Dyspraxia: Is it the hidden handicap?

Dyspraxia:  Is it the hidden handicap?

by Katherine J. Collmer, M.Ed., OTR/L

Dyspraxia, most concisely described, is a learning difficulty that “possesses the most interesting ‘melting pot’ mix of physical and mental characteristics.” (Patrick 2015 p. 11)  Once called a “disorder of sensory integration by Jean Ayes in 1972 and then labeled as “Clumsy Child Syndrome” in 1975, dyspraxia continues to be a confusing condition to classify.   The terms “Dyspraxia” and “Developmental Coordination Disorder” are commonly used interchangeably, however, it is felt by some professionals that they are not the same condition.  Dyspraxia is defined by the Dyspraxia Foundation USA as “a neurological disorder throughout the brain” that often comes with a variety of comorbidities, the most common [of these being] Developmental Co-ordination Disorder (also known as DCD). (“1 in 10 Odds”)  The UK branch further explains that “while DCD is often regarded as an umbrella term to cover motor coordination difficulties, dyspraxia refers to those people who have additional problems planning, organising and carrying out movements in the right order in everyday situations” and can also experience difficulties with “articulation and speech, perception and thought.” (“What is Dyspraxia,” Section “What is Dyspraxia?”)   Alison Patrick, in her book “The Dyspraxic Learner,” stresses that “the significant role that the mind plays in this condition cannot be underestimated.” (Patrick 2015 p. 17)

Developmental Dyspraxia, the term more commonly used to describe the developmental problems observed in children who are clumsy, describes the condition as “a failure to learn or perform voluntary motor activities despite adequate strength, sensation, attention, and volition (Missiuna & Polatajko, p. 620)”  It is felt that the term was chosen as a result of the belief that a link existed between apraxia and dyspraxia.  Due to the lack of empirical data that shows a causative link between apraxia – the condition that involves “the loss of ability to perform previously acquired movements” most commonly observed in adults who have experienced a cerebrovascular accident resulting in brain damage – and the problems of children who have the symptoms described above, the condition is often labeled simply as “Dyspraxia.” (Missiuna & Polatajko 1995 p. 620)  The roots of this confusion over labelling stem from two facts:  first, that there is no internationally agreed upon definition for the term “dyspraxia” and second, that the DSM-V does not list it among diagnosable conditions.  Instead, it is felt that dyspraxia would most suitably fall under the new reclassification of “Neurodevelopmental Disorders-Motor,” as some consider it a developmental coordination disorder (“Highlights of Changes”).  Steinman, et. al. make a further distinction that developmental dyspraxia should be considered in terms of praxis “rather than a diagnostic label” and referred to instead as “a specific neurologic sign of impaired execution of skilled learned movements. (p. 5)”  The authors stress that it can exist in children who demonstrate no other signs of neurological impairments, as well as in conjunction with other neurodevelopmental disorders such as autism and language disorders.  After all the discussions have been heard, it is not difficult to imagine a more fitting label than “the hidden handicap.” (Udoh & Okoro 2013, Kirby 1999)

It is difficult to estimate exactly how many children are affected by DCD/Dyspraxia due to the lack of an official diagnosis and consistent use of behavioral information to identify them.   However, 2009 study results out of the UK “suggested that up to one in every 20 children between seven and eight years of age may be affected by the condition to some degree.  It is felt that the disorder occurs three or four times more in boys than girls and that the condition “sometimes runs in families.”  (Developmental Co-ordination, Section “Who is affected).

Despite the confusion, understanding developmental dyspraxia remains an important concern for occupational therapists who are often presented with referrals for children who have handwriting difficulties, problems with self-care management, and social isolation that results from their clumsiness and uncoordinated behaviors (Missiuna & Polatajko 1995).  Without a clear definition for dyspraxia nor a diagnosis that outlines the symptoms associated with it, our assessment will be based upon our knowledge of the condition itself.  Children who present with these school-, home-, and socially based needs will appear physically capable, will not have intellectual needs, and often will not have any identifiable disease or medical condition.  Since dyspraxia is a developmental condition, it can present itself in the early years as children meet the prescribed developmental gross-motor milestones late and experience difficulty with fine-motor activities of daily living, such as tying their shoes or fastening buttons, very much like developmental coordination disorder.  From an occupational therapy standpoint, then, dyspraxia and the behaviors associated with it must be differentiated from those same behaviors that exist with a motor coordination condition.  Dyspraxia, in our practice area, is not viewed as a primary problem in motor coordination and the child must present with difficulties with ideation and planning to be regarded as dyspraxic from our point of view. (9)  Rather than be the result of a problem with motor execution, dyspraxic behaviors are felt to be a difficulty in formulating a plan of action, the problem presenting itself as the inability to efficiently plan and carry out skilled non-habitual motor acts in the correct sequence.   Although children with dyspraxia may have difficulty learning a new task, once they are able to master the skills that it demands, they can use those skills to repeat the task.  (9)  Their ability to use their skill development in the mastery of other similar activities is limited, however, as they are not able to effectively plan and execute new motor actions or generalize motor actions in a new situation.  (9)  From an occupational therapy standpoint, the child with dyspraxia will present with the following behaviors (10) that can be fall into four categories: (7)

Dyspraxic Behaviors Chart
Dyspraxic Behaviors
Categories of Dyspraxia

The appearance of “clumsiness” stems from their difficulty in transitioning from one body position to another, their poor discrimination of tactile input, an overall difficulty in relating their bodies to physical objects and space, and challenges with imitating actions or perceiving the direction of movement.  They are slower to develop both gross- and fine-motor skills and are often referred to occupational therapy for these reasons, particularly handwriting.  They may tend to prefer talking rather than performing and will often avoid new tasks altogether.  Their social behaviors result from their becoming frustrated with new situations because they are unable to approach these activities in an organized manner. The culmination of these symptoms and behaviors can be low self-esteem or self-concept.  (9)

Patten, in her newsletter article, “Dyspraxia from an Occupational Therapy Perspective,” suggests a battery of standardized assessments that will assist in the assessment process.  Goodgold-Edwards and Cermak, (10) stress that we must also have an understanding of the motor, sensory integrative, and cognitive and conceptual components of movement as we observe the children in both standardized testing environments and the performance of everyday activities.  Treatment strategies we select can include sensory integrative, perceptual motor, sensorimotor, cognitive goal-directed, and compensatory skill development approaches. (9)  These will most likely be combined in a remedial plan that addresses each child’s individual needs and will include skill areas such as rule learning as it applies to motor planning and motor learning; planning for managing movements as they occur that include goal-directed activities with performance expectations; the use of tasks that have a clear, functional identification within the practicing environment; the inclusion of cognitive strategies that allow for the child’s learning abilities and styles; and, perhaps most importantly, will be fun as well as challenging.  (10)  Of course, the complex nature of dyspraxia and the multiple needs that a child may experience will necessitate the development of a team approach. (7)

The implications of dyspraxic behaviors for the school-based occupational therapist are that we must consider the “whole child” in our development of a remedial plan or recommendations for adaptations.  Although the child may have been referred to therapy because of handwriting difficulties, it is vital that we look below the surface and develop the overall picture of his behaviors, from home, to school, to the playground, and the community.  With or without an official diagnosis, dyspraxia exists and will continue to present itself in our therapy rooms and clinics.

Katherine J. Collmer, M.Ed., OTR/L, owner, Handwriting With Katherine
Katherine J. Collmer, M.Ed., OTR/L, owner, Handwriting With Katherine

occupational therapist who specializes in the assessment and remediation of handwriting skills. In her current book, Handwriting Development Assessment and Remediation: A Practice Model for Occupational Therapists, she shares a comprehensive guide and consistent tool for addressing handwriting development needs. She can be contacted via her website, Handwriting With Katherine.

Collmer Handwriting Development Assessment and Remediation

 
 
 
 
 Disclaimer: The information shared on the Handwriting With Katherine website, blog, Facebook page, Twitter page, Pinterest page; in the Universal Publishing Handwriting Teachers’ Guides; on any guest blog posts or any other social media is for general informational purposes only and should not be relied upon as a substitute for sound professional medical advice or evaluation and care from your physician/medical team or any other qualified health care providers. Therefore, the author of these links/posts take no responsibility for any liability, loss, or risk taken by individuals as a result of applying the ideas or resources.
Photos are the property of Handwriting With Katherine and are not to be used in any fashion except as links to the appropriate blog or the Handwriting With Katherine website without the expressed, written permission of Katherine Collmer.  Those photos that include a link to the Pixabay site should be used only if they include the link to the photographer’s page that is provided with them.
 
  1. Patrick, Alison. “Introduction and Chapters 1 and 2.” The Dyspraxic Learner: Strategies for Success. 2015 ed. London: Jessica Kingsley Pub., 2015. 11-54. Print.
  2. “1 in 10 Odds Are That You Know Someone With Dyspraxia.” Dyspraxia Foundation USA. Dyspraxia Foundation USA, n.d. Web. 08 Oct. 2015. <http://www.dyspraxiausa.org/>.
  3. “What is Dyspraxia?” Dyspraxia Foundation.org.uk. Dyspraxia Foundation UK, n.d. Web. 8 Oct. 2015. <https://www.dyspraxiafoundation.org.uk/about-dyspraxia/>.
  4. Missiuna, C., and H. Polatajko. “Developmental Dyspraxia by Any Other Name: Are They All Just Clumsy Children?” American Journal of Occupational Therapy 49.7 (1995): 619-27. Web. 8 Oct. 2015.
  5. “Highlights of Changes From DSM-IV to DSM-5.” Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2013): n. pag. DSM5.org. American Psychiatric Publishing. Web. 8 Oct. 2015. <http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf>.
  6. Steinman, K. J., S. H. Mostofsky, and M. B. Denckla. “Toward a Narrower, More Pragmatic View of Developmental Dyspraxia.” Journal of Child Neurology 25.1 (2009): 71-81. Web. 8 Oct. 2015.
  7. Udoh, Nsisong A., and Cornelius C. Okoro. “Developmental Dyspraxia—Implications for the Child, Family and School.” International Journal of Academic Research in Progressive Education and Development IJARPED 2.4 (2013): 200-14. Web. 9 Oct. 2015.Caroline Lacey. London:
  8. Caroline Lacey, 1997. Ludlowlearning.com. OAASIS, Cambian Education Services. Web. 8 Oct. 2015. <http://www.ludlowlearning.com/downloads-icpa/Oaasis-Dyspraxia.pdf>. OAASIS website: www.oaasis.co.uk Cambian Education Services website: cambianeducation.com
  9. Patten, Natasha, Bcc OT. Dyspraxia from an Occupational Therapy Perspective (n.d.): n. pag. Dyspraxia Foundation.org.uk. Dyspraxia Foundation UK. Web. 8 Oct. 2015. <http://dyspraxiafoundation.org.uk/wp-content/uploads/2013/10/dyspraxia_and_Occupational_Therapy.pdf>.
  10. Goodgold-Edwards, S. A., and S. A. Cermak. “Integrating Motor Control and Motor Learning Concepts With Neuropsychological Perspectives on Apraxia and Developmental Dyspraxia.” American Journal of Occupational Therapy 44.5 (1990): 431-39. Web. 8 Oct. 2015.
  11. Kirby, Amanda. Dyspraxia: The Hidden Handicap. 2002 ed. London: Souvenir, 1999. Print.
  12. “Developmental Co-ordination Disorder (dyspraxia) in Children .” NHS Choices. National Health Services UK, n.d. Web. 09 Oct. 2015. <http://www.nhs.uk/Conditions/Dyspraxia-(childhood)/Pages/Introduction.aspx>.
 

Client-centered practice in pediatrics

For the month of September, the Handwriting is Fun! Blog will be sharing insights about the role of Occupational Therapy in the classroom.  In recent years, the role of OT, in general, has been changing with the waves of healthcare and education reforms.  Despite a certain amount of turmoil and confusion where those changes may have thrown us a curve ball, most often they have provided us with an opportunity to make a difference in an area in which we’ve longed to see an improvement.  Client involvement is an excellent example of a concept that can turn the tide in school-based and pediatric practice.   Although this concept is relatively new in pediatrics, it remains an important one to embrace as we enter this new generation of healthcare and education perspectives.  In that light, this week’s article focuses upon the concepts that define a client-centered therapeutic approach and the implications for its use in all facets of occupational therapy, including pediatrics and in the schools.

 

Inclusion geralt pixabay

 

 

Client-centered practice in pediatrics.

by Katherine J. Collmer, M.Ed., OTR/L

 

 

 

 

 

 

The rehabilitation process and client-centered practice:  Defined

The rehabilitation process can be defined as a “reiterative, active, educational, problem solving process focused on a patient’s behavior (disability)” that uses assessment, goal setting, intervention, and evaluation tools to achieve its objectives.  The objective of the rehabilitation process includes maximizing the client’s participation in his or her environment and to minimize the effects of pain and distress on the client and client families. (1)  In recent years, the approach to rehabilitation has moved from a “predominantly medical one to one in which psychological and sociocultural aspects are equally important.”  This has resulted in transforming the rehabilitation process into a client-centered practice where the personal perspectives and backgrounds of the client are becoming increasingly important.

The process of rehabilitation is complex (1) and works within a structure that demands the collaboration of a multi-disciplinary team who works toward client-specific goals and encourages involvement of the individual and his or her family.  (2)  In the past, this group included professionals from the medial, therapeutic, and ancillary staff of the hospital, school, clinic, or facility where the client was receiving services.  Family members and caregivers in the adult environment were invited to participate in team meetings, training, and decision making events along with the client.  The client’s level of participation in the process rested on his or her capacity for understanding the choices and for making decisions.   A child-centered rehabilitation process, however, typically includes the professionals on the team and the family members responsible for the child’s wellbeing.  The child most often serves in an “invisible role” on the team appearing for the assessment and therapeutic interventions but rarely for events that would determine his or her goals for therapy.  The move toward a client-centered practice has not completely turned the corner into pediatrics.

 

 

children omarmedinard pixabayThe rehabilitation process in the pediatric practice remains the same regardless of the arena within which it is carried out.  The provision of therapy in the clinic or hospital, the home or the school, begins and ends with the same tools as it seeks to achieve the highest level of independence for the clients.  Our clients are young, ranging from birth to around 18 years of age, and present with a wide range of strengths and needs.  They are all individuals and deserve strategies for care that respect them as such.

In that light, the process of their care in any environment should include them in what has been described as a “working alliance.” This relationship “is formed as individuals collaborate with one another to develop common goals and as they develop a sense of shared responsibility for working on tasks that are involved in achieving those goals.” (Bordin, E.S., 1979, qtd. in 4) The development and maintenance of rapport, mutual respect, and collaboration between therapists and their clients have been linked to the therapeutic relationship that standards of practice OT2fosters client participation in their own rehabilitation.  (4) Client participation has been considered a focal point in occupational therapy and is reflected in the professional standards established by the American Occupational Therapy Association.  They clearly state that occupational therapists will collaborate with the client in the assessment of his or her skills and during the development and implementation of the intervention plan. (5)

However, results of a 1995 study of the participation of adult patients in their rehabilitation process conducted by Northen et al. (5, quoted in 6) determined that the “maximum potential of client-centered practice was not realized throughout the treatment process.” This was linked primarily to inconsistencies in the use of structured methods for encouraging client participation in the initial process as well as during the ongoing rehabilitation process.  Given the lack of data available that tracks client involvement in the pediatric practice, it is of value to discuss the implications of client-centered rehabilitation with children.

 

Client-centered therapy and its implications for pediatric outcomes.

Client-centered therapy implies that the person for whom the services are designed will actively and willingly participate in the rehabilitation process and includes both a “behavioral” and a “motivational” component on his part.   In the case of student “involvement,” this translates to the “amount of physical and psychological energy” that he devotes to the learning experience.  This involvement can be measured in both quantitative and qualitative terms using testing and the observation of functional use of skills. The student achieves both functional and personal development through his participation in this working alliance.  And the effectiveness of that alliance rests upon “the capacity of (the practitioner) to increase student involvement. (8)

 

Success of a client-centered occupational therapy practice depends upon two principal components, as outlined by Maitra and Erway, in their article “Perception of Client-Centered Practice in Occupational Therapists and Their Clients:”

 

  1. The desire and ability of the clients to take part in the decision-making process, and
  2. The desire and ability of the occupational therapists to include clients in the decision-making process. (6)

 

These two components rely upon the development and implementation of a team-based strategy that is designed to enhance both client and therapist involvement in the client-centered process.  This type of strategy is based upon three factors for success:  rapport, a working reliance, and a stable relationship.

Client Centered Process

 

The development of rapport, a working alliance, and a stable working relationship requires “an ongoing communication process that involves the exchange of information.” (4)*

 

Rapport.  Children rely on trust within each of their daily interactions with teachers, therapists, and school personnel.  Trust in a therapeutic partnership begins with the gathering and sharing of information about the client and the therapist, the demonstration of “cooperative intent” during the initial stages of the alliance, and the regulation of the student’s involvement in decision-making events.  Trust is built during informal discussions about activities that each enjoys, challenges they have faced, and goals for the future.  It continues to develop when each understands that the other can be flexible and accept changes in plans or challenges that push comfortable boundaries.  And, most importantly, trust is built when the therapist recognizes the student’s need to have less distraction or increased interaction in order to be successful.

 

Working Alliance.  As the rapport continues to develop, the therapist and client begin to focus on the goals and tasks that will define the student’s therapy.  Eleanor Cawley, MS., OTR/L, in her book, The Student Interview, stresses that the use of effective communication techniques can produce benefits that improve diagnosis and outcomes, treatment adherence, (and) patient satisfaction….” (9)  She refers to communication strategies that build a working alliance as avenues of exchange that can help students to build “a sense of self and of personal identity.” While her information partnership geralt pixabaytargets the adolescent population, students of any age will experience a sense of belonging and importance when the therapy plan is shared with them and decision making involves them at an age-appropriate level.

Perhaps one of the most significant facets of the development of rapport and a working alliance is the therapist’s and the student’s combined response to the success or failure of a therapy technique.  Tickle-Degnen, in her AJOT article, “Client-Centered Practice, Therapeutic Relationship, and the Use of Research Evidence,” (4) suggests the use of a recording tool** that documents the goals of the treatment and whether or not the task or strategy is accomplishing them.  In addition, in an effort to enhance the working relationship, she suggests that “occupational therapists should incorporate client satisfaction and frustration ratings” into this recording tool.  Children can easily express their feelings of frustration with a task, as well as their sense that it is beneficial.  The working alliance is a “living relationship” that continues to expand and contract as it becomes a stable working relationship.

 

Stable Relationship.  This phase of the client-centered therapeutic process has been described as the place where the “hard work of therapy begins” and one where the challenges and changes that provide opportunities for growth and skill in therapy can also “enhance the probability of ‘errors’ during interaction (and) threaten the continuation of the relationship.” (4) Communication and student engagement become an even more significant set of tools during this phase as these changes and challenges will require intrinsic motivation on the part of the student.  While student engagement is considered to be among the better predictors of learning and personal development, (12 qtd. in 10) with positive links to critical thinking and grades, (11) it has also been identified as an important tool that allows our young clients to express their priorities, goals, and impressions of therapy.  A stable relationship that fosters rapport and a working alliance relies upon the therapist’s ability to work alongside students in an effort to maintain an “authoritative” position that “gains control through interaction with the student and incorporates the student’s opinions and ideas” into the rehabilitation process.  Ultimately, this results in a “Student-Therapist Partnership.”  (9)

 

Barriers to implementing a client-centered practice.  Research has unveiled 4 significant barriers to implementing a client-centered practice that can be reflected in every therapeutic environment:

Barriers to Client Centered Process

We, as the service provider have control over our knowledge base and our feelings of comfort or insecurity that surround the implementation of a client-centered approach to therapy.  We can influence a student’s intrinsic motivation by attending to the development of rapport, a working alliance, and a stable working relationship and by adapting the process to meet his particular learning, cognitive, and physical needs.  We can influence the environment with the demonstration of success within our personal practice of client-centered therapy and with discussions about the benefits for increasing a client’s sense of worth and self-efficacy.

 

Conclusions.

A client-centered approach to therapy is not a new concept.  The term was coined by Carl Rogers, an American humanistic psychologist, in his 1939 book, The clinical treatment of the problem child.  In it he stresses the importance of “individuality, holism, sense of self, the influence of the environment, values development, actualization, and goal-directed behavior” in both the individual’s overall development and the development of the client-therapist relationship.  (15, qtd. in 14) The Philosophical Base of Occupational Therapy (16) defines “participation in a meaningful occupation (as) a determinant of health.”  It stresses the same concepts of therapy as Rogers, describing the environment, intrinsic individual factors, occupational contexts, and inherent characteristics of the activity as significant factors to consider as we develop a focus and outcome expectations to encourage and enhance our clients’ engagement in meaningful occupations.  Children, our students and clients, deserve the opportunity to use “occupation” as a change agent, as well as an individual means to achieve their goals, and to experience a client-centered therapeutic approach as a means for active participation in their service plan.

 

Katherine J. Collmer, M.Ed., OTR/L, owner, Handwriting With Katherine

Katherine J. Collmer, M.Ed., OTR/L, is a pediatric occupational therapist who specializes in the assessment and remediation of handwriting skills and understands the link between handwriting skills and writing.  She can be contacted via her website, Handwriting With Katherine.
  Disclaimer: The information shared on the Handwriting With Katherine website, blog, Facebook page, Twitter page, Pinterest page; in the Universal Publishing Handwriting Teachers’ Guides; on any guest blog posts or any other social media is for general informational purposes only and should not be relied upon as a substitute for sound professional medical advice or evaluation and care from your physician/medical team or any other qualified health care providers. Therefore, the author of these links/posts take no responsibility for any liability, loss, or risk taken by individuals as a result of applying the ideas or resources.
 Photos are the property of the contributors of Pixabay and their use should include the link provided to the photographer’s source.
*The information in this section was adapted from Reference No. 4.
**Student Self-Assessments have been identified as tools that facilitate the collection of information relative to a student’s perception of his skill strengths and needs, his participation in therapy, and the value of the therapeutic interventions included in his rehabilitation plan.  Each self-assessment instrument should be reviewed prior to administration to measure its benefits and limitations for the audience for whom it is intended.   (13, 14)

References:

  1. Wade, D. T., and B. A. DeJong. “Recent Advances: Recent Advances in Rehabilitation.” Bmj7246 (2000): 1385-388. Web. 15 Sept. 2015. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118051/pdf/1385.pdf>.
  2. Wressle, Ewa. Client Participation in the Rehabilitation Process. Diss. Linköpings Universitet, 2002. Linköping: UniTryck, 2002. Print.
  3. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16, 252–260.
  4. Tickle-Degnen, L. “Client-Centered Practice, Therapeutic Relationship, and the Use of Research Evidence.” American Journal of Occupational Therapy4 (2002): 470-74. Web. 15 Sept. 2015.
  5. “Standards of Practice for Occupational Therapy.” The American Journal of Occupational Therapy6 (2010): S106-111. Web. 5 Aug. 2015. Prepared by The Commission on Practice and presented as a Supplement to the American Journal of Occupational Therapy
  6. Maitra, K. K., and F. Erway. “Perception of Client-Centered Practice in Occupational Therapists and Their Clients.” American Journal of Occupational Therapy3 (2006): 298-310. Web. 15 Sept. 2015.
  7. Northen, J. G., Rust, D. M., Nelson, C. E, & Watts, J. H. (1995). Involvement of adult rehabilitation patients in set- ting occupational therapy goals. American Journal of Occupational Therapy, 49, 214–220.
  8. Astin, Alexander W. “Student Involvement: A Developmental Theory for Higher Education.” Journal of College Student Development Sept/Oct 40.No. 5 (1999): 518-29. Web. 16 Sept. 2015.
  9. Cawley, Eleanor, MS, OTR/L. The Student Interview. 2013. Print.
  10. Gan, C., K. A. Campbell, A. Snider, S. Cohen, and J. Hubbard. “Giving Youth a Voice (GYV): A Measure of Youths’ Perceptions of the Client-Centredness of Rehabilitation Services.” Canadian Journal of Occupational Therapy2 (2008): 96-104. Web. 16 Sept. 2015.
  11. Carini, Robert M., George D. Kuh, and Stephen P. Klein. “Student Engagement and Student Learning: Testing the Linkages*.” Research in Higher Education Res High Educ1 (2006): 1-32. Web. 16 Sept. 2015.
  12. Engel-Yeger, B., L. Nagauker-Yanuv, and S. Rosenblum. “Handwriting Performance, Self-Reports, and Perceived Self-Efficacy Among Children With Dysgraphia.” American Journal of Occupational Therapy2 (2009): 182-92. Web. 8 Sept. 2015.
  13. Fredricks, Jennifer A., and Wendy McColskey. “The Measurement of Student Engagement: A Comparative Analysis of Various Methods and Student Self-report Instruments.” Handbook of Research on Student Engagement. New York: Springer, 2012. 763-82. Print.
  14. Corring, D., and J. Cook. “Client-Centred Care Means That I Am a Valued Human Being.” Canadian Journal of Occupational Therapy2 (1999): 71-82. Web. 16 Sept. 2015.
  15. Rogers, C.R. (1939). The clinical treatment of the problem child. Boston, MA.: Houghton Mifflin.
  16. “The Philosophical Base of Occupational Therapy.” American Journal of Occupational Therapy6_Supplement (2011): n. pag. Web. 16 Sept. 2015. Authored by The Commission on Education