Top-down or bottom-up occupational therapy assessment: which way do we go?
Article Type: Editorial
Subject: Performance appraisals (Methods)
Occupational therapists (Evaluation)
Authors: Brown, Ted
Chien, Chi-Wen "Will"
Pub Date: 03/01/2010
Publication: Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 College of Occupational Therapists Ltd. ISSN: 0308-0226
Issue: Date: March, 2010 Source Volume: 73 Source Issue: 3
Product: Product Code: 9918550 Employee Evaluation
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 221919010
Full Text: Using either a top-down or a bottom-up approach has been introduced to occupational therapy assessment and there has been a long debate about which approach is the most appropriate for contemporary occupational therapy practice (Weinstock-Zlotnick and Hinojosa 2004). Traditionally, bottom-up assessments have been used more frequently in occupational therapy practice and fit within the medical model (Stewart 1999). Bottom-up assessments tend to examine small, separate components of a client's skills or occupational performance components. They focus primarily on the body structure and function (impairments) level of the International Classification of Functioning, Disability and Health (ICF; World Health Organisation [WHO] 2001). Moreover, bottom-up assessments are frequently administered in contrived, standardised contexts, which may not be meaningful to the client and are often isolated from relevant daily life contexts. One example is the Peabody Developmental Motor Scales, 2nd edition, which evaluates children's grasping skills by observing them performing several simulated tasks (for example, stacking blocks and placing coins in a small box).

By contrast, top-down assessments take a global perspective and focus on the client's participation in his or her living contexts to determine what is important and relevant to him or her. This focus is linked more to the activities and participation levels of the ICF (WHO 2001). For example, the Assessment of Motor and Process Skills incorporates a client's input to determine which tasks are currently meaningful but challenging to his or her life participation and then assesses the client's occupational performance in real life contexts (Chard 2000). Therefore, the top-down assessment approach can assist occupational therapists to address more realistic and critical occupational issues.

Trombly (1993) advised occupational therapists to use top-down assessments that focus on critical roles as well as occupational performance issues, which include the ability to engage in activities of daily living, education, work, play, leisure and social participation. Hocking (2001) further provided a hierarchical conceptualisation of occupation as a guide for top-down occupational therapy assessment. In Hocking's (2001) view, top-down occupational therapy assessments are conceptualised as a hierarchy that consists of the meaning of occupation and its importance to creating and maintaining an individual's occupational identity at the top; the function or purpose of the occupation in the individual's life; the form that those occupations take; and, lastly, the occupational performance components. From this hierarchical perspective, occupational therapists need first to understand clients as occupational beings, with the client's unique occupational identity or meaning. The purpose of the client's occupation and its contribution to his or her own and others' lifestyles should then be identified. The observable characteristics of the occupations that are problematic need to be addressed subsequently. Finally, the individual's performance components or skills may be assessed if the cause of his or her occupational dysfunction is not evident and needs to be clarified (Tam et al 2008).

Since therapists can adopt a bottom-up, a top-down or a mixed directional approach to clients' assessment, it is important to be cognisant of both assessment approaches and the implications associated with each. Occupational therapists should decide which assessment direction is the most appropriate so as to ensure the provision of high quality, client-centred services.

Chard G (2000) An investigation into the use of the Assessment of Motor and Process Skills (AMPS) in clinical practice. British Journal of Occupational Therapy, 63(10), 481-88.

Hocking C (2001) Implementing occupation-based assessment. American Journal of Occupational Therapy, 55(4), 463-69.

Stewart S (1999) The use of standardised and non-standardised assessments in a social services setting: implications for practice. British Journal of Occupational Therapy, 62(9), 417-23.

Tam C, Teachman G, Wright V (2008) Paediatric application of individualised client-centred outcome measures: a literature review. British Journal of Occupational Therapy, 71(7), 286-96.

Trombly C (1993) Anticipating the future: assessment of occupational function. American Journal of Occupational Therapy, 47(3), 253-57.

Weinstock-Zlotnick G, Hinojosa J (2004) Bottom-up or top-down evaluation: is one better than the other? American Journal of Occupational Therapy, 58(5), 594-99.

World Health Organisation (2001) International classification of functioning, disability and health: ICF. Geneva: WHO.

(1) Monash University--Peninsula Campus, Frankston, Victoria, Australia.

Corresponding author: Dr Ted Brown, Associate Professor and Postgraduate Coordinator, Department of Occupational Therapy, Monash University--Peninsula Campus, Building G, 4th Floor, McMahons Road, PO Box 527, Frankston, Victoria, Australia 3199. Email:

Key words: Assessment, occupational performance, top-down and bottom-up assessments.

DOI: 10.4276/030802210X12682330090334

Ted Brown (1) and Chi-Wen (Will) Chien (1)
Gale Copyright: Copyright 2010 Gale, Cengage Learning. All rights reserved.