The study, led by Maria Lönn of Halmstad University together with colleagues from Halmstad University, Lund University and Swedish child and adolescent psychiatry services, is part of a larger research programme known as the SLEEP project. Rather than treating sleep as a single, unitary measure, the researchers asked a deceptively simple question: which specific sleep problems do parents of children with ADHD actually perceive as problematic before and after their children start using a weighted blanket? The answer matters because what clinicians classify as a sleep disorder does not always match what families experience as a problem in everyday life, and a client-centred approach, central to occupational therapy, depends on capturing that lived perspective.

The evidence base for weighted blankets rests on a sensory rationale. The deep pressure provided by the blanket’s weight is intended to help the child adapt to the environment, regulate physiological arousal and improve emotional regulation. Previous research from the same team had shown that children with ADHD who adhered to weighted blanket use had fewer parent-reported sleep problems than children who discontinued use, and that parents themselves slept better. But sleep is multidimensional, and sleep problems among children with ADHD are diverse and multifaceted, spanning difficulties at bedtime, during the night and across the following day. The new study set out to move beyond total scores and examine how each domain evolves.

The participants were drawn from an ADHD unit within a child and adolescent mental health service in southern Sweden. In the parent intervention trial, ninety-four children aged six to fourteen were randomised to begin a sixteen-week sleep intervention with either a weighted blanket or a lighter fibre blanket, using each for four weeks in a crossover phase before choosing their preference. Seventy-one children chose the weighted blanket. The present analysis focused on the forty-eight children who used the weighted blanket all nights or most nights, defined as four to seven nights per week, during the open-label phase, and for whom complete questionnaire data at both baseline and the sixteen-week follow-up were available, giving a final sample of forty-five children.

The weighted blankets themselves were fibre-weighted products weighing between four and ten kilograms, in a standard Swedish size of 150 by 210 centimetres. The appropriate weight for each child was decided independently by two occupational therapists based on background characteristics including age, gender, ADHD subtype, severity of sleep problems, and the child’s weight and height. Most of the children in the analysed sample used six-kilogram blankets. The children had uncomplicated DSM-5 ADHD diagnoses without significant comorbidities, and sleep problems were verified at the mental health service using parent-rated screening questions covering sleep initiation, sleep maintenance and sleep duration.

To capture parents’ perceptions, the researchers used the Children’s Sleep Habits Questionnaire, a thirty-three-item screening instrument divided into eight subscales: sleep onset, night wakings, sleep duration, daytime sleepiness, bedtime resistance, sleep anxiety, parasomnias and sleep-disordered breathing. Crucially, parents did not merely rate how often each behaviour occurred; they also rated whether they perceived it as a problem. If a parent marked at least one item within a subscale as problematic, the entire subscale was scored as problematic. Sleep-disordered breathing was excluded from the analysis because it was not a problem in this sample and was not expected to change. Changes between baseline and follow-up were tested with McNemar’s test, a statistical method suited to paired nominal data, with a p-value below 0.05 considered significant.

The baseline picture was dominated by two concerns. Before the weighted blankets were introduced, parents most frequently rated bedtime resistance, reported by 73.3 percent of parents, and daytime sleepiness, reported by 71.1 percent, as problems. Sleep onset difficulties and short sleep duration followed at 62.2 percent and 57.8 percent respectively, while night wakings, sleep anxiety and parasomnias were less commonly perceived as problems, each affecting roughly 38 to 40 percent of the sample. After sixteen weeks of weighted blanket use, the overall burden had clearly shifted: daytime sleepiness remained a problem for 37.8 percent of parents, bedtime resistance for 31.1 percent, sleep onset and sleep duration for 28.9 percent each, and sleep anxiety for 20 percent. Night wakings and parasomnias had become the least common concerns, reported by only 8.9 to 11.1 percent of parents.

The change analysis showed that parents’ perceptions improved across every subscale, with statistically significant shifts for all seven domains examined. The proportion of parents moving from ‘problem’ to ‘no problem’ ranged from about 27 percent to 42 percent depending on the domain. Bedtime resistance showed the largest shift, with 42.2 percent of parents, nineteen of forty-five, no longer perceiving it as a problem after the intervention, a change with a p-value of 0.000. Sleep onset delay followed at 37.8 percent, daytime sleepiness at 35.6 percent, sleep duration at 33.3 percent, night wakings at 31.1 percent, and sleep anxiety and parasomnias at 26.7 percent each. Among the parents who had specifically flagged each problem at baseline, a majority reported a shift from problem to no problem at follow-up, and persistent problems were especially rare for night wakings, sleep anxiety and parasomnias. Notably, three parents did report that sleep anxiety emerged as a new problem during blanket use, a reminder that individual responses can vary in both directions.

One intriguing discrepancy emerged when the authors compared these perception-based findings with their earlier trial data. In the previous study, which used actigraphy, an objective wrist-worn measure of sleep, no statistically significant change in sleep onset latency was found among children adhering to weighted blankets. Yet in the present study, 38 percent of parents reported that sleep onset delay had shifted from problem to no problem. The researchers suggest that parents may have experienced bedtime as smoother and less conflict-laden with the blanket, a change in the quality of the routine that does not necessarily translate into a shorter time to fall asleep as measured by a device. A weighted blanket may improve a child’s ability to handle emotional and behavioural difficulties at bedtime, enhancing the child’s own agency and reducing the parental support needed, even when the underlying sleep physiology is unchanged.

The authors are careful about the limits of their design. The study lacked a control group, the sample was small, and the results should be regarded as exploratory; causation cannot be firmly established. Subscales also contain different numbers of items, from a single item for sleep onset delay to eight items for daytime sleepiness, which means positive change can appear more readily in subscales with fewer items. The recruitment of children with uncomplicated ADHD, which excluded roughly half of patients referred to the service, including those with significant comorbidities such as anxiety, depression, autism or intellectual impairment, further limits generalisability. Nevertheless, the clinical relevance of the findings is high, particularly because parent-reported sleep problems tend to persist in children with ADHD and can worsen core symptoms, parental stress and maternal mental health. The team argues that asking parents about specific problematic sleep domains, using an instrument such as the Children’s Sleep Habits Questionnaire in a client-centred way, could serve as an appropriate starting point for evaluating weighted blanket interventions in paediatric occupational therapy practice, replacing a one-size-fits-all approach with one targeted to each family’s actual concerns, while future evaluations should assess multiple dimensions of sleep both before and after use.

Subject of Research: Parents' perceptions of sleep problems in children with ADHD before and after a weighted blanket sleep intervention

Article Title: Parents’ perceptions of sleep problems in children with ADHD when using weighted blankets

Article References: Lönn, M., Erlandsson, L.-K., Aili, K., Svedberg, P., Jarbin, H., & Larsson, I. (2025). Parents’ perceptions of sleep problems in children with ADHD when using weighted blankets. Scandinavian Journal of Occupational Therapy, 32(1), Article 2538474. https://doi.org/10.1080/11038128.2025.2538474

Image Credits: AI Generated

DOI: 10.1080/11038128.2025.2538474

Keywords: ADHD, weighted blankets, children's sleep, sleep problems, occupational therapy, parent perceptions, Children's Sleep Habits Questionnaire, bedtime resistance, sleep intervention, client-centred practice, pediatric sleep, Sweden

The study, led by Kristina Tomra Nielsen and colleagues as part of the Danish Intentional Relationship Model research program, set out to evaluate the clinical utility of three Danish-language questionnaires known collectively as the D-CAMQs. These instruments are adapted from the Clinical Assessment of Modes, developed by Renee Taylor to operationalize her Intentional Relationship Model. That model proposes that therapists draw on six distinct interpersonal communication styles, called therapeutic modes: Advocating, Collaborating, Empathizing, Encouraging, Instructing and Problem-solving. Advocating means helping clients access community resources; Collaborating shifts decision-making power to the client; Empathizing involves non-judgmental validation of thoughts and feelings; Encouraging instills hope and courage; Instructing structures, teaches and provides feedback; and Problem-solving guides clients through strategic reasoning about options. According to the model, no single mode is superior, and skilled therapists shift fluidly between them depending on what each client needs in the moment.

To capture how these modes play out in real therapy, the Clinical Assessment of Modes comes in three parts. Before therapy begins, clients complete the CAM-C1, rating how important each mode is to them on a five-point importance scale. After therapy concludes, clients fill in the CAM-C2, reporting how frequently they perceived their therapist actually using each mode. In parallel, the therapist completes the CAM-T, describing their own perception of how often they used each mode with that specific client. The Danish research team had previously translated and culturally adapted all three questionnaires following international guidelines for patient-reported outcome measures, establishing face validity and cultural relevance. What remained unknown was whether the instruments would function usefully in day-to-day clinical practice, not just in the psychometric laboratory.

Clinical utility, in this context, is a four-dimensional concept drawn from Andrew Smart’s multi-dimensional model. Appropriateness asks whether the instrument is relevant and improves clinical decision-making. Accessibility weighs the resources required, especially time, against the benefits gained. Practicability concerns whether instructions and functionality work smoothly, and acceptability addresses ethical, social and psychological concerns around use. The Danish team designed parallel surveys for clients and therapists, each mapped onto these four dimensions, and embedded the questionnaires into genuine therapy courses rather than staged research encounters. Clients completed their pre-therapy questionnaire at the first session, and therapists used the clients’ stated preferences to frame an explicit conversation about how they would work together. At the final session, clients reported on what they had experienced, and the paired results were discussed openly.

Eleven occupational therapists and forty-seven clients aged 23 to 97 took part, recruited from settings ranging from acute hospitals and municipal rehabilitation to psychiatry, home care and specialized neurorehabilitation. Most clients had been referred for neurological conditions. The therapists were all women and none had prior familiarity with the Intentional Relationship Model, making them genuine newcomers to the framework. Recruitment, originally targeting thirty therapists, was hampered by the COVID-19 pandemic, a constraint the authors acknowledge as a major limitation that renders the study exploratory rather than definitive.

The descriptive results painted a coherent picture. Clients rated all six modes as relevant, with median importance scores ranging from 15 to 20 out of a possible 25. Instructing emerged as the most important mode, while Advocating ranked lowest, a pattern echoed in the post-therapy ratings, where clients perceived frequent use of five modes but only occasional use of Advocating. Therapists’ self-ratings followed the same shape, with Advocating rarely used. At the group level, clients and therapists appeared to agree: no obvious discrepancies surfaced between the median profiles.

But when the researchers moved from group medians to individual-level statistics, a more complicated story emerged. Correlations between clients’ preferred modes before therapy and their perceived mode use afterward were moderate to weak, with Spearman’s rho values between 0.26 and 0.48. More strikingly, agreement between clients’ perceptions of mode use and therapists’ self-reported use was weak to trivial, and some correlations were negative, meaning that when a client perceived a mode being used more often, the therapist sometimes reported using it less. In other words, therapists and clients sitting across from each other for weeks of therapy frequently disagreed about the very communication style that defined their collaboration. The authors interpret this cautiously, noting that preferences and perceptions come from different perspectives and may converge differently, but they emphasize that such single-case discrepancies underscore why continuous dialogue about communication is essential rather than optional.

On the utility surveys, clients were largely enthusiastic. Fifty-seven percent felt it was highly relevant to share their communication preferences before therapy, 44 percent found it highly relevant to report and discuss experiences afterward, and 51 percent said discussing preferences significantly shaped the therapy process. Sixty percent judged the time spent on these discussions to be well justified by the benefits, 61 percent found the questionnaire instructions highly sufficient, and 86 percent reported no challenges discussing their preferences with their therapist. Acceptability exceeded 80 percent across both groups.

The therapists were harder to win over. Only 14 percent considered knowledge of client preferences highly relevant to specific therapy processes, and not a single therapist rated information about client experiences as highly relevant for future collaborations. Nearly half felt the time clients spent completing two full questionnaires was not matched by the insight gained, although 86 percent considered their own completion of the therapist form at least somewhat worthwhile. Free-text comments revealed practical friction: some clients, particularly those with cognitive challenges, were overwhelmed by the number of questions or misunderstood the items, requiring substantial assistance. Still, the therapists broadly endorsed the instruments’ acceptability, with one noting that the process had given her direct insight into what worked in individual patient courses, what to attend to, and what to do more or less of in her own therapeutic style.

The study’s significance lies less in any single number than in what it demonstrates about measuring something as elusive as interpersonal style. Structured questionnaires can open a conversation that might otherwise never happen, giving clients a legitimate voice in how they are treated and giving therapists a mirror for their own habits. The Danish versions of the Clinical Assessment of Modes questionnaires appear fit for that purpose, particularly the pre-therapy form, which seems well suited to framing the initial collaboration. At the same time, the authors caution that knowing a client’s preferences will not automatically change the relationship; therapists need deeper training in the six modes and in deliberately shifting between them to avoid suboptimal patterns such as mixing modes or missing a client’s needs entirely. With a small, pandemic-constrained sample and no prior IRM knowledge among participating therapists, the findings demand confirmation in larger, more representative studies, ideally supplemented by qualitative interviews. But the core message stands: clients and therapists do not always perceive the same therapy, and giving both sides a structured way to compare notes may be one of the most practical steps toward genuinely client-centred care.

Subject of Research: Clinical utility of Danish versions of the Clinical Assessment of Modes questionnaires in occupational therapy practice

Article Title: Clinical utility of the Danish versions of the Clinical Assessment of Modes Questionnaires

Article References: Nielsen, K. T., Pilegaard, M. S., Larsen, A. E., & Wæhrens, E. E. (2025). Clinical utility of the Danish versions of the Clinical Assessment of Modes Questionnaires. Scandinavian Journal of Occupational Therapy, 32(1), 1-12. https://doi.org/10.1080/11038128.2026.2615565

Image Credits: AI Generated

DOI: 10.1080/11038128.2026.2615565

Keywords: occupational therapy, therapeutic relationship, Intentional Relationship Model, therapeutic modes, clinical utility, questionnaires, client-therapist discrepancy, communication, psychometrics, Denmark, client-centred practice, rehabilitation

Researchers led by Rina Juel Kaptain of University College of Northern Denmark and the Parker Institute, together with colleagues from the University of Southern Denmark and Greve Municipality, surveyed occupational therapists involved in assistive technology service delivery across Danish municipal units. The target population comprised the 605 occupational therapists registered as working in this system in 2021. Using snowball sampling through professional networks and municipal department heads, the team collected questionnaire data over three weeks in April 2022. In total, 224 therapists responded and 206 completed the survey, meaning roughly one-third of the entire national workforce in assistive technology provision took part. Participants represented all five regions of Denmark and spanned wide ranges of age, professional experience and tenure in their current positions.

The findings paint a picture of an assessment practice built largely on personal judgement rather than standardised procedure. Nearly all participants, 92 percent, combined telephone interviews and home visits to gather information. Fifty-nine percent said they often used telephone interviews, while 74 percent reported conducting home visits. During those visits, 95 percent combined interviewing with direct observation of the client in their own environment, though only a quarter used questionnaires as an information-gathering method. The choice of approach often depended on the type of device requested: as one participant explained, larger cases always warranted a home visit, while smaller aids such as toilet aids, walkers or grippers were frequently handled in a single phone call.

More striking still was the near-absence of formal assessment instruments. Almost two-thirds of participants, 61.2 percent, reported not using standardised assessment tools at all. Among those who did, many relied on locally created questionnaires or checklists, or borrowed fragments of established instruments. Several therapists described drawing loosely on tools such as the Assessment of Motor and Process Skills, the ADL Taxonomy, the Canadian Occupational Performance Measure and the International Classification of Functioning, Disability and Health, but rarely in their entirety. Only 4 percent reported using a standardised tool in full, 17 percent used parts of a single tool, and 38 percent mixed parts of different tools together. Roughly 78 percent said their workplace had made no decisions about which tools should be used, and almost 80 percent reported having no guidelines about tool selection at all.

These results matter because the assessment step forms the foundation of the entire service delivery process. The European assistive technology service delivery model, developed through the HEART study of the European Commission and later refined by the AAATE and EASTIN consortium in 2012, describes seven steps: initiative, assessment, selection of the assistive solution, selection of the equipment, authorisation, implementation, and management and follow-up. Assessment occupies the second step and, according to the model’s recommendations, should evaluate the client’s individual needs using standardised procedures while keeping the client’s perspective at the centre. The Danish guidelines under the Social Service Law similarly emphasise a comprehensive, concrete and individual assessment performed in close collaboration with the client, who is regarded as best placed to express their own needs.

Previous research underscores why this matters. Systematic reviews show that satisfaction with and usefulness of assistive technology increase when professionals understand clients’ needs, expectations and preferences, and involve them in identifying personal goals. Studies from Bangladesh and elsewhere demonstrate that user involvement in service delivery predicts better outcomes of assistive technology use. Conversely, research on occupational therapy evaluation shows that when assessment relies solely on self-report through unstructured interviews without observation, important information about a client’s actual daily activity performance goes missing. A recent scoping review of the WHO European region likewise identified inadequate assessment procedures as a barrier to accessing high-quality assistive technology services.

Paradoxically, despite the variability and lack of standardisation, the surveyed therapists were largely content with their practice. Nearly three-quarters felt they had the opportunity to perform a relevant assessment, and 89 percent reported being satisfied or very satisfied with how they conducted it. The authors suggest this contentment may reflect the fact that assistive technology service delivery, unlike rehabilitation practice, lacks a strong tradition of working according to occupational therapy process models. Comments from participants revealed an awareness of constraints: some cited insufficient time and resources, noting that quantity of applications often took priority over quality of professional work, while others attributed their assessment ability primarily to accumulated experience, with one noting that forty years of practice helped.

The researchers argue that the absence of workplace guidelines effectively leaves each individual therapist’s discretionary judgement to determine how every client is assessed. They point to occupational therapy frameworks such as the Occupational Therapy Intervention Process Model and the Canadian Practice Process Framework, both of which include structured assessment phases focused on understanding the relationship between a client’s occupations and their contexts. A related Danish study found that when therapists used theoretical frameworks and structured instruments, they felt more professionally competent in the service delivery process. Employing such models as the backbone of standardised procedures could, the authors suggest, enhance equality in service quality and reduce the impact of varying experience levels across therapists.

The study does carry methodological caveats. Snowball sampling risks bias, and while the questionnaire was pilot tested to establish face validity, additional pilots with therapists from more diverse municipalities would have strengthened it. Even so, the broad national representation lends weight to the conclusion. The authors call for a standard minimum guideline for comprehensive assessment within the Danish assistive technology service delivery system, and propose renewed international work toward a standardised, interdisciplinary framework for the full service delivery process, one that keeps the user central and addresses satisfaction and abandonment of devices. Future research, they suggest, should examine whether assessment practices differ by device type, how other professions conduct such assessments, and whether integrating occupational therapy process models improves the Danish system overall.

For the millions of people worldwide who depend on assistive technology to manage daily life after illness, injury or age-related decline, the study is a reminder that the quality of a wheelchair or hearing aid is only as good as the assessment behind it. Denmark’s experience suggests that even in well-resourced welfare systems, the pathway from need to device can rest on practices that are neither uniform nor evidence-informed, and that closing this gap may be one of the most consequential improvements available in assistive technology provision.

Subject of Research: How Danish occupational therapists perform comprehensive assessments in the assistive technology service delivery process

Article Title: Comprehensive assessment as part of the assistive technology service delivery process

Article References: Kaptain, R. J., Riisager, M., Juul, C., Olsen, M. R., & Wæhrens, E. E. (2025). Comprehensive assessment as part of the assistive technology service delivery process. Scandinavian Journal of Occupational Therapy, 32(1), Article 2451287. https://doi.org/10.1080/11038128.2025.2451287

Image Credits: AI Generated

DOI: 10.1080/11038128.2025.2451287

Keywords: assistive technology, occupational therapy, assessment, service delivery, Denmark, standardised assessment tools, home visits, client-centred practice, survey, guidelines, rehabilitation, ADL