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Goal attainment scaling as a measure of meaningful outcomes Goal attainment scaling as a measure of meaningful outcomes

for children with sensory integration disorders. for children with sensory integration disorders.

Zoe Mailloux Pediatric Therapy Network

Teresa A. May-Benson Occupational Therapy Associates

Clare A. Summers The Children’s Hospital

Lucy Jane Miller University of Colorado at Denver and Health Sciences Center

Barbara Brett-Green University of Colorado at Denver and Health Sciences Center

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Recommended Citation Recommended Citation

Mailloux, Zoe; May-Benson, Teresa A.; Summers, Clare A.; Miller, Lucy Jane; Brett-Green, Barbara;

Burke, Janice P.; Cohn, Ellen S.; Koomar, Jane A.; Parham, L Diane; Roley, Susanne Smith; Schaaf,

Roseann C.; and Schoen, Sarah A., "Goal attainment scaling as a measure of meaningful

outcomes for children with sensory integration disorders." (2007). Department of Occupational

Therapy Faculty Papers. Paper 46.

https://jdc.jefferson.edu/otfp/46

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Authors Authors Zoe Mailloux, Teresa A. May-Benson, Clare A. Summers, Lucy Jane Miller, Barbara Brett-Green, Janice P. Burke, Ellen S. Cohn, Jane A. Koomar, L Diane Parham, Susanne Smith Roley, Roseann C. Schaaf, and Sarah A. Schoen

This article is available at Jefferson Digital Commons: https://jdc.jefferson.edu/otfp/46

254 March/April 2007, Volume 61, Number 2

With the ultimate aim of enhancing par-ticipation and engagement in mean-

ingful life activities, occupational therapistsestablish goals with individual people andtheir families that are infinitely unique anddiverse (Crepeau, Cohn, & Schell, 2003).The array of potential outcomes after inter-vention creates rich clinical practice butmakes implementing effectiveness researchcomplex. For more than 40 years (Ayres,1965, 1966; Parham & Mailloux, 2004),occupational therapists have identifiedsigns of poor or inefficient sensory process-ing and motor planning or coordinationfunctions—collectively known as sensoryintegration disorders—among various clin-ical populations. Research studies examin-ing the effectiveness of occupational ther-apy intervention with clients who havesensory integration problems have shownmixed results, as demonstrated by morethan 75 original studies, 2 meta-analyses,and 4 review papers (Parham et al., 2007).These studies clearly point out the chal-lenge of defining intervention in a standardway and identifying appropriate outcome

measures (Miller, 2003a; Miller & Kin-neally, 1993). Identifying standardizedmeans to capture the diversity of meaning-ful, functional outcomes that are noted bytherapists, families, and individuals whoparticipate in occupational therapy apply-ing a sensory integration approach (OT-SI)presents a special challenge to conductingreliable and relevant effectiveness research.The purpose of this article is to describe theefforts of a collaborative team of occupa-tional therapists to explore the potential ofgoal attainment scaling (GAS) as a mea-surement methodology that would cap-ture, in a reliable and valid manner, thediverse gains noted after use of the OT-SIapproach.

Goal Attainment ScalingGAS is a method originally developed foradults in the mental health arena as a pro-gram evaluation tool that facilitates patientparticipation in the goal-setting process(Kiresuk, Smith, & Cardillo, 1994). TheGAS methodology is congruent with the

THE ISSUE IS

Goal Attainment Scaling as a Measure of MeaningfulOutcomes for Children With Sensory Integration Disorders

Zoe Mailloux, Teresa A. May-Benson, Clare A. Summers, Lucy Jane Miller, Barbara Brett-Green, Janice P. Burke, Ellen S. Cohn, Jane A. Koomar, L. Diane Parham, Susanne Smith Roley, Roseann C. Schaaf, Sarah A. Schoen

KEY WORDS• goal attainment scaling (GAS)• pediatric• sensory integration• sensory processing

Zoe Mailloux, MA, OTR/L, FAOTA, is Director ofAdministration, Pediatric Therapy Network, 1815 West 213thStreet, Suite 100, Torrance, CA 90501; zoem@PTNmail.org.Teresa A. May-Benson, ScD, OTR/L, is ResearchDirector, The SPIRAL Foundation; and Clinical SpecialtyDirector, Occupational Therapy Associates, Watertown, MA.Clare A. Summers, MA, OTR, is Occupational Thera-pist, The Children’s Hospital, Denver, CO.Lucy Jane Miller, PhD, OTR, FAOTA, is AssociateClinical Professor, Departments of Rehabilitation Medicineand Pediatrics, University of Colorado at Denver and HealthSciences Center; Director, Sensory Therapies and Research(STAR) Center; and Director, KID Foundation, GreenwoodVillage, CO.Barbara Brett-Green, PhD, is Assistant Professor,University of Colorado at Denver and Health Sciences Center; Senior Researcher, KID Foundation, Greenwood Village, CO.Janice P. Burke, PhD, OTR/L, FAOTA, is Professor andChair, Department of Occupational Therapy; and Dean, wJefferson School of Health Professions, Thomas JeffersonUniversity, Philadelphia.Ellen S. Cohn, ScD, OTR/L, FAOTA, is Clinical Associ-ate Professor, Boston University–Sargent College of Healthand Rehabilitation Sciences, Boston.Jane A. Koomar, PhD, OTR/L, FAOTA, is Owner andExecutive Director, Occupational Therapy Associates, PC,and The SPIRAL Foundation, Watertown, MA.L. Diane Parham, PhD, OTR/L, FAOTA, is AssociateProfessor, Division of Occupational Science and OccupationalTherapy, University of Southern California, Los Angeles.Susanne Smith Roley, MS, OTR/L, FAOTA, is ProjectDirector, USC/WPC Comprehensive Program in SensoryIntegration, University of Southern California, Los Angeles; and Coordinator of Education and Research, Pediatric Therapy Network, Torrance, CA.Roseann C. Schaaf, PhD, OTR/L, FAOTA, is AssociateProfessor, Vice Chair, and Director of Graduate Studies,Department of Occupational Therapy, Thomas Jefferson University, Philadelphia.Sarah A. Schoen, PhD, OTR, is Clinical Instructor, Uni-versity of Colorado at Denver and Health Sciences Center;Director of Occupational Therapy, STAR Center; and SeniorResearcher, KID Foundation, Greenwood Village, CO.

Goal attainment scaling (GAS) is a methodology that shows promise for application to intervention effective-ness research and program evaluation in occupational therapy (Dreiling & Bundy, 2003; King et al., 1999;Lannin, 2003; Mitchell & Cusick, 1998). This article identifies the recent and current applications of GAS tooccupational therapy for children with sensory integration dysfunction, as well as the process, usefulness, andproblems of application of the GAS methodology to this population. The advantages and disadvantages ofusing GAS in single-site and multisite research with this population is explored, as well as the potential solu-tions and future programs that will strengthen the use of GAS as a measure of treatment effectiveness, bothin current clinical practice and in much-needed larger, multisite research studies.

Mailloux, Z., May-Benson, T. A., Summers, C. A., Miller, L. J., Brett-Green, B., Burke, J. P., et al. (2007). The Issue Is—Goal attainment scaling as a measure of meaningful outcomes for children with sensory integration disorders. Amer-ican Journal of Occupational Therapy, 61, 254–259.

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client-centered occupational therapy phi-losophy because GAS provides a means toidentify intervention outcomes that arespecifically relevant to individuals and theirfamilies. Through the use of interview dur-ing goal-setting and posttreatment sessions,the GAS process captures functional andmeaningful aspects of a person’s progressthat are challenging to assess using availablestandardized measures. Recent studies havefound that, although parents value observ-able sensory and motor changes tradition-ally reflected in standardized tests, theyplace greater value on those aspects of func-tioning that are not readily measured by tra-ditional outcome measures (Cohn, 2001;Cohn, Miller, & Tickle-Degnen, 2000).Because GAS captures individualizedprogress that is meaningful to the family,GAS is an appealing methodology for mea-suring change during and after OT-SI, bothin clinical and research applications.

Goal-Writing and Scaling

When Kiresuk and Sherman (1968) origi-nally developed GAS methodology, theydevised a very precise scaling method forwriting outcome goals that was based onthe probability that a particular outcomewould occur. This method, which involvedassigning specific numeric values to levels ofperformance expected to be achieved by theclient after intervention, was based on the

therapist’s experience and knowledge of theclient and his or her condition. Whenapplied appropriately, the distance betweenthe levels of the scale is equal and equallydistributed around the predicted level ofperformance. In this model, the emphasis ison conceptualizing goal attainment aroundthe projected outcome level of perfor-mance, rather than conceptualizing progressas a linear progression from a baseline orcurrent level of functioning. This conceptof GAS as reflecting the probability ofoccurrence of an outcome is key to allowingone person’s goal outcomes to be comparedto another person’s goal outcomes. There-fore, in writing the goals, the occupationaltherapist must attempt to (a) accurately pre-dict the level of performance the child isexpected to achieve after a specified periodof time and (b) identify equal incrementsabove and below the expected level ofperformance.

In general, a 5-point scale (–2 to +2) isused for scaling goals. Kiresuk et al. (1994)specified that 0 (zero) be used as the pre-dicted expected level of performance, with–1 indicating somewhat less than expectedperformance (see Table 1). Various otherresearchers have suggested different desig-nations for the levels within this ratingscale. Table 2 summarizes scaling systemssuggested in the literature for GAS, as wellas the scaling system used in pilot studies of

GAS application in OT-SI (Miller et al.,2007). See Table 3 for a sample GAS goal.

GAS ApplicationGAS has been successfully applied in previ-ous occupational therapy effectivenessresearch in various pediatric settings,including rehabilitation (Lannin, 2003;Mitchell & Cusick, 1998) and school sys-tem (Dreiling & Bundy, 2003; King et al.,1999). However, previous use of the GASprocess was highly individualized to meetthe needs of the specific program, resultingin a wide variety of GAS methodologies,some of which had little consistency to theoriginal GAS process (Kiresuk et al., 1994).

GAS Application in Sensory Integration Research

Single-site research application of GAS.The first known application of GAS in aresearch protocol for children with sensoryintegration dysfunction occurred in twopilot studies conducted between 1997 and2005. The studies examined the effective-ness of OT-SI for children from ages 4 to 12years who were identified as having atypicalresponsiveness to sensation (Miller et al.,2007). In these pilot studies, the childrenparticipated in OT-SI for 20 sessions over a10-week period. Effectiveness of the inter-vention was measured by examining pretest

The American Journal of Occupational Therapy 255

Table 1. Scaled Levels of Goal Attainment Scaling Rating Level Description

–2 Much Less Than Expected Outcome—This level reflects performance that is likely to occur approximately 7% of the time, ranging from regression to no or minor changes.

–1 Somewhat Less Than Expected Outcome—This level reflects performance that is likely to occur approximately 21% of the time and is somewhat less than expected for the intervention period.

0 Projected Performance Expected by the End of the Measurement Period—This level of performance indicates performance to the extent anticipated at the initiation of treatment for the given measurement period and is expected to occur approximately 43% of the time.

+1 Somewhat More Than Expected Outcome—This level of performance reflects performance that is likely to occur approximately 21% of the time and indicates somewhat more progress than expected during the intervention period.

+2 Much More Than Expected Outcome—This level reflects performance that is likely to occur approximately 7% of the time and is unusual because significantly more progress than expected occurred during the measurement period.

Table 2. Comparison of Goal Scaling Methods Used by Various ResearchersScaling Method

Level Ottenbacher & Cusick (1990) King et al. (1999) Miller et al. (2007) Kiresuk, Smith, & Cardillo (1994)

–2 Most unfavorable outcome likely Baseline Regression from current level Much less than expected outcome–1 Less than expected outcome Less than expected outcome Current level of performance Somewhat less than expected outcome0 Expected level Expected level Expected level Projected level of performance

+1 Greater than expected outcome Greater than expected outcome Greater than expected outcome Somewhat more than expected outcome+2 Most favorable outcome likely Much greater than expected outcome Much greater than expected outcome Much more than expected outcome

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and posttest changes in behavioralresponses using traditional standardizedassessments, including the Child BehaviorChecklist (Achenbach, 1991), the ShortSensory Profile (McIntosh, Miller, Shyu, &Dunn, 1999), and the Leiter InternationalPerformance Scale–Parent Rating (Roid &Miller, 1997), as well as physiological mea-sures such as electrodermal responses andheart period variability. Additionally, par-ents were interviewed at the initiation ofthe study to establish objectives writtenaccording to the GAS process. Objectiveswere developed to reflect potential inter-vention outcomes that were meaningful tothe parents and family and that were nottypically reflected in the standardized andphysiological measures. Exit interviewswith parents were conducted to evaluate thefunctional gains made by children.

Results of this study showed somechanges on various behavioral and physio-logical measures. However, GAS measuresreflected the most significant gains with apretreatment and posttreatment differencescore (M = 25.31, SD = 11.71, p < .0001)and a large effect size of 2.16. In contrast,the average effect size of the other outcomemeasures was .50. Thus, scaling goals usingGAS appeared to be the most sensitivemeans to reflect change in individual chil-dren after their participation in occupa-tional therapy. Further, this study demon-strated that GAS could capture individualchanges in daily life occupations that arefunctional, meaningful alterations in occu-pational performance over a short inter-vention period in a small sample (Miller etal., 2007).

Multisite clinical application of GAS. In2001, a federal multisite R21 planninggrant from the National Center for Medi-cal Rehabilitation Research (NCMRR)(National Institutes of Health/NationalInstitute of Child Health and HumanDevelopment/NCMRR) supported collab-oration among four university-basedresearch programs paired with three well-established clinical intervention sites. Theteams included the University of ColoradoHealth Sciences Center and The Children’sHospital, Denver; the University of South-ern California and Pediatric Therapy Net-work, Torrance; Boston University andOccupational Therapy Associates–Water-town; and Thomas Jefferson University,Philadelphia. The goal of this grant was toform a multisite team of clinicians andresearchers to plan for collaborative effec-tiveness studies of OT-SI. The collabora-tive team identified three primary issuesthat had to be addressed before the initia-tion of multisite intervention projects: (a)identify comprehensive physiological andbehavioral evaluation measures for childrenthought to have sensory integration dis-orders, (b) identify the primary characteris-tics of OT-SI so intervention would be reli-able across sites and develop a means ofassuring fidelity to this intervention, and(c) identify measurement methodologiesthat would reflect the functional andmeaningful gains made after OT-SI(Miller, 2003b).

The collaborative team identified GASas a potential outcome measure methodol-ogy that could capture and quantify indi-vidual functional changes. The therapists at

the three clinical sites examined the use ofGAS to measure change in clinical practiceon a trial basis as a part of their facilities’ongoing program evaluation. All of theclinical sites routinely developed therapeu-tic goals for every child receiving services attheir facility as part of their regular inter-vention programs, so GAS was easily incor-porated into this process.

To implement the GAS process in theclinical settings, primary GAS goal writerswere identified and trained. The occupa-tional therapists practiced writing severalgoals and received feedback from membersof the collaborative team. A general proce-dure for goal writing and scaling was devel-oped and agreed on by all therapists toensure similar increments for scaling. Next,each site used the GAS procedure with sev-eral children in their facility. All therapistsmet with parents in an initial goal-settingmeeting and wrote 3–5 scaled goals per par-ticipating child. All children received20–30 sessions of OT-SI, usually providedfor 1 hr, twice per week. After all sessionswere completed, a follow-up meeting wasconducted with the parents to rate the chil-dren’s progress on the goals. Three monthsafter implementing the GAS process in theclinical setting, participants from the threeclinical sites compared the application ofGAS in their individual programs, identi-fied strengths and weaknesses of GAS, andmade recommendations for application tomultisite research.

The team concluded that• GAS was a sensitive measure of clin-

ical change over a short period of interven-tion because all children across the sites

256 March/April 2007, Volume 61, Number 2

CONCERN: Inability to participate in a family dinner due to oversensitivities to textures, tastes, smells, and sound. GOAL: To be able to participate in a family meal at home, at friends’ and relatives’ homes, and at a restaurant, by decreasing oversensitivities to textures, smells,taste, and noise. INTERVENTION PERIOD: 20 sessions

–2Much Less Than Expected Level

–1Less Than Expected Level

0Expected Level of Performance

+1Better Than Expected Level

+2Much Better Than Expected Level

Tolerates the family eatingarea during mealtime withoutsigns of discomfort or dis-tress (e.g., crying, gagging,whining, or leaving the tableor room), 4 of 5 opportunities.

Tolerates 2 new foods on tableor other family members’plates without signs of dis-comfort or distress (e.g., crying, gagging, whining, orleaving the table or room), 4 of 5 opportunities.

Tolerates 2 new foods placedon own plate without signs ofdiscomfort or distress (e.g.,crying, gagging, whining, orleaving the table or room), 4 of 5 opportunities.

Takes 1 bite of 2 new foodsduring a meal without signs ofdiscomfort or distress (e.g.,crying, gagging, whining, orleaving the table or room), 4 of 5 opportunities.

Eats multiple bites of 2 newfoods without signs of dis-comfort or distress (e.g., crying, gagging, whining, orleaving the table or room), 4 of 5 opportunities.

Table 3. Sample Goal Attainment Scaling Goals for Children With Sensory Integration Dysfunction

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demonstrated the expected level of changeor better at follow-up.

• Each site noted that the parentsinvolved in the GAS process greatly valuedthe individualized goals and appreciatedthat functional and meaningful aspects ofoutcomes were addressed.

• The GAS goal-writing therapistsfrom the clinical sites differed in their inter-pretation of the meaning of some GAS con-cepts reported in the literature (such as“expected level of performance”) and intheir use of the scaling system. The multipletherapists involved in the multisite clinicalproject and the geographic distancesbetween them resulted in less consistency ingoal wording and relative distance betweenratings (e.g., 0 to 1; 1 to 2), or scaling, whenwriting GAS objectives, than that previouslyachieved in a single site. Thus, the informal,peer-training model that had been success-ful in the single-site pilot research study wasnot as effective for long-distance multisitetraining. Consistency between sites wasviewed as crucial for future implementationof multisite research.

• Each site concurred that the GASprocess held potential application to bothclinical practice as well as research; however,the time demands of the interview andfollow-up process that was inherent in theapplication of GAS made routine clinicaluse challenging.

In conclusion, consistent with the ini-tial pilot study, the collaborative team foundthat GAS was effective in identifying out-

comes that were meaningful to the parentsand family. However, although GAS appli-cation was consistent within single sites,increased uniformity of the GAS processacross multiple sites was needed before ini-tiation of a collaborative multisite project.

Reliability of GAS ApplicationReliable writing of goals was identified as aprimary need for replicable effectivenessstudies with children who have sensoryintegration disorders. The collaborativeteam noted that reliability needed to beestablished across and within sites for eachof the following steps:

• Identifying the individual goals thatare expected to change as a result of theintervention

• Scaling the goals into the levels ofexpected outcomes

• Determining which level best re-flects the person’s change during interven-tion and rating the scaled goals

Goal Setting and Goal Follow-UpProcessesIn most clinical settings where OT-SI isprovided, the child’s occupational therapistusually initiates writing goals that will beused to evaluate progress. Best practice inoccupational therapy includes the parentsin the goal-setting process and, ideally, thechild. Intervention goals should be func-tional and reflect occupational performance

areas valued by the child and family. Meth-ods of gathering information from parentsto develop goals have varied from askingdirect questions about difficulties to usingopen-ended interview methods allowingparents to generate areas of need with min-imal guidance or bias from the therapist(Miller & Summers, 2001).

When developing a GAS process foruse with children who have sensory integra-tion dysfunction, the collaborative teamrecommended the following steps:

• The occupational therapist trainedto write the GAS goals should review thechild’s records, including evaluation andsensory history, before conducting the par-ent meeting. To increase objectivity inreviewing progress, the GAS goal-writingtherapist and the therapist providing theintervention should not be the same per-son. This distinction would be important inan efficacy study in which control groups ofchildren who did and did not receive OT-SIwere included.

• The parent goal-setting meetingshould take place using a semistructuredinterview with consistent structure acrosssites. See Figure 1 for examples of guidingquestions.

• The GAS goal-writing therapistshould write five scaled goals according tothe criteria described below and in accor-dance with the GAS training program.

• The GAS goal-writing therapistshould review the scaled goals with theparents to validate the expected level of

The American Journal of Occupational Therapy 257

a. Tell me about your child. What are his/her strengths, his/her weaknesses?

b. What has led you to seek services for your child?

c. What concerns you most about your child? Tell me more specifically about. . . .

d. What is a typical (day, week) like for him/her?

e. Tell me about your family’s life. What kinds of things do you like to do? What is easy or hard for your family or its members?

f. Tell me about what you or other family members need to do to have things go smoothly for your child.

g. (Review the child’s evaluation and ask questions regarding functional areas of difficulty.) For example: I notice that __________________________ (e.g., mealtime) seems to be hard for him/her. Can you tell me more about that?

h. (After functional areas are covered): Tell me more specifically about ____________________ (each specific sensory area identified as problematic from the evaluation).

i. (Ask if appropriate): Our evaluations showed some difficulties/delays with ____________________. Is this something that has been of concern to you?

j. What are some goals you have for your child in the next 3 months or so? (Time frame may be variable.)

k. Looking ahead, what are some of the things you are hoping for your child?

l. Imagine we are sitting here talking 3 months [variable] from now. What changes would you like to see by that time?

Figure 1. Guiding questions for parents during goal-setting interview.

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performance. (The full scaled objectives arenot shared at this time to minimizeresponse shift bias, e.g., tendency to over-rate progress.) The parents rank-order thegoals based on importance to them, with ascore of 1 being the most important and 5being the least.

• For each child, goals should addressspecific need areas that reflect the Interna-tional Classification of Function (WorldHealth Organization, 2002) taxonomy orthe Occupational Therapy Practice Frame-work: Domain and Process (American Occu-pational Therapy Association, 2002). Theseareas are identified as priorities for familiesof children receiving occupational therapyservices (Cohn et al., 2000; Cohn, Dunphy,Pascal, & Miller, 2001). Goal areas includebody function or structure, client factors,activity function, participation, family-related concerns, and context or environ-mental accommodations.

• After a standard designated inter-vention period, a follow-up meeting shouldbe conducted with the parents to determinethe child’s progress on the scaled goals. Theoccupational therapist who wrote the goals(but not the treating therapist) should con-duct a semistructured exit interview.

• After the exit-interviewer deter-mines the child’s current level of function-ing based on the exit interview, an unscoredcopy of the scaled goals should be given tothe parents, who rate their perception oftheir child’s progress on the goals. This pro-vides feedback regarding the accuracy of thetherapist ratings.

Application of GAS toMultisite ProgramsThis preliminary collaborative applicationof the GAS process, as well as an extensivereview of the literature, determined thatGAS has been an effective outcome mea-sure within single-site studies and holdspromise for use in multisite applications.Further empirical research on validity andreliability across sites is necessary beforeGAS can be a reliable methodology for amultisite study. Specific reliability concernsare (a) consistent goal selection, wording,and measurability of the scaled goals; (b)consistency in establishing incrementsbetween levels of the scaled goals; and (c)

interrater reliability among occupationaltherapists both within and across sites. Inaddition to the reliability concerns, collabo-ration and discussion of the challenges ofapplying GAS in a multisite setting resultedin the development of a revised standardGAS goal-setting procedure as well as aGAS administration and scoring manualfor use across the clinical settings. The col-laborative team recommended that the nextsteps include development of a trainingprogram to be used at all of the clinicalsites, testing of interrater reliability withinand across sites for initial and post-intervention GAS rating, and determina-tion of validity of parent report by compar-ing post-intervention parent interviewswith observations of the child.

ConclusionGAS has unique application as an appliedresearch tool, especially if outcomes arevariable and standardized tests are not avail-able. GAS is especially promising for occu-pational therapy because it captures theindividuality of the meaningful and rele-vant changes in occupational performancethat have previously been difficult to mea-sure. The research planning collaborativeproject discussed here represents a newapplication of GAS across multiple sites.Reliable use of GAS has the potential toaddress important concerns related to treat-ment effectiveness.

Previous studies using GAS have var-ied methodologically and have rarelyaddressed reliability or validity issues inher-ent in the application of the GAS process.GAS requires that the goal-writing occupa-tional therapists accurately (a) identify goalareas important to families and clients, (b)identify the client’s projected outcome, (c)scale the objectives, and (d) rate perfor-mance at follow-up after intervention.Thus, it is critical for the GAS goal writersto have interrater reliability and for thegoals to measure valid outcomes that reflectchanges valued by the child and his or herfamily. For research measuring the effective-ness of occupational therapy intervention,these reliability and validity issues assumeeven greater importance. Considering thepotential value of this method in occupa-tional therapy, especially in application to

children with sensory integration disordersin which outcomes of intervention are typ-ically diverse and highly individualized,GAS offers therapists a unique method ofcapturing outcomes that are truly meaning-ful to children and their families. ▲

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The American Journal of Occupational Therapy 259

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