CRITICALLY APPRAISED PAPER (CAP)

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1 CRITICALLY APPRAISED PAPER (CAP) Ohl, A. M., Graze, H., Weber, K., Kenny, S., Salvatore, C., & Wagreich, S. (2013). Effectiveness of a 10-week Tier-1 response to intervention program in improving fine motor and visual motor skills in general education kindergarten students. American Journal of Occupational Therapy, 67, CLINICAL BOTTOM LINE This study could be useful for occupational therapy practitioners working in a school-based therapy setting. It provides some interesting and valid information concerning the importance of hand development and visual motor skills at an early age. The evidence suggests that these skills are important prerequisites for handwriting. Overall, the study did have some threats to validity, but the ideas and concepts presented and the results provide evidence that the Specialized Teaching and Enhancement of Performance Skills for Kindergarteners (STEPS-K) program yielded positive outcomes with the intervention study participants. The study did not prove that the intervention group had significantly better results than the control group for improving fine motor and visual motor skills in general education kindergarten classrooms. Even though the small effect size makes it hard to generalize these results to a larger population, on a small scale, the outcome measures did yield positive results. The STEPS-K program has a specific protocol to follow and provides the classroom teacher with assistance and consultation from the occupational therapist on a regular basis. The program seems to be a reliable resource that helps with consistency in the way that fine motor and visual motor skills are taught to kindergarten students. The STEPS-K program could help teachers identify children in need of referral for occupational therapy services. In turn, the use of this program could prevent the need for referral if the teacher has the tools, knowledge base, and support system to promote these important skills. RESEARCH OBJECTIVES List study objectives. Determine whether general education kindergarten students who received a 10-week responseto-intervention (RtI) program demonstrated significantly greater improvements in fine motor and visual motor skills than general education kindergarten students who did not receive the program DESIGN TYPE AND LEVEL OF EVIDENCE Level I: Randomized controlled trial 1

2 SAMPLE SELECTION How were subjects recruited and selected to participate? Please describe. Twelve general education kindergarten classrooms participated in the study. All kindergarten students in the intervention and control classrooms were invited to participate in this study. Written caregiver permission and signed child assent were obtained for all study participants. Consent was also obtained from school principals, the occupational therapist, and teachers. Inclusion Criteria Two kindergarten classrooms each from six urban elementary schools were recruited to participate in the study, for a total of 12 classrooms. The authors did not indicate any specific inclusion criteria other than that the children were members of the selected classroom. Exclusion Criteria No specific exclusion criteria were mentioned. Although it is not specifically stated, it is assumed that if the caregiver did not sign the permission form and child assent was not obtained, then the child was excluded from the study. SAMPLE CHARACTERISTICS N = (Number of participants taking part in the study) 75 #/ (%) Male 42 (56%) #/ (%) Female 33 (44%) Intervention group Control group Total Race or ethnicity 11/23.4% 12/42.9% 23/30.7% Black or African American 2/4.3% 1/3.6% 3/4% Asian 12/25.5% 7/25.0% 19/25.3% Hispanic or Latin American 11/23.4% 6/21.4% 17/22.7% Two or more ethnicities 4/8.5% 0/0% 4/5.3% Not reported 7/14.9% 2/7.1% 9/12% Disease/disability diagnosis General education kindergarten students INTERVENTION(S) AND CONTROL GROUPS Add groups if necessary Group 1: Experimental group Brief description of the intervention The experimental group (kindergarten class) received a 10-week RtI program based on the STEPS-K program. This program was developed for the study by H. Graze and K. Weber, in collaboration with general education kindergarten teachers, to promote the fine 2

3 How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? Group 2: Control group Brief description of the intervention How many participants in the group? Where did the intervention take place? motor and visual motor skills necessary for success in the kindergarten curriculum. The students were taught about positioning, posture, and breath. Then the occupational therapist introduced eight activities to the fine motor center. Skills addressed in the fine motor center included strengthening of the intrinsic hand musculature, finger isolation and pincer grasp exercises, separation of the two sides of the hand, translation, rotation, opposition, visual perceptual and visual motor skills, and bilateral coordination. As each activity was presented, the classroom teacher added it to the fine motor center and incorporated it into the school day. Additionally, the program included instruction in how to hold a pencil, cut with scissors, draw a person, and put on a coat. 47 The site was not explicitly indicated in the article; however, the authors indicated that pretest data were collected from 6 elementary schools in New York City. One general education kindergarten classroom was assigned to the experimental group at each school. Posttest data were only collected from 4 of the schools. The data from these four schools were used for the study. The teachers followed lesson plans provided by the occupational therapist. The same 4 occupational therapists (S. Kenny, C. Salvatore, S. Wagreich, and one occupational therapist who was not an author of the study) administered the assessments, collected data, and provided weekly classroom intervention. One of the four occupational therapists was assigned to each of the schools, which provided consistency with testing and intervention. The STEPS-K program consisted of three main parts: (1) direct intervention, in which an occupational therapist led ten 30-min lessons in collaboration with the classroom teacher once a week for 10 consecutive weeks; (2) a classroom fine motor center, with new activities introduced throughout the 10 lessons; and (3) additional consultation time between the occupational therapist and teacher throughout the 10-week intervention period. The intervention period was 10 weeks. No intervention was provided to the control group. The article reported that the control group students were assessed with the same battery as for the experimental group for pre- and posttest. 24 NR 3

4 Who delivered? How often? For how long? NR NR The period was for 10 weeks. Intervention Biases Check yes, no, or NR and explain, if needed. Contamination: NO Cointervention: YES Timing: YES Site: NR Comment: There was no chance for contamination from the intervention group, because the control group did not receive any intervention. However, the article includes no information about whether the control group received any type of therapy or intervention outside of the study. Comment: The researchers did mention that some children in each group were receiving related services as part of their Individualized Education Program. The amount of related services was consistent between the groups. Comment: The duration of the study was 10 weeks at the beginning of the school year. There was a 3-month follow-up survey about the continued use of the STEP-K program and the amount of consultation still being provided. The researchers did report that the teachers continued consulting with the occupational therapist after the study was complete. Comment: The sites were not explicitly indicated other, although the authors reported that the study took place in general education classrooms in 6 urban schools (2 schools were excluded from the final results). They provided no information as to whether the site created any conflicting interests or biases. Use of different therapists to provide intervention: NO Comment: Four occupational therapists (one at each of the four schools) performed the assessments and the intervention. Because the therapists were not blinded to the study groups, this could have created a bias. However, five experienced occupational therapists who were not involved in the intervention and who were blind to the study conditions scored the assessments. MEASURES AND OUTCOMES Complete for each measure relevant to occupational therapy. Measure 1 Name/type of measure used Bruininks Oseretsky Test of Motor Proficiency (2nd ed.; BOT-2) Fine motor skills were assessed with this test. The BOT-2 is a standardized test of gross and fine motor skills in children ages The 4

5 What outcome was measured? reliable? valid? When is the measure used? Measure 2 Name/type of measure used What outcome was measured? reliable? valid? When is the measure used? Measure 3 Name/type of measure used Manual Coordination subscale has acceptable test retest reliability (r =.62.79) and interrater reliability. The BOT-2 has been found to be sufficiently valid to be considered an acceptable instrument for measuring what it is indented to test. Fine motor skills were assessed with this test. YES YES Participants were initially assessed before the beginning the program to determine baseline scores, and reassessment was conducted at the end of the 10-week study period. Beery Buktenica Developmental Test of Visual Motor Integration (5th ed.; VMI). The VMI is a norm-referenced standardized test for children ages 2 18 that requires the child to draw geometric forms arranged in a developmental sequence. The VMI has sound psychometric properties, with high interrater (r =.92) and test retest reliability (r =.89). This test has also been found to be valid for assessing visual motor. A short form containing only 21 items is available for children ages 2 7; the short form was used in this study and administered in a group. The VMI was used in this study to assess visual motor skills YES YES Participants were initially assessed before the beginning of the program to determine baseline scores, and reassessment was conducted at the end of the 10-week study period. Developmental Scale of Pencil and Crayon Grips This measure describes and provides pictures of 10 types of pencil or crayon grips used by children. The interrater and test retest reliability were found to be sufficient by the original developers of the test. The validity of the assessment was not provided in this study (Schneck & Henderson, 1990). Additional searches did not yield any results specifically about the validity of this outcome measure. However, one study did allude to the fact that the researchers found discrepancies (which could affect validity), in that not all of the children in their study had a grasp that fitted into the scale suggested by Schneck and Henderson (Burton & Dancisak, 2000). 5

6 What outcome was measured? reliable? valid? When is the measure used? Measure 4 Name/type of measure used What outcome is measured? reliable? valid? When is the measure used? Measure 5 Name/type of measure used What outcome is measured? Pencil grip NR NR Participants were initially assessed before the beginning the program to determine baseline scores, and reassessment was conducted at the end of the 10-week study period. Therapist Teacher Interaction Log This interaction log has not been tested for reliability or validity. The researchers developed this log to provide a framework for occupational therapists to keep track of the time spent in the classroom each week and the type of contact they had with the intervention teacher. The Therapist Teacher Interaction Log is not described in detail. It is reported to be a time log of the number of minutes the four staff occupational therapists spent with the intervention classroom teacher throughout the study. A total of 573 min was logged among the 4 occupational therapists, with each therapist spending between 6 and 33 min/week with the intervention teachers. Consultation was most commonly related to the integration of occupational therapy into the curriculum. NR NR This log was maintained for the intervention group classroom for the entire length of the study. Classroom Teachers Use of Strategies or Modifications Survey The authors developed this measure for use in the study. It has not been tested for reliability or validity. This survey assessed the classroom teachers use of the strategies or modifications they learned directly from the occupational therapist, the number of students referred for occupational therapy, the continued use of the fine motor center, and continued consultation with the occupational therapist 3 months postintervention. Neither details about the survey nor information about specific strategies and modifications was included in the article. The STEPS-K was developed by two of the authors, H. Graze and K. Weber, specifically for the study. Materials were supplied by the teachers; therefore, different materials and methods might have been used in each classroom. Skills 6

7 reliable? valid? When is the measure used? addressed included strengthening of the intrinsic hand musculature, finger isolation and pincer grasp exercises, separation of the two sides of the hand, translation, rotation, opposition, visual perceptual and visual motor skills, and bilateral coordination. Other lessons included in the STEPS-K program were how to hold a pencil, cut with scissors, draw a person, and put on a coat. The use of different materials and methods in the different classrooms could have resulted in inconsistencies, which makes comparison more difficult. NR NR This survey was completed only one time, 3 months after completion of the study. Measurement Biases Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. NO Comment: The four occupational therapists who performed the pretest, posttest, and intervention were not blinded to group assignment. This could have influenced the results, because the evaluators might have favored the intervention group by skewing the performance and results in their favor. These four occupational therapists only recorded the data and did not score the assessments. Five additional occupational therapists (blind to the study conditions) scored all of the tests (BOT-2, VMI, and Developmental Scale of Pencil and Crayon Grips). Was there recall or memory bias? Check yes, no, or NR, and if yes, explain. NO Others (list and explain): Comment: There was no memory or recall bias for the outcome measurements listed above. RESULTS List key findings based on study objectives. Include statistical significance where appropriate (p <.05). Include effect size if reported. The results of the fine motor and visual motor scores from the study were presented with t scores and effect size (Cohen s d). The statistical significance was set at p <.05 for the twotailed t test for the BOT-2. For the intervention group, t = 2.06, p =.023, and for the control group, t = 1.203, p =.120. These results show that statistical significance was achieved for the intervention group and that there were no significant findings for the control group (actually a decrease from the pretest). The statistical significance set for the one-tailed t test for the VMI was p <.01. For the intervention group, t = 2.46, p =.009, and for the control group, t = 0.336, p =.370. Again, the results indicate that statistical significance was 7

8 achieved for the intervention group and not for the control group (decrease from the pretest). Statistical significance was proven for the intervention group s VMI and BOT-2 scores; however, the overall effect size, when compared with the control group, was small (VMI, Cohen s d = 0.34; BOT-2, Cohen s d = 0.24). This indicates that the study lacked enough power (because of the small sample size) to show a bigger difference between the control and intervention groups. The results of the pencil grip pre- and posttest assessments showed that no significant differences in pencil grip existed between the intervention and control groups either at the onset of the study, 2 (7, N = 73) = 11.31, p =.126, or after the intervention, 2 (5, N = 70) = 2.41, p =.790. After reviewing the data and discussion, the authors determined that both groups did show positive changes in their developmental progression with pencil grip frequency. The changes were somewhat consistent between groups, so no statistical change was noted between the groups. Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR, and if no, explain. NO Comment: Initially, the researchers collected data on 113 students, which would have provided adequate power for a medium effect size. Because the data from two schools could not be used, the number of students decreased to 75, with a small effect size. The smaller sample size did not allow for a significant difference between the control and intervention groups. The effect size for intervention results (VMI, Cohen s d = 0.34; BOT-2, Cohen s d = 0.24) indicates minimal differences between groups, although the study found statistically significant fine motor and visual motor outcomes with the experimental group. Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain. YES Comment: The authors used unpaired t tests (independent t tests) to report demographic characteristics of the study participants and of the occupational therapists and classroom teachers from the four schools. They used a paired t test to report fine motor and visual motor pretest and posttest scores to determine the effectiveness of the STEPS-K program (Table 3). The authors used a paired t test to compare the data for pencil grip frequencies for the control and intervention groups at pretest and posttest to determine the effectiveness of the intervention program (Table 4). Were statistics appropriately reported (in written or table format)? Check yes or no, and if no, explain. YES Comment: The statistics were appropriately reported in narrative and table formats. Was the percentage or number of participants who dropped out of the study reported? YES 8

9 Limitations What are the overall study limitations? The authors did attempt to decrease the risk of a validity threat by randomly assigning classrooms to the control and intervention groups, gaining consent from all individuals who were part of the study (consent from school principals, occupational therapists, and teachers and both caregiver permission and child assent for study participants), and providing consistency of intervention strategies. The same occupational therapist was assigned to each intervention group for the entire 10 weeks. In addition, the researchers recruited five occupational therapists who were blind to the study to score the data and provide the analysis. Despite the authors attempts to control validity, some questionable areas of threat were noted throughout the study. The first concern is that the researchers did not adequately explain how the classrooms were randomized in the study. It is not clear who selected and randomized the classrooms that received the intervention. Additionally, neither the teachers nor the treating therapists were blinded to the intervention group, which could have posed a bias to work a little harder with the intervention group than the control group to achieve better results. The researchers also did not indicate whether the control group and intervention group teachers were located in close proximity. The possibility of the control group teacher observing the intervention group would increase if classrooms were close together. The demographic characteristics also indicate that the control group teachers had almost 3 more years of experience working with children (control = years, intervention = years). The greater level of experience might have allowed the control group teachers to have a better understanding of how to develop fine motor and visual motor skills in young children (e.g., through continuing education, research, or trial-and-error methods). Overall, the researchers did report that they found significant fine motor and visual motor outcomes; however, because the study was not adequately powered, the overall effect size between the control and intervention groups was small. The small effect size caused a concern with the generalizability of these results, because it is more difficult to see true differences between the groups when a limited number of participants are involved in the study. The small effect size could be attributed to the short time frame of the study. A longer study time would have allowed the students to develop and increased their fine motor and visual motor skills to show a greater increase in performance. There was also a significant difference in the number of participants in the intervention group (n = 47) compared with the control group (n = 28). Initially there were 113 participants, which would have been adequate to power the study, but because two schools did not meet the deadline for posttesting, the number of participants who could be included in the final data analysis decreased. The loss of these participants could explain the difference in the participant numbers for each group. The validity of the Developmental Scale of Pencil and Crayon Grips was not indicated in this study. Additional database searches were performed, with no results related specifically to validity. However, one study was found that indicated that researchers reported they consistently could not fit the grasp of the some of the children in their study into one of the 10 types outlined in the Developmental Scale of Pencil and Crayon Grips. This poses a validity threat if this measure cannot be consistently used by various individuals for research or outcome assessments. 9

10 CONCLUSIONS State the authors conclusions related to the research objectives. The authors concluded that preliminary evidence shows that a Tier 1 RtI program can improve fine motor and visual motor skills in kindergarten students; however, they reported that further research is needed with a larger number of participants. References Burton, A. W., & Dancisak, M. J. (2000). Grip form and graphomotor control in preschool children. American Journal of Occupational Therapy, 54(1), Schneck, C. M., & Henderson, A. (1990). Descriptive analysis of the developmental progression of grip position for pencil and crayon control in nondysfunctional children. American Journal of Occupational Therapy, 44(10), This work is based on the evidence-based literature review completed by Patti Calk, OTD, MA, LOTR, and Tonya Keene, LCOTA, MOTS, University of Louisiana at Monroe. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: 10

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