development and standardization of a “do–eat” activity of ... · larly during the...
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The American Journal of Occupational Therapy� 47
Development and Standardization of a “Do–Eat” Activity of Daily Living Performance Test for Children
KEY WORDS• activities of daily living• ecosystem• motor skills disorders• reproducibility of results
Naomi Josman, PhD, is Associate Professor, Department of Occupational Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel, Haifa 31905 Israel; [email protected]
Ayelet Goffer, MSc, is Adjunct Lecturer, Department of Special Education, Faculty of Education, Oranim Academic College of Education, Kiryat Tivon. At the time of the study, she was master’s-degree student, Department of Occupational Therapy, University of Haifa, Mount Carmel, Haifa, Israel.
Sara Rosenblum, PhD, is Chair and Senior Lecturer, Department of Occupational Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel, Haifa, Israel.
BACKGROUND. The Do–Eat was developed to evaluate daily task performance abilities among children with developmental coordination disorder (DCD). This study investigated the tool’s reliability and validity.
METHOD. Participants were 59 children ages 5 to 6.5 years; 30 children diagnosed with DCD according to the DSM–IV–TR; and a control group of 29 children, who were matched for age, gender, and sociodemographic background.
RESULTS. Both the Do–Eat and the accompanying Parent Questionnaire yielded high internal consistency (αs = .89–.93). Construct validity was demonstrated by significant between-group differences on the Do-Eat (t [57] = 14.09, p < .001) and the Parent Questionnaire (t [57] = 3.64, p < .001). Significant correlations between children’s scores on the sensory–motor component of the Do–Eat and the Movement Assessment Battery for Children final score confirmed concurrent validity (r = −.86, p < .001).
CONCLUSIONS. Results suggest that the Do–Eat is a reliable, valid tool for identifying children at risk for DCD.
Josman, N., Goffer, A., & Rosenblum, S. (2010). Development and standardization of a “Do–Eat” activity of daily living performance test for children. American Journal of Occupational Therapy, 64, 47–58.
Naomi Josman, Ayelet Goffer, Sara Rosenblum
Developmental�coordination�disorder�(DCD)�is�characterized�by�motor�impair-ment�that�significantly�interferes�with�a�child’s�activities�of�daily�living�(ADLs)�
and� academic� achievement (Criterion�A�and�B�of� the�Diagnostic and Statistical Manual of Mental Disorders, 4th�ed.,�text�rev.�[DSM–IV–TR];�American�Psychiatric�Association�[APA],�2001;�Dewey�&�Wilson,�2001;�Miyahara�&�Mobs,�1995).
Research�analyzing�ADLs�of�children�with�DCD�has�pointed�to�evidence�that�these�children�participate�less�than�their�peers�in�daily�household�activities�and�in�educational�and�social�settings�(Cermak�&�Larkin,�2002).�Ayres�(1985)�claimed�that�children�with�sensory–motor�difficulties�learn�daily�skills�later�than�their�peers�and�do�so�in�an�ineffective�manner.�They�become�frustrated�while�trying�to�learn�new�skills�and,�as�a�result,�avoid�participating.�The�difficulties�manifested�in�basic�daily�functions�are�evident�in�dressing,�personal�hygiene,�and�eating�as�well�as�in�instrumental�ADLs� (IADLs),� such� as�preparing� food� (May-Benson,� Ingola,�&�Koomar,�2002).
A�study�conducted�by�May-Benson�(1999)�focused�on�children�with�dyspraxia�during�school�years�and�found�that�71%�of�children�had�difficulty�using�cutlery�and�tying�shoelaces,�46%�had�difficulty�dressing�and�buttoning,�and�67%�displayed�messy�eating.�Hoare�(1994)�found�that�young�children�with�DCD�have�difficulties�related�to�eating,�such�as�chewing�different�types�of�food,�pouring�milk�into�a�glass,�cutting�food,�and�clearing�dishes�from�the�table.�They�have�difficulty�eating�with�cutlery�and�tend�to�soil�themselves�and�their�immediate�surroundings.�The�manner�in�which�
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they�eat�has�a�negative�impact�on�their�family�environment�at�mealtimes�and�is�used�as�a�justification�by�classmates�for�taunting�(Hoare,�1994).�When�children�with�DCD�get�to�school,�they�experience�difficulty�in�acquiring�writing�skills�(Benbow,�1995)�and,�over�time,�increasingly�fail�to�com-plete�written�tasks�and�assignments�in�a�reasonable�amount�of� time� (Benbow,�2002).�Because� of� impaired� function,�many�children�with�DCD�are�referred�for�occupational�or�physical� therapy� (Dunford,� Street,� O’Connell,� Kelly,� &�Sibert,� 2004;� Green� et� al.,� 2005;� Peters,� Henderson,� &�Dookun,�2004).
Reliable�assessment�tools�for�validating�the�DSM–IV–TR�criteria�for�diagnosis�of�a�child�with�DCD�referred�for�treatment�are�scarce;�although�this�state�of�affairs�has�been�documented�in�the�literature,�the�consequences�are�inade-quate�interventions�for�these�children�(Dewey�&�Wilson,�2001).�For�example,�research�into�the�course�of�treatment�of�children�with�DCD�over�several�years�found�that�by�age�8,�a�typical�child�with�DCD�has�been�referred�to�10�differ-ent�therapeutic�sources�within�the�medical�service.�These�sources�often�include�two�terms�of�treatment�in�occupa-tional� therapy� within� different� frameworks� (Missiuna,�Moll,�Law,�King,�&�King,�2006).�These�findings�demon-strate� the� need� to� develop� a� viable� assessment� tool� that�provides�a�clear�and�comprehensible�indication�of�the�func-tion�of� children�with�DCD�and� facilitates� the�design�of�tailored�intervention�goals�based�on�specific�demonstrated�needs�(Dunford�et�al.,�2004;�Miller,�Missiuna,�Macnab,�Malloy-Miller,�&�Polatajko,�2001).
According� to� the� literature,� functional� difficulties� of�children�with�DCD�manifest�themselves� in�the�children’s�ability�to�dress,�in�eating-related�activities,�and�in�handwrit-ing�difficulty.�The�assessment�tool�described�in�this�article�addresses�these�specific�areas.�The�need�for�viable�tools�that�address�function-related�difficulties�is�especially�amplified�by�the�research�literature,�which�has�documented�the�impaired�quality�of�life�of�the�child�and�his�or�her�family�resulting�from�these�difficulties� (Sprinkle�&�Hammond,�1997).�Because�these� children� cannot�perform�daily� functional� activities,�their�lives�and�those�of�their�families�are�fraught�with�intense�feelings�of�frustration�(Cermak�&�Larkin,�2002).�Parents�of�children�with�DCD�have�reported�that�accomplishing�tasks�requires�considerable�time�and�energy�(May-Benson,�1999),�and�severe�tensions�are�aroused�within�the�family,�particu-larly�during�the�early-morning�rush�routine�and�at�mealtimes�(Missiuna,�2001).
The�significance�of�such�children’s�incompetent�ADL�performance�has�previously�been�discussed.�Daving,�Andren,�and�Grimby�(2000)�indicated�that�independence�in�everyday�activities�actually�enhances�adaptation�to�the�environment�and�optimizes�function.�Likewise,�having�control�over�self-
care�activities�contributes�to�the�child’s�feelings�of�compe-tence� and� improves� integration� in� school� (Chapparo� &�Hooper,�2005).�Therefore,�impairments�in�everyday�func-tioning� interfere�with� the� child’s� ability� to�participate� in�family�and�school�activities�(Case-Smith,�1993).
In�light�of�this�evidence,�the�ability�to�assess�daily�activity�functioning�in�children�with�DCD,�emphasizing�quality�of�performance� and�participation,� is� imperative� (Cermak�&�Larkin,�2002;�May-Benson�et�al.,�2002).�However,�the�puz-zling�plight�of�children�with�DCD,�and�the�heterogeneous�nature�of�their�symptoms�and�presenting�difficulties�(comor-bidities),�make�the�process�of�assessment�extremely�compli-cated�and�raise�many�issues�regarding�the�adequacy�of�various�testing� methods� (Gibbs,� Appleton,� &� Appleton,� 2007;�Henderson� &� Barnett,� 1998;� Wann,� Mon-Williams,� &�Rushton,�1998;�Wilson,�2005).
Existing�methods�for�evaluating�the�performance�of�chil-dren�with�DCD�include�(1)�both�parent�and�teacher�ques-tionnaires—for�example,�the�Developmental�Coordination�Disorder� Questionnaire (Wilson,� Kaplan,� Crawford,�Campbell,�&�Dewey,�2000)�and�the�Children�Activity�Scale�Parent�and�Teacher�(ChAS–P–T;�Rosenblum,�2006)—and�(2)�assessment�tools—for�example,�the�Movement�Assessment�Battery�for�Children�(M–ABC;�Henderson�&�Sugden,�1992)�and�the�Bruininks–Oseretsky�Test (Bruininks�&�Bruininks,�2005;�for�a�discussion�regarding�evaluation�of�performance�in�children�with�DCD,�see�also�Henderson�&�Barnett,�1998;�Missiuna,�Rivard,�&�Bartlett,�2003,�2007).
Most�assessment�tools�developed�for�children�with�DCD�are�based�on� a� “bottom-up”� approach,�whereby� a� child’s�difficulties�are�evaluated�by�analyzing�gross�and�fine�motor�skills�(Mandich,�Polatajko,�Mancab,�&�Miller,�2001).�These�tests�exclude�any�evaluation�of�performance�related�to�daily�activities�(Crawford,�Wilson,�&�Dewey,�2001).�Moreover,�they�do�not�include�cognitive�performance�skills,�despite�the�importance�of�evaluating�the�relationships�between�cognition�and�sensory–motor�skills�(Ylvisaker�&�Szekeres,�1998)�and�their�relationship�to�performance�of�daily�tasks�(Katz,�2005).�In�addition�to�these�tools,�more�recent�tools�have�been�devel-oped,� based� on� a� “top-down”� approach� (e.g.,� Perceived�Efficacy�and�Goal�Setting�in�Young�Children;�Missiuna�&�Pollock,�2000);�however,�these�tools�do�not�address�IADLs.�Both�bottom-up�and�top-down�tools�for�children�with�DCD�described� here� raise� questions� regarding� their� ecological�validity�(Barnett�&�Peters,�2004).
According�to�Kvavilashvili�and�Ellis�(2004),�the�term�ecological validity�refers�to�both�the�task’s�degree�of�represen-tativeness�and�the�ability�to�generalize�test�results�to�ADLs�in�the�natural�environment.�In�that�context,�one�may�ask�what�relationships�exist�between�specific�tasks�(such�as�draw-ing�a�triangle�in�the�Beery–Buktenica�Developmental�Test�
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The American Journal of Occupational Therapy� 49
of�Visual–Motor�Integration�(Beery�&�Buktenica,�1997)�or�threading�beads� in�the�M–ABC)�and�the�child’s�everyday�home�or�school�performance�and�participation.�To�the�best�of�our�knowledge,� only�one� assessment� that� includes� the�child’s�ability�to�perform�functional�everyday�tasks�has�been�cited�as�a�possible�measure�for�children�with�DCD,�namely�the�Vineland�Adaptive�Behavior�Scale�(Sparrow,�Cicchetti,�&�Balla,�2005).�This�tool�was�actually�developed�for�assess-ing�children�with�mental�retardation�and�autism�(De�Bildt�et�al.,�2005)�but�was�not�initially�intended�for�children�with�atypical� brain�development� (Kaplan,�Wilson,�Dewey,�&�Crawford,� 1998)� or� specific� learning� disabilities� (Kirby,�Davies,�&�Bryant,�2005),�such�as�DCD.
In�summary,�a�review�of�the�literature�underscores�the�paucity�of�viable�top-down�tools�that�are�ecologically�valid�and�do�not�rely�solely�on�parental�reports.�Most�ADL�assess-ments�were�designed�for�children�with�complex�disabilities�and� are� inappropriate� for� children�with�DCD,� attention�deficit� hyperactivity� disorder,� and� learning� disabilities.�Moreover,�on�the�basis�of�several�citations�cited�earlier�in�this�article,�Missiuna�et�al.�(2007)�recently�indicated�that�an�accepted� standard� for� the� assessment� of� DCD� is� still�lacking.
This� article�presents� the�Do–Eat� (Goffer,� Josman,�&�Rosenblum,�2009)�as�an�assessment� tool� for� IADL�perfor-mance�among�children�with�DCD.�The�Do–Eat�is�an�ecologi-cally�valid�assessment�tool�that�focuses�on�food�preparation�and�on�drawing,�writing,� and� cutting.�The� assessment� is�based�on�both�top-down�and�bottom-up�approaches.�The�tool’s�purpose�is�to�evaluate�relevant�performance�areas�for�children�with�DCD�and�to�assist�in�establishing�customized�goals�and�objectives�for�intervention�with�these�children.�In�this�article,�we�describe�the�development�of�the�Do–Eat�and�report�respective�reliability�and�validity�measures,�specifically�interrater�and�internal�reliability�and�concurrent�and�con-struct�validity.
Method
Participants
Participants�included�59�children,�ages�5�to�6.5�years,�who�were�selected�for�the�study�as�a�convenience�sample.�We�used�this�constricted�age�group�to�reduce�the� likelihood�of�age�constituting�an�intervening�variable�in�the�study,�given�that�children’s�performance�abilities�improve�with�age.�All�study�participants�were�Hebrew� speakers�who� attended� regular�schools� and�preschools.�The� study�group� consisted�of�30�children�who�were�diagnosed�as�having�DCD,�as�defined�by�the�DSM–IV–TR�(APA,�2001)�and�on�the�basis�of�scoring�<15th�percentile�on�the�Movement�Assessment�Battery�for�
Children�(M–ABC;�Henderson,�&�Sugden,�1992).The�con-trol�group�consisted�of�29�children�who�were�matched�on�age,� gender,� and� sociodemographic�background�with� the�study�group.�In�both�groups,�77%�of�children�were�boys,�and�23%�were�girls.�No�significant�age�differences�between�the�groups�were�evident�(research�group�age�range�=�58–78�months,�mean�[M]�=�68.2�months,�standard�deviation�[SD]�=�5.19;�control�group�age�range�=�59–81�months,�M�=�68.8�months,�SD =�5.42).�On�the�basis�of� information�from�a�survey�that�is�routinely�done�in�the�Israeli�educational�sys-tem,�we�excluded�children�with�physical�or�communication�limitations� (cerebral�palsy,�pervasive�developmental�delay,�visual� impairment,� or�hearing� impairment)� and� children�with�mental�retardation�from�the�study.
All�of�the�children�in�both�groups�had�at�least�an�“ade-quate”� cognitive� and� meta-cognitive� performance� level,�based�on�the�results�of�the�mean�score�of�the�cognitive�and�meta-cognitive�items�of�the�ChAS–P–T�(see�the�description�of�this�measure�in�the�next�section).�The�mean�score�for�both�groups�on�both�questionnaires�was�greater�than�the�“almost�well”� performance� level� (for� the�Children�Activity� Scale�Parent� [ChAS–P]:� children�with�DCD,�M� =�4.02,�SD =�0.68;�typically�developing�children,�M�=�4.54,�SD�=�0.38;�for�the�Children�Activity�Scale�Teacher�[ChAS–T]:�children�with�DCD,�M�=�3.79,�SD�=�0.73;�typically�developing�chil-dren,�M�=�4.44,�SD =�0.54);�the�lowest�score�for�the�ChAS–P�was�2.29�(2�=�adequate),�and�the�lowest�score�for�the�ChAS–T�was�2.57.
Instruments
“Do–Eat” Questionnaire and Test. The�Do–Eat�is�an�eco-logical�test�administered�in�the�child’s�natural�surroundings,�such�as�the�family�kitchen�or�the�kindergarten.�The�child�is�asked�to�perform�three�tasks:�(1)�make�a�sandwich,�(2)�prepare�chocolate�milk,�and�(3)�fill�out�a�certificate�of�outstanding�performance�for�him-�or�herself�(see�Figure�1).�Throughout�the�child’s�performance,�he�or�she�receives�(1)�a�score�for�per-forming�the�task,�(2)�an�analysis�score�for�sensory–motor�skills,�and�(3)�an�analysis� score� for�executive� functions�(EF).�For�example,�the�task�performance�requires�pouring�milk�into�a�glass�as�part�of�preparing�chocolate�milk.�The�sensory–motor�analysis�skills�evaluated�are�motoricity,�posture�and�movement�relationships,�motor�planning,�bilateral� coordination,�fine�motor�coordination,�and�sensation.�The�EF�analysis�compo-nents�evaluated�are�attention,�initiation,�sequencing,�transi-tion�from�one�activity�to�another,�spatial�and�temporal�orga-nization,� inhibition,� problem� solving,� and� remembering�instructions�(see�the�Appendix).
Test�scores�range�from�1�(unsatisfactory performance)�to�5�(very good performance).�As�the�test�is�administered�to�the�child,� parents� simultaneously� complete� a� questionnaire�
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50� January/February 2010, Volume 64, Number 1
consisting�of�12�positive�statements�(e.g.,�“My�child�eats�and�drinks�without�getting�dirty”).�Parents�are�required�to�rank�each�statement�on�a�scale�ranging�from�1�(never, indi-cating�difficulties)�to�5�(always, indicating�very�good�per-formance).� The� following� outcome� measures� can� be�
obtained�from�the�tool:�an�overall�total�task�performance�score,�an�overall�score�analyzing�sensory–motor�skills,�and�an�overall�score�analyzing�EF�associated�with�task�perfor-mance.�The�test�also�provides�a�summary�test�score�that�incorporates�the�average�of�the�three�scores�and�a�summary�score�for�the�parent�questionnaire.
Recent�research�aimed�at�establishing�the�Do–Eat’s�dis-criminant�validity�among�three�age�groups�of�typically�devel-oping�children�(5–6,�6–7,�7–8)�and�gender�has�been�reveal-ing:�Significant�differences�were�obtained�between�age�groups�(F[2,�85]�=�8.38,�p�=�.000,�η2�=�.16),�for�gender�differences�(F[1,�85]�=�8.45,�p�=�.005,�η2�=�.09),�and�for�their�interaction�(F[2,�85]�=�3.61,�p =�.031,�η2�=�.08;�for�more�details,�see�Frisch�et�al.,�2009).
Movement Assessment Battery for Children.�The�M–ABC�(Henderson�&�Sugden,�1992)�was�designed�to�identify�and�evaluate�children�with�mild�to�moderate�motor�impairment.�This�assessment�enjoys�widespread�use�in�clinical�and�research�contexts�and�is�currently�considered�the�most�appropriate�tool�of�its�kind�for�evaluating�motor�impairment�(Crawford�et� al.,� 2001;� Geuze,� Jongmans,� Schoemaker,� &� Smits-Engelman,�2001;�Van�Waelvelde,�De�Weerdt,�De�Cock,�&�Smits-Engelsman,�2004).�The�battery�consists�of�two�parts:�(1)�a�test�that�is�performed�on�an�individual�basis�with�the�child�and�(2)�a�questionnaire�given�to�an�adult�who�knows�the�child�and�observes�him�or�her�on�a�daily�basis.�It�consists�of�eight�subtests�of�motor�function,�including�three�that�test�manual�dexterity,�two�that�assess�ball�skills,�and�three�that�assess� static� and�dynamic�balance.�The�battery�has� been�standardized�for�age,�providing�norms�for�children�ages�4�to�12�in�four�age-related�item�sets.�Children�can�score�between�0�and�5�on�each�item,�and�the�total�score�will�range�from�0�to�40,�with� increased� impairment� associated�with�higher�scores.�The�final�score�is�converted�to�a�percentile,�thus�serv-ing�as�a�criterion�for�determining�children�at�risk�for�DCD�(15th�percentile)�and�children�at�high�risk�for�DCD�(5th�percentile).
Extensive� information�on� the�M–ABC’s� validity� and�reliability�is�presented�in�the�manual�(Henderson�&�Sugden,�1992)�and�in�Henderson�and�Barnet�(1998).�The�M–ABC�was�translated�into�Hebrew�(translation�and�backtranslation)�with�the�publisher’s�permission.�In�this�study,�we�used�the�test�only,�without�the�questionnaire.
Children Activity Scale–Parent and Teacher. These�ques-tionnaires�were�developed�to�identify�children�ages�4�to�8�at�risk� for�DCD,�based�on� their�parents’�or� teacher’s� report�(Rosenblum,�2006)�or�both.�The�questionnaire�is�brief�and�requires�5�to�10�min�to�complete.�The�ChAS–P�includes�27�items�regarding�activities�that�have�been�found�to�be�defi-cient�among�children�with�DCD.�The�ChAS–T�includes�22�items�similar�to�those�of�the�ChAS–P�but�referring�to�the�
Figure 1. Do–Eat tasks: (A) preparing a sandwich, (B) preparing a milk drink, and (C) filling out a certificate of outstanding performance for self.
A
B
C
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The American Journal of Occupational Therapy� 51
school�environment.�The�items�address�issues�of�gross�and�fine�motor�activities,�learning,�organization�in�space�and�time�during�performance�of�daily� activities,� self-care,�mobility,�and�play.�The�parent�or�teacher�is�asked�to�rate�how�the�child�performs�certain�activities�in�comparison�to�his�or�her�peers�on�a�5-point�Likert�scale�(1�=�less adequately,�2�=�adequately,�3�=�almost well,�4�=�well, and�5�=�very well).�The�outcome�measure�is�an�average�score�ranging�from�1�to�5.�Children�who�obtain�a�mean� score� ranging� from�1� to�3.42�on� the�ChAS–T,� a� mean� score� ranging� from� 1� to� 3.82� on� the�ChAS–P,�or�both�are�categorized�as�possibly�having�DCD.
Seven� items�on�both� the�ChAS–P�and� the�ChAS–T�measure�learning�and�organization�abilities�in�various�envi-ronments�(e.g.,�Item�5,�“learning�new�movement�skills,”�or�Item�19,�“organization�in�time�and�space�in�preparation�for�eating”;�for�further�details,�see�Rosenblum,�2006).�We�com-puted�a�mean�score�for�those�seven�items�to�screen�for�the�cognitive� and�meta-cognitive� level� of�performance�of� the�participants�in�this�study.
Internal� consistency,� construct�validity,� and�concur-rent� validity� with� the� M–ABC� have� been� reported� and�suggest�that�the�ChAS–T�and�ChAS–P�are�reliable�tools�to�identify�children�at�risk�for�DCD�(for�further�details,�see�Rosenblum,�2006).
Procedure
The�Board�of�Education’s�Committee�on�Activities�Involving�Human�Subjects�approved�all�recruitment�and�intervention�procedures.�Parents�signed�a�consent�form�and�completed�both�the�ChAS–P�and�the�Do–Eat�questionnaires.�Teachers�filled�out�the�ChAS–T,�and�Ayelet�Goffer�collected�all�data.�Each�child�underwent�two�sessions:�(1)�testing�on�the�M–ABC�and�(2)�testing�on�the�Do–Eat.�All�assessments�were�conducted� either� at�home�or� at� school.�The�Do–Eat�was�conducted�in�a�kitchen�environment�or�in�a�room�with�a�sink,�faucet,�and�suitable�worktable.
Data Analysis
To�examine�whether� the�groups�with�and�without�DCD�differed�with�respect�to�the�M–ABC�items,�we�performed�frequency�and�Mann–Whitney�analyses.�We�computed�the�calculation�of�interrater�reliability�for�the�Do–Eat�test�overall�final�score�according�to�Polit�and�Hungler’s�(2003)�formula,�and�we�used�Cronbach’s�α�coefficient�to�compute�internal�consistency�for�Do–Eat�components.
We�analyzed�the�differences�between�the�group�with�DCD�and�the�control�group�by�means�of�a�t�test�for�nonequivalent�groups.�We�analyzed�the�questionnaire’s�concurrent�validity�with�Pearson�correlation�coefficients:�Respective�correlations�were�computed�between�the�Do–Eat�sensory–motor�com-ponent�score�and�the�M–ABC�overall�score�and�between�the�Do–Eat�and�ChAS–P�and�ChAS–T�overall�scores.�Likewise,�we�computed�Pearson�correlation�coefficients�to�determine�the�relationships�between�the�Do–Eat�test�and�Do–Eat�par-ent�questionnaire�overall�scores.
ResultsBefore�we�present�the�Do–Eat�reliability�and�validity�results,�we�describe�the�participants’�performance�on�the�eight�M–ABC� subtests.�As�presented� in�Table�1,�Mann–Whitney�analysis�applied�to�these�eight�items�yielded�statistically�sig-nificant�differences�between�the�children�with�and�without�DCD.�The�results�of�this�analysis�indicated�that�the�children�with�DCD� received� significantly�higher� scores� (i.e.,� per-formed�worse)�on�all�eight�M–ABC�subtests,�meaning�that�their�manual�dexterity,�ball�skills,�and�static�and�dynamic�balance�abilities�were�inferior�to�those�of�the�control�group.
Content and Face Validity
The�Do–Eat�tasks�were�selected�on�the�basis�of�the�respective�literatures�relating�to�functional�deficits�among�children�with�DCD.�This�background�included�(1)�structured�interviewing�
Table 1. A Comparison of Performance on the Eight Movement Assessment Battery for Children (M–ABC) Subtests for Children With and Without Developmental Coordination Disorder (DCD; Mann–Whitney Analysis)
Subtest M–ABC Item Description
Children With DCD (n = 30)
Children Without DCD (n = 29)
Z p <Mean SD Mean SD
Manual dexterity 1 Positioning coins in bank box 3.43 1.15 1.71 1.04 –5.04 .001Manual dexterity 2 Threading a lace 4.50 1.13 2.46 1.79 –4.87 .001Manual dexterity 3 Drawing a line into a trail 2.23 1.54 0.40 0.81 –4.66 .001Ball skills 1 Bouncing and catching a ball with one hand 2.80 1.39 0.46 0.93 –5.61 .001Ball skills 2 Throwing a bean bag into a box 2.76 1.56 0.30 0.46 –5.96 .001Static balance Standing on one leg 2.61 1.67 0.26 0.58 –5.72 .001Dynamic balance 1 Jumping on a rope 1.96 2.07 0.23 0.72 –3.77 .001Dynamic balance 2 Heel-to-toe walking on a line 2.76 1.61 0.10 0.30 –6.23 .001
Note. SD = standard deviation.
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52� January/February 2010, Volume 64, Number 1
of�teachers�and�parents�of�children�with�DCD�on�everyday�functioning;�(2)�observation�of�children�in�kindergarten�envi-ronments;�and�(3)�analysis�of�functional�tools�developed�for�adults,� such�as� the�Assessment�of�Motor�and�Process�Skills�(Fisher,� 1995)� and� the� Revised� Kitchen� Task� Assessment�(Baum�&�Edwards,�1993).
On� the�basis�of�Fisher� (1995)�and�Baum�&�Edwards�(1993),� the�Do–Eat’s�developers�decided�to� focus�on�three�main�activities�encompassing�the�main�areas�of�performance�in�which�children�with�DCD�characteristically�experience�dif-ficulties:�basic�activities�of�sustenance�(eating),�adaptation�to�the�environment�(dressing,�tying�apron),�and�crafting�(draw-ing,�writing,�and�cutting;�Perr,�2004).�Respective�task�require-ments� and� scoring� sheets�were�designed� and� constructed.�Each�of�the�three�tasks�was�scored�separately�and�included�three�measures:�activity�performance,�sensory–motor�perfor-mance�skills,�and�executive�function�performance�skills.
The�content�was�validated�by�five�expert�consultants�and�five�experienced�pediatric�occupational�therapists.�This�pro-cess�was�used� to�determine� the�degree�of� correspondence�between�the�tool�scenario�and�prescribed�instrument�objec-tives�and�the�consistency�of�both�content�and�face�validity,�as�described�by�Benson�and�Clark�(1982).
Three� experienced�occupational� therapists� (with�>10�years�of�experience�in�pediatric�practice)�were�subsequently�invited�to�evaluate�a�child�with�DCD,�videotape�the�evalu-ation�process,�and�then�rate�the�performance.�The�therapists�analyzed�their�evaluations�in�combination�with�the�video-taping,�approved�the�clarity�of�task�and�guidance�instruc-tions,�agreed�on�a�25-�to�30-min�per�child�allotment� for�evaluation�completion,�and�verified�that�the�tool�captured�a�reliable�and�satisfactory�profile�of�everyday�performance.�In�addition,�the�therapists�observed�that�using�Do–Eat�was�a�meaningful�experience,�revealing�unique�and�important�
everyday� child� activities.� In� addition,� completion�of� the�three�scoring�sheets�provided�them�with�further�insight�into�the�child’s�functioning.
Reliability and Validity Studies
Once�the�final�version�of�the�tool�was�established,�the�sub-sequent�phase�of�development�involved�a�preliminary�deter-mination�of�the�assessment�tool’s�reliability�and�validity.
Interrater reliability. An�interrater�reliability�test�was�con-ducted�for�all�assessment�items.�A�child�diagnosed�with�DCD�was�evaluated�and�videotaped�while�performing�the�Do–Eat.�Two�occupational�therapists�with�>10�years�of�experience�viewed�the�video�and�rated�performance�on�the�score�sheets,�contemporaneously� with� the� researcher� (Ayelet� Goffer).�These� raters�were� aware�of� the� study�objectives�but� con-ducted� their� evaluations� independently� of� one� another.�Moreover,�these�raters�were�not�members�of�the�initial�focus�groups�conducted�for�instrument�development.�A�high�inter-rater�reliability�was�obtained�(rs�=�.92–1)�among�all�three�assessors.
Internal consistency. Internal�consistency�was�evaluated�for�each�of�the�three�Do–Eat�components�on�the�basis�of�data�from�59�participants,�yielding�satisfactory�results.�High�internal�consistency�was�obtained�for�performance�skills�(α�=�.93),�sensory–motor�skills�(α�=�.90),�and�executive�func-tions�skills�(α�=�.89).�Internal�consistency�for�the�parents’�questionnaire�was�.91.�Differences�in�performance�between�the�two�groups�are�presented�in�Table�2.
Construct and concurrent validity. Construct�validity�for�the�Do–Eat�was�assessed�by�gauging�the�tool’s�ability�to�dis-tinguish�between�the�groups�of�children�with�and�without�DCD.�We�determined� concurrent� validity�by� comparing�Do–Eat�scores�with�those�on�the�M–ABC�(Henderson�&�Sugden,�1992)�and�the�ChAS–P�(Rosenblum,�2006).
Table 2. Performance of Both Groups on Do–Eat Components
Component
Children With DCD (n = 30) Children Without DCD (n = 29)
No. of Items Range of ScoresMean SD Mean SD
Tying an apron and making a sandwich Task performance 23.73 4.04 34.17 3.60 8 1–40 Sensory–motor 19.30 2.38 30.34 3.36 7 1–35 Executive functions 27.37 5.38 37.24 6.17 9 1–45Preparing chocolate milk Task performance 25.73 3.12 34.69 6.89 8 1–40 Sensory–motor 19.40 2.13 30.75 3.37 7 1–35 Executive functions 28.30 5.85 37.38 6.78 9 1–45Filling out a certificate Task performance 7.63 1.82 12.06 1.91 3 1–15 Sensory–motor 20.00 3.89 30.96 2.62 7 1–35 Executive functions 30.13 5.01 39.51 5.34 9 1–45
Note. DCD = developmental coordination disorder; SD = standard deviation.
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The American Journal of Occupational Therapy� 53
As�presented�in�Table�3,�the�t test�conducted�for�unre-lated� samples� showed� significant�differences�between� the�group�with�DCD�and� the� control� group�on� all�Do–Eat�components,�with�the�control�participants�displaying�better�performance.�We� found� significant�differences�on�perfor-mance�of�the�three�different�tasks�(t[57]�=�14.04,�p <�.001),�for�sensory–motor�skills�(t[57]�=�16.82,�p <�.001),�and�for�executive�functions�(t[57]�=�6.92,�p <�.001).�We�also�found�significant�differences�between� the� groups� for� the�overall�score�on�the�parents’�questionnaire�(t[57]�=�3.65,�p <�.001).
Concurrent validity.Correlation between the Do–Eat and the M–ABC. To�
establish� the� correlation�between� the�M–ABC�assessment�score�and�the�Do–Eat�assessment�score,�we�pinpointed�the�relationship�between�the�M–ABC�and�the�Do–Eat�sensory–motor�component�score�on�the�basis�of�the�rationale�that�the�M–ABC� essentially� addresses� sensory–motor� skills.� We�obtained�a�strong�negative�correlation�between�the�M–ABC�and�the�sensory–motor�score�for�the�overall�sample�(r =�−.86,�p <�.001).�Analysis�of�the�correlations�between�the�M–ABC�and�Do–Eat� sensory–motor� scores� for� each� study� group�indicated� a� weak� negative� significant� correlation� for� the�DCD�group�(r =�−.37,�p <�.001),�whereas�no�significant�cor-relation�was�obtained�for�the�control�group.
Correlation between Do–Eat and Children Activity Scale–Parent and Teacher. A significant�moderate�correlation�was�found�between�the�summary�scores�of�the�Do–Eat�test�and�the�ChAS–P�questionnaire�for�the�entire�sample�(r =�.56,�p =�.00).�We�found�no�significant�correlations�in�either�of�the�groups�(DCD�or�control).�An�examination�of�the�correlation�between� the�Do–Eat� test� and� the�ChAS–T�questionnaire�showed�a�high�correlation�throughout�the�entire�sample�(r =�.75,�p =�.00).�We�obtained�a�similar�trend�when�analyzing�the�correlations�in�each�group:�We�found�a�significant�high�correlation�for�the�DCD�group�(r =�.63,�p <�.001)�and�a�mod-erate�correlation�for�the�control�group�(r =�.40,�p <�.05).
Correlation between the Do–Eat test and the Do–Eat par-ents’ questionnaire. We�found�significant�moderate�correla-tions�between�the�Do–Eat�summary�score�and�the�Do–Eat�
questionnaire�final�scores�for�the�entire�sample�(r =�.54,�p <�.00).�In�the�DCD�group,�the�correlation�was�.41�(p <�.05),�whereas�for�the�control�group,�it�was�.40�(p <�.05).
DiscussionOur�objectives�in�this�study�were�to�describe�the�Do–Eat’s�development�and�establish�its�reliability�and�validity.�Both�objectives�were� supported.�We� established� the�Do–Eat’s�reliability�by� examining� interrater� reliability� and� internal�consistency.�A�high�rate�of�interrater�reliability�was�obtained�between�three�examiners�for�all�of�the�assessment�items.�This�concurrence�is�important�because�the�Do–Eat�is�based�on�a�structured�observation.�Dunn�(2000)�claimed�that�evaluat-ing�a�structured�observation�is�extremely�difficult�because�it�demands�that�the�evaluator�comprehensively�use�his�or�her�knowledge�and�skill�to�glean�significant�information�from�a�given�interaction�between�the�child�and�his�or�her�environ-ment.�The�internal�consistency�examination�found�a�high�degree�of�correspondence�between�the�items�analyzed�in�each�category�of�the�test�and�the�questionnaire.�This�high�item�correspondence�confirms�that�the�items�in�each�category�do�actually�evaluate�the�same�content�(Anastasi,�1997).
The�Do–Eat�distinguished�between�children�with�DCD�and�typically�developing�children,�thereby�allowing�one�to�draw� significant� conclusions� regarding� children’s� general�functioning� in� their� day-to-day� lives.�These�findings� are�especially�pertinent�in�light�of�the�dearth�of�performance-based�assessment�tools�for�children�in�general�(Bundy,�1993)�and�for�children�with�DCD�in�particular�(Cermak�&�Larkin,�2002).�The�important�implication�is�that�the�Do–Eat�enables�a�comparison�of�child� functioning� in�relation�to�peers�by�focusing�on�everyday�performance�in�natural�surroundings�(Kramer�&�Hinojosa,�1999).
Profile of Daily Functioning in Children With DCD
Disparities between children with DCD and children with intact development. As�noted�earlier,�we�had�two�reasons�for�choosing�to�focus�on�children�with�DCD�in�this�study:�The�first�related�to�the�DSM–IV–TR’s�definition�of�DCD,�and�the�second�related�to�the�heterogeneity�of�this�group�of�chil-dren.�The�DSM–IV–TR�definition�of�DCD�(APA,�2001)�implies�a�possible�cause–effect�relationship�between�deficits�in�motor� coordination� (Criterion�A)� and�daily� function–related�difficulties�(Criterion�B;�Geuze�et�al.,�2001).�These�links� were� not,� however,� specified� and� were� overlooked�because� of� the� lack� of� appropriate� assessment� tools.�Henderson�and�Barnett�(1998)�claimed�that�analysis�of�the�relationship�between�motor�impairment�and�daily�difficulties�is� contingent�on� the� availability� of� a� satisfactory� tool� for�assessing�a�child’s�limitations�in�performing�daily�tasks.
Table 3. A Comparison Between Children With and Without Developmental Coordination Disorder (DCD) for the Do–Eat Components Performance Skills and Parents’ Questionnaire Scores
Do–Eat Components
Children With DCD (n = 30)
Children Without DCD
(n = 29) t(57) p <
Task performance 57.17 81.93 14.04 .001Sensory–motor skills 59.30 92.52 16.82 .001Executive functions 85.57 114.17 6.92 .001Final score for Do–Eat parents’ questionnaire
54.37 62.21 3.65 .001
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54� January/February 2010, Volume 64, Number 1
The�Do–Eat�assessment�provides�relevant�information�regarding�these�links�between�motor�impairment�and�per-formance�of�daily�activities,�thus�supporting�the�handful�of�other�studies�that�have�addressed�everyday�functional�perfor-mance�using�alternate�methods�to�the�customary�question-naire�assessment.�Rodger�et�al.� (2003)�studied�motor�and�functional�ability�in�children�with�DCD�(ages�4–8);�everyday�functioning� was� analyzed� on� the� basis� of� the� Pediatric�Evaluation�of�Disability�Inventory�(Haley,�Coster,�Ludlow,�Haltiwanger,�&�Andrellos,�1992),�although�this�inventory�was�designed�to�evaluate�children�with�more�severe�limita-tions� than�DCD.�A�review�of� research�by�Missiuna�et�al.�(2007)�showed�that�children�with�DCD�performed�at�aver-age�levels�in�mobility�areas,�whereas�functioning�in�self-care�areas�was�<1�standard�deviation�from�the�average�point;�these�children�showed�difficulties�in�brushing�their�teeth,�cleaning�their�noses,�and�tying�shoelaces.�We�similarly�corroborated�these�findings�in�this�study:�Children�with�DCD�performed�significantly�more�poorly�than�typically�developing�children�on�several�types�of�everyday�functioning�and�activities.�These�findings�support�the�claim�for�a�link�between�coordination�deficits�and�impairment�of�daily�functions.
Evaluating�children�with�DCD�poses�a�significant�chal-lenge�because�of�the�heterogeneous�nature�of�this�population.�Missiuna� et� al.� (2007)� claimed� that� the�heterogeneity�of�children�with�DCD�is�represented�by�a�wide�range�of�varia-tion�in�their�manifestations�of�everyday�performance,�from�difficulties�in�performing�many�tasks�to�difficulties�on�spe-cific�tasks.�Burton�and�Miller�(1998)�therefore�emphasized�the�need�to�use�an�extensive�battery�of�assessments�to�provide�information� about� each� child’s� specific� functioning.�This�heterogeneity� is� likewise� characteristic�of�our�participants�with�DCD,�as�is�evident�from�their�scores.
Scores�ranged�from�260�to�163�points�on�the�Do–Eat�test�and�from�35�to�13.5�points�on�the�M–ABC.�This�wide�range�of� scores�demonstrates� the� significant� variability� in�children’s�functioning,�even�in�cases�with�similar�diagnoses.�These�differences� cannot�be� explained�by�one� score.�The�Do–Eat’s�content�and�structure�provide�a�detailed�view�of�diagnostic�information�that�goes�beyond�a�single�score.�By�reviewing�the�score�components,�one�can�pinpoint�the�spe-cific�nature�of�the�impairment�and�the�impact�of�each�com-ponent�and�performance�skill�on�the�child’s�general�func-tioning,� thus� highlighting� difficulties� and� functional�strengths.�The� study� results�point� to� a�disparity�between�children�with�DCD�and�typically�developing�children�on�all�skills� observed,� including� sensory–motor� skills,� executive�functions,�and�performance.
Regarding�cognitive�and�meta-cognitive�skills,�although�children� with� DCD� received� an� adequate� score� for� this�domain�on�the�Children�Activity�Scale�Parent�and�Teacher�
screening�tool,�they�performed�significantly�more�poorly�on�the�EF�component�of�the�Do–Eat�than�did�typically�develop-ing�children.�These�results�indicate�that�the�Do–Eat�is�indeed�sensitive� to� the� sensory–motor� and�EF� aspects� of�perfor-mance�among�children�with�DCD.�These�findings�underline�the�assertion�that�DCD�is�not�manifested�merely�in�motor�coordination�difficulties�but�that�it�is�a�multicharacteristic�deficit�with�a�significant� impact�on�functional�ability�and�everyday�participation�(Cermak,�Gubbay,�&�Larkin,�2002:�Kadesjo�&�Gillberg,�1999).
Score gap between children with DCD and typically develop-ing children on the DCD Parent Questionnaire. The�Do–Eat�evaluation�includes�a�test�and�a�questionnaire�aimed�at�pro-viding�an�extensive�functional�profile�that�may�significantly�serve�the�design�of�a�personal�intervention�plan.�This�com-bination�of�test�and�questionnaire�enables�both�components�to�validate�one�another.�The�parent�questionnaire�provides�information�about� functioning� in�general,� apart� from�the�testing� situation� (Glascoe�&�Dworkin,� 1995);� promotes�parental�cooperation�during�the�process;�and�focuses�on�the�client’s�needs�(Wilson�et�al.,�2000).�The�parent�questionnaire�significantly�identified�children�with�DCD,�a�finding�com-patible�with�reports�by�parents�of�children�with�DCD�that�underline�their�child’s�difficulties�with�daily�functioning�in�general�and�eating�in�particular�(Hoare,�1994).�Green�et�al.�(2005)�also�obtained� similar�findings:� the�Developmental�Coordination�Disorder�Questionnaire parent�questionnaire�(Wilson�et�al.,�2000)�distinguished�between�children�with�DCD�and�typically�developing�children,�and�children�with�DCD�scored�significantly�more�poorly.
Link between the Do–Eat and the M–ABC. We� found�a�strong�and�significant�correlation�between�the�M–ABC�and�Do–Eat�sensory–motor�skills�for�all�participants,�but�only�a�weak�correlation�was�evident�for�the�DCD�group.�The�cor-relation�between�M–ABC�and�the�Do-Eat�sensory�scale�was�–.86�for�the�entire�group�but�only�–.37�for�the�DCD�group.�This�result�implies�that�sensory–motor�performance�skills�do�not�fully�impair�the�ability�to�perform.�This�result�strength-ens�the�claim�that�assessing�DCD�only�via�sensory–motor�tasks�limits�a�fuller�depiction�of�daily�functioning�and�cannot�serve�as�a�viable�stand-alone�diagnostic�tool�(Green�et�al.,�2005).�We� found�no� significant� correlation�between�M–ABC� and� Do–Eat� sensory–motor� skills� for� the� typically�developing�group.�A�possible�reason�for�this�may�be�the�lack�of�variability�in�this�group,�given�the�constricted�age�range�of�the�children�tested�and�the�small�group�size.
Link between Do–Eat and the ChAS–T and ChAS–P. Correlations�between� the�ChAS–T�and�ChAS–P�and� the�Do–Eat�assessment�were�similar�to�those�reported�in�the�lit-erature�between� standardized� assessments� and�parent� and�teacher� questionnaires,� ranging� between� .40� to� .59�
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The American Journal of Occupational Therapy� 55
(Schoemaker,�Smith-Engelsman,�&�Jongmans,�2003;�Wilson�et�al.,�2000).�The�strength�of�correlations�is�usually�weak�to�moderate,� thus� supporting� the� currently� accepted�notion�that�although�questionnaires�may�have�advantages,�they�can-not�substitute�for�an�evaluation�process�(Wilson�et�al.,�2000).�In� recent� years,� the� viability� and� reliability�of�parent� and�educator� reports� on� child� functioning� have� been� widely�debated.�Wilson� et� al.� (2000)� claimed� that�many� factors�influence�questionnaire�validity,�such�as�coexisting�deficits,�thereby� confounding� reliable� questionnaire� reports.�Moreover,�a�questionnaire�is�susceptible�to�both�parents’�and�teacher’s�expectations�of�the�child,�as�well�as�those�of�profes-sionals�(Case-Smith,�1995).
In�addition,�questionnaire�responses�may�be�influenced�by�the�time�and� location�of�completion�(e.g.,� the�waiting�room�or�the�therapy�clinic;�Green�et�al.,�2005).�These�con-textual�effects�may�also�serve�to�clarify�our�study�findings.�As�presented� previously,� correlations� between� the� Do–Eat�assessment�and�the�teacher�questionnaire�(ChAS–T)�were�stronger�than�those�obtained�for�the�Do–Eat�and�the�parent�questionnaire� (ChAS–P).�By�contrast,�Rosenblum�(2006)�found�stronger�correlations�between�the�M–ABC�and�the�parent�questionnaire.�Likewise,�Green�et�al.�(2005)�showed�that�the�Developmental�Coordination�Disorder�Question-naire parent�questionnaire�enhanced�identification�of�DCD�compared�with� the�M–ABC� teacher� questionnaire.�This�disparity�may�be�attributable�to�the�fact�that�our�study�was�conducted�mainly� in�kindergarten� settings,� teachers�were�briefed�on�study�objectives�and�were�invited�to�participate�in�the�process,�and�teachers�informed�parents�and�allowed�sev-eral� to�observe� the�assessment�process.�Relationships�with�most�parents�were�limited,�with�the�exception�of�those�few�parents� of� children� who� were� the� researcher’s� clients.�Therefore,�teachers’� involvement�and�awareness�may�have�influenced�and�even�biased�their�questionnaire�reports.
In�summary,�the�analysis�of�the�relationships�between�the�overall�Do–Eat�score�and�other�assessment�tools�provides�evidence�of�a�significant�relationship.�Specifically,�significant�correlations�between�the�Do–Eat’s�sensory–motor�compo-nent�and�the�other�assessment�tools�were�obtained�for�both�the�total�sample�and�the�sample�of�children�with�DCD.�The�Do–Eat�evaluation�tool�therefore�shows�considerable�prom-ise�for�diagnosing�DCD,�substantially�advancing�our�under-standing�of�the�deficit�beyond�mere�functional�difficulties�in�areas�of�motor�coordination.
Limitations
Data�collection�for�the�study�and�the�Do–Eat�testing�process�was�conducted�by�Ayelet�Goffer,�who�was�also�involved�in�designing� and�developing� the� tool.�The� study� sampled� a�limited�number�of�children�(30�in�the�study�group�and�29�
in�the�control�group)�by�means�of�a�convenience�sample.�Therefore,� care�needs� to�be� exercised� in� generalizing�our�findings�and�future�research�hypotheses�to�other�groups�of�children.
Recommendations for Future Research
This�study’s�findings�underscore�the�Do–Eat’s�potential�to�distinguish� between� children� with� DCD� and� typically�developing�children�ages�5�to�6.5.�Future�studies�should�include�testing�children�diagnosed�with�DCD�who�are�>6.5�and�evaluating�children�with�learning�disabilities,�attention�deficit�hyperactivity�disorder,�or�both.� In� this� study,�we�examined�the�reciprocal�relationships�among�various�assess-ment�components.�Future�studies�should�examine�the�rela-tionships�among�sensory–motor�performance�skills,�execu-tive�functions,�and�general�performance.�A�study�to�evaluate�test–retest�reliability�is�being�conducted�in�the�near�future�to�explore�the�stability�of�scores�over�time�for�those�with�DCD�and�other�populations.�In�the�next�step�of�validating�the� Do–Eat,� a� large-scale� study� with� random� samples�should� be� conducted� to� build� norms� for� this� novel�instrument.� s
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Appendix. Scoring Example: Preparing Chocolate MilkScoring: 5 = excellent performance, 4 = good performance, 3 = fair performance, 2 = poor performance, 1 = very poor performance, 0 = not observed.
Child’s name: __________________________________________________
Task performanceTask Score (0–5) RemarksBringing box to the tableSpreading out items on the table Putting chocolate powder and milk in the glassMixing the drinkWashing handsCleaning the tableDrinking Overall score _____________________ = average score 7
Sensory–motor skills analysisSkills Score (0–5) RemarksMotoricityPosture and movement relationshipsMotor planningBilateral coordinationFine motor coordinationSensationOverall score _____________________ = average score 6
Executive functionsSkills Score (0–5) RemarksAttentionInitiationSequencingTransition from one activity to anotherSpatial and temporal organizationInhibitionProblem solvingRemembering instructionsOverall score _____________________ = average score 9
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The American Journal of Occupational Therapy� 57
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CE-135
NEW
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Early Childhood:� Occupational Therapy Services for Children Birth to FiveEdited by Barbara E. Chandler, PhD, OTR/L, FAOTA • Earn 2 AOTA CEUs (20 NBCOT PDUs/20 contact hours).
In this new SPCC, you will take an enlightening journey through occupational therapy with children at the earliest stage of their lives.
The course focuses on community-based programs and explores how federal legislation drives occupational therapy practice and how practitioners can articulate and demonstrate the profession’s long-standing exper-tise in transitioning early childhood development into occupational engagement in natural environments.
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