INTRODUCTION
Down syndrome (DS) is the most frequently occurring chromosomal disorder, affecting approximately 1 in every 700 live births.1 It is characterized by musculoskeletal impairments that include low muscle tone, ligamentous laxity, and decreased strength.2 Compared with children developing typically, children with DS have delayed gross motor skills,3 and decreased postural control.4 Furthermore, children with DS require more time to learn motor skills as movement complexity increases. As a result, many children with DS do not completely achieve the motor abilities measured by the Gross Motor Function Measure (GMFM) by the age of 6 years.3 These motor challenges are especially important as they contribute to lower levels of physical activity in children with DS5 that decrease further with increasing age.6
Reduced participation in physical activity is due in part to decreased availability of appropriate community-based services.5 According to a study by Menear,5 parents of children with DS report social interaction as the primary motivator for their children to participate in physical activities. In addition, parents recognize the need for help from physical activity specialists in increasing appropriate community-based physical activity programs for their children. Developing community-based services in conjunction with physical activity specialists is likely to increase motor skills and physical activity in children with DS.
The availability of athletically based community services for children with disabilities has increased, with resultant improvements in physical function and overall well-being.7 Community services that incorporate the arts may also facilitate children's communication with others, encourage their self-expression, and provide them with an experience of social interaction and sense of community belonging.8 Furthermore, arts programs that are movement based may also improve a child's health and development, movement quality, and alter the trend of sedentary lifestyles for children with DS.9,10 Nevertheless, the availability of community art programs that incorporate physical activity continues to be limited for children with disabilities.11,12 As social interaction can be a primary motivator for children with DS, community-based dance programs provide an effective way to increase physical activity while promoting social interaction for children with developmental disabilities.
Positive benefits of adapted dance programs have been reported in children with cerebral palsy13–15 and those with learning disabilities.16 Reports include improvements in balance,13,15 perception of dance ability,14 and motor performance.16 Pediatric physical therapists (PTs) can help by modifying class structure to optimize the physical, social, and behavioral aspects of children's participation in community dance classes.17,18 Specifically, providing physical assistance, using adaptive equipment, and incorporating Individualized Education Program goals have resulted in enhanced class structure and individual participation, and high satisfaction with physical therapy consultative services reported by dance instructors.17 Improvements after dance training have been reported in individuals with DS.18–21 The feasibility of integrating an 11-year-old girl with DS into a program including dance, voice, and acting resulted in improved quality of life and motor abilities.18 A case study reported benefits of an inclusive recreational dance program for a 21-year-old individual with DS that included expanding his social circle, engaging him cognitively, and becoming physically active.19 An 18-week dance-based training program explored the effects on postural control in static standing in young adults with and without DS, and found after training that the young adults with DS improved their use of visual input for controlling center of pressure.20 A study examining the effects of a 4-month dance exercise program at a junior high school for students with special needs reported significant changes in a proficiency score devised by the author, with significantly higher proficiency scores in students with DS compared with those with autism.21
These 4 preliminary studies support the beneficial outcomes for individuals with DS. However, more empirical evidence is needed to support the gross motor outcomes of these programs. The purpose of this pilot study was to measure the effects of a community-adapted dance program led by ballet faculty with support from PTs (Ballet Moves) on gross motor abilities and participation outcomes in children with DS. We hypothesized that participants would demonstrate improved scores on Dimensions D and E of the Gross Motor Function Measure-88 (GMFM-88)22 and report improved performance and satisfaction scores on the Canadian Occupational Performance Measure (COPM).23 Furthermore, we were interested in qualitative feedback from the caregivers about the program.
METHODS
Study Design
This pilot study had a 1-group pretest/posttest design with measurements taken before and after the adapted dance program.
Participants
A convenience sample of children with DS ages 4 to 13 years was invited to participate in the Ballet Moves program. Potential participants were identified by clinicians serving this population at a large Midwestern pediatric medical center and through flyers distributed through a specialty clinic for DS. Inclusion criteria included ability to stand and walk independently, ability to follow simple verbal instructions, and medically able to participate in a 60-minute group exercise session. Children were allowed to continue with existing therapy or community programs. Fourteen children with DS participated in the Ballet Moves program. Six caregivers agreed and signed consent for their children to attend additional visits at the clinic to complete pre- and posttests. The study was reviewed and deemed exempt by the Institutional Review Board because it was an established community educational program. Demographic characteristics of participants are shown in Table 1.
TABLE 1 -
Participant Characteristics
| Participant |
Age, y |
Gender |
Concurrent Therapy Services |
Other Concurrent Program Involvement |
Attendance |
| 1 |
4 |
Male |
Clinic-based: OT, ST |
None |
18/20 |
| 2 |
7 |
Male |
Clinic-based: ST
School-based: OT, PT, ST |
Adapted soccer |
19/20 |
| 3 |
4 |
Male |
Clinic-based: ST
School-based: OT, PT, ST |
None |
18/20 |
| 4 |
7 |
Male |
Clinic-based: PT, OT, ST |
None |
15/20 |
| 5 |
4 |
Female |
Clinic-based: ST
School-based: OT, PT, ST |
Swim lessons |
15/20 |
| 6 |
13 |
Female |
Clinic-based: OT, ST |
Hip hop, special Olympics, swim lessons, basketball, tennis, music |
17/20 |
Abbreviations: OT, occupational therapy; PT, physical therapy; ST, speech therapy.
Intervention
Ballet Moves is an adaptive dance program created by a professional ballet troupe in partnership with PTs at the pediatric medical center. This program is designed to foster creative expression for individuals with special needs and consists of 20 classes (1 class per week, duration 1 hour) led by a qualified ballet faculty member (with 25 years' teaching experience) with a ballet dancer present as a peer for demonstration. Based on their age at the time of enrollment, students were assigned to a younger class (ages 4 to ≤7.5 years) or older class (ages >7.5 to 14 years). These age groups were selected to distribute the number of students in each class as evenly as possible. The younger class included community volunteers who were available to buddy with each child for assistance. This volunteer group was composed of older teens and adults developing typically. All classes were supported by 1 to 2 experienced PTs (combined experience of 8 years, range = 1-7 years), with dance experience. The PT's role was to provide environmental adaptations, provide physical assistance, encourage appropriate positions, promote use of both right and left sides, provide staff training, and provide behavioral management. Environmental adaptations included minimizing use of the ballet barre so that students would not hang on them, and covering the windows to the waiting area to avoid disengagement and limit the students' desire to exit the room. Physical assistance included providing postural support as needed for challenging activities, and allowing the students to experience the feeling of jumping, leaping, and tip-toes. Encouraging appropriate positions included promoting tailor sitting rather than w-sitting. Promoting use of both right and left sides included encouraging students to alternate their advancing leg with activities instead of always using the same leg. Staff training included increasing awareness of and promoting progress toward goals identified on the COPM, educating on appropriate handling of children (eg, lifting them from the trunk rather than from the hands), and instructing them in simple sign language to communicate with students. Behavioral management included redirecting the students to the task at hand. The dance class combined creative movement and traditional ballet activities, often incorporating props such as tambourines, hula hoops, and scarves. Examples of activities included running, heel and toe walks, body isolations (isolating movement to one body part), clapping to various rhythms, pliés (bending and straightening the knees), relevés (rising on the tips of the toes), tendus (a position in which a limb is stretched out), port de bras (moving and posing the arms), chassés (a gliding step in which one foot displaces the other similar to a gallop), skipping, jumping/leaping activities, balance activities, pantomime, and improvisation. Breaking complex skills into parts and repetition of skills and movements were used to promote learning. Activities were individual, partner, and group focused.
Procedures
Pre- and posttests were completed before and after the program at the institution's outpatient therapy clinic and were approximately 1 hour in length. Five out of 6 participants completed pretests 1 week prior to the start of the program. The remaining participant (participant 6) completed the pretests 5 days following the first class because of scheduling conflicts. Four out of 6 participants completed posttests 1 week following completion of the program. The remaining 2 (participants 1 and 5) completed the posttests 19 days after the last class due to winter break. Conditions and procedures were standardized across all testing sessions. Pre- and posttests were completed by 2 PTs supporting the program, with 8 years of combined pediatric PT experience and trained in outcome measures. One therapist always completed the GMFM with each child while the other PT always completed the COPM with the parent. At the time of GMFM posttesting, the administering therapist was blind to the pretest scores. At the last session, all parents were given the opportunity to provide qualitative feedback with an open response paper survey provided by ballet faculty and returned at the end of the class session.
Outcome Measures
Dimensions D and E of the GMFM-8822 were administered to the children according to the guidelines in the manual to assess gross motor activity abilities. The GMFM-88 has been validated and shown to be responsive to clinically meaningful change in children with DS.24 Dimension percentage scores, as described in the manual for the GMFM-88, can be used when detecting change over time in a specific area of interest. Dimensions D (Standing) and E (Walking, Running, and Jumping) were chosen as they reflect higher motor skills that would be likely to improve in the dance program for children of this age. Each item is scored on a 4-point scale, ranging from 0 (does not initiate) to 3 (completes item).
Performance and satisfaction with individualized participation goals were assessed at pre- and posttests with the COPM.23 The COPM is a standardized client-centered semistructured interview designed to detect change in a client's self-perception of occupational performance over time. The COPM has been used with a variety of people, enables client-centered practice, and supports outcomes research.25 At the pretest visit, the caregiver identified up to 5 goals for which they anticipated positive outcomes following the adapted dance program. The performance and satisfaction scores for each goal were summed and averaged and resulted in a score up to 10 for each area. The same caregiver identified and rated the goals at the pre- and posttests. Caregivers did not view previous results. Overall scores generated from the COPM were used for analysis.
At the last session, caregivers were asked to report on the program's perceived benefits for their child's physical, cognitive, and emotional abilities.
Data Analysis
Data for each individual were visually examined. Group data for GMFM Dimensions D and E and COPM scores were analyzed with the Wilcoxon signed rank test. In an effort to determine meaningful changes, we compared each participant's specific pre- and posttest scores on GMFM items 77 (running), 81 (jumping), and 86 (climbing stairs) to published predicted probabilities for children with DS achieving those items by a particular age.3 Parental qualitative feedback in the categories of physical, cognitive, and emotional benefits to the child was summarized with example comments provided for each category.
RESULTS
The participants attended an average of 17 of 20 sessions (range 15-19). There was significant improvement in Dimensions D (z = 10.5, P = .03) and E (z = 10.5, P = .03) of the GMFM-88, indicating improvements in gross motor abilities (Figure 1 for individual participant results). Scores for items 77 (running), 81 (jumping), and 86 (climbing stairs) are shown in Table 2.
;)
Fig. 1.: (A) GMFM-88 Dimension D scores. (B) GMFM-88 Dimension E scores. GMFM indicates Gross Motor Function Measure.
TABLE 2 -
GMFM Pre- and Postassessment Scores for Selected Items
| GMFM Item |
Passing Score for Achievement of Item3 |
Participant (Age, y) |
Preassessment |
Postassessment |
| 77 |
Score of 3. Runs 15 ft (2.74 m), stops, and returns |
1 (4) |
1 |
3 |
|
|
2 (7) |
2 |
3 |
|
|
3 (4) |
1 |
3 |
|
|
4 (7) |
1 |
3 |
|
|
5 (4) |
1 |
1 |
|
|
6 (13) |
3 |
3 |
| 81 |
Score of ≥2. Jumps forward at least 2 inches (5.08 cm), both feet simultaneously |
1 (4) |
1 |
2 |
|
|
2 (7) |
2 |
3 |
|
|
3 (4) |
0 |
2 |
|
|
4 (7) |
3 |
3 |
|
|
5 (4) |
1 |
1 |
|
|
6 (13) |
3 |
3 |
| 86 |
Score of ≥1. Walks up at least 2 steps from the base of the stairs, alternating feet, without holding on |
1 (4) |
0 |
1 |
|
|
2 (7) |
0 |
2 |
|
|
3 (4) |
0 |
1 |
|
|
4 (7) |
0 |
1 |
|
|
5 (4) |
0 |
1 |
|
|
6 (13) |
3 |
3 |
Abbreviation: GMFM, Gross Motor Function Measure.
Changes in COPM Performance (z = 9.5, P = .06) and Satisfaction (z = 9.5, P = .06) scores were not significant, although both improved for 5 of 6 participants. The most common goals for participants were related to interacting with peers, gross motor skills, endurance, and safety awareness. Caregivers of 5 out of 6 participants identified interacting with peers as a goal with improvement in performance (baseline mean 5.4, post mean 6.8) and satisfaction (baseline mean 3.8, post mean 7.2). Caregivers of 5 participants had a goal related to gross motor skills such as jumping, ball skills, and stairs with improvement in performance (baseline mean 3, post mean 5.8) and satisfaction (baseline mean 4.2, post mean 6.4). Caregivers of 3 participants had a goal related to endurance with improvement in performance (baseline mean 4, post mean 5.3) and satisfaction (baseline mean 3, post mean 5). Caregivers of 3 participants had a goal related to safety awareness with improvement in performance (baseline mean 3.3, post mean 6) and satisfaction (baseline mean 2, post mean 5). Figure 2 graphs individual participant results.
Fig. 2.: (A) COPM Total Performance scores. (B) COPM Total Satisfaction scores. COPM indicates Canadian Occupational Performance Measure.
Written Parent Feedback
At the last session, parents of 5 of 14 children provided written feedback on the perceived benefits of the program for their child's physical, cognitive, and emotional abilities. Three were parents of children who had completed pre- and posttests. Comments were reviewed by the authors to gain a deeper appreciation of parental perceived benefits of the program and learn what the experience meant to the student and family (Table 3). Additional comments that did not fit into the categories of physical, cognitive, and emotional abilities included the following: “She loves to come to ballet. She enjoys dance, music.” “It was great to have a regularly scheduled time to receive so much positive attention.” “We are very thankful to everyone working so hard for these kids.” “I very much appreciate the patience and attention given to the children.” “The teachers/volunteers have been very motivational for her.”
TABLE 3 -
Samples of Written Parent Feedback
| Perceived Benefit |
Parental Quote |
| Physical |
“Moving with peers/working together.”
“Strength in leg and foot works. Stamina; he can run a longer distance and make more numbers of consecutive jumps. Another development and improvement in him is his balance. He can make turns without falling.”
“Improvement in balance, coordination, learning to skip, standing on one foot, hopping, core strength and endurance.” |
| Cognitive |
“Being part of a group/routines in a novel environment. Watching other children try new ways to move and being willing to try as well.”
“Following directions, growing independence. Learning vocabulary-dance terms, pretend play, counting.”
“Attention span and following directions were improved.”
“Attention seems to have lengthened with less escapes (although still present).”
“Following directions and staying in her place better.” |
| Emotional |
“As he got used to coming he was happier to come and smiled more often during play. He was also able to tolerate the open space more along with the louder music.”
“This ballet class was a big step for him to be exposed to a new environment and people. I think his social skills are much better than 3 months ago. I was also surprised to see he remembers certain ballet routines. Before he started the ballet, he could not relax and calm himself down, always running around. But ballet helped him to learn how to relax.”
“Getting along with others-social skills.”
“I just think it was a great experience for her to be with a true group of her peers in a social/active setting. She is involved in a number of activities, but this was special.”
“The familiarity of the program each week allowed her to increase participation and confidence as the program progressed.”
“Class helps her to learn respect for others, discipline, being in a group. I am sure this helps in other areas of her life-home, school.” |
DISCUSSION
These findings are consistent with the hypothesis that an adapted dance program meeting once per week for 20 weeks improves gross motor abilities in children with DS. Dimensions D and E of the GMFM include items such as single leg support, jumping, and running, which were all targeted activities in the program. The greatest improvement in Dimensions D and E of the GMFM-88 was for participant 5, who started with the lowest scores in these domains. Participant 5 was also observed to have more difficulties with behavior and attention at initiation of the program and was anecdotally observed by ballet faculty and PT to have improved in this area over the course of the sessions. The smallest improvement in Dimensions D and E of the GMFM-88 was for the oldest participant, participant 6, who started with the highest scores for Dimensions D and E of participants and likely experienced a ceiling effect.
Due to the lack of a control group, we are not able to conclude that these changes occurred beyond what would be expected with developmental maturation. However, Palisano et al3 identified predicted probabilities for children with DS achieving skills on the GMFM that are helpful when interpreting our findings. Over the course of the program, 5 of 6 participants in our study achieved at least 1, 4 out of 6 achieved 2, and 2 out of 6 achieved 3 new gross motor skills for which Palisano et al had reported predicted probabilities (eg, the predicted probability of achieving item 77 on the GMFM [runs 15 ft, stops, and returns] at age 4 years is 25% and at age 6 years is 67%). Participants 1 to 4 achieved this item over the course of the program, participant 5 did not achieve this item, and participant 6 performed this item at pretest. The predicted probability of achieving item 81 of the GMFM (jumps forward at least 2 inches, both feet simultaneously) at age 4 years is 18% and at age 6 years is 84%. Participants 1 and 3 achieved this item over the course of the program, participant 5 did not achieve this, and participants 2, 4, and 6 performed this item at pretest. The predicted probability of achieving item 86 of the GMFM (walks up at least 2 steps from the base of the stairs, alternating feet, without holding on) at age 4 years is 18% and at age 6 years is 77%. Participants 1 to 5 achieved this item over the course of the program and participant 6 performed this item at pretest. The predicted probabilities by Palisano et al suggest that some of the changes we observed would not have occurred solely as a result of developmental maturation. In addition, although participant 5 did not meet criteria for a passing score for items 77 and 81, she demonstrated the most improvement in GMFM Dimensions D and E. Her improvement in these dimensions may reflect increased ability to follow directions rather than improved motor skills.
Our results suggest that the gross motor benefits of an adapted dance program are greater for younger children and they are likely to gain gross motor skills earlier than anticipated for the majority of children with DS at their age. Our results are also consistent with motor growth curves, which indicate that for children with DS during the first 6 years of life scores improved the fastest at younger ages, and then leveled off as the predicted upper limit of gross motor function is approached.3
Although not statistically significant for the group, improvement was noted for COPM performance and satisfaction scores in 5 of 6 participants. The oldest participant's COPM goals included higher-level task-specific skills, such as riding a 2-wheeled bike and climbing in and out of the pool. Because these goals were not specifically targeted by the dance program, participant 6's performance was not reflected in an improved score. As this was the first year of the program, it was difficult to guide parents in appropriate goal setting without knowing exactly what the program would involve and the potential benefits for their children.
Our results support Menear's work indicating that social interaction is a primary motivator for children with DS to participate in physical activities.5 In this pilot study, social interaction was an overarching benefit of the program reported by parents across all categories (physical, cognitive, emotional, and other). Taken as a whole, other commonalities appreciated in the parent feedback from our study were their overall gratitude for the program, their children's improved ability to attend and follow directions, and the apparent benefit of a weekly scheduled class. In addition, parents provided feedback about perceived physical benefits that corresponded with improvements observed on the GMFM.
LIMITATIONS
This pilot study provides initial information as to the benefits of an adapted dance program on motor skills and participation goals in children with DS. However, the small sample size, convenience sampling methods, and lack of a control group limit the generalizability of the findings. Families who chose to enroll their children in this program may be different from families that chose not to participate. The participant families might have engaged in physical activity outside the scheduled class, which may account for the observed changes in gross motor function. We did not control for concurrent activities or therapies during the program. Parent feedback was informally gathered at the conclusion of the program and therefore was not provided by all families. It is possible that the families who did not provide feedback had negative experiences. Participant 6 (13 years) may be an outlier, and thus her results should be interpreted with caution, as the program did not specifically target identified COPM goals and she experienced a ceiling effect on the GMFM. In future studies, we recommend that the therapist who administers the outcome assessments remain uninvolved with any portion of the intervention, to control for potential bias. Larger samples and a control group are needed to continue to explore the effects of adapted dance on outcomes in children with DS.
CONCLUSIONS
This study provides preliminary support for the use of an adapted dance program to improve gross motor abilities and participation in children with DS. Further feedback from caregivers was overwhelmingly positive and the program was well accepted by the dancers, their families, and our community. In addition, this study prepares the foundation for future projects that build collaborations between clinicians and community organizations to enhance participation of those with developmental disabilities. Future studies should examine the effects of the adapted dance program in a larger sample size and include more rigorous qualitative methods.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the parents and children who participated, Sarah Fox, PT, who assisted with data collection and class support, Julie Sunderland, Director of Education at the Cincinnati Ballet for coordinating the program, Donna Weber, Instructor at the Cincinnati Ballet, and Mr and Mrs Thomas G. Cody for their financial support of the program.
REFERENCES
1. Parker SE, Mai CT, Canfield MA, et al. Updated national birth prevalence estimates for selected birth defects in the United States, 2004–2006. Birth Defects Res A Clin Mol Teratol. 2010;88(12):1008–1016.
2. Pitetti K, Baynard T, Agiovlasitis S. Children and adolescents with Down syndrome, physical fitness and physical activity. J Sport Health Sci. 2013;2(1):47–57.
3. Palisano RJ, Walter SD, Russell DJ, et al. Gross motor function of children with Down syndrome: creation of motor growth curves. Arch Phys Med Rehabil. 2001;82(4):494–500.
4. Shumway-Cook A, Woollacott MH. Dynamics of postural control in the child with Down syndrome. Phys Ther. 1985;65(9):1315–1322.
5. Menear K. Parents' perceptions of health and physical activity needs of children with Down syndrome. Downs Syndr Res Pract. 2007;12(1):60–68.
6. Esposito PE, MacDonald M, Hornyak JE, Ulrich DA. Physical activity patterns of youth with Down syndrome. Am J Intellect Dev Disabil. 2012;50(2):109–119.
7. Murphy NA, Carbone PS. Promoting the
participation of children with disabilities in sports, recreation, and physical activities. JAMA Pediatr. 2008;121(5):1057–1061.
8. King G, Kingsnorth S, Sheffe S, et al. An inclusive arts-mediated program for children with and without disabilities: establishing community and an environment for child development through the arts. Child Health Care. 2016;45(2):204–226.
9. Albin CM. The benefit of movement: dance/movement therapy and Down syndrome. J Dance Educ. 2016;16(2):58–61.
10. Jobling A, Virji-Babul N, Nichols D. Children with Down syndrome: discovering the joy of movement. J Phys Educ Recreat Dance. 2006;77(6):34–54.
11. Majnemer A, Shevell M, Law M, et al.
Participation and enjoyment of leisure activities in school–aged children with cerebral palsy. Dev Med Child Neurol. 2008;50(10):751–758.
12. Modell SJ, Rider RA, Menchetti BM. An exploration of the influence of educational placement on the community recreation and leisure patterns of children with developmental disabilities. Percept Mot Skills. 1997;85(2):695–704.
13. Lopez-Ortiz C, Gladden K, Deon L, Schmidt J, Girolami G, Gaebler-Spira D. Dance program for physical rehabilitation and
participation in children with cerebral palsy. Arts Health. 2012;4(1):39–54.
14. Zitomer MR, Reid G. To be or not to be–able to dance: integrated dance and children's perceptions of dance ability and disability. Res Dance Educ. 2011;12(2):137–156.
15. Stribling K, Christy J. Creative dance practice improves postural control in a child with cerebral palsy. Pediatr Phys Ther. 2017;29(4):365–369.
16. Couper JL. Dance therapy: effects of motor performance of children with learning disabilities. Phys Ther. 1981;61(1):23–26.
17. Hunter KG, Piner SK, Rosenberg AE. Pediatric physical therapists' consultation with a community dance instructor: a case report. Pediatr Phys Ther. 2004;16(4):222–229.
18. Becker E, Dusing S.
Participation is possible: a case report of integration into a community performing arts program. Physiother Theory Pract. 2010;26(4):275–280.
19. Reinders N, Bryden PJ, Fletcher PC. Dancing with Down syndrome: a phenomenological case study. Res Dance Educ. 2015;16(3):291–307.
20. Gutiérrez-Vilahú L, Massó-Ortigosa N, Costa-Tutusaus L, Guerra-Balic M, Rey-Abella F. Effects of a dance program on static balance on a platform in young adults with Down syndrome. Adapt Phys Activ Q. 2016;33(3):233–252.
21. Ito Y, Hiramoto I, Kodama H. Factors affecting dance exercise performance in students at a special needs school. Pediatr Int. 2017;59(9):967–972.
22. Russell DJ, Rosenbaum PL, Wright FV, Avery LM. Gross Motor Function Measure (GMFM-66 and GMFM-88) User's Manual. 2nd ed. MacKeith Press; 2013.
23. Law M, Baptiste S, McColl M, Opzoomer A, Polatajko H, Pollock N. The Canadian Occupational Performance Measure: an outcome measure for occupational therapy. Can J Occup Ther. 1990;57(2):82–87.
24. Russell D, Palisano R, Walter S, et al. Evaluating motor function in children with Down syndrome: validity of the GMFM. Dev Med Child Neurol. 1998;40(10):693–701.
25. Carswell A, McColl MA, Baptiste S, Law M, Polatajko H, Pollock N. The Canadian Occupational Performance Measure: a research and clinical literature review. Can J Occup Ther. 2004;71(4):210–222.
