the title and abstract, which is explained by the scope of the descriptors used. The removal of 24 studies after full reading is justified because they are not the reference in focus, even though they contain elements that could be associated with it in their titles and/or abstracts.

Table 1
Search strategies and number of studies included in the final analysis.

Search strategies	Number of studies identified	Number of studies for final analysis
CAPES Periodical Portal	307	1
BVS	958	1
Academic Google	590	2*
Scielo Brasil	64	0
Revista de Terapia Ocupacional da Universidade de São Paulo	62	0
Cadernos de Terapia Ocupacional da UFSCar/Cadernos Brasileiros de Terapia Ocupacional	62	3
Revista Interinstitucional Brasileira de Terapia Ocupacional	85	1
Revista CETO	14	11
Request made to the CETO	5	5*
Authors’ CV	5	2
TOTAL	2.152	26

• ^*
  Identification of gray literature. Source: Elaborated by the authors.

Figure 1
Flowchart of search and inclusion of studies. Source: Prepared by the authors.

The first study that deals with the framework constructed by Jô Benetton with children dates back to 1993 (Benetton, 1993). Table 2 presents the characterization of the selected studies and Figure 2 shows the distribution of studies over time.

Table 2
Characterization of the studies analyzed.

Author/Year	Type of study	Participants and location of the intervention
Benetton (1993)	Experience report	Two children (no ages specified) with a medical diagnosis of Autism3 , without specification of the place of care
Almeida (1995)	Experience report	A group of children (no number specified), in a public Children’s Psychiatric Day Hospital, in São Paulo, SP.
Montanari (1995)	Experience report	Individual care for “[…] hyperactive children with learning disorders, behavioral disorders and mental disabilities” (Montanari, 1995, p. 56), in a private practice, in Belo Horizonte, MG. It does not specify the number of children and ages.
Matsukura (1997)	Case study	An eight-year-old child, medically diagnosed with Autism, attended at the Physiotherapy and Occupational Therapy Service of the Federal University of São Carlos, SP.
Amaro et al. (1998)	Experience report	A seven-year-old child, born prematurely, attended at a public educational institution in Mauá, SP.
Matsukura (2001)	Case study	Five-year-old child, medically diagnosed with Autism, without specifying place of care.
Takatori et al. (2001)	Case study	A six-year-old child, medically diagnosed with Hoffmann Syndrome, attended at a public rehabilitation unit in São Paulo, SP.
Benetton et al. (2000)	Theoretical-practical study	11-year-old child without specified medical diagnosis monitored at CETO, in São Paulo, SP.
Takatori et al. (2004)	Theoretical-practical study	Hospitalized children, without specifying age, monitored in different hospital contexts.
Pellegrini (2007)	Theoretical-practical study	Three children of different ages (five, eight, ten-years-old), with children and adolescent mental health problems, without specifying the location of care.
Pellegrini (2008)	Theoretical-practical study	Two six-year-old children, without specifying medical diagnosis or location of interventions.
Takatori & Oshiro (2009)	Case study	Five-year-old child, medically diagnosed with Prader-Willi Syndrome, monitored in home care, in São Paulo, SP.
Hernandes (2010)	Case study	An 11-year-old child, medically diagnosed with Asperger’s Syndrome, monitored in home care, in Marília, SP.
Takatori (2010a)	Theoretical-practical study	Children with physical disabilities of different ages (four, six and eight years-old), attended at a clinic linked to a public educational institution, in São Paulo, SP.
Takatori (2010b)	Multiple case study	Four children:
		1. Child aged three years and seven months, medically diagnosed with Cerebral Palsy (CP)
		2. Eight-year-old child, medically diagnosed with spastic hemiparesis resulting from a stroke.
		3. Six-year-old child, medically diagnosed with CP.
		4. Seven-year-old child, medically diagnosed with Duchenne Progressive Muscular Dystrophy.
		All attended at a teaching clinic at a public higher education institution.
Martini (2010)	Experience report	Four-year-old child without specified medical diagnosis, using a wheelchair and with motor difficulties, attended at a public institution. No city reference.
Sousa (2010)	Theoretical-practical study	Child aged two years and four months, without specifying medical diagnosis.
Coelho (2012)	Experience report	Five-year-old child medically diagnosed with CP, receiving home care, in São Paulo, SP.
Santarosa (2012)	Experience report	Two-year-old child, medically diagnosed with CP, in a public rehabilitation institution, without specifying city.
Takatori (2012)	Multiple case study	Four children:
		1. Child aged three years and seven months, medically diagnosed with CP.
		2. Eight-year-old child, medically diagnosed with spastic hemiparesis resulting from a stroke.
		3. Six-year-old child, medically diagnosed with CP.
		4. Seven-year-old child, medically diagnosed with Duchenne Progressive Muscular Dystrophy.
		All attended at a teaching clinic at a public higher education institution.
Varela & Martins (2015)	Experience report	Eight-year-old child, medically diagnosed with CP, without specifying place of care.
Varela et al. (2019)	Experience report	Five-year-old child, medically diagnosed with Rett Syndrome, with complex communication needs, without specifying location of care.
Varela et al. (2020)	Experience report	Four-year-old child, medically diagnosed with Precocious Epileptic Encephalopathy, with complex communication needs, cared for at home and in a private office.
Cestari et al. (2022)	Experience report	Six-year-old child, medically diagnosed with ASD, seen in a private office in Matão, SP.
Mastropietro et al. (2022)	Experience report	Seven-year-old child, without specifying a medical diagnosis, also monitored in psychiatry and psychology, seen in a private office, in Ribeirão Preto, SP.
Varela et al. (2022)	Experience report	Eight-year-old child, medically diagnosed with ASD, seen in a private office.

• Source: Elaborated by the authors.

Figure 2
Number of Published Studies × Publication Periods⁴ . Source: Elaborated by the authors.

Of the 26 studies, 25 were published in Portuguese, and one of them in English (Takatori & Oshiro, 2009). Six studies, all with case study or multiple case study methodologies⁵ , they come from academic research, resulting from master’s (Matsukura, 1997, 2001; Takatori et al., 2001; Hernandes, 2010) and doctoral (Takatori, 2010b, 2012) research. Eleven studies are characterized as experience/case reports⁶ . Since 2000, theoretical practical studies have already referred to the DOTM.

Six studies were carried out with children with neurological injuries (Coelho, 2012; Santarosa, 2012; Takatori, 2012; Varela & Martins, 2015; Varela et al., 2019, 2020), six with children with ASD (Benetton, 1993; Matsukura, 1997, 2001; Takatori, 2010b); two with hospitalized children (Almeida, 1995; Takatori et al., 2004) and one with a child with a genetic disease (Takatori & Oshiro, 2009). The ages of the children ranged from two years of the youngest child (Santarosa, 2012) to 11 years of the oldest (Hernandes, 2010).

The interventions were carried out in multiple spaces, seven of which were in a private clinic/office (Montanari, 1995; Benetton et al., 2000; Pellegrini, 2007; Varela et al., 2020, 2022; Cestari et al., 2022; Mastropietro et al., 2022), eight in public services (Almeida, 1995; Matsukura, 1997, 2001; Takatori et al., 2001, 2004; Takatori, 2010a, 2010b, 2012), four in homes (Takatori & Oshiro, 2009; Hernandes, 2010; Coelho, 2012; Varela et al., 2020) and three in unspecified institutions (Benetton, 1993; Martini, 2010; Santarosa, 2012). The majority describe services in the capital of São Paulo, in individual sessions, and two of them describe group services (Almeida, 1995; Varela & Martins, 2015).

Qualitative Results

Treating children under the Occupational Therapy Paradigm

Studies that explicitly discuss the paradigmatic issue of occupational therapy practices with children oppose training focused on the exclusive care of deficits. Benetton (1993), Almeida (1995), Montanari (1995) and Amaro et al. (1998) present such reflections, discussing the need to abandon a normative practice focused on caring for deficits, such as adequate movement to carry out activities. The authors advocate the construction of a practice aimed at discovering what children can do, their emotions and potential, as can be seen: “[...] creation of new experiences, where the child can review their strengths” (Almeida, 1995, p. 34).

[...] when talking about special children, the term physical rehabilitation was always associated [...] I felt distant from this form of action, as I perceived the search to experience emotions and experiences that exist in each child [...] without a single concern with adequate movement when carrying out activities. (Montanari, 1995, p. 56).

Takatori et al. (2001), Takatori & Oshiro (2009), Takatori (2010a, 2010b), Sousa (2010), Martini (2010), Coelho (2012), Santarosa (2012) and Varela & Martins (2015), studies belonging to the third phase of construction of the DOTM, now more clearly outline practices centered on the paradigm in which the DOTM is inserted. Illness, deficits, and limitations are part of children's reality, but we seek to expand health and inclusion in social spaces. According to Takatori & Oshiro (2009), understanding the medical diagnosis is an important step, however, not the one that will define the form of treatment, as there is a risk of understanding the child only based on the deficits. Furthermore, there is a risk of rigidifying care aimed at these deficits – and at standardization and cure – by only seeing the absences, explicit in the speech of the medical team and family members. Studies discuss the risk of imprisoning the child and not offering a space for doing, despite the child's disability or difficulty (Takatori et al., 2001; Coelho, 2012).

[...] the normalization of tone, muscle gain, range of movement are aspects present in the therapeutic process [...], but they are not the end point in occupational therapy. We want the patient to do things and that, in these “doings”, something personal can be present and be recognized by the other, providing their inclusion in social spaces (Takatori et al., 2001, p. 104).

Understanding children’s needs based on situation analysis: situational diagnostic

The studies discuss the importance of knowing the child, their needs and desires, based on their everyday life, including the activities and people who participate in their lives, and also the observations of the occupational therapist (Martini, 2010; Varela et al., 2022). The first publication of the DOTM with children using situational diagnostic was by Amaro et al. (1998). For the situational diagnostic, the occupational therapist seeks to discover the place that children occupy or do not occupy, what they like to do, what they already do, or do not do in their everyday lives (Takatori & Oshiro, 2009; Sousa, 2010; Mastropietro et al., 2022; Cestari et al., 2022; Varela & Martins, 2015). Mastropietro et al. (2022) discuss that situational diagnosis is marked by freedom, being constructed without the use of previously established protocols and assessments, considering the desires and needs of each child in a unique way.

Based on the parents’ report and these initial observations, the elements for composing an initial situational diagnostic were gathered, including the impact of communication difficulties on Sara's everyday life, her interests and perception of an attentive and interested look (Varela et al., 2019, p. 129).

The triadic relationship with children: outlining concepts and discussing their dynamic functioning

The triadic relationship in productions with children was referenced for the first time in Pellegrini (2007), although the therapeutic relationship has been discussed in previous studies (Benetton, 1993; Almeida, 1995; Montanari, 1995; Matsukura, 1997, 2001; Amaro et al., 1998). As a relationship composed of three terms, the studies provide information about the definitions of each term and their characteristics, sometimes conceptually, sometimes indicating actions of the terms in the triadic relationship.

Target person

As previously presented, the target person is always understood in its singularity. However, the articles point out that the child who usually arrives for occupational therapy finds themselves excluded from part of everyday activities, being immersed only in care activities (Martini, 2010; Pellegrini, 2007, 2008; Sousa, 2010). Furthermore, they are generally recognized for what they failed to achieve in terms of their global development: not speaking or walking within the expected time, not being able to play or interact with others, for example (Martini, 2010, p. 28) (Pellegrini, 2007, 2008.

Occupational therapist

There is a series of knowledge that the occupational therapist is called upon to possess: theoretical knowledge of occupational therapy (Pellegrini, 2007; Sousa, 2010), child development and various interdisciplinary techniques (Takatori, 2010a, 2012). Varela & Martins (2015) exemplify this idea by stating that, to care for children with CP, it is important to seek training to promote the care that this health condition demands, citing: Bobath Neuroevolutionary Method, Sensory Integration, Brunnstrom, Béziers and theories of cognitive development.

The occupational therapist is presented as responsible for managing the relationship so that new experiences and learning can happen, and as someone available to carry out activities and play, helping to identify the strengths and limits of each child and in the construction of brands that will bring about changes in everyday life (Takatori et al., 2001; Pellegrini, 2008; Mastropietro et al., 2022; Cestari et al., 2022).

Conceptually, Benetton et al. (2000) highlight the psychoeducational character of occupational therapy and describe that educational action “[...] is fundamentally characterized by considering culture, social aspects, the individual, limitations, difficulties [...]” (Benetton et al., 2000, p. 5). It is through it that one can awaken the desire to try and learn more (Pellegrini, 2007, 2008; Hernandes, 2010; Martini, 2010; Coelho, 2012; Santarosa, 2012; Takatori, 2010a, 2010b; Mastropietro et al., 2022).

Furthermore, Coelho (2012) and Takatori (2012) highlight that the child is in the process of establishing their physical and mental abilities. Therefore, it is important to have a wide repertoire of techniques for carrying out activities to support the construction of teaching and learning processes that become significant in the child's life, and that can be rescued with or without the presence of an occupational therapist. Martini (2010) discusses that the occupational therapist moves actively, teaches and encourages the child, looking for spaces for learning to happen, helps when the child has not yet acquired their own resources or specific skills, finding strengths that can be transported to other activities in their everyday lives.

To this end, both Benetton et al. (2000) as Takatori et al. (2001) discuss the relevance of developing a insightful and investigative observation to understand the way in which each child does or doesn´t do activities, to offer them experimentations that allow them to discover their way of doing things. In this sense, Benetton (1993) describes the importance of allowing the child to conduct their occupational therapy, to experience being who they are and how they relate. To do this, it is important for the occupational therapist to learn to deal with their own silence and allow the child to lead, reveal and present their desire. This author discusses that the occupational therapist needs to have an “imperative affect” to break the limits of a body that does not speak or show itself, describing it as necessary for any occupational therapist who wants and needs to overcome the barrier imposed by the target person, the “[...] silence of their own desires, desires, anticipated knowledge, anxiety and anguish” (Benetton, 1993, p. 4).

Activities

Regarding activities, the first studies with children came from the transition period between the first and second phases of DOTM development, with understanding in psychoanalysis. Benetton (1993), Almeida (1995), Montanari (1995) and Amaro et al. (1998) discuss the use of activities as an expressive resource, a possibility of maintaining external reality, increasing self-knowledge and enabling the understanding of the child's psychodynamics (Matsukura, 1997; Amaro et al., 1998).

With the theoretical-conceptual development of the DOTM, the use of the concept of activities as an instrument becomes explicit in the studies, “[...] activities, the instrument of our actions, are indicated, suggested, proposed to be experienced as a creative experience” (Takatori, 2010a, p. 48). Takatori (2010a, 2010b) states that playing is a necessary area for a child's development and that it enables the experience of creative and spontaneous living, referring to the health process sought in occupational therapy – with reflections in dialogue with psychoanalyst Donald Winnicott (Takatori, 2010a).

The activities, considered as an instrument, were always described in their multiplicity: singing, drawing, painting, and eating. However, after publications by Pellegrini (2007, 2008), playing began to be defined as “[...] the instrument ACTIVITIES of occupational therapy in the childhood clinic” (Pellegrini, 2008, p. 41). Later articles (Sousa, 2010; Martini, 2010; Coelho, 2012; Santarosa, 2012) use this definition, although they continue to present activities other than playing:

[...] one of their favorite activities [...] is time to eat. [...] such activity became part of the sessions, whether talking about it, or having a snack at home with their favorite foods (Coelho, 2012, p. 55).

The discussion about activities is intrinsically associated with the concept of setting. All studies present a description of a setting, which normally refers to the occupational therapy room where “[...] nothing is neutral. It has objects that must be to the liking of the therapist who uses it” (Pellegrini, 2007, p. 42). For Pellegrini (2008) and Takatori (2010a), the setting must be attractive and arouse curiosity; contain diverse, simple materials, such as graphic materials and toys that can be explored in different ways. Coelho (2012, p. 42) discusses that the setting is a “[...] space for doing, creating and producing [...]”. For Sousa (2010, p. 42), in their home care, the setting is a space “[...] from the house to the world [...]”.

The fourth terms in the therapeutic process: family, teams… social

All studies emphasize the need to work with the different actors in the child's daily life. Although the articles report the inclusion of family members, visits to schools and the use of groups, they do not mention or define the concept of the fourth term which, in the DOTM, is the concept representing the social, always in composition with the triadic relationship.

Montanari (1995), Martini (2010) and Coelho (2012) discuss that it is not just about giving guidance, but about involving these actors in the process, to think about the child's development as well as the expansion of their everyday lives. As Sousa (2010, p. 43) explains, “[…] the therapist sometimes has the child as one of the vertices, and sometimes moves towards the parents, siblings, domestic helpers, [...]”.

[...] the adults who lived with him got to know his way of doing things and his acquisitions: his parents started to be with him, doing their own activities, without having to do his activities together; the psychologist no longer worked on the “right” way for him to do things; the doctor, after visiting the occupational therapist’s office, started to look differently at his capabilities; and the teacher changed times – more time for what was difficult to learn and less time for what was already known (Mastropietro et al., 2022, p. 1233).

Regarding group work, only two studies discuss this type of service. Almeida (1995) reports the creation of a group to receive children in a Day Hospital, after spending the weekend at home, promoting expression, communication and interpersonal relationships. Varela & Martins (2015) indicate the child's participation in a group of activities given the need to promote their interpersonal relationships, which were being experienced with difficulties in the school context.

Analyzing activities with children: Associative Path

Only three studies (Hernandes, 2010; Mastropietro et al., 2022; Cestari et al., 2022) describe carrying out activity analysis using the Associative Path technique. Hernandes (2010) presents the use of the technique as an element for carrying out situational diagnostic. Mastropietro et al. (2022) and Cestari et al. (2022) describe cases in which, after many experiments in the triadic relationship, the child can have experiences with multiple activities and materials to construct new meanings about themselves, their tastes, and difficulties.

In Cestari et al. (2022), the focus is the presentation of the Associative Path process. The groupings made by the child were the starting point for dialogue with the occupational therapist who, with each meaning given by the child, asked questions and brought back memories and associations, seeking to expand their reflections, allowing them to gain more awareness about themselves in their everyday life.

[...] “when I did these things I was worried about all the monuments, there are times when I get really worried about some things and I stay confused for a long time” (Group 1); “[...] this group is because they were the first books I started making” (Group 2); “[...] these activities were to face my fear of rain and because I learned about plants and space” (Group 3); and “[...] they were alone, and it is not good to be alone” (Group 4) (Cestari et al., 2022, p. 2).

[...] the “sticky” activities could be associated with the activity of being “stuck to his little fingers”, opening space for F. to become aware that he needed help to get out of the “sticky” and that this also had impacts on their relationships (Mastropietro et al., 2022, p. 1235).

Discussion

Over a period of 30 years (1993-2022), the 26 studies identified offer evidence of the DOTM construction process. Productions prior to 1994 bring psychodynamic understandings with greater strength. After this period, studies begin to explicitly present concepts and processes that make up the DOTM (Marcolino & Fantinatti, 2014). However, the understanding of children in their uniqueness, in their ability to do and learn, always remained present, seeking to overcome practices aimed at the normativity of the body and expected child development. All the studies analyzed state that treatment focused on deficits can tighten understandings about the child in their context, in addition to missing opportunities to promote, as well as document, changes in the real lives of the children, as highlighted by Kreider et al. (2014), Calheiros et al. (2019) and Ferreira et al. (2022).

This set of values ​​and practices is organized in what Jô Benetton identified as the paradigm of occupational therapy (Benetton et al., 2021), or, as Novak & Honan (2019) call it, a contemporary paradigmatic perspective. In the same direction, O’Brien & Kuhaneck (2019) discuss the relevance of occupation-based practice models to support therapeutic reasoning seeking engagement in what is important for the child and family.

The studies analyzed highlighted the understanding of children as persons with needs and desires, building the situational diagnostic with multiple information, in a free and non-protocolar way. Although assessment instruments are not the first choice in DOTM – as evidenced in this review – they can be used based on identified needs, as well as other reference structures or care approaches (Benetton et al., 2021). Although occupation-based practice models develop specific instruments, O’Brien & Kuhaneck (2019) emphasize that assessments must be sensitive to children's needs, which corroborates our findings.

The occupational therapy intervention in DOTM is centered on the triadic relationship (Benetton, 1994). The findings of this review explain both conceptual elements of the triadic relationship and its dynamic functioning, and are in line with the theoretical propositions of the DOTM (Benetton, 1994). However, the concept of activities, as an instrument (means) of intervention in the multiple possibilities of experimentation, seems to have been limited by Pellegrini (2007, 2008) only to playing – a conceptual question for future investigations.

Regarding the dynamic functioning of the triadic relationship, our results highlight educational actions as central to the DOTM, anchored in the understanding that children are in the process of learning and developing capabilities and skills. Such educational actions are managed so that the triadic relationship remains in motion, being triggered from activities and games carried out by/with the child, whether chosen freely and spontaneously, or even suggested by the therapist, ensuring the child´s desire and engagement in doing. Practices with an educational focus that seek to offer the “right challenge” to children, mainly by solving problems generated by the child themselves, optimize pleasure and expand the possibilities of success (Novak & Honan, 2019).

Furthermore, evidence indicates that free play not guided by the occupational therapist to stimulate or achieve certain treatment purposes presents itself as a significant activity for the child, providing satisfaction, joy and facilitating social engagement (Kuhaneck et al., 2019). In our review, Benetton (1993) highlights the need for occupational therapists to learn to silence their desires, especially in relation to expected social norms, so that children can be themselves and relate in their own way. Novak & Honan (2019) show that interventions that begin child-centered promote motivation and become relevant to them.

Another aspect with robust evidence is the centrality of the family in this process (Novak & Honan, 2019). The knowledge of parents (and also teachers and caregivers) about the child and their preferences, in addition to the ample time spent with them, can be crucial for designing interventions from a collaborative perspective (Calheiros et al., 2019; Fernandes et al., 2019; Novak & Honan, 2019; Romagnoli et al., 2019; Beisbier & Cahill, 2021; Lage et al., 2022; Ferreira et al., 2022). Some of the studies in this review show that the activities carried out by the child go beyond the occupational therapy setting, gaining social space. They also indicate that everyday activities require shared solutions with the people who live with the child so that they can be carried out more easily or to expand the possibilities of carrying out new activities.

It is not just about performing repetitions of exercises or activities beyond the therapy space, whether at home or at school (Novak & Honan, 2019), but about encouraging activities that the child needs or likes to do, so that they can be done in their everyday life. In this sense, the people who live with them and who are important to them need to know their abilities, capabilities and limits so that they can also build new meanings about their possibilities. Such findings are in line with evidence about the importance of building interventions in the child's real life (Guerzoni et al., 2008; Brooks & Bannigan, 2018; Romagnoli et al., 2019; Novak & Honan, 2019; Fernandes et al., 2019; Beisbier & Cahill, 2021).

Regarding the possibilities for constructing meanings by children, only the most recent studies began to incorporate the description of Associative Path. The possibility of experiencing multiple activities based on the child's desires and needs seems to have allowed them to make associations between aspects of their lives, including symptoms, with transformations that occurred in occupational therapy. Research in our field has also been expanding methodological possibilities to give visibility to children's perspectives, but it´s important to consider that many children treated in occupational therapy have severe motor and sensory conditions with communication difficulties (Rosenberg & Erez, 2022).

Questions for future research

Although we do not wish to limit the possibilities of investigation based on the evidence offered by this review, future research may aim to: (a) build instruments that favor the identification of needs and the effectiveness of interventions supported by the DOTM; (b) deepen the relationship between multiple activities and theoretical production about playing; (c) analyze the applicability of the DOTM with children in different sociocultural contexts; (d) analyze the potential results of practices supported by this framework directly with children and other relevant people; (e) expand understanding of the possibilities of using groups with children under this framework; (f) understand the use of the Associative Path technique or other communication processes to construct meanings or evaluate the intervention.

Final Considerations

This review made it possible to map and describe Brazilian occupational therapy productions using the theoretical-methodological framework constructed by Jô Benetton in interventions with children. 26 studies distributed over the last 30 years were identified, carried out with children of different ages, with different medical and situational conditions, in public and private treatment contexts.

The children were understood in their uniqueness. The interventions were concerned with overcoming the focus on expected social normativity, focusing on (a) the child's engagement and desire in what they do; (b) in the child's perspectives and meaning; (c) in the construction of shared solutions with the people around them; (d) in the concreteness of the child's real life. Aspects congruent with the main evidence of interventions that aim to increase participation in activities for children with different conditions.

The study made it possible to give visibility to a body of theoretical-practical knowledge aligned with the occupational therapy paradigm, allowing a glimpse into its process regarding concepts that still require greater clarity. The possibility of making the methodological procedures of the scoping review more flexible allowed us to give visibility to a body of knowledge that has not yet been fully integrated into the academic research culture. Thus, a rich material of evidence based on practice and suggestions for future research to be explored with more rigorous methodologies to produce more robust evidence is presented.

In this way, we hope to contribute to the practice of occupational therapy with children by systematizing aspects of a Brazilian framework that considers children and their families in their uniqueness and situationality, through dynamic intervention and evaluation processes that seek to expand health spaces and social participation.

• 1
  Center for studies in Occupational Therapy, currently Center for Specialities in Occupational Therapy.
• 2
  It is a system developed by the Conselho Nacional de Desenvolvimento Científico e Tecnológico do Brasil, which integrates a database of CVs of researchers, research groups and institutions.
• 3
  The medical diagnosis is described according to the publication, understanding that there are other current classifications.
• 4
  Benetton et al. production was not included (s/d).
• 5
  Such research can be quantitative or qualitative, presents greater methodological rigor, analyzes a complex situation and requires approval from a research ethics committee (Alpi & Evans, 2019).
• 6
  This type of study describes some fact, individual or group experience about a lived situation; it must follow ethical standards, but approval from a research ethics committee is not required (Alpi & Evans, 2019).
• How to cite: Cestari, L. M. Q., Lopes, K. P., Bertolozzi, R. C. D., & Marcolino, T. Q. (2024). The Jo Benetton’s theoretical-methodological framework in occupational therapy with children: a scoping review. Cadernos Brasileiros de Terapia Ocupacional, 32, e3532. https://doi.org/10.1590/2526-8910.ctoAO270835322

• Funding Source

  This work was carried out with support from Pesquisa do Estado de São Paulo (FAPESP) – Process n. 21/14571-6.

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Edited by

Section editor

Profa. Dra. Késia Maria Maximiano de Melo

Publication Dates

• Publication in this collection
  09 Sept 2024
• Date of issue
  2024

History

• Received
  22 Feb 2023
• Reviewed
  13 Mar 2023
• Accepted
  05 May 2024