Findings from P4C

Description of the Children

In Year 1, 241 children were accepted by P4C OTs from active client lists and waitlists at the Central West or Hamilton Niagara Haldimand Brant Community Care Access Centres (CCACs). P4C OTs, using observation and collaboration with educators, identified 351 additional children who had not previously been identified and/or referred by the school but who were having difficulty participating. A detailed description is available for 246 children who became research participants.

  • OTs identified children almost one year earlier and identified a higher proportion of girls than were typically referred to the CCAC.
  • When children were identified, they received service right away, with no need for the school to complete a referral to the CCAC.
  • Waitlists were eliminated at no additional cost.
  • Many of the children who displayed coordination difficulties also had other co-occurring health conditions.

Research Participants

The first year of P4C service began in November 2013. Children in each school who were on either the active caseload or waitlist for school health occupational therapy services (and who were referred to the CCAC for fine motor difficulties or were anticipated to have motor coordination challenges) were transferred by the CCAC to the P4C OT for service. Parents of these 241 children provided consent first to the CCAC and then to the P4C OT for the P4C health care services. The P4C OTs also observed children in classrooms and collaborated with educators to identify 351 additional children who required occupational therapy services.

During the first year, the OTs obtained health care consent for all 592 children to receive the P4C service. A Project Coordinator approached these families and asked them to become research participants. 392 families agreed to receive information about the study:

  • 246 families provided health care consent and also agreed to be part of the two-year study.
  • 346 families provided health care consent but did not want to be research participants.

Waitlist and Newly Identified Comparison

We compared the children who were transferred to the P4C OTs in Year 1 from each CCAC (children who were either designated to receive active service that year or children who were still on the waitlist) with the children who were identified by P4C OTs and educators over the first school year.

Active/Waitlist Newly Identified Total
* Age of identification and relative proportion of girls differs significantly from active/waitlist children.
Children who received P4C service in Year 1 241 351 592
Consented to participate in study 115 (48%) 131 (52%) 246
Boys 97 91 188
Girls 18 (15.6%) 40* (30.5%) 58
Mean Age
8.62 years
(5 to 12 years)
7.81* years
(4 to 13 years)
8.19 years
Table 1 Children referred from the CCAC waitlist compared with Children newly identified as needing service by the P4C OT and an Educator

As can be seen in Table 1, the two participating CCACs transferred 241 children to the P4C service; an additional 351 children were identified directly by P4C OTs in collaboration with educators. There was no difference in the percentage of families who consented to participate in the study in either group. Of great interest, there was a statistically significant difference in the proportion of girls identified by OTs through direct observation of children in the school as compared to the number of girls transferred by the CCACs. This suggests that girls are less likely to be referred to the CCAC through the existing referral system.

However, the most important finding is that P4C led to earlier identification of children with special needs, with no formal assessment or screening mechanism. Not only were the children on average almost one year younger than those on the waitlist, but they received service right away, without having to be referred and put on a lengthy waitlist. Children were identified as early as junior kindergarten. In other models of service delivery, children often have to be in Grade 1 before they can be referred.

Children Participating in the Study

The OTs helped to recruit 246 children and families into the study by the end of May 2014. While new children continued to be identified and to receive health care consent throughout Year 2, no additional children were recruited into the study.

The 246 research participants did not differ in any important way from the 592 children who were referred to and received OT services in the first year with regard to age, sex, the CCAC that was providing service, or the school board that they attended.

Characteristics of Children in the Study
Boys 188 (76%)
Girls 58 (24%)
Mean Age (Range) 8.19 years (4 to 13 years)
Grade Range Junior Kindergarten to Grade 8
Number of Children by School Board
Peel District School Board 153 (62%)
Halton District School Board 46 (19%)
Hamilton Wentworth Catholic District School Board 47 (19%)
Number of Children by Community Care Access Centres
Central West CCAC 153 (62%)
Hamilton Niagara Haldimand Brant CCAC 93 (38%)
Table 2

Describing the Families

Parents of the children who were research participants were asked to complete a number of questionnaires, either online or in hard copy. Multiple reminders and phone calls were made to increase the rate of response. Of the 392 families who agreed to receive information about the study, 246 families (63%) returned completed packages of questionnaires when their child was recruited into the study.

Again, a comparison of these 246 children with the 592 children showed no significant differences in age, sex, CCAC, or school board. Therefore, we can presume that the description of the 246 children and families who responded is likely representative of the larger group who consented to be in the study, but we cannot say so with absolute certainty.

From the 246 parent responses, we know that:

  • Most families understood and spoke English in the home (79.7%); other languages were spoken by 19.5% of families; no research families spoke French as their first language.
  • 214 (87%) of the respondents were mothers; 28 (11.4%) were fathers.
  • The majority of families included two parents (81.7%); in most families, both parents worked outside of the home for pay (72%); 61 (24.8%) had one spouse who was caring for the family full-time.
  • Most families had two or three children.
  • In approximately 20% of families, neither partner had post-secondary education.
  • Income of families was quite evenly distributed across income levels with a median income of $60,000 to $80,000; 19.5% were below the Ontario poverty level for families.
  • 62% of respondents were in Peel; 19% were from Halton; 19% from Hamilton-Wentworth.
  • The majority of the children in the study were first (38.6%) or second (39.4%) born.
  • 78% of children were born full-term; 19.1% were preterm.
  • Very few children had been reviewed by an Identification Placement Review Committee (IPRC); 14% were reported to have a designation of exceptionality.
  • 38% of children had an Individualized Education Plan (IEP) at the beginning of the study.
  • According to parent report, nearly 60% of children had an IEP at the end.

Co-occurring Diagnoses of the Children

Children were invited to enter the study because they were experiencing motor coordination challenges. Parents were also asked about any other diagnoses/formal identification that their children might have.

Based on parental report, speech/language difficulties were most commonly noted, with Attention Deficit Hyperactivity Disorder (ADHD) and Learning Disabilities also frequently co-occurring.

Co-occurring Diagnoses Active / Waitlist, N=115 Newly Identified, N=131 Total, N=246
ADHD 21 (18%) 27 (21%) 48 (20%)
Speech / Language 33 (29%) 26 (20%) 59 (24%)
Learning Disabilities 24 (21%) 23 (18%) 47 (19%)
Autism Spectrum Disorder 4 (3%) 3 (2%) 7 (3%)
Other 47 (41%) 67 (51%) 118 (48%)
Table 3

Children who had “other” co-occurring diagnoses included children with visual or hearing impairments, and a variety of genetic and medical syndromes; about 12% of children were noted by parents to have anxiety. Seventeen children (7%) had already received a diagnosis of Developmental Coordination Disorder from a physician. Parents could identify more than one co-occurring diagnosis; in fact, in addition to motor coordination challenges, 56% of children were reported to have from one to three co-occurring health or developmental conditions. There were no important differences in the diagnoses reported by parents across the two sources of referral.

Detailed Description of Research Participants

Parents were asked to complete three questionnaires regarding their observations of their child’s coordination, behaviour and participation at home. In addition, the child’s educator was asked to complete questionnaires about children’s behaviour and about their ability to participate at the same level as other children in specific school settings.

Standardized Measurement Measure completed by:
Parents Educators Research Assessor
Coordination Coordination Questionnaire
Behaviour / Attention Strength and Difficulties Questionnaire (SDQ) Strength and Difficulties Questionnaire (SDQ)
Participation at Home Participation and Environment Measure for Children and Youth (PEM-CY)
Participation in the community Participation and Environment Measure for Children and Youth (PEM-CY)
Participation at school School Function Assessment (SFA) Movement Assessment Battery for Children (MABC-2)
Table 4

Parent Report of Coordination Issues

The Developmental Coordination Disorder Questionnaire (DCDQ; Wilson, 2007) is a 15-item measure that was modified, with the permission of the author, so that the title said “Coordination Questionnaire”. The DCDQ has been shown to have adequate reliability and validity. Parents were asked about activities that they might observe at home and to rate each statement as “not at all like my child” (1) to “extremely like my child” (5). Of the 246 parents, 239 (97.1%) completed this questionnaire.

Active / Waitlist Newly Identified Probable DCD Total Children
* The percentage of children below 8 years of age who were identified by the P4C OT differs significantly from children referred from active or wait lists
DCD Q scores below cutoff 60 (54%) 72 (57%) 132 (55%) 239
Boys 50 47 97
Girls 10 25* 35
DCD Q scores below cutoff, by age band
5–8 years 11 (18%) 30 (42%)* 41 (31%) 106
8–10 years 35 (58%) 29 (40%) 64 (48%) 98
> 10 years 14 (23%) 13 (18%) 27 (20%) 35
Table 5

There was an important difference in how many young children were identified by the OTs, and how many more girls were identified, relative to the children on the waitlist. Once again, this shows that the P4C OTs found lots of younger children who were struggling; there were significantly more younger children in the newly identified group in comparison to the children referred from the participating CCACs.

Only 55% of parents rated their child’s ability to perform these motor tasks as being well below what you would expect for their age and stage of development. It is possible that this questionnaire is less sensitive for children seven years of age or younger. Universal design for learning and working with children in small groups would be likely to be more beneficial when children are young and parents have not yet identified a concern.

For children older than eight years of age, however, parents seemed to be more aware that their child was having motor difficulties. In particular, parents reported differences in activities that might also be performed at school: printing or writing being illegible or the child being very slow; taking more effort to print and using incorrect pressure on the pencil; difficulty cutting out shapes. Of interest, parents of older children did not report many difficulties with self-care or gross motor tasks that are likely to be observed at home. The problems reported by parents were more consistent with issues likely to be observed by educators. It is possible that educators had shared their concerns with parents by the time the child was in Grade 2 or 3.

Parent and Educator Report of Child Behaviours

The Strength and Difficulties Questionnaire (SDQ) (Goodman, Meltzer, & Bailey, 1998) is a 25-item measure used to screen for behaviour problems in children aged 4–17 years. The measure is composed of five scales including: emotional symptoms, conduct problems, hyperactivity, peer problems, and pro-social behaviours. Higher scores on each scale indicate greater presence of the trait. Higher scores in the first four scales therefore reflect more behavioural problems; however, the pro-social scale measures positive behaviours and so is expected to be high. The SDQ has adequate reliability and has shown convergent validity with other childhood measures.

In the Partnering for Change study, parents completed the SDQ at two time points. The results of the first time point are presented here, when the child was first referred to the study; educators also completed the measure at this time. From our original sample of 246 children, 193 were rated on the SDQ by both parents and educators at the start of the study.

Parents and educators generally agreed with respect to their ratings for most of the domains covered by the SDQ. For example, irrespective of whether they were on a waitlist or identified by OTs, hyperactivity was viewed by both parents and educators to be the most noticeable behavioural problem for children. The concern about hyperactivity is consistent with the parent report about co-occurring diagnosis of ADHD. Conduct problems and peer problems were not viewed as a significant concern by either group.

Parents and educators differed in their evaluation of children’s pro-social (positive) skills; specifically, educators were more likely to view children as less socially skilled than were parents.

Interestingly, parents whose children were referred to P4C by the OT were more likely to report concerns about emotional problems than were educators. Although this subscale score was not elevated to a clinical level, it is consistent with the higher rate of anxiety diagnoses reported in this group of children. This suggests that children who are struggling but not been identified as having difficulties could be developing secondary emotional issues such as anxiety.

The SDQ was re-administered in the second year of the study. Here, the outcome of interest was whether or not there was a change in children’s behaviour over the two-year time frame. This change is described in Individual Child Outcomes.

Children Referred from Active Service / Waitlist

Graph: Children Referred from Active Service / Waitlist
Figure 6

Children Identified by P4C OT

Graph: Children Identified by P4C OT
Figure 7

Parental Report of Participation in Activities at Home and in the Community

The Participation and Environment Measure for Children and Youth (PEM-CY) (Coster, Law, & Bedell, 2010) looks at participation in three different settings: home, school and community. The original PEM-CY has been shown to be a reliable and valid measure of participation and environment that is appropriate for a broad range of children (Coster et al., 2011). With permission of the authors, modifications were made to the PEM-CY including wording changes and a reduction in the number of items and categories. The school section was eliminated as it was being captured by the School Function Assessment. The other changes were made to enable ease of administration and online completion.

At the outset of the study, almost all children were rated by their parents as participating in all activities captured by this measure in a relatively typical way. They participated more frequently in activities at home rather than in the community. The outcome of interest was whether there was a change in the frequency with which they participated in various activities over the duration of the study. This change is described in Individual Child Outcomes.

Educator Report of Participation in School Settings

Educators were asked to complete the School Function Assessment (SFA) (Coster, Deeney, Haltiwanger, & Haley, 1998), which measures the extent to which the child requires assistance from adults to participate at school. The SFA helps to identify tasks that either support or hinder participation in the school setting.

In Year 1, educators reported that 179/246 children were in regular classrooms and 14 were in self-contained classrooms (two did not report this information). At the start of the study, many children were reported to be having some degree of difficulty participating in school activities without adult assistance. Only 33% of children were rated as participating much like the other children. Children were noted to have the most difficulty participating fully in the classroom, on the playground and during transitions to different activities or locations. Fewer difficulties were reported in managing bathroom routines, mealtimes or taking a bus or car to and from school. There was great variability in participation with most children requiring some adult assistance and some requiring constant supervision to participate.

Educator report of children’s participation at the beginning of the study was compared with the report of the educator who saw the child in the next grade, at the beginning and end of Year 2. Changes did occur and are presented in Individual Child Outcomes.


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  3. Coster, W., Law, M., & Bedell, G. (2010). Participation and Environment Measure — Children and Youth (PEM-CY). Boston, MA: Boston University.
  4. Coster, W., Bedell, G., Law, M., Khetani, M., Teplicky, R., Liljenquist, K., Gleason, K., Kao, Y. (2011). Psychometric evaluation of the Participation and Environment Measure for Children and Youth. Developmental Medicine and Child Neurology, 53,1030-1037.
  5. Coster, W., Deeney, T., Haltiwanger, J., Haley, S. (1998). School function assessment. San Antonio, TX: Psychological Corporation.