Comprehensive Occupational Therapy Evaluation (COTE)

Purpose

The COTE is a behavior rating scale that is used to delineate occupational therapy’s unique role in comprehensive adult mental health programs. It is used to identify behaviors (general behaviors, interpersonal behaviors, task behaviors) that impact occupational performance, define these behaviors to decrease misinterpretations, communicate a large amount of information in a simple manner to other team members, and to allow easy retrieval of data needed for treatment planning and evaluating progress. 

Basic Information

• Title/Author(s):
  Comprehensive Occupational Therapy Evaluation (COTE) Scale
  Developed by: Susan Larson, Ann Haut, and Catherine Platt
  
  

• Year of Development & Publisher:
  
  

  • Developed and published in 1978.
    
    

  • Publisher: The American Occupational Therapy Association (AOTA).
    
    

  • Found in: Comprehensive Occupational Therapy Evaluation Scale (COTE), AOTA Publications.
    
    

Assessment Details

• Identify TWO Types:
  
  

  • Criterion-referenced
    
    

  • Observation-based performance assessment
    
    

• Cost & How to Access:
  
  

  • Cost:
    
    

    • Originally available for purchase through AOTA, but today it is often accessible through academic libraries or textbooks that reprint the scale.
      
      

  • Access:
    
    

    • Some adapted versions are available through university OT departments and clinical education resources.
      
      

    • Full original test manual may require purchase or library access.
      
      

• Population & Setting:
  
  

  • Population:
    
    

    • Primarily used with adults with mental health conditions, though it can be adapted for individuals with cognitive, emotional, or behavioral impairments.
      
      

  • Setting:
    
    

    • Inpatient psychiatric units, community mental health centers, outpatient behavioral health clinics, rehabilitation settings, day treatment programs.
      
      

• Purpose & Areas Assessed:
  
  

  • Purpose:
    
    

    • To provide a structured observation tool that helps occupational therapists assess behaviors related to general task performance, interpersonal skills, and psychological functioning during engagement in therapeutic activities.
      
      

  • Behavioral Areas Assessed (26 behaviors total across 3 domains):
    
    

    • General behavior (e.g., appearance, activity level, reliability)
      
      

    • Interpersonal behavior (e.g., sociability, cooperation, attention-getting behavior)
      
      

    • Task behavior (e.g., engagement, organization, concentration)
      
      

Administration & Scoring

• Administration:
  
  

  • Time Required:
    
    

    • Observation typically occurs during a typical therapy session (30–60 minutes).
      
      

    • Formal scoring takes an additional 5–10 minutes after the session.
      
      

  • Format:
    
    

    • Conducted through direct observation of client behaviors during structured activities.
      
      

• User Qualifications:
  
  

  • Administered by licensed occupational therapists or occupational therapy students under supervision.
    
    

• Materials Required:
  
  

  • COTE rating scale sheet
    
    

  • Client engaged in a purposeful or therapeutic activity
    
    

  • Pen/pencil
    
    

• Scoring:
  
  

  • Each of the 26 behaviors is scored on a 5-point ordinal scale:
    
    

    • 0 = Normal behavior
      
      

    • 1 = Minimal problem
      
      

    • 2 = Mild problem
      
      

    • 3 = Moderate problem
      
      

    • 4 = Severe problem
      
      

  • Higher total scores indicate greater dysfunction.
    
    

  • Scores can be grouped into subscores reflecting general, interpersonal, and task behaviors to guide treatment planning.
    
    

Psychometrics/Standardization

• Reliability:
  
  

  • Early research reported moderate to high interrater reliability for the majority of the 26 items (Larson et al., 1978).
    
    

  • Some follow-up studies suggest that reliability improves with observer training.
    
    

• Validity:
  
  

  • Face validity and content validity are considered strong — behaviors selected were clinically relevant to occupational functioning.
    
    

  • Construct validity supported in psychiatric settings; higher scores associated with more severe psychiatric symptoms (e.g., schizophrenia, depression).
    
    

• Norms:
  
  

  • No strict normative data.
    
    

  • Behaviors are interpreted relative to the setting and expectations for functioning in typical occupational therapy sessions.
    
    

Critical Thinking Sections

Strengths

• Structured but flexible — Allows therapists to observe natural client performance while systematically rating important functional behaviors.
  
  

• Broad applicability — Can be used across many mental health diagnoses and levels of severity.
  
  

• Quick scoring after session — Once trained, therapists can complete ratings in under 10 minutes.
  
  

• Supports treatment planning — Highlights specific behavioral and interpersonal areas to target in therapy.
  
  

• Encourages real-time clinical reasoning — Observation of "in the moment" occupational performance is essential.
  
  

Weaknesses

• Requires clinical training and practice — New users may score inconsistently without training.
  
  

• Subjectivity in scoring — Despite structured format, ratings can vary between observers if no consensus guidelines are applied.
  
  

• No updated norm-referenced scores — Interpretation depends heavily on therapist experience and contextual knowledge.
  
  

• Less suited for severe cognitive impairments — May be challenging to apply meaningfully with clients who cannot engage even minimally in task activities.