When Wendy Coster joined Sargent’s faculty in 1986, she began working with a team to develop a way to measure the functional ability of children with disabilities, from which eating skills they had mastered to how much help they needed to get dressed. The result, the Pediatric Evaluation of Disability Inventory (PEDI), revolutionized how occupational therapists and other rehabilitation providers measured the effectiveness of their interventions by focusing on outcomes that were meaningful to children and their families. Developing additional measures became a focus of Coster’s career, while, at the same time, she was guiding the college’s OT department to the top of its field—the Doctor of Occupational Therapy (OTD) program has been ranked first among peers by U.S. News & World Report in three of the four rankings since 2008. Coster (’75) retired in August after 35 years at the college.
Tatiana Pontes, who joined the Sargent faculty in September 2020, assumed the role of director of the OTD program in September 2021. Pontes, a clinical associate professor, brings an international perspective to Sargent, having grown up and studied in Brazil and, most recently, working as a research associate at the University of Western Ontario in Canada. Like Coster, she has focused on developing ways to better understand and measure the everyday activities and development of children.
In April, the two colleagues spoke via Zoom about the evolution of occupational therapy, Sargent’s influential role in the field, and where they see their profession heading.
Tatiana Pontes: As someone who just arrived at Sargent, I would love to hear your perspective on how the occupational therapy department has changed over the years.
Wendy Coster: The level of education of our students has changed: We no longer have an undergraduate program—our entry level is a clinical doctorate, which reflects how important the knowledge is that we have, how much education is required to develop those skills, and the maturity and professionalism that goes with that. The other way things have changed is the sense of the profession as a vital part of the healthcare system—as playing a major role in health and well-being, particularly for people with disabilities, and seeing ourselves as more autonomous, not just helpers to the medical world.
Also, Sargent moved into a new building in 1990. It felt symbolic of taking a big step up in our place in the University. It’s been a really exciting time with a lot of growth, a lot of change.
How has occupational therapy changed in Brazil since you were a student?
TP: Occupational therapy in Brazil began with a focus on supporting occupational performance, with the goal of enabling participation in daily life. However, with the growth of the medical model, which focuses on fixing bodily injuries and curing illnesses, many occupational therapists shifted their focus to remediating underlying medical issues. Over the past two decades, we have made a concerted effort to return to our original path—as well as expanding beyond health to promoting social justice. However, the profession in Brazil has still not fully embraced occupation as the core concern of the profession.
WC: I think that’s gone on all around the world, with occupational therapy trying to reconnect with its original orientation and its original philosophical base, after becoming enamored of the medical world and thinking that we have to think like that. But medicine is also coming closer to viewing what we do as part of what is needed for health. They’re realizing that, beyond treating the body, they must think about the person and what’s meaningful and important in their life and in their daily activity. It’s nice to have been in the profession long enough to see that.
Your orientation from Brazil fits really well with our emphasis on community-based practice, particularly with our students focused on what they can contribute to issues of social justice.
TP: I think that’s why I feel so at home at BU. Many programs tend to be more disease-centered instead of occupation-centered—that’s not what happens here.
“In our OT program, we don’t have a course on clinical conditions because we don’t want students to be thinking about the people they see as a diagnosis. We want them to think first about them as a whole being.” —Wendy Coster
WC: Different schools have different strengths. I think Sargent is in a unique place. We’re more oriented to the world of arts and sciences. The downside is how hard it’s been to connect sometimes when we do have joint interests with the medical campus. I’m hoping that that will begin to change in the years ahead.
TP: Of course we want to have a stronger relationship with them, but I think it’s an asset to be able to have our own perspective.
WC: I see a lot of emphasis on basic science and very traditional research approaches that are disease- or condition-focused—but in our OT program, we don’t have a course on clinical conditions because we don’t want students to be thinking about the people they see as a diagnosis. We want them to think first about them as a whole being.
Another thing that comes with being in a research-intensive university like BU is an obligation to contribute to the mission of generating knowledge. I’m very proud of the fact that our faculty have always been known for their scholarship. At Sargent, we developed a cadre of people who are interested in advancing measurement in the field. We began talking about function and the importance of looking at whether an intervention changed what the person could do in daily life, to evaluate whether it was worthwhile or not. We are now looking at people’s daily lives: Did they get back to doing what they wanted to do and are they participating in their communities? That was not happening.
TP: Your development of the PEDI was a major turning point, because we started looking at what had changed in a child’s life that impacted what they could do. Now, I’m interested in understanding why children develop the array of activities or occupations in which they engage. My research is focused on the creation of a new measure that focuses on understanding the development of children’s daily activities.
The way that occupational therapy has changed—we can tell that history by talking about the measures that have been created and used at BU.
WC: That’s true. I certainly never knew when I started out working on measures that it was going to be my whole career. I thought I was going to take care of one problem and then go on and do other things.
I was working with children with emotional and behavioral disorders. And I was testing them the way I was taught to test them, using developmental tests, which told me they were delayed—which I already knew. Nothing in the assessment that I did helped me suggest a strategy to help that child function better. There was a total disconnect.
If there was a child with cerebral palsy, everybody was focused on how impaired they were, how much spasticity they had. Nobody was dealing with whether any of the things they did really changed what the child could do, because there was literally no way of measuring that. It seems so obvious now, but it was radical back then.
One of the interesting things that we found in an early study with the PEDI was that even if the child’s impairments didn’t change very much, they could still change functionally after some of these interventions. That really contradicted a lot of the theories of that time and reshaped people’s thinking about good outcomes.
TP: The work you have done has impacted our profession globally—the PEDI has been translated and adapted in 18 countries. Something that drew me to BU is how the program embraces a global perspective of occupational therapy, not just an American perspective. You and the program recognize what is happening worldwide.
WC: OT, for a while, was very US-centric. One of the benefits of the internet, and also the ease of travel, has been that we’ve become more aware of what’s going on in the rest of the world and have recognized that our colleagues from other countries have quite a lot to teach us, and have perspectives and skills that are very innovative and help break out of that medical model. When you look at some of the countries that have more centralized healthcare systems, they have allowed innovation in a way that ours hasn’t, particularly crossing into social welfare and health promotion.
There’s so much good work going on in other countries. I’m eager for our students to get exposed to that.
TP: I think Sargent OT’s community-based practice will get stronger and I think we will be incorporating more of the concepts of occupational justice and trying to understand occupational disruption—and how systems can impact people’s lives.
WC: You and I have actually revised a summer course that touches on these issues of social economic and political factors that influence people’s daily lives. We look at the system and policy level, so students can see how the intersection of these factors constrain what people can do and limit them from being able to use their capacities. That requires understanding things that are outside of what the classic OT focus has been. Like understanding food insufficiency and what the impact of that is on very diverse populations, older adults, and children and families. These things all intersect. OT has always had a holistic perspective on the individual—we’re trying to take that holistic perspective to the global level to see what these larger systems enable or don’t enable people to do. The events of the last year have really pushed that and it’s where I see very exciting work going on.
That’s the real shift—from health as a physical or disorder-related condition to health as a sense of well-being, which is the World Health Organization definition. You’re going to be able to lead that effort, and that helps me leave comfortably, knowing that the people continuing this work have that same kind of vision and excitement about the possibilities.