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Review

Defining Goal-Directed Training for Children with Cerebral Palsy: A Scoping Review and Framework for Implementation

by
Angela Shierk
1,2,*,
Bridget Barry Thias
1,
Haley Becker
1,3,
Baylee Allen
1,3,
Benjamin Chaiprasert
1,
Katherine C. Lampe
1,
Ava Wallace-McCollom
1,
Aidan O’Brien
1,3 and
Heather Roberts
1,3
1
Department of Clinical Research, Scottish Rite for Children, Dallas, TX 75219, USA
2
Department of Applied Clinical Research, UT Southwestern Medical Center, University of Texas, Dallas, TX 75390, USA
3
Department of Occupational Therapy, Texas Woman’s University, Denton, TX 76204, USA
*
Author to whom correspondence should be addressed.
Children 2025, 12(8), 1039; https://doi.org/10.3390/children12081039
Submission received: 17 June 2025 / Revised: 25 July 2025 / Accepted: 28 July 2025 / Published: 8 August 2025
(This article belongs to the Special Issue Children with Cerebral Palsy and Other Developmental Disabilities)
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Versions Notes

Abstract

Highlights

What are the main findings?
  • Defines and synthesizes the core components of Goal-Directed Therapy (GDT) for children with cerebral palsy through a comprehensive scoping review.
  • Identifies measurable benefits of GDT across ICF domains, including motor function, self-care, communication, and participation, based on evidence from 112 intervention studies.
What is the implication of the main finding?
  • Proposes a structured eight-step GDT framework to support therapists in implementing GDT with fidelity across settings and severity levels.

Abstract

Background/Objectives: This scoping review aimed to define goal-directed training (GDT) and its impact on outcomes for children with cerebral palsy (CP), and to develop a structured framework outlining its core components for effective implementation. Methods: Using the Arksey and O’Malley framework and PICO criteria, nine databases were searched and reference lists reviewed. Two reviewers independently screened and extracted data, which were analyzed using a qualitative descriptive approach. Results: From 1273 articles, 156 met inclusion criteria, including 112 efficacy studies (53 randomized trials, 53 non-randomized trials, 6 secondary analyses) involving 4708 children aged 3 months to 21 years (mean age 6.7 years). Interventions addressed all GMFCS and MACS levels. Ninety outcome measures across ICF domains were used. GDT was associated with improvements in motor function, hand use, self-care, communication, and participation. Findings were synthesized into an eight-step GDT framework highlighting collaborative goal setting, goal analysis, strategy determination, structured practice, feedback, re-evaluation, and generalization. This framework supports consistent, high-quality GDT implementation across settings and disciplines. Conclusions: In conclusion, GDT shows broad functional benefits and emphasizes individualized, client-centered care. The review offers a practical, evidence-informed framework to guide clinicians and researchers in delivering GDT with fidelity.

1. Introduction

Cerebral palsy (CP) is a group of permanent disorders that affect movement and posture, caused by nonprogressive disturbances to a child’s brain during pregnancy or infancy [1]. Individuals with CP may also experience epilepsy, secondary musculoskeletal problems, and impairments in sensation, perception, cognition, and behavior, all of which can limit daily activities [1]. Current literature highlights goal-directed training (GDT) as a method to improve function in children with CP, where the child actively practices their desired goal or task [2].
Training-based interventions such as GDT, which use varied and repetitive activities focused on a child’s specific goals to promote neuroplasticity and improved function, are considered standard for improving function in children with CP [3]. While GDT is effective, there remains a gap between evidence and clinical implementation, highlighting the need for better knowledge translation strategies for healthcare professionals [4]. Current literature shows variability in how GDT is described and delivered, with limited guidance on its core components [5,6]. Without clear protocols or frameworks, providers struggle to implement GDT as intended [5]. This article addresses this gap by defining GDT and evaluating its impact on measurable outcomes for children with CP through a scoping review, ultimately proposing a framework that outlines its core components to support consistent and effective practice.

2. Materials and Methods

2.1. Protocol and Registration

To systematically identify and review the literature, we utilized the five-step scoping review methodological framework developed by Arksey and O’Malley [7]. This scoping review was conducted in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist to ensure methodological rigor and transparency. The protocol for this review was registered on the Open Science Framework [8].

2.2. Eligibility Criteria

Inclusion criteria included peer-reviewed articles from the past 20 years that describe goal-directed or goal-oriented training or therapy as an intervention for youth with CP. Youth includes infants, toddlers, preschoolers, children, and adolescents. Studies not in English or lacking full-text access were excluded. Studies not published in English were excluded due to the language proficiency of the review team, which may introduce language bias. While translation tools were considered, the team determined that relying on automated or third-party translations could compromise accuracy and interpretation, especially for nuanced clinical or contextual findings. as the reviewers are English-speaking only and the timeframe of 20 years was adequate to establish the content needed.

2.3. Information Sources

Authors were not contacted; however, reference lists of systematic reviews were reviewed to locate individual articles. The first search was in September 2023 with the last in December 2023. Databases searched included PubMed, Academic Search Complete (EBSCO), CINAHL Complete (EBSCO), Nursing and Allied Health (Proquest), Cochrane, Scopus, Psychology Database (ProQuest), Google Scholar, and Up to Date.

2.4. Search Strategy

Search terms were selected based on an initial search for GDT and expanded to include related terms commonly used in the literature. Consistent search strands were used across databases for simplicity and consistency. Terms included “goal-directed therapy” OR “goal-oriented therapy” OR “goal-oriented training” OR “goal-directed training” and “cerebral palsy”. The MESH term for “cerebral palsy” was used for PubMed, Academic Search Complete and CINAHL Complete. Additional articles were identified by manually reviewing the reference lists of articles that met inclusion criteria and searching the first author’s name using the author tab in Scopus. The search strategy was validated by confirming that articles citied in two key systematic reviews identifying GDT as an evidence-based intervention for children with [9,10] were captured. Each database was searched individually, and the number of articles retrieved from each was documented.

2.5. Selection of Sources of Evidence

All articles retrieved were imported into the reference management system Covidence, where duplicates were removed. Two independent reviewers completed each stage of the review process, with a third reviewer verifying the results. The review stages included (1) review of titles and abstracts, (2) full text review, and (3) data extraction. Prior to initiating the review, inclusion and exclusion criteria were discussed among the team. To enhance consistency and reduce bias, reviewers engaged in calibration exercises using a subset of articles and met regularly to discuss the application of criteria. All screening and extraction were conducted in real time by two reviewers, with consensus reached collaboratively and adjudicated by a third reviewer when needed. Team meetings occurred biweekly throughout 2024 to discuss article eligibility, ensure reliability, and maintain rigor in the screening and data extraction process. Articles that met the inclusion criteria were analyzed to identify and summarize the key components of GDT and its impact across domains of the International Classification of Functioning, Disability and Health (ICF).

2.6. Data Charting Process

The following information was extracted into Covidence from each article: first author, date of publication, short title, population, intervention, comparator, perception of intervention, outcome measures, results, key findings, and additional comments. Population data extracted included diagnoses, age (range and mean), gender, Gross Motor Function Classification System (GMFCS) levels, Manual Ability Classification System (MACS) levels, and other classification data. It was also noted whether multiple diagnoses were included and if results were reported separately or combined. Descriptions of the intervention included dose and key components. Perceptions from participants, caregivers, and therapists were included when available. Outcome measures were identified along with the corresponding ICF domain assessed. For quantitative studies, the impact of the intervention on each outcome measure was assessed, focusing specifically on areas where GDT demonstrated a positive effect. For qualitative studies, key findings and themes were summarized. From January to April 2025, the research team continued to meet biweekly for data analysis and synthesis, engaging in frequent discussions to ensure consistent and thoughtful coding. This iterative process supported the development and validation of themes through consensus. As a final validity check, reviewers confirmed whether each article contained relevant information on GDT or its impact.

2.7. Synthesis of Results

Extracted data were summarized and categorized including demographic information, frequency of outcome measures, and improvements. Outcome measures showing improvement were listed and totaled to describe the overall impact of the intervention. Using qualitative descriptive approach [11], two reviewers identified seven key themes of GDT based on intervention descriptions across articles. These themes were validated by counting how frequently they appeared across the included articles. The identified GDT themes, combined with clinical expertise, informed the development of a step-by-step therapeutic process to guide healthcare professionals in implementing GDT.

3. Results

3.1. Selection of Sources of Evidence

The initial database search yielded 1198 articles, with an additional 75 articles identified through citation searching for a total of 1273 articles. After removing duplicates, 970 studies remained for screening. Following the title and abstract review, 237 full-text articles were assessed for eligibility. Of these, 81 were excluded, and a total of 156 articles met inclusion criteria (Figure 1).

3.2. Characteristics of Sources of Evidence

Of the 156 studies, 112 reported on the efficacy or effectiveness of interventions including 53 randomized trials, 53 non-randomized trials, and 6 post hoc or secondary analyses.

3.3. Study Participants

The 112 quantitative studies included 4708 participants from 3 months to 18 years old with a mean age of 6 years and 8 months (SD 1 year and 3 months). Participants included 2560 males and 1738 females. There was representation of participants at each GMFCS and MACS level, although most participants fell within levels I-III (Table 1).

3.4. Outcome Measures and ICF Domains

The ICF framework includes five components: body structures/functions, activity, participation, personal factors, and environmental factors [12]. While some outcome measures assessed more than one domain, the majority assessed activity, with fewer addressing body structures/function and participation (Figure 2).
Demographic data was the only personal factor measure identified. No outcome measures were used to exclusively measure environmental aspects, though some included supplemental questions on the environment. Ninety outcome measures were used across the 112 intervention studies. The Canadian Occupational Performance Measure (COPM), Goal Attainment Scale (GAS), Gross Motor Function Measure (GMFM), the Pediatric Evaluation of Disability Inventory (PDEI), and the Assisting Hand Assessment (AHA) were the most frequently used outcome measures (Table 2). For an overview of outcome measures and the ICF domains identified, refer to Supplemental Material Table S1.

3.5. Impact of GDT

GDT led to improvements in self-care [2] and motor outcomes including dexterity, grip, functional hand-use, balance, and walking endurance [2,19,47,63,66], and is recommended over other interventions to address underlying impairments [2]. Gross motor and quality of life outcomes were better in GDT groups than those in traditional therapy [68]. Children who participated in GDT, especially group-based settings, showed increased participation and motivation throughout intervention [54,63,71,115,116]. Mobility improved across GMFCS levels when using whole-task practice and real-life contexts [2]. GDT improved social performance by increasing opportunities for communication and problem-solving, encouraging children to be active participants in expressing with their feelings, solutions, and preferences [75]. Caregivers expressed that their child’s achievements exceeded their expectations, and they felt more knowledgeable and satisfied in their ability to support their child toward future goals [75,117].

3.6. Key Themes Identified in GDT Intervention

The key themes of GDT were identified and validated through a frequency count of their occurrence across articles (Table 3). These themes included: collaborative goal setting, family-centered practice, specific training techniques, therapy dose, social engagement, multidisciplinary approaches, and outcome monitoring.
Theme 1.
Collaborative Goal Setting.
Collaborative goal setting involves working with the child and family to establish intervention goals [16,44,118]. This approach, which includes family-centered and child-directed goal setting, aims to enhance functional performance and promote independence in daily activities [68,83]. Approximately 79 percent of the articles included collaborative goal setting (Table 3). Out of those 124 articles, 44 included the COPM and 41 the GAS (Table 2) as an aid in goal setting. Additionally,15 articles used interviewing prior to intervention to establish functional goals [48,75,76,77,78,79,81,82,83,86,90,91,100,108,153].
Theme 2.
Family-Centered Practice.
Family-centered practice prioritizes the family’s self-determination, decision-making capacity, and self-efficacy throughout the therapeutic process [14,37,44,70,120]. Key aspects of this approach include family-focused strategies, the family’s role in therapy, effective communication, and family education [120]. Approximately 58% of the articles reviewed discussed family-centered practice (Table 3).
Theme 3.
Specific Training Techniques.
Specific training techniques for GDT typically involve an individualized programs tailored to each child’s goals [2,16,18]. These techniques are often described in detail to guide intervention planning and implementation [156]. In this review, 67% of the included articles provided descriptions of specific training techniques (Table 3). Among these, constraint-induced movement therapy (CIMT) and bimanual therapy were the most frequently utilized.
CIMT involves constraining the less impaired or unaffected hand to encourage intensive practice with the affected hand during unilateral tasks [28,48,49,61,94,109]. CIMT involves repetition and shaping [99] and has well-established positive effects in children with unilateral CP [99]. Bimanual therapy, another common training technique utilized for children with CP, involves intense repetitive practice using both hands during bilateral tasks [28,99] to promote daily functioning [54]. HABIT focuses on intensive, progressive training [24,94] to improve bimanual coordination through functional activities and play [95,102] to increase independence [93]. These specific training techniques improve hand function in children with CP [102] and are among the most used approaches as they reduce limitations through daily practice in their natural environment [99].
Theme 4.
Therapy Dose.
Therapy dose refers to the length and frequency of intervention sessions [2,124,140,141,164]. Approximately 76% of the articles included a documented therapy dose or a comparison of doses (Table 3). Of those 119 articles, 89 were intervention studies with a documented dosage, while 31 were qualitative or descriptive studies that discussed dosage. Dosages ranged from approximately two hours over six months in a non-randomized experimental study [147] to the maximum dosage of 479 h over 3 years in a long-term repeated interval rehabilitation study [90]. The average therapeutic hours spent was 53.5 (median = 42). The average intervention duration was 9 weeks (median = 6 weeks).
Theme 5.
Social Engagement.
Social engagement encompasses interpersonal interactions that occur during activity [44,52,71,138]. Of the 156 articles included in the review, approximately 19% discussed social engagement or used primary or secondary outcome measures that assessed social engagement (Table 3). The social environment fostered engagement through approaches including group-based interventions, camp-based models, and community-integrated interventions. The social environment can also be reduced to support skill development, in these scenarios it is important to practice the skill across contexts, including social context to meet mastery.
Theme 6.
Multidisciplinary Approaches.
Multidisciplinary approach is the collaboration of healthcare professionals and other individuals involved in the child’s GDT [50,156] to target specific skills needed within their daily routine [31,161]. Within multidisciplinary approaches, home and school-based therapies were identified. Healthcare professionals are often the first team members individuals consider; however, caregivers are also a key component of this team for their ability to increase their child’s potential within a home-based program [131]. In school-based therapy settings, physical therapists, occupational therapists, and speech language pathologists [64] often collaborate with teachers and teaching assistants to create group interventions tailored to children’s goals, identified through outcome assessments [63]. Multidisciplinary approaches were included in 30% of the articles (Table 3). Out of those 47 articles, 31 included home-based therapy and 25 school-based as approaches to intervention using a multidisciplinary approach.
Theme 7.
Outcome Monitoring.
Outcome monitoring refers to tracking a child’s progress during the intervention, using feedback loops between caregivers and clinicians or assessment during the intervention to adjust the treatment as needed [2,40,66,77,131]. Approximately 15% of the articles incorporated outcome monitoring, either through ongoing progress assessments or structured feedback mechanisms during the intervention (Table 3). Fourteen of these studies included outcome measures during the intervention phase [2,14,37,39,40,41,43,63,66,67,69,75,77,78,99,108,113,114,118,131,136,147,152,160].

3.7. GDT Framework

Based on the identified and validated themes, a structured Goal-Directed Training (GDT) Framework was developed to guide healthcare professionals in delivering GDT with consistency and fidelity. The framework synthesizes the core components found across the literature and integrates clinical expertise to outline a stepwise therapeutic process. This framework is intended to support individualized, evidence-based intervention planning for children with cerebral palsy. The core components of the GDT Framework are defined in Table 4 and visually represented in Figure 3.

4. Discussion

While GDT is effective for children with CP [3], there is a need for knowledge translation and a clear guide for implementation strategies to ensure that healthcare providers are providing the most effective interventions available [4]. This article defines GDT and its impact on measurable outcomes for children with CP through a scoping review resulting in the development of a framework that more clearly describes its core components to help providers carry out GDT more effectively.

4.1. Collaborative Goal Setting

Collaborative goal setting engages caregivers in creating realistic, meaningful goals. As experts on their child’s needs, caregivers play a vital role in care decisions [83]. This collaborative approach ensures interventions align with the child’s needs while respecting the family’s values, preferences, and worldview. In addition to the caregiver perspective, child-directed goal setting focuses on the child’s interests and needs, aiding their engagement and motivation in the GDT process. When interventions focus on the child’s goals, they help build a sense of competency and self-efficacy [42], motivating the child to try new tasks, even those they previously found challenging.
The theme of collaborative goal-setting directly informed steps 1 and 8 of the GDT Framework. Step 1 focuses on identifying and setting individualized, function-based goals through a collaborative approach targeting meaningful activities. Step 8 emphasizes reassessing and setting new goals in collaboration with the child and family. The involvement of both caregiver and child perspectives is central to collaborative goal setting and reinforces a family-centered approach throughout the GDT process.

4.2. Family-Centered Practice

Promoting family-centered practice requires ongoing communication and empowerment throughout the intervention process. Feedback mechanisms, such as home diaries, home programs, and frequent caregiver contact, support collaborative problem-solving and help ensure skills transfer to the home environment [14]. These strategies also create opportunities for caregivers to share input on progress and guide necessary adjustments. Family-centered approaches should intentionally include efforts to build caregiver capacity and promote empowerment. Such interventions have been shown to reduce burden and stress [68], while also increasing caregivers’ confidence and understanding of their child’s potential [75].
Family-centered principles are embedded throughout the GDT Framework. Steps 1–3 emphasize the family’s role in setting meaningful goals and planning interventions. Steps 4–8 maintain the family’s position as a key team member through caregiver training, inclusion in outcome monitoring, and opportunities for feedback and program adjustments. Active family involvement is essential and is supported through consistent training, communication, and guidance.

4.3. Specific Training Techniques

Specific training techniques reduce a child’s limitations and support increased participation in their natural environment [99]. Before implementation, both the family and the child must receive thorough education and feel confident in the approach. For safety and effectiveness, these techniques should only begin once confidence is established. A key factor in the success of a specific training techniques is the collaboration between the family and the provider. Together, they identify meaningful, goal-directed activities [18] and adjust the intensity and duration of training as needed over time [16,99].
These principles inform steps 3–8 of the GDT Framework, where the child engages in targeted practice toward a specific skill or goal using techniques selected by a multidisciplinary team. In step 3, the provider works closely with the family and child to design a personalized plan that reflects with the child’s individual needs. The provider also fosters motivation and commitment by creating an optimally challenging practice environment, clearly defining the therapy dose, and ensuring the family understands how to carry out the techniques effectively. Importantly, therapy dosage plays a critical role in the overall success of specific training techniques.

4.4. Therapy Dose

Optimal therapy dosage depends on several factors, including the child’s individual needs, the complexity of the goal, type of intervention, available resources, and context of care [2]. Although the precise dose required to achieve long-term improvements in upper limb motor outcomes remains uncertain, previous systematic reviews suggest a target of 30–40 h over 6 months [140,141]. High-dose programs such as CIMT and bimanual training are well supported by evidence, while smaller-dose interventions have shown limited effects on upper-limb motor function is limited [2,124,141]. A full dose of CIMT or bimanual therapy is typically necessary for motor improvements, though a half dose may still support gains in occupational performance [47]. Notably, GDT has demonstrated positive effects on activity, participation, and motor function even at a lower therapeutic doses [52,123].
Despite these findings, dosage decisions are often shaped more by system-level constraints than by multidisciplinary team recommendations, frequently resulting in suboptimal dosing for neuroplastic change [131]. When aligned with family preferences and evidence-based practice, home programs can be an effective way to increase therapy dosage and overcome implementation barriers [127,131,164].
These insights informed several steps of the GDT Framework. In step 3d, providers determine the therapy dosage based on the family needs, environmental factors, and the outcome goals. In step 4, the established dose is implemented. In steps 5 and 6, dosage may be adjusted based on progress monitoring and feedback from the child, family, and team.

4.5. Social Engagement

Children with CP typically engage in leisure and recreation that is less varied, less social, and more sedentary compared to their peers [48,69]. While social engagement is a key factor influencing participation in school, activities, and leisure, it is often under-assessed or treated as a secondary outcome in research. Group-based interventions, however, offer a valuable strategy, supporting individual goal achievement within shared social activities. These settings naturally promote social interaction, motivation, and participation [14,63,86]. Group play and peer interaction help children develop social skills organically, while also enhancing activity levels and motor function [44,83]. Improvements in social engagement through GDT may reflect the child’s abilities to apply problem-solving skills in social contexts or result from increased physical activity stimulating social growth [65]. Because of this, social engagement should be an intentional part of intervention planning, especially in group settings, which offer a natural and indirect method for fostering these skills [75].
These considerations informed steps 2–7 of the GDT Framework. In steps 2 and 3, providers assess social factors as potential barriers or facilitators in goal achievement and identify environmental supports, including social contexts. In steps 4–7, GDT principles are applied to encourage skill acquisition, particularly when goals are social in nature or occur in social environments. Throughout this process, alignment with multidisciplinary team ensures that social engagement opportunities are integrated intentionally and effectively into treatment planning.

4.6. Multidisciplinary Approaches

Home-based therapy supported by a multidisciplinary team typically involves coaching caregivers to deliver daily interventions [145]. Each team member plays an active role in ensuring that the prescribed interventions are implemented effectively and aligned with the child’s goals [145]. Through the training and knowledge provided by the multidisciplinary team, parents gain the confidence and skills needed to support their child’s therapy at home [130].
In school-based therapy, cross-disciplinary collaboration involves professionals from different fields working together to support a child’s progress toward academic and school-related goals. Therapists offer ongoing advice and support to the teachers and staff through regular visits, guided by the GDT process [75]. By the end of the intervention, school-based professionals often report increased knowledge in motivating and training children using the GDT process [75].
These examples of multidisciplinary care informed the development of each step in the GDT Framework, highlighting the importance of continuous involvement and communication within the multidisciplinary to provide comprehensive care. A coordinated, multidisciplinary approach ensures that the child’s goals are addressed through individualized interventions. Regular outcome monitoring further supports the effective implementation of GDT.

4.7. Outcome Monitoring and Alignment with ICF Domains

Outcome monitoring emerged as a critical component of the GDT Framework, with two central subthemes: (1) using progress monitoring assessments during the intervention period and (2) engaging caregivers through feedback to review progress and adjust the intervention accordingly. Tracking outcome measures enables clinicians to monitor progress and enhance sensitivity to intervention efficacy [66]. Regular feedback allows caregivers to stay informed about their child’s progress and helps clinicians identify improvements, adjust difficulty, and tailor the program to stimulate continued progress [40,131]. Programs that enact strategies for ongoing reflection and performance reporting can foster a sense of competence, achievement, and motivation, supporting sustained engagement goal-directed activities [136]. Caregiver feedback can be delivered in various formats, including face-to-face updates, phone calls, video check-ins, or email [2].
Outcome monitoring is embedded throughout the GDT Framework. In step 2a, providers establish baseline performance using standardized outcome measures. In step 5, feedback between the therapy team and family informs real-time adjustments to the intervention. Step 6 continues this feedback loop following mid-program assessment, and in step 8, post-intervention assessment data is obtained and analyzed to determine whether new goals should be established.
Selection of outcome measures should be guided by a clear understanding of the intervention’s purpose, which can be effectively informed by the International Classification of Functioning, Disability and Health (ICF) framework [130]. The ICF provides a shared language for describing health and functioning across disciplines and has helped shift the focus of therapy from isolated impairments to a holistic, participation-centered approach [2]. While many interventions for children with CP target activity-level outcomes, a substantial number still focus on body structures and functions [22]. The GDT Framework encourages thoughtful selection of outcome measures aligned with meaningful goals across ICF domains, reinforcing the importance of personalized, goal-directed therapy.

4.8. Limitations

This scoping review includes some limitations. First, multiple reviewers were involved in the screening and data extraction stages, which may have introduced variability and subjectivity in the interpretation of findings. Second, the search was limited to articles published in English within the past 20 years, potentially excluding relevant studies outside this timeframe or in other languages. This decision reflects a balance between comprehensiveness and feasibility, and is a recognized limitation of the review. Future research may consider including non-English studies with appropriate multilingual expertise to expand global representation. Although the initial search was completed in 2023 and yielded a large number of articles, screening, extraction, and synthesis continued throughout 2024 and early 2025. Due to limited resources, the literature search was not updated beyond this period, and newly published studies may not have been captured. This is acknowledged as a limitation, and future updates of this review may consider including more recent publications to enhance currency. Additionally, gray literature was not included, as the volume of peer-reviewed results was sufficient for addressing the aims of the scoping review.

5. Conclusions

This scoping review identified seven key themes central to goal-directed therapy (GDT): collaborative goal setting, family-centered practice, specific training techniques, therapy dose, social engagement, multidisciplinary approaches, and outcome monitoring. These themes were consistently reflected across a wide range of studies and disciplines, forming the foundation for a comprehensive GDT Framework. This framework outlines both the step-by-step process and specific guidelines needed to help healthcare professionals implement GDT with fidelity.
Evidence suggests that GDT positively impacts multiple domains, including motor function, self-care, communication, problem-solving, parental knowledge and confidence, and child motivation. However, variability in how GDT is implemented has contributed to a gap between research and practice. By clearly defining the core components and therapeutic process, this review provides a practical, systematic approach for integrating GDT into routine care. The resulting framework offers clinicians and researchers a shared model to support intervention planning, delivery, and evaluation, ultimately enhancing functional outcomes for children with CP.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/children12081039/s1, Table S1: Outcome Measures, ICF Domains, and Subdomains.

Author Contributions

Conceptualization, A.S., H.R. and A.O.; methodology, A.S., H.R. and A.O.; formal analysis, H.B. and B.A.; investigation, H.B., B.A., A.S., H.R., K.C.L. and B.B.T.; resources, A.S. and H.R.; data curation, H.B., B.A. and A.W.-M.; writing—original draft preparation, H.B., B.A. and A.S.; writing—review and editing, B.B.T., B.C., K.C.L., A.W.-M., A.O. and H.R.; visualization, A.O.; supervision, A.S.; project administration, A.S.; funding acquisition, H.R. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Data Availability Statement

Not applicable.

Acknowledgments

We would like to acknowledge the invaluable contributions of the occupational therapy graduate students from Texas Woman’s University for their support in reviewing and extracting data from articles for this scoping review. Their dedication, attention to detail, and thoughtful collaboration were essential to the success of this project. We are grateful for their hard work and commitment to advancing knowledge in the field.

Conflicts of Interest

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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Children 12 01039 g001
Figure 1. PRISMA flow diagram.
Figure 1. PRISMA flow diagram.
Children 12 01039 g001
Children 12 01039 g002
Figure 2. Outcome measures by ICF domain. Abbreviations: 1-MWT, One Minute Walk Test; 2-MWT, Two Minute Walk Test; 6-MWT, Six Minute Walk Test; 9HPT, Nine Hole Peg Test; ABAS, Adaptive Behavior Assessment System; ABILHAND, Manual Ability Measure for Children with Upper Limb Impairments; ABILOCO, Abilities in Locomotion Questionnaire; ACPC, Assessment of Preschool Children’s Participation; Activlim, Activity Limitations Questionnaire; AHA, Assisting Hand Assessment; AIMS, Alberta Infant Motor Scale; AMPS, Assessment of Motor and Process Skills; APS, Assistance to Participate Scale; AROM, Active Range of Motion; BBT, Box and Block Test; BFMDRS, Burke-Fahn-Marsden Dystonia Rating Scale; BoHA, Both Hands Assessment; BOT-2, Bruininks-Oseretsky Test of Motor Proficiency, Second Edition; BRIEF, Behavior Rating Inventory of Executive Function; BSID-III, Bayley Scales of Infant Development, Third Edition; CAPE, Children’s Assessment of Participation and Enjoyment; CAS, Caregiver Assistance Scale; CHEQ, Children’s Hand-use Experience Questionnaire; CHORES, Children Helping with Responsibilities, Expectations, and Supports; CHQ, Child Health Questionnaire; COPM, Canadian Occupational Performance Measure; COSA, Child Occupational Self-Assessment; CPQOL, Cerebral Palsy Quality of Life Questionnaire; DASS, Depression Anxiety Stress Scales; DMQ, Dimensions of Mastery Questionnaire; EQ-5D, EuroQol 5-Dimension Questionnaire; EVGS, Edinburgh Visual Gait Score; FAQ, Functional Assessment Questionnaire; FES, Family Environment Scale; FIM, Functional Independence Measure; FMA, Fugl-Meyer Assessment; FTSST, Five Times Sit to Stand Test; GAS, Goal Attainment Scaling; GMFCS, Gross Motor Function Classification System; GMFM, Gross Motor Function Measure; GMPM, Gross Motor Performance Measure; GMs, General Movements; Handwriting Speed Test, Handwriting Speed Test; HAT, Hypertonia Assessment Tool; HHS, Harris Hip Score; HiMAT, High-level Mobility Assessment Tool; HINE, Hammersmith Infant Neurological Examination; HNNE, Hammersmith Neonatal Neurological Examination; HOME—Infant/Toddler, Home Observation for Measurement of the Environment—Infant/Toddler Version; IPCA, Inventory of Ptential Communicative Acts; Jebson-Taylor, Jebson-Taylor Hand Function Test; Kidsscreen, KIDSCREEN Health-Related Quality of Life Questionnaire for Children and Adolescents; Life-H, Assessment of Life Habits; MA2, Melbourne Assessment 2; MAS, Modified Ashworth Scale; MFPT, Manual Form Perception Test; MMT, Manual Muscle Testing; MPST, Muscle Power Srint Test; MST, Meter Sprint Test; MTS, Modified Tardieu Scale; MUUL, Melbourne Assessment of Unilateral Upper Limb Function; OSAS, Observational Skills Assessment Score; PAS, Postural Assessment Scale; PBS, Pediatric Balance Scale; PDMS, Peabody Developmental Motor Scales; PEDI-CAT, Pediatric Evaluation of Disability Inventory—Computer Adaptive Test; PEDI-QL, Pediatric Quality of Life Inventory; PEM, Participation and Environment Measure; PEM-CY, Participation and Environment Measure for Children and Youth; PMAL, Pediatric Motor Activity Log; PQRS, Performance Quality Rating Scale; PROM, Passive Range of Motion; PSFS, Patient-Specific Functional Scale; PVQ, Pediatric Volitional Questionnaire; QUEST, Quality of Upper Extremity Skills Test; REEL-2, Receptive-Expressive Emergent Language Test, Second Edition; SCALE, Selective Control Assessment of the Lower Extremity; SCUES, Selective Control of the Upper Extremity Scale; SFA, School Function Assessment; SMC, Selective Motor Control; STS, Sit to Stand Test; SRT, Shuttle Run Test; TAPQOL, TNO-AZL Preschool Children Quality of Life Questionnaire; TARC Assessment System, Topeka Association for Retarded Citizens Assessment System; TIS, Trunk Impairment Scale; TUG, Timed Up and Go Test; UL-3DMA, Upper Limb 3-Dimensional Motion Analysis; VOAA, Video Observations Aarts and Aarts.
Figure 2. Outcome measures by ICF domain. Abbreviations: 1-MWT, One Minute Walk Test; 2-MWT, Two Minute Walk Test; 6-MWT, Six Minute Walk Test; 9HPT, Nine Hole Peg Test; ABAS, Adaptive Behavior Assessment System; ABILHAND, Manual Ability Measure for Children with Upper Limb Impairments; ABILOCO, Abilities in Locomotion Questionnaire; ACPC, Assessment of Preschool Children’s Participation; Activlim, Activity Limitations Questionnaire; AHA, Assisting Hand Assessment; AIMS, Alberta Infant Motor Scale; AMPS, Assessment of Motor and Process Skills; APS, Assistance to Participate Scale; AROM, Active Range of Motion; BBT, Box and Block Test; BFMDRS, Burke-Fahn-Marsden Dystonia Rating Scale; BoHA, Both Hands Assessment; BOT-2, Bruininks-Oseretsky Test of Motor Proficiency, Second Edition; BRIEF, Behavior Rating Inventory of Executive Function; BSID-III, Bayley Scales of Infant Development, Third Edition; CAPE, Children’s Assessment of Participation and Enjoyment; CAS, Caregiver Assistance Scale; CHEQ, Children’s Hand-use Experience Questionnaire; CHORES, Children Helping with Responsibilities, Expectations, and Supports; CHQ, Child Health Questionnaire; COPM, Canadian Occupational Performance Measure; COSA, Child Occupational Self-Assessment; CPQOL, Cerebral Palsy Quality of Life Questionnaire; DASS, Depression Anxiety Stress Scales; DMQ, Dimensions of Mastery Questionnaire; EQ-5D, EuroQol 5-Dimension Questionnaire; EVGS, Edinburgh Visual Gait Score; FAQ, Functional Assessment Questionnaire; FES, Family Environment Scale; FIM, Functional Independence Measure; FMA, Fugl-Meyer Assessment; FTSST, Five Times Sit to Stand Test; GAS, Goal Attainment Scaling; GMFCS, Gross Motor Function Classification System; GMFM, Gross Motor Function Measure; GMPM, Gross Motor Performance Measure; GMs, General Movements; Handwriting Speed Test, Handwriting Speed Test; HAT, Hypertonia Assessment Tool; HHS, Harris Hip Score; HiMAT, High-level Mobility Assessment Tool; HINE, Hammersmith Infant Neurological Examination; HNNE, Hammersmith Neonatal Neurological Examination; HOME—Infant/Toddler, Home Observation for Measurement of the Environment—Infant/Toddler Version; IPCA, Inventory of Ptential Communicative Acts; Jebson-Taylor, Jebson-Taylor Hand Function Test; Kidsscreen, KIDSCREEN Health-Related Quality of Life Questionnaire for Children and Adolescents; Life-H, Assessment of Life Habits; MA2, Melbourne Assessment 2; MAS, Modified Ashworth Scale; MFPT, Manual Form Perception Test; MMT, Manual Muscle Testing; MPST, Muscle Power Srint Test; MST, Meter Sprint Test; MTS, Modified Tardieu Scale; MUUL, Melbourne Assessment of Unilateral Upper Limb Function; OSAS, Observational Skills Assessment Score; PAS, Postural Assessment Scale; PBS, Pediatric Balance Scale; PDMS, Peabody Developmental Motor Scales; PEDI-CAT, Pediatric Evaluation of Disability Inventory—Computer Adaptive Test; PEDI-QL, Pediatric Quality of Life Inventory; PEM, Participation and Environment Measure; PEM-CY, Participation and Environment Measure for Children and Youth; PMAL, Pediatric Motor Activity Log; PQRS, Performance Quality Rating Scale; PROM, Passive Range of Motion; PSFS, Patient-Specific Functional Scale; PVQ, Pediatric Volitional Questionnaire; QUEST, Quality of Upper Extremity Skills Test; REEL-2, Receptive-Expressive Emergent Language Test, Second Edition; SCALE, Selective Control Assessment of the Lower Extremity; SCUES, Selective Control of the Upper Extremity Scale; SFA, School Function Assessment; SMC, Selective Motor Control; STS, Sit to Stand Test; SRT, Shuttle Run Test; TAPQOL, TNO-AZL Preschool Children Quality of Life Questionnaire; TARC Assessment System, Topeka Association for Retarded Citizens Assessment System; TIS, Trunk Impairment Scale; TUG, Timed Up and Go Test; UL-3DMA, Upper Limb 3-Dimensional Motion Analysis; VOAA, Video Observations Aarts and Aarts.
Children 12 01039 g002
Children 12 01039 g003
Figure 3. Goal-directed training framework.
Figure 3. Goal-directed training framework.
Children 12 01039 g003
Table 1. Demographics.
Table 1. Demographics.
(n = 4708)n%
Gender
Male256054%
Female173837%
Not reported4109%
GMFCS
I73516%
II59713%
III51511%
IV3558%
V1904%
Not reported231649%
MACS
I4339%
II91619%
III3277%
IV681%
V631%
Not reported290162%
MeanSD
Age6.8 years 1.3 months
Abbreviation: GMFCS: Gross Motor Classification System; MACS: Manual Ability Classification System.
Table 2. Most commonly used outcome measures and source citations.
Table 2. Most commonly used outcome measures and source citations.
Outcome MeasureCountCitations
Canadian Occupational Performance Measure (COPM)44[13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56]
Goal Attainment Scale (GAS)39[13,14,15,20,23,29,30,31,32,33,34,35,36,39,40,43,44,46,52,53,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74]
Gross Motor Function Measure (GMFM)37[16,17,19,31,36,41,45,46,52,55,59,63,64,65,66,68,69,72,73,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92]
Pediatric Evaluation of Disability Inventory (PEDI)31[16,17,19,21,24,25,27,30,32,37,39,41,45,51,52,62,63,64,65,67,69,71,72,74,75,82,83,84,86,88,93]
Assisting Hand Assessment (AHA)25[13,14,21,26,32,38,47,48,49,51,53,54,56,61,63,93,94,95,96,97,98,99,100,101,102]
Box and Block Test (BBT)15[19,20,25,26,27,28,51,63,80,89,98,100,101,103,104]
Jebson-Taylor Hand Function Test (JTHFT)12[27,32,46,47,51,61,95,100,101,102,103,105]
ABILHAND-kids12[13,14,19,21,28,36,46,51,53,96,102,103]
Quality of Upper Extremity Skills Test (QUEST)10[32,39,40,43,61,62,67,72,94,106]
The Modified Ashworth Scale (MAS)8[39,56,73,76,98,107,108,109]
The Melbourne Assessment of Unilateral Upper Limb Function (MUUL)7[13,14,48,49,96,101,108]
Minute Walk Test (1, 2, 6, or 10)6[19,55,80,93,110,111]
Peabody Developmental Motor Scales (PDMS)5[15,43,74,106,112]
Bruininks-Oseretsky Test of Motor Proficiency (BOT) 5[29,80,83,95,113]
Performance Quality Rating Scale (PQRS)5[30,37,42,89,114]
Table 3. GDT framework themes: frequency and source articles.
Table 3. GDT framework themes: frequency and source articles.
ThemeCountPercentageCitations
Theme 1:
Collaborative Goal Setting		12379%[2,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,81,82,83,84,86,88,89,90,91,99,100,101,102,105,106,108,112,114,115,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142,143,144,145,146,147,148,149,150,151]
Theme 2:
Family-Centered Practice		9058%[2,13,14,15,16,17,18,19,23,24,26,27,32,33,34,36,37,40,41,42,44,47,48,49,52,53,54,55,56,57,59,61,63,65,66,67,68,69,70,71,72,74,75,76,77,79,81,88,89,90,95,97,99,100,101,105,106,113,115,116,117,119,120,121,122,123,124,125,126,128,129,131,134,135,136,137,139,142,145,147,148,149,151,152,153,154,155,156,157,158]
Theme 3:
Specific Training Techniques		10467%[2,13,14,15,16,18,19,20,21,22,24,26,27,28,29,31,32,33,34,35,36,40,41,42,47,48,49,50,52,53,54,55,57,59,60,61,63,65,68,69,75,76,77,78,79,80,82,85,86,87,88,90,91,92,93,94,95,97,98,99,100,101,102,103,104,105,106,108,109,110,111,112,114,116,118,119,120,125,127,128,129,130,131,132,134,135,136,137,139,140,143,145,146,147,148,151,152,155,156,157,159,160,161,162]
Theme 4:
Therapy Dose		11876%[2,13,14,16,17,18,19,20,21,24,25,26,28,29,31,32,33,34,35,36,38,40,41,46,47,48,49,50,51,52,53,54,55,56,57,58,60,61,63,67,68,69,70,71,72,73,74,75,76,77,78,80,81,82,83,85,86,87,88,89,90,91,92,93,94,95,96,97,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,121,123,124,126,127,128,129,130,131,132,133,135,137,138,139,141,144,146,147,148,151,154,156,157,158,160,162,163,164]
Intervention Studies88 [13,14,16,17,18,19,20,21,24,25,26,27,28,29,31,32,33,34,35,36,38,40,41,46,47,48,49,50,51,52,53,54,55,56,57,58,60,61,63,67,68,69,70,71,72,73,74,75,76,77,78,80,81,82,83,85,86,87,88,89,90,91,92,93,94,95,96,97,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,116,147,160,162]
Qualitative Studies31 [2,115,117,118,119,121,123,124,126,127,128,129,130,131,132,133,135,137,138,139,141,144,146,148,151,154,156,157,158,163,164]
Theme 5:
Social Engagement		2819%[13,30,31,41,44,48,52,63,65,69,71,75,76,83,86,88,93,120,127,128,132,137,138,147,151,152,158,162]
Theme 6:
Multidisciplinary Approaches		4630%[14,19,21,25,31,39,40,41,43,46,48,49,50,53,62,63,64,65,70,71,74,75,83,85,92,93,94,99,100,101,108,120,123,128,129,130,131,136,137,138,145,148,152,153,156,161]
Home-Based Therapy31 [14,21,25,39,40,43,50,53,62,65,70,71,74,75,83,94,99,100,101,120,123,128,129,130,131,137,138,145,148,152,153]
School-Based Therapy24 [14,25,31,39,41,48,50,63,64,65,71,74,75,83,93,94,120,129,136,137,138,153,156,161]
Theme 7:
Outcome Monitoring		2415%[2,14,37,39,40,41,43,63,66,67,69,75,77,78,99,108,113,114,118,131,136,147,152,160]
Table 4. Goal-directed training process steps, specific guidelines, and associated themes.
Table 4. Goal-directed training process steps, specific guidelines, and associated themes.
StepsSpecific GuidelinesAssociated Themes
1. Goal Setting: Identify individualized goals1a: The collaborative approach begins with multiple stakeholders, including the client, parent, teacher, and therapy team.Collaborative goal setting, Family-centered, Multidisciplinary approaches
1b: The goals should have a functional focus and should target meaningful activities.
1c: The goals should be defined and measurable.
2. Goal Analysis: Identify goal limiting factors2a: It is important to determine what skills are needed, which skills are difficult, and which skills are strengths. These will be assessed through baseline measurements.Family-centered, Social engagement, Multidisciplinary Approach, Outcome monitoring (2a)
2b: Task analysis will need to be performed to determine any barriers and facilitators. The provider will need to consider multiple domains which can include motor, cognition, social, communication, and the environment.
3. Determine Strategies and Practice3a: The provider will then need to determine the approach. The approach can be remedial, accommodative, include modifications, mixed, evidence-based, or family preference depending on their needs.Family-centered, Specific training techniques, Therapy dose (3d), Social engagement (3c), Multidisciplinary approach
3b: When determining the activities and tasks, the provider will need to provide the family and child with motivation, seeking out the best way to engage them, and finding the just right challenge.
3c: The provider will then need to determine the environmental supports including the different domains of social, physical, modifications, products, and technology.
3d: The provider will determine the dose, which is the amount of time to practice the skill or goal together.
3e: The provider will need to educate the family and client on the intervention strategies through practicing the skill or goal together.
4. Targeted Practice of the Skill/Goal Family-centered (especially at home), Specific training techniques, Therapy dose, Social engagement (depending on if their goal is social or performed in social contexts), Multidisciplinary approach
5. Provide Feedback and Progressive TailoringContinue step 4 throughout this process while in collaboration with the therapy team, the family, and the client.Family-centered, Specific training techniques, Therapy dose, Social engagement (depending on if their goal is social or performed in social contexts), Multidisciplinary approach, Outcome monitoring
6. Re-evaluate, Progress TrackingContinue to collaborate with the therapy team, the family, and the client. At this time, it is important to re-evaluate Step 2 ‘Goal Analysis’ as needed, depending on the client’s progress with the skill or goal. Family-centered, Specific training techniques, Therapy dose, Social engagement (because you go back to step 2), Multidisciplinary approach, Outcome monitoring
7. Practice Goal Across ContextsContinue practice until mastery of the goal is achieved within different contexts of their daily life. Family-centered, Specific training techniques, Therapy dose, Social engagement, Multidisciplinary approach
8. Evaluate Need for New Goals Collaborative goal setting, Family-centered, Multidisciplinary approach, Outcome monitoring
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MDPI and ACS Style

Shierk, A.; Barry Thias, B.; Becker, H.; Allen, B.; Chaiprasert, B.; Lampe, K.C.; Wallace-McCollom, A.; O’Brien, A.; Roberts, H. Defining Goal-Directed Training for Children with Cerebral Palsy: A Scoping Review and Framework for Implementation. Children 2025, 12, 1039. https://doi.org/10.3390/children12081039

AMA Style

Shierk A, Barry Thias B, Becker H, Allen B, Chaiprasert B, Lampe KC, Wallace-McCollom A, O’Brien A, Roberts H. Defining Goal-Directed Training for Children with Cerebral Palsy: A Scoping Review and Framework for Implementation. Children. 2025; 12(8):1039. https://doi.org/10.3390/children12081039

Chicago/Turabian Style

Shierk, Angela, Bridget Barry Thias, Haley Becker, Baylee Allen, Benjamin Chaiprasert, Katherine C. Lampe, Ava Wallace-McCollom, Aidan O’Brien, and Heather Roberts. 2025. "Defining Goal-Directed Training for Children with Cerebral Palsy: A Scoping Review and Framework for Implementation" Children 12, no. 8: 1039. https://doi.org/10.3390/children12081039

APA Style

Shierk, A., Barry Thias, B., Becker, H., Allen, B., Chaiprasert, B., Lampe, K. C., Wallace-McCollom, A., O’Brien, A., & Roberts, H. (2025). Defining Goal-Directed Training for Children with Cerebral Palsy: A Scoping Review and Framework for Implementation. Children, 12(8), 1039. https://doi.org/10.3390/children12081039

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