Kaplan, Sandra L. PT, PhD; O'Connell, Melanie D. MSPT
Physical therapists and occupational therapists work with preschool children in special education classes to increase functional independence in preparation for kindergarten placement. The ability to don outerwear for various school activities, such as smocks for art classes or coats for colder weather, is one functional task typically expected of preschool children and kindergarteners. To date, no studies have been found that describe the level of coat-donning independence of preschool children in special education.
A component task analysis defines the temporal sequence of steps to complete a task, provides a common language and understanding of the process, and is easy to apply to motor tasks.1 Children can be evaluated on the number of steps completed independently or the speed to complete the entire sequence. A component task analysis is more sensitive to actual skill performance than a single criterion or line item found in standardized tools because it reflects incremental improvements over time as steps are mastered. The defined sequence of steps can help clinicians or teachers to identify which part of a task is most challenging for individual children and may influence the choice of interventions.1 No studies have been found describing the use of task analyses for teaching or documenting coat-donning mastery.
Dressing Skills in Children Developing Typically
The ability of children to dress themselves is an indicator of developing coordination and hand skills, and success is associated with increased self-esteem.2 Normative expectations of dressing in preschool children who are developing typically is limited to guidance from developmental scales,3–10 textbooks,2,11–13 and observations by teachers and parents.14,15 There is consensus in the United States that 4-year-old children who are developing typically are expected to dress and undress themselves,2,11,12 but they may have difficulty with clothing orientation—that is, front versus back; right versus left11,12; and fasteners, such as buttons, zippers, or laces.12,13,15,16 Cultural differences for the age to achieve independent dressing may also exist. Children in Hong Kong achieve independence at a younger age than American children.17 In most sources, general references are made to dressing skills and are not specific to donning a coat.
Dressing Skills in Children With Disabilities
No studies were found that describe coat donning in children with disabilities, and research on general dressing skills in children with disabilities is specific to the type and magnitude of disability. The WeeFIM was tested on 5 groups of children diagnosed with varying developmental delays to demonstrate the validity of the tool.18 Children with limb deficiencies (
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= 7.5 years) and Down syndrome (
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= 8.8 years) were delayed in their ability to dress independently. Although the WeeFIM scores the level of assistance needed to perform specific tasks, it does not specify which part of the dressing task is difficult or an impediment to independence.
In a qualitative study of 23 children, aged 5 to 7 years, with developmental coordination disorder, very few were dressing independently as compared with children who were developing typically,19 and performance was characterized by a lack of initiation, slower dressing speed, difficulty with spatial orientation, and the need for physical prompts.19 These studies support clinical observations that preschool children with disabilities may require a range of assistance for dressing, and that many may not be independent in coat donning prior to kindergarten entry.
Strategies for Donning a Coat
There are 2 approaches to donning a coat independently. The traditional method used by adults is to place one arm in a sleeve and reach behind the back to thread the other arm through the opposite sleeve. The coat-flip method positions the coat on a table or the floor and the coat is flipped overhead.
Donning a front-opening coat in the traditional manner is an assumed sequence for which no task analysis was found; however, descriptions of donning front-opening shirts are available. Putting on front-opening shirts requires anticipation and assistance from toddlers to hold out their arms for sleeves at 18 to 24 months of age.13 At 24 to 30 months, toddlers may find the first armhole of “garments,”13 and by 36 to 42 months, they can push the second arm into the remaining sleeve and pull shirts onto their shoulders.9 Completion occurs when children can independently orient and don “front-opening garments,” but descriptions typically do not include managing fasteners.
The coat-flip technique teaches children to lay coats upside down and inside up on the floor, stick both arms into the armholes, and flip the coats overhead and onto the shoulders. This bilateral arm movement in the sagittal plane may be easier than rotational movements in the horizontal plane required for the traditional method. The coat flip may provide more orientation cues because coats are in front of the children before donning, rather than oriented to one side. Initially, the coat-flip method may be easier for toddlers, but the limited references on this technique may be due to its lack of social acceptability in older children and adults. No task analyses have been found for the coat-flip technique but descriptions with photos are available at teacher/parent Web sites.14,20 Both methods, as they occur in school settings, are linked to the environmental context of getting to the coat, retrieving it from a storage location (hook or storage cubicle), orienting it, and then donning it. Expectations of fastening the coat are more variable.
Coat-Donning Measures in Standardized Assessments
Assessment tools that are commonly used to evaluate children include the Brigance Diagnostic Inventory of Early Development—2nd Edition (Brigance IED II),5 the Hawaii Early Learning Profile for Preschoolers Checklist (HELP),9 the Peabody Developmental Motor Scales—Second Edition,7 the Pediatric Evaluation of Disability Inventory (PEDI),8 the School Function Assessment (SFA),6 and the Functional Independence Measure for Children (WeeFIM).10 The Brigance IED II, HELP, and SFA are criterion-referenced tests and are not designed to assign age levels to children,21 but they do provide expected age ranges for skills used in dressing, such as buttoning6 or donning shirts and pants.10 Age ranges for donning a front-opening garment are included in the HELP (3-3.6 years),9 the PEDI (50%-75% of 3- to 4-year-olds),8 and the Brigance IED II (begin assessing at 2.5 years).5 The SFA suggests that 95% of children should be managing their clothing by kindergarten, including a front-opening garment.6
Front-opening garment typically refers to a shirt, but could include sweaters or jackets. In 1978, the Brigance3 specifically assessed “puts on coat” at 3 years' developmental age. The item was replaced in 1991 by “puts on long-sleeved garment with opening in the front” at age 2.5 years.4 The Brigance IED II,5 the SFA,6 the HELP,9 and the PEDI8 differentiate between pullover and front-opening garments; the first 3 of the former tests indicate that independence with front-opening garments occurs prior to independence with pullovers,5,6,9 and the PEDI8 indicates the opposite. Coats typically open in front, but no tools specify whether the garment is a coat or a shirt. Coats may be more challenging for preschool children than front-opening garments because coats are bulkier and heavier and can bunch shirtsleeves as the arms slide into the coat sleeves.
No assessment tools have been found to evaluate children using the coat-flip technique. Anecdotal evidence suggests that children can be independent as early as age 3 years using the coat-flip method.14 Although current assessment tools are useful for evaluating the broad development of children and for identifying skill deficits, they neither identify the deficient skills nor provide direction for teaching mastery.
The limited references on expected norms for coat donning in children developing atypically and the lack of task detail in standardized tools to assess coat-donning skills result in highly variable methods of documenting skill and progress toward independence. To reduce variability, standardize documentation, and improve documentation efficiency for coat donning, the Newark Therapy Service clinicians developed task analyses and scoring codes for each coat-donning method to use in school-based services. The purpose of this article is to describe the use of the task analyses for school-based documentation and the skill levels of a sample of preschool children in special education classes.
This study is a retrospective review of school-based documentation from urban preschool children in special education classes, who received weekly consultative physical therapy (PT) or occupational therapy (OT) services from 2003 to 2007. Eligible records had at least 2 measures of the coat-donning task and a recorded birth date. Random numbers were assigned to each case to create a data set without personal identifiers. Data include case numbers; dates of birth; diagnoses when available; and up to 3 scores of task independence per academic year, 1 for each marking period that the children were in the school district. The method of coat donning was not specified and gender was assigned post hoc by clinician interviews because routine preschool documentation did not record this. The study had institutional review board approval.
Task Analyses and Performance Codes
The coat-donning task analyses and scoring codes were developed by several Newark Therapy Service clinicians for both techniques on the basis of literature review, developmental scales, clinical experience, skill observation, and school expectations (Table 1). Face and content validity of the task sequences were established through review of the written steps and trial use with preschool children. Initial versions of the sequences were modified to clarify descriptions of steps and to determine consensus on the score codes. Additional Newark Therapy Service clinicians repeated the review of the revised task sequence and trial use of the task analyses and score codes to ensure clarity prior to implementation. This iterative process for developing task analyses is appropriate when the temporal sequence has minimal flexibility.1 Once consensus on the scoring codes was established, no other psychometric tests were conducted.
The traditional coat-donning technique has 13 possible steps (Table 1) with 4 criterion levels: 1 = No performance of any of the first 6 steps, 2 = initiates task by completing any of the first 6 steps, 3 = partial completion by performing more than 6 steps but are not independent or not consistent, and 4 = consistently independent in completing all 13 steps with only occasional cueing. The coat-flip technique has 11 possible steps (Table 1) and scoring is the same for levels 1, 2, and 3. Children who independently complete all 11 steps receive scores of 4. For both techniques, initiation of the task includes having the children find their coats on classroom hooks or in storage cubicles; task completion includes coat fastening.
Task performance was recorded before the November, February, and May parent progress reports. Depending on their age of entry into the school district, the children could have a maximum of 6 consecutive scores recorded, 3 annual scores over 2 years of preschool.
Classroom Consultations for Dressing Skills
The preschool classes in this study received supplemental consultative services with the hope that whole class interventions might reduce the need for future individually mandated services. Clinicians spent 1 to 2 hours per week in assigned classes addressing various kindergarten readiness skills, inclusive of coat donning. Clinicians provided child-specific strategies for the teachers and aides to foster the next steps in the tasks, worked directly with individual children, and reevaluated progress. Given multiple tasks to address, coat donning may not have been the clinicians' only focus during consultations; however, the coat-donning sequences were practiced daily as part of classroom routines.
Early intervention services transition children into preschool throughout the school year; so, the first recorded scores could occur in any of the 3 marking periods. Thus, cases are organized into 4-month age groups within each year to align children chronologically by the age of their first scores, regardless of the marking period they started in. Because of within-subject variability across marking periods, coat-donning independence is defined by consistent scores of “4” without evidence of regression or when the last available score is a 4 if there are no subsequent measures. The latter occurs if children age out of preschool or move out of the district. Data were organized in Microsoft Excel. Frequencies and measures of central tendency were calculated with SPSS 16.0 (version 16.0 for Windows; SPSS Inc, Chicago, IL).
A sample of convenience (n = 601) was available for harvesting, of which 171 records met both criteria of having a recorded birth date and at least 2 scores for coat donning (Figure 1). The sample ages ranged from 3 to 5.3 years, with 102 males, 33 females, and 36 children with unrecorded gender (Table 2). Seventy-five children (43.9%) had no documented diagnosis but qualified for special education placement. Seventy-six children (44.4%) were diagnosed with autism spectrum disorder and 20 (11.7%) had a mix of diagnoses (Table 2). One hundred one children (59%) began consultative OT or PT services at 3 years of age, 67 (39%) began at 4 years of age, and 3 (1.7%) began at 5 years of age (Table 3).
Performance at the Start and End of Data Collection
Of the 171 children, 21(12%) were not initiating any steps of coat donning at baseline, 46 (26%) were initiating the task, 82 (48%) were partially completing the task, and 22 (13%) were independent (Table 3). Only 15 of the 22 children maintained independence: 5 declined from their baseline performances and did not regain independence and 2 had declines from baseline but regained independence (Table 4).
Of 101 children who started services at the age of 3 years, 16 (15.8%) were not initiating the task at baseline, 34 (34%) were initiating fewer than 6 steps, 43 (42.5%) were partially completing the task, and 8 (7.9%) were independent but only 5 maintained independence. Final scores indicate that 38 children (37.6%) achieved or regained independence, and 58 (57.4%) did not achieve independence. Of the 67 children who started at the age of 4 years, 5 (7.5%) were not initiating the task at baseline, 12 (18%) were initiating less than 6 steps, 36 (53.7%) were partially completing the task, and 14 (21%) were independent but only 10 maintained independence (Table 3). Final scores indicate that 20 children (29.8%) achieved or regained independence, and 37 children (55.2%) did not achieve independence. The 3 children who started services at the age of 5 years could partially complete the task at baseline; 2 children achieved independence.
Overall, of 171 children, 15 (8.8%) were independent in coat donning at baseline and maintained independence, and 60 (35.1%) gained or regained independence (Figure 1). Thus, 75 (43.9%) children in the sample were independent in coat donning prior to kindergarten. The remaining 96 children (56.1%) did not achieve independence by the last available measure. Of the 96 children, 50 (52%) were eligible for more preschool, 32 (33.3%) had interrupted service, and 14 (14.6%) were eligible for kindergarten but would need assistance with coat donning (Figure 1).
Time to Achieve Independence
Children initially scoring a “1” (no initiation of the task) at baseline appeared to need more marking periods (
Equation (Uncited)Image Tools
= 4, SD = 0) to achieve independence than children scoring a “2” (initiation of the task;
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= 3.69, SD
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= 1.377), and they appeared to need slightly more time to achieve independence than children scoring a “3” (partial completion of the task;
Equation (Uncited)Image Tools
= 3, SD = 1.291); however, the differences are not significant. Overall, 60 children (35%) achieved independence in coat donning over 2 to 6 marking periods, with 27 children needing only 2 marking periods to achieve independence (Table 4).
Independence by Kindergarten Eligibility
Between 2003 and 2007, 89 of 171 children (52.0%) completed preschool and were kindergarten eligible; 47 of the 89 children began services at 3 years of age, 39 began at 4 years of age, and 3 began at 5 years of age. Of the 3-year-old children, 5 (10.6%) were independent in donning coats at baseline, 38 (81%) gained independence prior to kindergarten, and 4 (8%) still required assistance at the end of preschool. Of those who were 4 years old, 10 (26%) were independent in donning coats at baseline, 20 (51%) gained independence prior to kindergarten, and 9 (23%) still required assistance at the end of preschool. Of the 5-year-old children, 2 gained independence prior to kindergarten and 1 did not. Overall, 75 of 89 children (84.3%) eligible to start kindergarten were independent in coat donning by the end of preschool and 14 (16%) still required assistance.
This article describes the successful use of coat-donning task analyses with scoring codes for standardizing school-based documentation and the first known longitudinal description of this skill in preschool children attending special education classes. The data were collected over a 4-year period of PT and OT consultative services and include 171 urban preschool children, aged 3 to 5 years, whose task analysis scores were recorded for up to 6 consecutive marking periods.
The Coat-Donning Task Analyses
The task analyses reduced the variations in school-based documentation among clinicians by providing consensus-based, contextually relevant temporal sequence descriptions for 2 methods of donning coats. The steps in the task analyses provided a common language among clinicians, teachers, and school personnel; clarified the task sequence so teachers could reinforce the steps throughout the school day; and helped clinicians focus on the critical impediments to independence.
The scoring codes provided a fast and consistent method of documenting skill levels across different therapists, disciplines, classrooms, and schools. As children transferred within the district, or clinicians were reassigned to school settings, the same task analyses and scoring codes were used. Daily documentation efficiency improved because therapists could reference the task step, rather than write lengthy task descriptions. Documenting task performance in each marking period was faster by using numerical codes, and the use over 4 years provided data to describe the incremental changes in coat-donning independence, though the data were limited by the absence of established reliability. The forms used to record scores were designed for school-based documentation, rather than to collect data. Because the teachers and clinicians knew the children, gender and the coat-donning method used were not recorded on the form. Nevertheless, the forms did quickly identify for both teachers and clinicians those children who were making progress across the marking periods.
Both coat-donning task analyses include the use of fasteners as criteria for independence. The task analyses were developed to achieve skills that teachers felt were important in this school district, and the SFA item analysis indicates that by kindergarten, 95% of children should be able to manage their clothing, including the ability to use buttons and zippers.6 These sources suggest contextual validity for the inclusion of fasteners. In contrast, other sources suggest that although manipulation required with snaps8,9 and buttons5,7, 8, 9 may be achieved prior to the age of 5 years, the ability to connect a zipper ranges from 4.5 to 6 years of age.8,16 It is not clear whether more children in this sample would be considered independent in coat donning alone if fasteners were not a condition for independence. Conversely, seeing so many children achieve independence indicates that fasteners may be a reasonable expectation by kindergarten entry.
Skill Acquisition Data
Contrary to preschool children who are developing typically and can independently don coats by 3 years,3 only 13% of this sample were initially independent in donning a coat, 87% were not independent, and a greater percentage of 3-year-old children were delayed than were 4-year-old children. Of those 89 children eligible for kindergarten, 75 were independent in coat donning by the end of preschool but 14 (16%) still required assistance, in contrast to the typical 5% expected for kindergarteners.6 The difference between 3- and 4-year-old children is in accord with literature reporting that 4-year-old children show greater coordination, hand skills, and independence in their activities of daily living.2 However, the data from the start of services and from those ready for kindergarten placement suggest a widespread presence of functional delay in this sample.
There may be multiple explanations for the delays in these preschool children. Forty-four percent of the cohort (n = 76) had a diagnosis of ASD, and 44% (n = 75) had no formal diagnosis but qualified for special education placement; eligibility is often because of speech and language impairments. Many children with ASD have accompanying motor delays,22,23 and children with significant speech and language delays at 4 to 5 years of age may have coordination difficulties.24 Thus, children with autism and/or speech and language delays may also have impairments with motor coordination needed for coat donning.
Children with disabilities often receive more assistance with daily-living skills.25 Parents or caretakers may provide assistance to children with disabilities, even when it is not needed, to be more time efficient. Allowing opportunities at home for children to independently engage in self-care activities may influence skill performance.26 Therefore, the need for parental efficiency may limit practice opportunities and could explain delays in skill acquisition of preschool children in special education classes. In contrast, parents of children with disabilities expect opportunities for independence building when their children move from home to preschool.27 Children who have not practiced skills at home may have lower scores upon entry to formal school settings, but integrating self-care skills within the preschool environment may offset parental time limitations.
The unique characteristics of urban school populations may influence the results. Mobility, particularly short distance moves, among low-income families in distressed settings is higher than national averages, and may be related to economic and social instability.28 Children initially placed in one preschool setting may change schools, or school districts, depending on family circumstances. Having family routines is associated with increased cooperation, social competence, and compliance and may provide protection against environmental stressors.29 Frequent changes in family and home routines, such as the mobility described in low-income families, may affect children's consistency of self-care routines and practice opportunities. In this sample, 32 of 171 children (19%) were lost to follow-up during the preschool years.
Performance fluctuations are noted across the period of data collection, and 5 of 22 children who were initially independent appeared to regress, receiving codes for “partial completion” following a code for “independent.” Fluctuating scores may be the result of increased difficulty when bulkier coats are substituted for lighter jackets as the seasons change, increased environmental demands from classroom layouts as children change preschool placements from year to year, natural variability in performance related to cooperation or behavioral levels, or variability in clinician coding.
Finally, there are no data on the frequency of daily practice. Thus, the marking periods needed to achieve independence are preliminary descriptions, which might be influenced by opportunities for practice in school and at home. Nevertheless, they may be helpful for projecting timelines for coat-donning goals in preschool settings.
Recommendations for future studies include establishing reliability of the scoring codes, recording of the coat-donning methods to investigate how quickly each can be learned, and more frequent scoring, to better identify the time frames needed for task mastery. The data are specific to one urban school district and may not be representative of other geographic locations, settings, or case mixes; so, replication in rural and suburban settings is needed. Access to diagnoses and control of practice frequencies would be helpful to understand the effect of interventions to facilitate independence. Although the potential for inaccurate or missing data is inherent in the use of clinical records,30 this study provides preliminary evidence for the benefits of using task analyses with scoring codes to document incremental acquisition of self-care skills in school-based services.
This retrospective study of the longitudinal records of preschool children describes the benefits of using task analyses and scoring codes to document the coat-donning independence of these children in special education classes. The task analyses and scoring codes facilitate a common language among clinicians and teachers, improve efficiency of documentation, and provide repeated measures of task performance necessary for clinical data collection. The study provides reference values for urban preschool children in special education who received weekly PT or OT classroom consults. Literature suggests that most 3-year-old children developing typically are expected to be independent in coat donning. In contrast, 87% of the 3- to 5-year-old preschool children in special education classes in this study were not independent at baseline and by the final measure, 14 of 89 (16%) children eligible for kindergarten still needed assistance. Those who achieved independence did so within 2 to 6 marking periods. Further study is needed to determine the reliability of the score codes; the difference in skill acquisition times for each method of coat donning; and the effect of specific diagnoses, practice frequency, and intervention approaches on the rate of skill acquisition.
We thank the clinicians of the Newark Therapy Services faculty practice for their commitment to measurable outcomes that led to the development of task analyses, and Alma Merians, PT, PhD, for her editorial insights.
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activities of daily living; child; clothing; physical therapy/methods, preschool; special education; task performance and analysis
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