846220
research-article2019
CRE0010.1177/0269215519846220Clinical RehabilitationPritchard-Wiart et al.
CLINICAL
REHABILITATION
Original Article
A review of goal setting theories
relevant to goal setting
in paediatric rehabilitation
Lesley Pritchard-Wiart1 ,
Sandra Thompson-Hodgetts2
Ashley B McKillop1,2
Clinical Rehabilitation
2019, Vol. 33(9) 1515­–1526
© The Author(s) 2019
Article reuse guidelines:
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https://doi.org/10.1177/0269215519846220
DOI: 10.1177/0269215519846220
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and
Abstract
Background: Goal setting in paediatric rehabilitation is influenced by shifting parent, sibling, caregiver,
and child roles over time and evolving child developmental capacity for participation in the process.
A theoretical and evidence-informed approach to goal setting, specific to paediatrics, would provide a
framework for goal setting in practice and facilitate systematic evaluation of the effects of goal-setting
processes on child and family outcomes.
Objective: To provide an overview of relevant goal-setting theories and their implications for paediatric
rehabilitation.
Methods: Prevalent theories were identified from relevant rehabilitation, motivation, behaviour change,
and goal-setting literature. Implications for goal setting in paediatrics are summarized according to goalsetting and action-planning phases: (1) preparation, (2) formulation of goals, (3) formulation of action plan,
(4) coping planning, and (5) follow up.
Results: Social cognitive theory, self-determination theory, Health Action Process Approach, Mastery
Motivation, and goal-setting theory are reviewed. Examples of implications for goal setting include, sharing
information with families about the purpose of goal setting; identifying goals that are specific, proximal,
challenging, and important to the child; and addressing self-efficacy.
Conclusion: The theories reviewed have clear implications for paediatric rehabilitation research and practice.
They address considerations not typically discussed in adult rehabilitation such as observing children to obtain
information about meaningful goals when they are unable to communicate them directly and the importance
of establishing flexible processes that will accommodate changing family roles over time. Research is needed
to evaluate the effects of goal-setting processes and strategies on outcomes in paediatric rehabilitation.
Keywords
Goal setting, action planning, paediatric, rehabilitation, theory
Received: 25 July 2018; accepted: 1 April 2019
1Department
of Physical Therapy, Faculty of Rehabilitation
Medicine, University of Alberta, Edmonton, AB, Canada
2Department of Occupational Therapy, Faculty of Rehabilitation
Medicine, University of Alberta, Edmonton, AB, Canada
Corresponding author:
Lesley Pritchard-Wiart, Department of Physical Therapy,
Faculty of Rehabilitation Medicine, Rm. 2-50 Corbett Hall,
University of Alberta, Edmonton, AB T6G 2G4, Canada.
Email: lwiart@ualberta.ca
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Introduction
Collaborative goal setting is recognized as a key
component of paediatric rehabilitation practice;
however, research evaluating the effects of goal
setting with children and families is limited,1 and
existing literature on goal setting in paediatrics
lacks theoretical depth.2 The application of goalsetting approaches that are grounded theoretical
frameworks evaluated and supported in other contexts would enhance practice and research in paediatric rehabilitation. While a synthesis of relevant
theoretical frameworks has been developed for
adult rehabilitation,3 there are additional considerations for working with children and families.
Many younger children or children who have
reduced cognitive and/or communication capacity
require parents to represent their interests in the
goal-setting process. Therefore, goal setting in paediatrics must consider how children’s participation
in the goal-setting process can be optimized to
ensure goals are meaningful and motivating.
Optimizing child engagement in goal setting
requires consideration of strategies for how to
engage children who are unable to articulate goals
and who may otherwise demonstrate the capacity
to identify meaningful and motivating activities
through their actions and reactions; a consideration
that has not been explicitly addressed in the adult
literature. In addition, in contrast to adults, goal
setting with children can be challenging due to the
need to consider ongoing physical and cognitive
development and the uncertainly many parents
experience regarding long-term outcomes for their
children. Goal setting in paediatrics therefore
requires flexible processes that will accommodate
changing family and child roles over time and consider how therapists can support children in decision-making about rehabilitation goals and
intervention strategies within an evolving family
context. While there may be very similar considerations for rehabilitation with adults and older
adults; currently, goal-setting literature is focussed
on adults outside of the rehabilitation context.
Specific considerations for the application of goal
setting with children and families are therefore
required to inform research and practice in paediatric rehabilitation.
Clinical Rehabilitation 33(9)
The purpose of this article is to provide the basis
for a theoretical framework relevant to goal setting
in paediatric rehabilitation. Theories were selected
based on frequent use in adult rehabilitation goal
setting3,4 and from relevant literature in paediatric
rehabilitation,2,5,6 and include: social cognitive theory,7 self-determination theory,8 Health Action
Process Approach,9 Mastery Motivation,10 and
goal-setting theory.11 Strategies that align with the
theoretical frameworks are presented according to
five phases of goal setting proposed by Lenzen
et al.:4 (1) preparation, (2) formulation of goals, (3)
formulation of action plan, (4) coping planning,
and (5) follow up.
Review of relevant theories
Social cognitive theory
Social cognitive theory, a well-known theory for
explaining human behaviour, has been applied in
various clinical settings, including goal setting
with adults.12 The development of social cognitive
theory represented a significant shift away from
traditional behaviourist theories that viewed human
behaviour as the product of the external environment; an input output model that left little room for
the role of cognitive and other individual factors
that influence human behaviour.12 According to
social cognitive theory, behaviour can be explained
by dynamic interactions between the environment
(anything external to the person), the person (cognitive, affective, and biological processes), and
behaviour factors, an interaction Bandura12,13
described as triadic, reciprocal causation. This
dynamic interaction is context dependent with
components not always acting at the same time, at
the same strength, or bidirectionally.12
Self-efficacy, a concept first described by
Bandura in 1977,7 is frequently emphasized in goal
setting and action planning, behaviour change, and
self-management literature. Self-efficacy, one’s
perceived ability to accomplish a particular level of
performance, operates independently of skill. That
is, individuals with high skill level can perform
poorly in the presence of low self-efficacy.12 Selfefficacy, therefore, guides what individuals decide
to pursue, the degree of effort in goal pursuit, and
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Pritchard-Wiart et al.
the amount of time dedicated to accomplish a goal
despite the existence of barriers.7 A child with high
self-efficacy may select more challenging goals, be
more motivated, and ultimately demonstrate higher
goal-related performance, compared to a child with
similar skills and lower self-efficacy.
Different types of self-efficacy have been
described in the literature, including coping selfefficacy (beliefs in one’s ability to cope in difficult
circumstances) and task self-efficacy (beliefs in
one’s ability to accomplish a particular action/
task).14 Task self-efficacy may be more immediately important in paediatric rehabilitation settings,
while coping self-efficacy or perceived abilities to
manage barriers or stressors, may be more associated with long-term behaviour change. Since selfefficacy can be nurtured and developed,12,15 it
should be considered in the paediatric rehabilitation context to maximize performance. Specific
strategies to enhance self-efficacy include facilitating performance accomplishments (e.g. child successfully performs behaviour), vicarious experience
(e.g. watching someone else successfully perform
the behaviour), providing verbal persuasion (e.g.
positively encouraging the child to successfully
perform a behaviour), and the experience of emotional arousal (e.g. reducing stress when he or she
performs behaviour).7 Clinical strategies for selfefficacy support include demonstration of rehabilitation-related activities (perhaps by peers or in the
context of group rehabilitation), positive encouragement, developing strategies to address potential
barriers to behaviour change, and facilitating successful achievement of tasks. For example, children with disabilities who participated in a physical
activity programme demonstrated increased selfefficacy following the programme.16
Self-regulation, as described in social cognitive
theory, is one’s ability to control motivation,
thought processes, emotional states, and behaviour.12,15 It is a mechanism through which individuals judge if their behaviour is consistent with their
internal standards and, if not, modify their behaviour accordingly. For example, an adolescent with
a goal related to increased walking endurance may
increase her physical activity level upon reflection
that she is still experiencing difficulty with longer
distances at school. When individuals are knowledgeable about their performance, self-regulation
can increase motivation; highlighting the importance of providing regular feedback on progress
related to meaningful rehabilitation goals. Children
typically begin to develop self-regulatory capacity
in the toddler years;17 however, it is important to
consider that some children may not develop the
capacity for self-regulation of complex tasks.18
Self-determination theory
Self-determination theory, a macro-theory of
motivation and personality, purports three essential psychological precursors for self-motivated
and engaged behaviour: competence, relatedness,
and autonomy.19 In the context of goal setting and
action planning, competence means feeling capable and confident about success with goal-related
tasks, relatedness refers to feeling supported
towards goal attainment in empathetic relationships, and autonomy is the ability to choose personally meaningful goals.6 Ryan and Deci8 suggest
that children innately try to fulfil these psychological needs and so consideration of all three factors is necessary in goal setting and action
planning. A significant body of research exists to
support the influence of these psychological factors on health-related outcomes in a variety of
clinical contexts.20
Self-determination theory describes three motivational processes that are relevant to goal setting
and action planning: (1) amotivation, referring to
pursuit of a goal that was neither identified by nor
of known interest or value to the child; (2) extrinsic
motivation, which involves internalizations of
goals not driven by inherent satisfaction of the
activity; and, (3) intrinsic motivation, which
reflects internal motivation to participate in a selfdetermined activity.21 Recognizing where a child
falls on this continuum can help therapists understand how much external influence may be required
to regulate behaviour towards one’s goals.22 For
example, in addition to understand which goals are
important to children, it is important to understand
why children consider the goals important. This
information may also provide context for therapists
1518
who feel frustrated when a child (and/or family)
does not ‘follow through’ with therapy recommendations, perhaps because goals are not intrinsically
motivating. Since individuals who exhibit intrinsic
motivation are interested, excited, and confident
about tasks at hand, goals that arise from intrinsic
motivation are more likely to result in enhanced
performance, creativity, self-esteem, and general
well-being and are less likely to require external
rewards to enhance performance.23
In the paediatric rehabilitation context, it is common for parents and therapists to identify goals for
children.24,25 It is important to consider that externally identified goals that are not meaningful to the
child may result in lower motivation and engagement; a state that will likely result in suboptimal performance. Individuals who pursue externally driven
goals but do not succeed can experience self-blame
and guilt and potentially other poor psychological
outcomes such as anxiety and depression.20 Parents
and older children and adolescents may experience
tension between their commitments to therapeutic
recommendations and a lack of internally motivated
engagement in goal-related activities potentially
leading to feelings of failure and guilt.26 Indeed,
there is some evidence that collaboration in paediatric rehabilitation can be one-sided, with parents’ primarily following therapists’ instructions and
advice.27 This knowledge highlights the importance
of ensuring that the individual(s) whose behaviour is
required to change, whether they be children and/or
their parents, identify personally relevant and meaningful goals.
Sometimes, setting rehabilitation strategies that
are not internally motivating to the child is necessary. It is important to note, however, that children
have less capacity to pursue goals that are not
intrinsically motivating, although their ability to do
so does increase over time.28 Older children
become increasingly capable of internally driven
engagement, but they may require some external
support to maintain motivation to engage in therapeutic activities.8 Ensuring that parents and
therapists collaborate on strategies to help engage
and motivate the child is essential when children
are not internally motivated. The use of external
rewards may improve proactive and engaged
Clinical Rehabilitation 33(9)
behaviour for children who are not intrinsically
motivated, eventually leading to an improved sense
of competency and increased intrinsic motivation.22 However, external rewards can undermine
motivation in instances where individuals already
have a high level of intrinsic motivation.29
In addition to evaluating a child’s current goalrelated performance, therapists can consider the
use of strategies to enhance competence and autonomy. For example, goal difficulty affects perceived
competence and internal motivation. Easily attainable goals may appear more motivating due to
more immediate goal attainment; however, according to self-determination theory, achievement of a
challenging goal leads to increased sense of competence and thus increased intrinsic motivation.8
Therefore, challenging goals may be more desirable for a child who is highly intrinsically motivated.23 Research in education has demonstrated
that children with teachers who promote autonomy
show greater intrinsic motivation, curiosity, and
improved academic performance compared to children with more directive teachers.30 A similar relationship has been documented between parenting
styles and children’s intrinsic motivation.31
Goal-setting theory
Goal-setting theory, rooted in neurobehavioural
and industrial, organizational psychology, is
focused on elucidating relationships between goal
qualities (e.g. specificity, goal difficulty, and learning vs. performance-based goals), self-efficacy and
the goal initiator (i.e. self-identified, participatory
or externally established goals), and performance
in the industrial workplace. This body of research,
based on over 400 laboratory and field experiments, provided the foundation for workplace performance research in organizational psychology.11
Successful activity performance is influenced
by numerous personal and environmental factors,
including individual ability, goal commitment,
effective feedback, the nature of facilitators/barriers in the environmental context, and task complexity relative to the individual’s ability. Improved
workplace performance is consistently associated
with specific, difficult goals rather than vague
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Pritchard-Wiart et al.
goals (e.g. ‘do your best’), regardless of whether
the goals are self-identified or externally established.11 Rehabilitation research conducted with
adults has also demonstrated that specific goals can
increase physical activity for adults with diabetes32
and that individuals with traumatic brain injuries
performed better with specific goals and feedback
on their performance.33 Difficult goals that remain
within an individual’s capability elicit more time,
dedication, and effort from the individual, and produce better outcomes irrespective of who sets the
goals, as long as the purpose of the goal is understood and perceived to be personally important.11
Of particular interest in rehabilitation, are the
potential positive effects of goal attainment on
well-being,34 particularly when attainment is
related to challenging goals.11
Goal-setting theory highlights the importance
of considering level of goal difficulty. Research
has demonstrated a positive relationship between
perceived goal difficulty and effort towards goal
achievement as long as the goal is considered
attainable.11 Exceptions to this relationship
include the pursuit of complex goals that require
learning new skills or requisite task knowledge
and the presence of conflicting goals. For example, a child who is trying to increase walker use at
school may be frustrated because it interferes with
energy conservation strategies needed to pursue
academic goals. In this example, child and family
priorities in the school context need to be established. Personality characteristics also play an
important role in determining how individuals
respond to goal difficulty. Individuals with a
greater desire to learn will likely select goals that
are more challenging while those who focus on
their performance have a tendency to avoid difficult goals that are challenging to master,35 that is,
difficult goals may lead to suboptimal outcomes
when they are appraised as threats rather than
challenges.11
Mastery motivation
Originally described by White,36 Harter,37 and
Yarrow et al.,38 Mastery Motivation, as defined by
Morgan et al.10 is the ‘psychological force that
stimulates an individual to attempt independently,
in a focused and persistent manner, to solve a problem or master a skill or task which is at least moderately challenging for him or her’ (pg. 319). While
Mastery Motivation is present in individuals of all
ages, research has primarily focussed on infancy
and early childhood.10 Mastery Motivation is particularly important in relation to goal setting
because engaging young children in rehabilitation
is contingent upon identifying activities that are
intrinsically motivating.
A defining characteristic of Mastery Motivation
is the development of self-initiated strategies to
independently and repeatedly attempt tasks in
order to master a skill. Mastery motivation can be
observed across multiple domains, including
social and gross and fine motor skills, and the
extent of Mastery Motivation can vary across
domains.10 For example, a child who is very motivated to move and engage in gross motor play,
who makes repeated attempts to run and climb but
does not show interest in engaging with other children may simultaneously demonstrate high gross
motor mastery motivation and low social mastery
motivation.
Mastery Motivation suggests that therapeutic
activities that follow the child’s lead are more
likely to be both enjoyable for the child and successful due to the child’s internal drive to
attempt and master the task. Therefore, observing children engaging in activities, particularly
in natural settings, can enhance understanding
of the activities that are motivating and provide
a basis for goal discussion. This is particularly
true for younger children or children who can
most effectively demonstrate activity preferences through their actions.
Health action process approach
The Health Action Process Approach, and other
related theories of behaviour change, is frequently
used as the basis for developing and evaluating
positive health behaviours. Health Action Process
Approach incorporates aspects of social cognitive
theory and is a continuum and phase-based model
that emphasizes both the motivational and
1520
volitional aspects of behavioural change.39
Consideration of the volitional aspects of behaviour change represented an expansion of pre-existing theoretical models that focussed on the
importance of precursors including intention, barriers, social norms, and perceived self-efficacy, but
did not emphasize post-intentional volition that is
important for the translation of intention into
action.9 The emphasis on risk perception in the preintentional stage in other models was deemed
important but inadequate for actual behaviour
change; it merely provides information that can be
considered for creating or enhancing motivation.
The unpacking of the ‘black box’ of post-intentional volition suggests that, in addition to task
self-efficacy, maintenance, recovery self-efficacy,
strategic action planning, and coping planning are
important considerations for sustainable behaviour
change and therefore should be considered in rehabilitation goal and action plans.
Of particular relevance to rehabilitation is the
differentiation between factors associated with
goal setting and goal pursuit. That is, understanding factors associated with both motivation and
action is important for rehabilitation strategies that
rely on ongoing behaviour change. Second, the
continuum model provides clinicians with insights
into the different types of conversations that would
likely be helpful, depending on where children and
families exist on the continuum. For example,
strategies for individuals at the pre-intention phase
will likely involve facilitating child and/or parent
understanding of perceived outcomes, risks, and
task self-efficacy, while useful support at the intention phase will likely involve more detailed action
and coping planning. Established behaviour change
methodologies, such as Health Change Australia©,40
are largely based on this approach.
Clinical Rehabilitation 33(9)
Preparation
Preparation refers to activities that occur prior to
setting goals, such as family education and reflection on values and important goal areas. Goal setting can be overwhelming for families, particularly
those new to the process, and parents of young
children may not feel as prepared to identify rehabilitation goals for their children.26 Therefore, the
preparation stage can serve an important purpose;
encouraging child and parent reflection about the
activities that are important to them, as well as
ensuring that families understand that rehabilitation interventions are guided by the activities that
they value and consider meaningful.
All of the theories reviewed emphasize the
importance of engaging the child in identifying
their own goals or ensuring that goal-related activities are motivating for the child if goals are identified by a parent and/or professional. Using
innovative options for starting goal discussions
with therapists, such as taking pictures or videos or
drawing activities the child would like to improve,
could increase child engagement in the goal-setting
process. These strategies can provide a foundation
for discussing the outcomes that are important and
meaningful to the child and may be less intimidating than discussing goals with therapists with little
or no lead-time. Parents of children and youth who
are not engaged in a goal-setting discussion can
also be encouraged to reflect on the skills or activities that their child is repeatedly attempting and
trying to master. This approach has already been
advocated in paediatric physical and occupational
therapy.41 Therapists can also take opportunities to
discuss family values and priorities so that co-construction of goals during goal formulation can be
accomplished in a way that reflects family values
and evolving, context-dependent, long-term goals.
Clinical implications
Goal formulation
Practical strategies that align with the theories
described are discussed below, and outlined in
Table 1. Strategies were mapped by the authors
onto relevant theories by identifying key concepts
for each theory articulated in the literature and the
strategies that aligned with them.
Since all of the theories reviewed here reinforce the
importance of identifying personally meaningful
goals, children should be involved in the goal-setting processes to the greatest extent possible.
Research suggests that children as young as five
years old can actively participate in goal setting
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Pritchard-Wiart et al.
Table 1. Alignment of theories and goal-setting and action-planning strategies by stage.
Stage/strategy
Preparation
Share information with families about the purpose of goal setting
Make a concerted effort to understand parent and child worldview and why
certain activities are important to them
Encourage parents and children to think about their goals prior to
discussion (e.g. ask children to take photographs or video or draw pictures
of the activities they would like to discuss)
Goal formulation
Identify goals that are specific, proximal, important to the child, and difficult,
but do not exceed child and parent capabilities
Ensure goals are personally meaningful to the child and parents
Ensure goals are important to the child and parents
Consider activities that the child is attempting but has not yet fully mastered
Consider level of task self-efficacy related to goal (e.g. self-efficacy rating
scale)
Consider setting parent/caregiver behaviour goals in addition to child
focussed goals (if behaviour change of parent is required)
Ensure goal conversation allows for co-construction of goals
Use standardized tools such as the COPM, PEGS, or PACS to facilitate goal
identification
Formulation of action plan
Engage parent and child in process to identify ideas for integrating activities
into their daily routines
Ensure child/parents understand rationale for intervention strategies and
linkage to goals
Coping planning
Discuss potential barriers to ongoing therapy activities, how they can be
addressed and confidence in addressing them
Address confidence in dealing with barriers, particularly if coping selfefficacy is low
Follow up
Ensure consistent focus on goal (alignment of therapy activity to goal and
ensure child and parent understand the link)
Use confidence enhancing strategies, particularly if task self-efficacy is low
(e.g. encouragement, constructive feedback, and group models of therapy
with children of similar ability levels)
Ensure intermittent progress evaluation and feedback related to goal
attainment for child and parent (e.g. video comparison to baseline)
SCT
SDT
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MM
HAPA
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SCT: Social Cognitive Theory; SDT: Self-Determination Theory; GST: Goal-Setting Theory (Locke and Latham); MM: Mastery Motivation; HAPA: Health Action Process Approach; COPM: Canadian Occupational Performance Measure; PEGS: Perceived Efficacy
and Goal-Setting System; PACS: Paediatric Activity Card Sort.
using formalized goal-setting tools42,43 such as the
Perceived Efficacy in Goal-Setting System44 or the
Preferences for Paediatric Activity Card Sort;45
tools specifically geared towards activities common in childhood. The Canadian Occupational
Performance Measure46 has also been used with
children as young as seven.24 Other strategies, such
as starting goal discussions with reviewing pictures
or videos taken by the child may also be effective
for increasing child engagement.
1522
We advocate for a ‘child first’ approach whereby
child-identified goals provide the foundation for
goal discussions. This approach emphasizes the
importance of maximum child engagement and
does not preclude active involvement of parents
and therapists in the goal identification process.
This approach, applied to young children or children who are unable to communicate their goals,
involves taking cues from the child by focussing
activities that motivate the child; those which they
demonstrate repeated attempts to master. Children
may be more aware of goals related to their school
environments than their parents.43 Importantly,
achievement of important goals is empowering and
may mitigate the development of learned helplessness. A ‘child first’ approach emphasizes the
importance of adopting flexible approaches to goal
setting that enable therapists to choose from a
‘toolbox’ of strategies in order to optimize child
engagement and honour changes in family priorities and decision-making processes over time.
Self-identification of goals ensures they are
more meaningful and connected to individual
contexts and daily routines. In a study conducted
with adolescents with cerebral palsy, motivation,
as measured by the Dimensions of Mastery
Questionnaire,47 did not strongly predict activity
participation. Preference for activities, however,
was a strong predictor of participation in all participation dimensions (i.e. diversity, intensity,
with whom, where, and enjoyment) as measured
by the Children’s Assessment of Participation and
Enjoyment (CAPE). This research suggests that
while Mastery Motivation may be an important
contributor to goal persistence related to specific
skills, therapists who wish to facilitate increased
participation must take into consideration child
preferences for activities.48
There are unique considerations for engaging
children in goal identification. A child’s capacity to
set goals will evolve over time as their cognitive
and emotional skills develop. In addition, child
self-awareness and social awareness changes over
time, likely affecting the goals they identify as
important. Therefore, therapists must consider the
developmental trajectory of child autonomy in the
context of unique family decision-making cultures
Clinical Rehabilitation 33(9)
that change over time. Furthermore, by supporting
the child in the goal-setting process, therapists
could contribute to increased child involvement in
medical decision-making, thus playing a role in
teaching children self-advocacy. In other contexts,
adolescents who receive increased autonomy support from adults report greater overall life satisfaction.49 Development of medical decision-making
skills has implications for the transition to adulthood, which has been a focus in paediatric rehabilitation over recent years.50
It is important that therapists reflect on their
beliefs and assumptions to ensure their approach
to goal setting is strength-based; capitalizing on
the existing strengths and interests of children.
Some professionals who work with children with
autism spectrum disorder, for example, may
strive to avoid perpetuating restricted or perseverative interests. A previous study related to
autonomous goal setting for youth with autism
spectrum disorder18 suggested that professionals,
but not parents or youth with autism spectrum
disorder, saw restricted interests as a barrier to
collaborative goal setting. Rather, some parents
felt that goals would be most meaningful when
they reflected their child’s interests and strengths.
This perspective has been supported by research
in an educational setting, which demonstrated
that incorporating restricted interests into goal
setting and action planning increased motivation
towards engagement and outcomes for children
with autism spectrum disorder.51
In the goal formulation stage, strategies to
evaluate and develop self-efficacy should be
considered with parents52 and children.53 In addition to more informal strategies for determining
level of self-efficacy, such as determining if children and parents appear confident about their
abilities to implement strategies,53 simple rating
scales can also be used for understanding how
one rates their perception of task or coping selfefficacy. For example, the Stanford Chronic
Disease Self-Management Programme implemented a six-item scale54 to assess self-efficacy
related to proceeding with action plans. Simple
self-efficacy tools similar to this one could be
used to determine if self-efficacy is adequate for
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the child and family to proceed with the rehabilitation plan, or low, indicating that the action plan
needs to be reconsidered and/or self-efficacy
needs to be addressed. Therapists may wish to
use established behaviour change approaches
such as motivational interviewing55 to facilitate
discussion about self-efficacy and to provide a
structure for working towards sustainable behaviour change.
It is important to reflect on how goal qualities
can affect child and parent motivation and engagement including the effects of goal specificity, proximity (i.e. steps towards a larger goal), and level of
goal difficulty. While specific goals serve the obvious purpose of ensuring that therapists and families
are clear on the intended rehabilitation outcomes,
they are also likely to be more motivating than general goals, resulting in improved outcomes. Goalsetting theory and self-determination theory also
suggest that difficult, yet attainable goals, particularly for individuals who view challenge positively
and are highly intrinsically motivated, may also
result in better outcomes. Proximal goals are also
more likely to be more motivating, since progress
towards goals is observable. Therapists are ideally
positioned to guide goal difficulty and proximity.
For example, therapists can guide a child who
wants to play basketball who would benefit from
initial goals related to specific ball skills. This
approach ensures that goals are grounded in the
activities that are meaningful to families while capitalizing on therapist skills, knowledge, and experience. In addition, consideration of goal setting as a
co-constructed process allows therapists to engage
in a flexible way with families by providing input
and guidance as desired by families.56,57 This collaborative approach prioritizes the activities that
are important and meaningful to children and families but does not preclude therapist input. In fact,
parents have indicated that they do not always
want sole responsibility for identifying therapy
goals.26,56,57 In addition, therapists may feel more
comfortable with a collaborative approach, since
they have articulated hesitancy about relinquishing
responsibility for goal setting to families out of
concern that parents will identify unattainable
goals.25
Formulation of the action plan
Clearly, children and parents must be able to link
intervention strategies to goals in order to sustain
intervention. Sometimes, as in the case of functional therapy, this relationship will be obvious,
other therapeutic activities may be perceived as
being somewhat distant from the end goal. For
example, it may not be obvious to the child how
progressive resistance training could potentially
contribute to their goal related to improved walking efficiency. It is important that children and
families understand the potential linkages between
therapeutic activities and goals. The International
Classification of Functioning, Disability and
Health58 may be useful for facilitating this discussion with families.59 Motor learning principles
would also suggest that activities should ultimately
move to whole practice in meaningful contexts;60
making the links between intervention and goals
clear. Clear articulation of discrete steps in a goaldirected action plan can also be a useful strategy
for children who have difficulty with abstract
concepts.18,42,43
Coping planning
Barriers to behaviour change are common, especially when an individual is attempting to make
long-term changes. For example, environmental
barriers (either physical or social), unexpected
external events, such as illness, or competing time
demands, such as caregiving or work commitments, will almost inevitably occur in the context
of families’ daily lives. Coping planning involves
identifying potential barriers and strategies to mitigate them and ensuring that individuals are confident that they can address these barriers (i.e. coping
self-efficacy). Discussing such strategies with families can stimulate thinking about how barriers can
be addressed in the long term.
Follow up
Enacting strategies to reflect on and report on performance throughout the therapy process can support an ongoing sense of competence, achievement,
1524
and motivation and can also help maintain dedication to goal pursuit. Practical tools can be used to do
this, including communication with others involved
with the child (e.g. school or child-care staff) via
daily communication books, creating goal sheets
with pictures of the child participating in goalrelated activities, and ensuring that goals are clearly
visible to all in inpatient settings. Re-evaluating
goal progress at regular intervals throughout therapy provides children and their caregivers feedback
about goal-related performance. For example, taking videos of the child at baseline and at regular
intervals throughout therapy can provide some
direct feedback about progress and increase motivation to continue towards the child’s goal.
Discussion
The theories and related research reviewed provide
some insight into the factors to consider during
goal setting, many of the principles require evaluation in the paediatric rehabilitation context. They
also, however, highlight some significant gaps in
knowledge regarding the application of goalsetting theories to practice and research. While the
theories reviewed are robust and have been evaluated in other contexts, particularly with adults
without disabilities, specific application to paediatric rehabilitation needs to be evaluated. For example, while there is evidence to suggest difficult
goals result in improved performance, there is also
evidence from one study in adult rehabilitation that
easier goals are associated with improved goal
performance when self-efficacy is low.61 In addition, Locke and Latham’s work11 on goal setting in
industrial work settings suggests that it does not
matter who sets goals, only that the performing
individual believes the goals to be important.
This relationship may not be demonstrated in rehabilitation; certainly, the importance of identifying
personally meaningful goals suggests that the
individual whose behaviour is expected to change
should be optimally engaged in the goal-setting
process. It is entirely possible that participation in
goal identification is less important in industrial
work settings11 than the subjective importance of
goals identified in rehabilitation.62 These examples
highlight gaps in the research on rehabilitation goal
Clinical Rehabilitation 33(9)
setting and the need to explore how theories that
we have ‘imported’ apply to unique rehabilitation
contexts. Further evaluation of the application of
existing theories to rehabilitation will reveal if
development of rehabilitation specific goal-setting
theory is needed.
Additional research is also required to explore
the effectiveness of rehabilitation based on goals
that are clearly guided by the infant or young
child’s interest in attempting particular skills and
tasks, that is, the application of Mastery Motivation
to goal setting. Mastery Motivation has been identified as an important factor to consider in the paediatric rehabilitation context. For example, factors
associated with Mastery Motivation have been
explored in adolescents with cerebral palsy.63
Context-focussed therapy64 encourages therapists
to follow the lead of the child and consider goals
related to the skills that young children are attempting,
but the effects of this approach on child outcomes
have not been formally evaluated.
Clinical messages
•• Theories related to goal setting and
behaviour change have direct implications for paediatric rehabilitation including the importance of optimizing the
child in the goal-setting process, consideration of self-efficacy and ensuring an
ongoing focus on goals throughout
rehabilitation.
•• Flexible goal-setting approaches are
needed to accommodate evolving capacity to engage in the goal-setting process
and changing family decision-making
culture over time.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial
support for the research, authorship, and/or publication
of this article: L.P.-W. is supported by the Canadian
Child Health Clinician Scientist Training Programme
1525
Pritchard-Wiart et al.
(CCHCSP), and the Women and Children’s Health
Research Institute (WCHRI) through the generous support of the Stollery Children’s Hospital Foundation and
Alberta Policy Wise for Children and Families. S.T.H.O.T. was also supported by Alberta Policy Wise for
Children and Families at the time of manuscript
creation.
ORCID iDs
Lesley Pritchard-Wiart
-0002-6684-376X
Ashley B McKillop
-6799-7472
https://orcid.org/0000
https://orcid.org/0000-0001
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