Meeting the Needs of a Pediatric Clinic 1 Improving Assessment and Intervention Strategies Using Evidence-Based Practice: Meeting the Needs of A Busy Pediatric Outpatient Clinic Caroline E. Patterson Department of Occupational Therapy Indianapolis University Purdue University Author Note: No conflicts of interest to disclose. Acknowledgments The completion of this experience and resulting products would not be possible without the support from numerous professors and dedicated therapists. I would like to acknowledge those that have committed to my own education as well as the development of dozens of devoted doctoral students. First I would like to thank Dr. Julie Bednarski and Dr. Annie DeRolf for their constant guidance and encouragement throughout the learning process. Their supervision and leadership supported me throughout the entire capstone process from its earliest stages to fruition. Their reassuring words and empowering advice provided the backbone upon which this research rests. I would like to thank Dr. Leah Van Antwerp for her individualized counsel and overwhelming support. The vast amount of experience she offered was indispensable to the planning process and outcome analysis. Her constructive feedback fostered a deeper understanding of what it means to provide client-centered care and address the role of occupational justice within the scope of occupational therapy. To Dr. Anthony Chase, whom there would be no statistical data without. I would not have been able to complete an in-depth evaluation and analysis of results without your exceptional experience and essential knowledge. Your guidance throughout the IRB and data interpretation process has been invaluable. A special thank you to my incredible site mentor, Abby Ellis who worked diligently to prepare and accommodate for all the challenges a doctoral student brings in the midst of changing department spaces. Your guidance regarding all aspects of my education remains instrumental in the development of my professional career and growth as a therapist. Your dedication to all clients and their families is apparent in your everyday enthusiasm and commitment to inclusive care. Finally, to my friends and family, who have supported me throughout this entire process. I could not imagine completing my education without the tireless love and encouragement of my parents. I am grateful for every day so far and all the years to come. Table of Contents Introduction 6 Needs Assessment 8 Literature Review Process 9 Demographics 9 Strengths 10 Needs Identified 10 Barriers 11 Literature Review 13 The Miller Function and Participation Scales 13 Handwriting 15 Gap Analysis 21 M-FUN Assessment 21 Handwriting 21 Guiding Model/Theory 22 Adult Learning Theory 22 Person-Environment-Occupation-Performance Model 22 Capstone Project Plan and Process 23 Curricular Threads 24 Project Goals and Objectives 25 Project Implementation 27 Seminar Development 27 Program Planning 28 Project Evaluation 31 M-FUN Results 31 Group Interview 33 Discussion 35 Data interpretation and impact 35 Sustainability 38 Conclusion 39 References 41 Appendix A 46 Appendix B 48 Appendix C 50 Appendix D 52 Abstract The pediatric outpatient therapy department at a local hospital has recently been granted a new treatment space with additional services and resources to meet the evolving needs of the department. These needs included increased productivity demands, lack of adequate motor skill assessments, and deficiency of interventions targeting handwriting deficits. This capstone experience is focused on identifying and addressing the needs of the clinicians within the new therapy space. After completion of an individualized needs assessment and thorough literature review, I identified two major gaps within the evolving clinic. During my time on site, I provided an in-depth electronic seminar to clinicians describing appropriate administration and scoring procedures. This information was utilized to develop a competency evaluation for the hospital to assess the interrater reliability of the new assessment tool within the clinic. After analyzing the data, it was clear the therapists were both valid and reliable when scoring the assessment. Next, the occupational therapists were interested in obtaining information and materials to begin planning for a new handwriting group within the clinic to address poor legibility and writing skills. I prepared an extensive seven-week curriculum along with detailed resources and parent communication handouts and provided them to the clinic for future implementation. At the end of fourteen weeks, through a qualitative interview process, clinicians indicated they were both satisfied and appreciative of the program development Keywords: Pediatric, M-FUN, Assessment, Handwriting Improving Assessment and Intervention Strategies Using Evidence-Based Practice: Meeting the Needs of A Busy Pediatric Outpatient Clinic With the growth of the pediatric department’s facilities, comes an increase in demands and a decrease in time available to address emerging concerns. The site of this capstone project, (a pediatric outpatient department) serves a diverse community with various medical and social needs. This capstone experience is focused on meeting the needs of these growing facilities utilizing evidence-based research and client-centered design. Due to recent changes related to the COVID-19 crisis, productivity demands have increased and therapists are left struggling to complete the required daily documentation. Previously, the hospital allotted therapists one hour per day to complete documentation, chart review patients, plan sessions, and research best treatment methods. At this time, clinicians no longer have scheduled documentation intervals, and are expected to schedule patients every hour. As a result, clinicians are left to document and complete all other tasks through their lunch hour. This has resulted in a drastic decrease in program initiation, assessment development, and inclusion of best practice treatment. After completing a thorough needs assessment, I identified two specific fundamental gaps that have occurred as a result of the reduction in documentation and research time: inefficient occupation-based assessment methods and a lack of evidence-based interventions for handwriting proficiency. The purpose of this capstone experience is to address these needs while supporting the use of evidence-based interventions and assessment methods. first portion of the capstone experiential focuses on the development of a new training module to teach the administration and scoring procedures of the newly acquired Miller Functional and Participation Scales (M-FUN) assessment. I utilized this seminar to create competency evaluations for both current and future employees. The goal of this presentation and competency is to reduce the need for clinicians to spend individual time researching and learning a new assessment while ensuring clinicians provide patients with occupation-based methods to accurately and efficiently measure participation and performance skills. Additionally, the second portion of the experiential focuses on the development of a new handwriting program to be implemented in a group setting. I will provide clinicians with a thoroughly researched curriculum designed to improve handwriting intervention techniques while increasing productivity through a group therapy design. Throughout this process, I provided direct treatment to gain clinical experience and develop a deeper understanding of how best to meet the needs within the clinic. By the end of the fourteen-week experience, the therapists were competent in the administration and scoring procedures of the M-FUN resulting in an improvement within the evaluation process. A formal competency exercise and brief statistical analysis demonstrated standardization and proficiency among administering therapists. Additionally, I provided detailed handwriting interventions and relevant resources in the form of a group curriculum to address patient needs while maintaining high productivity standards. These initiatives ultimately decreased the burden of research and development on current therapists while increasing the quality and quantity of evidence-based practice within the clinic. The need to utilize valid and reliable assessments with good psychometric properties is essential to the occupational therapy process. The implementation of this new tool reflects best practice and encourages a more thorough and holistic assessment that the clinic can utilize to develop appropriate and meaningful intervention strategies. The intentional selection of occupation-based interventions will ultimately result in improved outcomes for the children and families the clinic serves. The process of promoting continuing education regarding relevant evaluation and assessment techniques encourages the use of contemporary research and critical thinking skills in clinical practice. Ensuring a rigorously defined protocol for the administration, scoring, and interpretation of the assessment process fosters equal opportunity regarding the ability to receive services as well as support the health and wellbeing of a vulnerable population within the community. Within the practice of pediatric occupational therapy (OT), there are various aspects that a clinician may address. Commonly addressed issues include feeding, gross and fine motor deficits, cognitive delays, social skills, sensory processing, and many more. With these extensive topics to tackle, other skills can sometimes be overlooked. Handwriting proficiency, despite being a valuable ability, is an example of a commonly overlooked skill. Frequently, teachers are left with the responsibility to work on this skill although they do not receive in-depth training on the topic. Parents often disregard indications of poor handwriting because they are unaware of age-equivalent expectations, or they consider it an outdated talent. In reality, handwriting competence requires an extensive array of important developmental skills, including motor and visual dexterities. Needs Assessment The site hospital is located near a large group of neighborhoods just south of Indianapolis. The pediatric outpatient center is located in an adjacent building to the main hospital. They currently service children in southern Indianapolis and surrounding areas such as Greenwood and Southport. The process of completing a needs assessment began with conducting an in-person interview within the therapy gym with the site mentor. The interview lasted one hour wherein we discussed multiple capstone ideas. After a review of the literature surrounding best practice methods, I conducted a second interview. Both interviews were focused on demographic information, student and educator goals, and idea cumulation (see Appendix A for questions asked). Literature Review Process The literature review was a lengthy process that began by developing a question that highlighted the population, interventions, comparisons, and outcomes (PICO) desired. For example “What intervention strategies resulted in improved legibility in children who received occupational therapy services versus those that received no services.” These questions were then used to identify keywords as search terms in various research databases such as PubMed and PsychInfo. Filters excluded adult populations and outdated articles. Next, I assessed the collected articles for quality, with systematic reviews placed as the highest priority of inclusion. Research designs including only one subject such as case reports, as well as studies with poor evaluation methods were discarded. Over 400 studies were imported into Covidence for further evaluation. These studies were individually scanned for relevance and quality. A final review with in-depth analysis and annotations resulted in a group of research papers that accurately depicted the questions and goals identified during the interviews. Demographics This site most commonly treats patients aged two through seven, with many clients in preschool and kindergarten. In the past, there has been a larger proportion of male clients, however, in recent years they have had an equal distribution of males and females. The two most common diagnoses seen at the clinic are autism spectrum disorder and developmental delays. While there are clients from various socioeconomic classes, a majority of families have a relatively low socioeconomic status with an estimated 70 percent utilizing Medicaid insurance. Additionally, clients are both from traditional nuclear families as well as complex integrated families. Therapists usually see clients weekly and attempt to schedule sessions at the same time and day each week. The majority of sessions are 60 minutes with the exception of children under one who are scheduled for 45 minutes. The site mentor, a skilled OTR, has experience running a free adaptive dance group for children with disabilities during summer, but there are no current therapy groups being billed in the clinic. In the past, speech therapists have run a feeding group but it was considered unsustainable. Initially, we discussed the idea of fully implementing group services, however, due to national health concerns surrounding the COVID-19 pandemic, in-person groups have been temporarily placed on hold. Strengths The pediatric outpatient center has identified its current strengths, including the efficient use of a multidisciplinary approach. Physical therapists, speech therapists, and occupational therapists closely and efficiently work together to create a fluid and functional therapy plan. Therapists also work closely with each other and with clients to create a personalized scheduling plan. The clinicians feel as though the parents play an active role in their children’s care and are able to carry through with prescribed therapy in the home setting. Needs Identified Throughout the needs assessment process, I was able to identify what gaps were present within the new clinic as well as barriers to the development and implementation of these designs. Therapists had been using the Peabody Developmental Motor Scales-Second Edition (PDMS-2), to assess motor deficits during many initial evaluations. The clinicians described their dissatisfaction with this method, explaining they felt the items were not occupation-based and frequently did not reflect the child’s skills accurately. The site mentor indicated an interest in utilizing a new assessment, the M-FUN to improve the effectiveness of their evaluation methods. The clinic was able to order the assessment and related materials but descried apprehension regarding the need to learn the administration methods as well and scoring procedures for the assessment. We decided clinicians would greatly benefit from a presentation discussing the administration and scoring procedures to reduce the burden on each therapist while encouraging congruent scoring methods. After beginning the experience on-site in January of 2021, I was able to meet with the education coordinator for the hospital. She discussed the need to develop a method to assess upcoming competency requirements for the pediatric outpatient staff and expressed interest in utilizing the M-FUN learning module to demonstrate proficiency in a relevant skill. After further discussion, I suggested the module be presented in an electronic format to allow future employees to access the information and encourage sustainability. Additionally, the therapists were interested in creating a group to improve handwriting performance. The occupational therapists report they have a great deal of children struggling with handwriting legibility who would benefit from an intensive program dedicated to the skill. Many children display deficits in motor planning, coordination, and visual perception that limit their success in early writing skill development. Therapists emphasized the importance of using evidence-based interventions to support the treatment process. Various HWT resources are already available within the clinic but are not frequently utilized due to lack of organization. They also believe a group setting would benefit the children by providing an introduction to the development of social skills, communication, and self-regulation required within a classroom setting. Barriers A major concern for all therapists interviewed was the increase in work demands combined with a reduction in time allotted to research and implement novel treatment strategies. Therapists often see a patient every hour during the workday with the exception of lunch, which they utilize to complete documentation. When there are no cancellations, all additional work including communicating with insurance, scoring assessments, and collaborating with parents are completed outside of the traditional workday. Therapists relayed they could not proficiently learn the M-FUN with the time provided and were concerned they would score the assessment inconsistently, resulting in skewed data regarding patient development. Another issue described throughout this process was the inability to focus intensely on handwriting skills within the OT sessions. Many children with significant deficits in handwriting and motor planning skills receive services to develop adequate legibility within writing tasks. Insurance and complex medical needs often limit a clinician’s ability to conduct a therapy session incorporating only handwriting training. Instead, writing would be a portion of the session with various other needs and abilities addressed. Due to limited time and resources, these interventions are often not part of a comprehensive evidence-based program. Unfortunately, these strategies rarely resulted in significant improvements in sizing, spacing, or legibility. Therapists believe a group setting intended for intense handwriting interventions using an evidence-based curriculum would result in improved performance and participation patterns for clients. Additionally, serving multiple children at one would address concerns related to high productivity standards while maintaining an elevated quality of care. Another issue that arose during this process was the developing health crisis related to the COVID-19 virus. At the time of the needs assessment, no groups were currently running, however, it was an identified goal to integrate groups into the new clinic space. To preserve the health and safety of both children and staff, administration placed all group activities on hold during the spring of 2020, with an expected 6 feet distance to be maintained between all clients as recommended by the Center for Disease Control. Literature Review An in-depth literature review was conducted regarding the psychometric properties of the M-FUN, as well as evidence supporting the use of HWT interventions. Research was necessary to determine the M-FUN is an acceptable replacement for other motor assessments and can accurately identify deficits in a variety of motor skills. Relevant literature also supported the use of HWT curriculum within a group among a variety of settings. This information is necessary to ensure ethical treatment and the use of best practice methods. The Miller Function and Participation Scales At the initiation of the capstone, the outpatient center utilized the Peabody Developmental Motor Scales-Second Edition (PDMS-2), a commonly used assessment tool in pediatric settings. Despite this, it has been shown to be subject to significant ceiling effects. Additionally, there are extraneous items on various subtests that reduce the efficiency of the assessment, indicating a need for revision in subsequent editions (Chien & Bond, 2009). Furthermore, a study performed by van Hartingsveldt et al. (2005) determined that although the PDMS-2 has excellent interrater reliability, the fine motor portion of the assessment had substantial concerns. A study assessing a group of children with motor deficits, identified only 39 percent as delayed when using the Peabody assessment tool, demonstrating strikingly low sensitivity (van Hartingsveldt et al., 2005). The Miller Function and Participation Scales is a commonly utilized tool to assess functional performance in children ages 2-8 years, across a variety of occupational areas through the measurement of fine, gross, and visual-motor skills. The assessment has demonstrated excellent test/retest reliability, interrater reliability, and internal consistency, for all three subsections of the test, for both typically developing and delayed children as reported by the Shirley Ryan Ability Lab (“Miller function & participation scales,” 2017). The M-FUN has been shown to have concurrent validity with the PDMS-2 but “may provide additional information regarding the neurological profile of the child” (Holloway et al., 2019, p. 193). Additionally, the MFUN demonstrates strong specificity (ranging in a score between .8 and 1.0), implying it can accurately detect individuals without delays (“Review of the Miller Function & Participation Scales (M-FUN)” (2011). Ultimately, the PDMS-2 is a commonly utilized tool in pediatric settings that demonstrates adequate reliability and validity, however, there are various issues related to its sensitivity and specificity. The M-FUN has similar rates of reliability and validity but may include increased rates of sensitivity to more accurately identify deficits in the patient population. Additionally, the M-FUN provides a unique neurological foundations profile that can identify individualized skill deficits for each child to assist in accurately developing personalized intervention approaches. Although the M-FUN has many parts and can be a lengthy assessment averaging over 60 minutes in its entirety, it provides a holistic view into a client’s abilities. The activities used to assess a child’s skills are occupation-based and represent realistic play skills. An organized and practiced approach to administering the assessment can facilitate a smoother evaluation while increasing client rapport. An accurate and efficient introduction to this assessment to ensure its standardization of use within the clinic would be beneficial in providing a better standard of care for clients and families. Ultimately, the use of this assessment will allow therapists to more accurately identify specific skills deficits and create intervention approaches that target appropriate skills and replicate daily activities. Handwriting Diagnoses An initial interview with the outpatient pediatrics center described autism spectrum disorder (ASD) as a common diagnosis seen at the clinic. Many children with autism (among other diagnoses) may demonstrate reduced grip strength and intrinsic musculature of the hands. This can have a drastic effect on academic performance, as grip and pinch strength are important factors in the development of pencil control and handwriting legibility, as well as functional fine motor tasks (Alaniz et al., 2015). Kushki et al. (2011) discuss the concerning correlation of ASD with handwriting difficulties. They identify impairments in fine motor control and visual-motor integration as likely factors in this relationship between children with ASD and poor writing legibility. Another common comorbidity seen within the clinic is the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). Although many typically developing children report trouble with handwriting tasks, studies suggest that children with ADHD perform worse on handwriting, fine motor, and general coordination assessments. Often these children demonstrate excessive pressure and speed, leading to poor legibility when writing (Racine et al., 2008). Shen et al. (2012) identified a positive correlation between visual-motor integration and handwriting legibility. They have also demonstrated children with ADHD have been shown to score lower on tasks demanding upper limb and hand-eye coordination and visual-motor integration when compared with controls. This trend depicts the misalignment between skills required and skills observed in children with ADHD and suggests a method for developing client-centered interventions aimed at improving coordination and legibility. While ADHD represents a significant portion of handwriting referrals, many other diagnoses can result in illegible handwriting such as developmental coordination disorder (DCD) and other disorders with cognitive and motor deficits (Baldi et al., 2018). An observational study performed in 2010 utilized kinematic data to demonstrate children with DCD struggle to perform the open-loop and closed-loop motions necessary for fluent handwriting. An intervention that promotes visual feedback with visual and verbal prompting may be an excellent method for teaching letters to those who struggle with DCD (Chang & Yu, 2010). The Role of Occupational Therapy Despite the ever emerging technology present in today’s society, basic handwriting remains a crucial skill that incorporates various performance skills described in the Occupational Therapy Practice Framework such as: stabilize, grip, manipulate, sequence, and many more ("Occupational Therapy Practice Framework: Domain and Process—Fourth Edition," 2020). Deficits in these skills must be identified early in a child’s academic career as it can greatly impact their occupational performance. Feder and Majnemer (2007) suggest there is evidence indicating that up to 30 percent of school-aged children may suffer from handwriting difficulties and that these are unlikely to resolve without additional intervention strategies. Although teachers take on the role of handwriting education in school, when difficulties arise teachers may utilize different methods of instruction which can lead to disorganization and confusion. A recent survey found that teachers in primary school were utilizing a wide variety of techniques that do not currently represent best practice (Cantin & Hubert, 2019). Occupational therapists (OTs) are uniquely trained to understand the underlying causes of poor legibility and to view the client in a holistic manner to address multiple personal aspects that may improve participation and performance. In addition to direct handwriting tasks, OTs can recommend evidence-based activities to promote fine motor and in-hand manipulation skills as a preparatory task to be performed outside of therapy. These preparatory tasks aimed at developing fine motor skills have been shown to improve legibility in preschool age children (Seo, 2018). Another study revealed that children who worked with an occupational therapist in school improved significantly in letter legibility over those who also struggled with handwriting but did not receive additional therapy services (Case-Smith, 2002). The Handwriting Without Tears Program The outpatient pediatric clinic currently possesses materials from the Handwriting Without Tears (HWT) program which will be utilized for a handwriting group to be implemented in the future. Donica (2015), described the significant effects of HWT in kindergarteners learning to print. Children using the HWT method improved and scored higher on all 10 sub-scores of the handwriting assessment compared to similar children who learned through general education with no specific program. A study that compared two classes in a Head Start program demonstrated similar results. The class utilizing the HWT tools made more significant improvements in prewriting, kindergarten readiness, and fine motor skills, indicating the program may be beneficial to utilize in similar scenarios (Lust & Donica, 2011). An examination of the effectiveness of the HWT program revealed that participating students achieved significantly higher on the Minnesota Handwriting Assessment post-test scores on aspects of form, size, spacing, and alignment (Roberts et al., 2014). Despite the successful history of HWT in general classrooms, it is also crucial to assess its usefulness with less traditional children. In a small-scale study, HWT was shown to be a useful tool to teach handwriting skills to children with intellectual disabilities (Grindle et al., 2017). Additionally, HWT has been shown effective in children with autism and developmental delays. Another small-scale study performed by Carlson et al. (2009) supports the use of tracing procedures found in the HWT program as an effective way to teach letters. A unique study performed by Australian researchers Patton and Hutton (2016) explored the perspective of parents of children with autism receiving HWT instruction. Parents identified the occupational therapist’s role as essential to encouraging parent and teacher involvement. Fluctuations in the children’s mood, as well as time spent in therapy, were both identified as limitations to participation in handwriting training. Ultimately, parents perceived the therapists’ approach utilizing HWT as enabling and engaging. While the HWT program has demonstrated significant validity in improving handwriting skills, it is important to highlight that findings support the most important aspect of a successful intervention is intensive practice. Children enrolled in an intensive handwriting group made significant improvements in legibility compared to a group of children enrolled in a handwriting class focused on visual motor skill development (Howe et al., 2013). Researchers conducted a systematic review in 2011 assessing various studies implementing handwriting techniques to improve coordination and legibility. The final results emphasized the need for intensive practice with additional repetition at home for a minimum of 20 sessions. Improvements in handwriting speed appear to require even more intensive practice (Hoy et al., 2011). A particularly thorough systematic review investigating the effectiveness of various pediatric occupational therapy interventions provides further evidence of the value of handwriting training. Researchers utilized the “Evidence Alert Traffic Light System” to categorize common interventions based on their efficiency and effectiveness. Within this extensive review, researchers highlighted the crucial statement that interventions emphasizing the activity level of the International Classification of Functioning, Disability, and Health (ICF) model, using a top-down approach, (including handwriting task training) better support children in reaching occupational goals. When combined with a top-down approach, four aspects of therapy provide a strong foundation for the development of new skills: a focus on the child’s goals, concentration on occupational participation and real life application, intense repetition, and grading procedures to accommodate the “just right challenge” (Novak & Honan, 2019). Ultimately, utilizing these aspects in conjunction with HWT education will likely provide a strong and effective strategy to improve handwriting skills among children with a variety of different backgrounds and diagnoses. Additional Techniques In addition to the potential programs available, clinicians need to be aware of the additional interventions that may be utilized in conjunction with handwriting training. Pade et al. (2018) described a positive correlation between overwriting and erasing with body displacements and movement in the chair. Children who did not lean on the backrest generally demonstrated better legibility. This relationship between posture, body positioning, and writing performance is an important factor for clinicians to consider when developing handwriting skills. Pencil grasp is another aspect of handwriting that is addressed within the scope of OT. Although a dynamic tripod grasp is often cited as the preferred grasping pattern, various other ways may be equally efficient, especially considering children who may experience disabilities. Research shows that among mature grasp patterns, there is no significant effect on speed or legibility (Schwellnus et al., 2012). Enforcing specific grasp patterns that are unnatural and uncomfortable may be detrimental to therapy and hinder progress. Another commonly disputed component of handwriting education is the effectiveness of sensorimotor interventions with more practical applications. Denton et al. (2006) reported little to no benefits in a sensorimotor approach compared to “therapeutic” or occupation-based interventions. Goyen and Duff (2007) comment that kinesthetic training, often used as a sensorimotor strategy, has yet to be convincingly validated. Another study explored this relationship and found that both sensorimotor and task-oriented interventions showed gains in speed and legibility. While this appears to contradict previous findings, researchers suggest an important component incorporated into both groups was the use of higher-level functions, employing cognitive and executive functioning skills (Weintraub et al., 2009). Zwicker and Hadwin (2009) also suggest the use of cognitive interventions over sensory approaches and Saleem and Gillen (2019) suggest that mental practice in addition to repetitive task performance can better improve assessment scores. These studies provide valuable data which may suggest a change from the traditional use of sensorimotor interventions in handwriting education. Assessments The Handwriting Proficiency Screening Questionnaire for Children (HPSQ-C) is reported as having a high internal consistency ( α=.77) and is a valid tool to identify deficiencies in school-aged children (Rosenblum & Gafni-Lachter, 2015). The Handwriting Legibility Scale (HLS) is also reported as having a high internal consistency (α=0.92) and validity, indicating it may be a useful tool to identify handwriting deficiencies across multiple languages (Barnett et al., 2018). Conclusion Ultimately, these studies suggest that a long-term intensive program, focusing on handwriting practice has the potential to increase handwriting legibility in children with various disorders. After an extensive synthesis of the research, it is evident that many children with common disorders such as ASD, ADHD, and DCD are likely to exhibit poor handwriting due to a variety of physiological and environmental factors. The role of occupational therapy is vital in providing skilled client-centered therapy within a holistic lens. OTs can provide a variety of intervention strategies in conjunction with relevant theories of practice to facilitate an adequate learning model. Many existing programs often implemented by OTs have demonstrated efficacy in improving handwriting legibility in school-age children. The HWT program, which will be implemented at the clinic, also exhibited significant legibility gains when utilized by children with various disabilities. In addition to these programs, other aspects of treatment should also be considered including posture, positioning, hand strength, sensory input, and occupational relevance. Gap Analysis M-FUN Assessment The clinicians currently use multiple assessment tools with an emphasis on the Peabody Developmental Motor Scales - Second Edition (PDMS-2). The occupational therapists are dissatisfied with this assessment and believe it lacks the valuable psychometric property of sensitivity and is not occupation-based. They have recently invested in obtaining a new standardized assessment, the M-FUN, to identify motor delays in the clinic. According to the therapists, there is little opportunity available to individually read and learn the protocols for a new assessment. Therapists are in agreement that they are experiencing increasing work demands, with a reduction in time to research best practice methods. They are interested in the development of a teaching protocol to direct the implementation of the new assessment and ensure standardization throughout the clinic. Additionally, the current therapists and education coordinator are seeking methods to develop relevant competency opportunities to cultivate and maintain applicable clinical skills and knowledge. Handwriting Therapists are seeing an increase in children with fine motor deficits that are struggling in academic tasks such as handwriting. Currently, the occupational therapists do address fine motor skills and may practice grasping patterns, but less emphasis is placed on detailed handwriting proficiencies. Therapists are interested in starting a weekly program but need assistance in getting the program started and keeping it sustainable. The rapid expansion of the COVID-19 crisis has emphasized these deficits in legibility as children learn from home and lack access to individuals with experience to address these problems. Unfortunately, in-person groups are currently placed on hold within the clinic setting. Despite this obstacle, clinicians are still interested in program development including curriculum and material acquisition. Guiding Model/Theory Adult Learning Theory The portion of the capstone experience focused on providing education on a new assessment tool is guided by the adult learning theory. This concept identifies various principles that characterize adult learning. Some main considerations are: adults are often internally motivated and self-directed, they bring life experiences to apply to the learning process, they are goal and relevancy oriented, and enjoy practical application of knowledge. It is essential we take into consideration how adults prefer to ascertain information as we aim to provide an effective and efficient learning module. Person-Environment-Occupation-Performance Model The above findings provide credence for the use of the Person-Environment-Occupation-Performance model to be utilized within the pediatric clinic. Factors including physiological functions, personal skills, and cognition levels represent the holistic view of the “person” while posture, positioning, and physical modifications or aids represent the “environment”. Research previously discussed that emphasizes the need for task-based practice in a meaningful context exemplifies the “occupation” and finally the legibility, and functional outcomes personify the “performance” facet of the model. Therapists bring all these aspects together to create a holistic intervention that meets the client’s needs and expectations. Capstone Project Plan and Process After meeting with my site mentor on several occasions, it was clear the therapists were interested in learning to administer and score the M-FUN within the clinic. Because the physical therapists on-site utilized separate assessments, the OTs decided they only required information on the first two subsections of the M-FUN: visual motor and fine motor skills. Using a variety of resources including literature, mentor experience, and certified educational courses, I developed a plan to create a detailed seminar which I would present in person to the appropriate therapists. Following a meeting with the hospital’s education coordinator, we determined that to increase sustainability, the presentation should be distributed electronically to allow repetitive use and review of the material. Initially upon planning the capstone project, my site was interested in the development and implementation of a handwriting group utilizing the Handwriting Without Tears Protocol. As a student, I would browse various materials available within the clinic and online to develop a weekly plan composed of assessments, interventions, and materials used each session. I submitted a detailed plan to the Indiana University’s institutional review board, which received approval prior to the start of the doctoral experience. Initially, the group was to be implemented during the capstone experiential with the site mentor and myself co-leading the group. A pre-assessment would be administered to the clients along with a survey for parents to complete prior to the start of the program. In order to evaluate the success of the group, a post-test and survey would be provided to statistically analyze the effectiveness of the group and intervention methods. Due to the evolving health crisis, the hospital placed in-person groups on hold until further notice. Online video groups were considered but staff determined this option was not sustainable in the present climate. As a result, my site mentor and I modified the program development portion of the project to include only the planning and creation of materials needed for weekly sessions. Curricular Threads I demonstrated entry-level competency in the area of socially responsive healthcare by completing a professional development course on the Miller Function and Participation Scales (M-FUN) Assessment and training staff members on the use of the M-FUN in practice. Research supports that the M-FUN demonstrates improved reliability measures and represents greater inclusivity than the currently utilized Peabody assessment. Overall, the M-FUN demonstrates a stronger focus on occupations and takes a client-centered approach to evaluating skills. To ensure use of a statistically sound model of assessment I tested for interrater reliability of administration from the OTs at the clinic. Confirming that the assessment is valid and reliable in this setting is a vital component of ethical practice. Utilizing an assessment without standardization would be harmful to clients and create inequitable care standards. I also demonstrated this through the handwriting group planning process. Proposed interventions are based on detailed research provided through a thorough literature review. Techniques utilized are backed by evidence and individualized to target client needs with the approval of experienced therapists. The handwriting techniques identified have demonstrated success among children with a variety of diagnoses. Thus, all students in the group will benefit from the instruction and techniques applied. Additionally, I demonstrated critical inquiry and reflective practice utilizing clinical reasoning skills regarding client needs, evidence-based interventions, and activity modification. Some of these decisions may be based on the feedback provided by both the staff and the clients seen at the clinic. All intervention techniques are built on evidence-based research collected through an in-depth literature review. Project Goals and Objectives By the end of this capstone project, my goals were to have completed the following: Project Goal 1: Effectively instruct therapists within the clinic in the use of the Miller Function and Participation Scales (M-FUN) assessment within 8 weeks. Objective 1: Attend a course detailing how to successfully administer and score the M-FUN assessment in order to assure competency before instructing others. Objective 2: All OTs in the pediatric clinic have received instruction in administering the M-FUN and maintain access to relevant resources to guide future administration and scoring efforts. Objective 3: All OTs in the pediatric clinic have completed a mock case study, evaluating a child’s performance on the M-FUN visual motor and fine motor subsections. Objective 4: Interrater reliability between therapists is measured by percent agreement with a standard deviation of less than three. Project Goal 2: Successfully plan the development of a sustainable weekly handwriting group utilizing Handwriting Without Tears (HWT) materials provided by the clinic within fourteen weeks. Objective 1: Collaborate with clinic partners to plan, develop, and organize a handwriting program using HWT curriculum during the second half of the capstone experience. Objective 2: Collect and categorize materials needed for each week in preparation for the handwriting group. Objective 3: Assist in creating any materials needed in preparation for the assessment and evaluation of the handwriting group. Project Goal 3: Gain clinical experience working with children in an outpatient setting with a variety of disabilities to improve understanding of clinic needs and appropriate implementation strategies. Objective 1: Gain advanced knowledge in administering various assessments including the M-FUN, through research, observation, and clinical practice. Objective 2: Gain experience creating and implementing interventions with children in the clinic, using evidence-based practice and guided by an experienced site mentor. Objective 3: Gain advanced knowledge on a variety of diagnoses including causes, symptoms, and treatment options through therapist interviews and self-directed research. Project Implementation Seminar Development During the first week of onsite learning, I met with multiple OTs employed within the pediatric clinic to gather a general sense of how familiar they were with the new assessment and their views on the need for improved evaluation methods and outcomes. All five therapists were interested in adopting the M-FUN administration protocol and believed it would ultimately improve the quality of service provided to clients and their families. Before initiation of the capstone experiential, I applied for monetary funding through a grant request and was awarded a sum of money to be utilized during the project implementation. I utilized this funding to attend a virtual seminar on the administration, scoring, and interpretation of the M-FUN assessment. This seminar is accredited by the American Occupational Therapy Association (AOTA) and is presented through the Star Institute with the goal to improve education on sensory-related topics for a variety of therapy providers. The course includes four hours of video presentation along with multiple handouts, relevant examples, and a comprehensive quiz to assess knowledge. After completion of the course and an in-depth review of the administration guide and examiners manual, I developed my own seminar composed of an animated PowerPoint with narration spanning approximately 90 minutes. The presentation includes details about the assessment’s appropriate uses, components of measurement, psychometric properties, administration guidelines, scoring examples, interpretation analysis, and procedure, as well as a final quiz regarding learned material. This in-depth presentation was provided to all OTs within the clinic by week 6 who were encouraged to watch it throughout the week at their convenience. Subsequently, during a one-hour training exercise, I provided the therapists with a completed workbook of the visual-motor subsection with simulated answers and asked them to score each item independently. After scoring, therapists participated in a group discussion to compare answers and address any discrepancies in scoring procedures. Additionally, during a second in-service, all OTs watched a video of myself administering the fine motor subsection of the assessment on a child. Each therapist completed a score sheet and interpreted the results. Again, therapists participated in an open discussion to analyze any differences in scoring ideology and ask questions regarding best practice methods. With advice provided by a faculty specializing in research methodology, I analyzed the collected data to assess the interrater reliability of the assessment when all five therapists were presented with the same documents. Results of this procedure are presented within the evaluation section and appendix. Program Planning The second half of the capstone experiential focused on the planning and preparation for a future handwriting program to be implemented as a weekly group therapy. My site mentor provided me with an overview of the HWT program. In the past, she has attended HWT workshops and has access to a variety of educational materials. In order to become familiar with the program, I utilized various components within my own treatment planning such as Mat Man, Touch and Flip Cards, and the “Wet-Dry-Try” protocol. After a discussion regarding the most effective methods to implement the group, we decided the service should be directed at kindergarten-aged children who demonstrate competency in basic pre-writing strokes such as vertical/horizontal lines and circles. The group will consist of two therapists and six children who already attend the clinic for additional services. Children must be able to appropriately and safely engage within the group setting. Due to global health concerns, implementation of the group process has been delayed, however, approval to begin development and advertising for upcoming group sessions was approved by management while onsite. After consulting with clinicians regarding previously successful groups, we determined the handwriting group would be executed throughout the summer to align with Perry Township’s summer break, as many children who attend the clinic follow this schedule. The summer break lasts eight weeks between the dates of May 27th and July 26th. The program will run for a total of seven weeks to accommodate families who may take a vacation during the break from school. To ensure all interventions were evidence-based and represented best practice methods, I reviewed the literature previously collected and extensively read the resources provided by my site mentor and the clinic. I worked over the course of three weeks to develop an intense curriculum using the HWT protocol, divided into seven segments. An example of the syllabus for week one can be in Appendix B. Each session lasts one hour and uses a familiar schedule to improve performance and provide consistency within the group setting. The first and last session includes a simple free assessment called “The Screening of Handwriting Proficiency” provided electronically by the HWT corporation. This assessment is utilized to evaluate the effectiveness and efficiency of the group by assessing improvements in each child’s writing and legibility patterns. Additionally, the interventions include instruction on using “Mat Man” to introduce basic shapes in relation to visual-motor skills. Session two through five focus on the identification and formation of each letter of the alphabet using the wooden shapes, tracing practice, and the “wet-dry-try” method. These techniques offer intense repetition practice, essential for supporting permeant learning patterns and storage into long-term memory. Education will focus on correct stroke sequencing as well as top-down letter formation indicated through the HWT protocol. During this group, therapists will only teach capital (uppercase) letter formation. It is encouraged these letters are learned first as they incorporate developmentally simpler motor patterns and reduce confusion related to letter sizing and placement. Letters will be taught based on developmental writing patterns to support sequential learning and increase success. Vertical and horizontal lines emerge as an early skill, and thus letters with these stroke patterns such as E and F are taught first. Diagonal lines require increased coordination as the child crosses midline visually and physically. As a result, these letters are often more challenging and will be taught after mastery of the other letters. In addition to these foundational skills, therapists will incorporate sensory-motor components that include songs, games, sensory boxes, and playdoh. Children will also learn how to support improved writing performance through the use of an appropriate pencil grip and good posture. While many activities provide the opportunity to individually develop essential skills, other tasks incorporate teamwork and problem-solving skills to support a better transition to a school or classroom setting. In addition to a weekly curriculum, I have also created a weekly handout to provide to parents. Because clinicians have a very limited amount of time between sessions, it was a noted concern that they would be unable to discuss the events of the session with each parent. To maximize the amount of time spent within each session, while reducing the need to discuss progress with each family, a handout will be provided at the end of each session. This handout describes what the child did during group therapy, the letters learned, and what should be completed as homework before next week’s therapy session. To emphasize the importance of handwriting skills, and intensive practice I also developed a letter to families which will be distributed before the first weekly group session. The document discusses why their children will learn letters out of alphabetical order and what skills are being developed throughout the process. After completion of all aspects of curriculum and parent resource development, the OTs met for a one-hour in-service. The meeting consisted of a brief overview of the curriculum followed by a group interview regarding the clinicians’ opinions of the final product. Results of this interview will be presented within the evaluation section and appendix. Project Evaluation M-FUN Results The M-FUN visual-motor portion consists of 8 items scored by each therapist, then combined for a total score. A designated number represents each occupational therapist, represented in the charts as OT 1, 2, etc. Numbers in each column and the total score represent the raw data collected. Each of these is converted into a scaled score that is used to graph and categorize the child’s skill level. The bottom row of each graph contains scaled scores transformed from the raw data (See Appendix C). Behavior ratings, (item 8 and item 6 in the visual motor and fine motor subsections respectively) were unable to be calculated based on simulated evaluations. As a result, these items were not considered when calculating individual percent error or agreement. Reliability Within the visual-motor subsection, items two, three, four, six, and seven had 100 percent agreement among all clinicians, indicating a well understood and universal scoring ideology. Items one and five (Amazing Mazes and the Draw a Kid Game) displayed the highest variation among scores, with 60 and 40 percent agreement respectively. Despite this discrepancy, the standard deviation among these items were .71 and 1.48, suggesting clinicians had minimal divergence from the mean. When calculating totals, 2/5 therapists had the same raw score, however, the standard deviation was only 1.92 indicating a very small margin of variance. This is reflected in the scaled scores, with three out of five clinicians documenting the same result. The standard deviation for scaled scores between therapists is the smallest, at 0.55 (See Appendix C: Table 1). This consistency among scaled scores indicates excellent interrater agreement within the visual-motor subsection between participating therapists. Within the fine motor subsection, items one, three, four, and five had 100% rates of agreement. Item two, (The Clay Play Game) had a 60 percent agreement among therapists, however, the standard deviation of responses was only .89, indicating low variation among answers. The total raw scores also had a 60 percent agreement rate, however, all responses were within one point of the “agreed upon score”. These results are reflected in the scaled scores which have a 100% agreement rate of 8 (See Appendix C; Table 3). This indicates excellent interrater reliability and establishes a standard for consistent care throughout the clinic. Validity To assess the validity of the clinicians’ results, their mean scores were compared to an accepted value. These values were scored by myself and supported by the examples and sample items provided by Lucy Miller Ph. D., OTR/L, (the developer of the M-FUN assessment) through the Star Institute’s seminar. Appendix C: Table 2 displays the percent error for the average scores among all five clinicians. The total raw score has an average percent error of 2.8% suggesting an excellent degree of validity. The scaled scores have an error rate of 8.57 percent which is likely emphasized due to small sample size. Ultimately, the mean observed scaled score is less than one point away from the expected score, indicating good overall validity. The fine motor portion of the assessment also had very little percent error on each item. Four out of five items had an average error rate of 0%. The total raw scores averaged a percent error of only .56% and the total scaled scores also had a percent error of zero (See Appendix C: Table 4). Among the five therapists at the clinic, they achieved the highest potential validity score with a 100% agreement rate among the scaled scores in this section. Group Interview The group interview following an explanation of the handwriting curriculum was an evaluation method used to replace the initial data collection process. As the group was unable to be implemented due to health restrictions, the evaluation focuses on the clinicians’ perception of the efficiency/effectiveness of the developed plan. A list of six open ended questions was provided and discussed amongst the therapy team while I recorded and assessed responses for common themes. The provided questions can be found in Appendix D. Overall, clinicians indicated that the most beneficial aspect of the project was the development of a streamlined curriculum that would not require therapists to perform any additional tasks prior to the start of the session. Clinicians will not need to research any topics/skills before the initiation of the group, nor will they have to collect extensive supplies between sessions once the group is implemented. This was an intentional facet of development as the OTs had previously indicated a significant strain at work due to lack of time. Most clinicians see children each hour with less than three minutes to clean and prepare for the next child’s session. The OTs felt as though the prepared sheets and resources were a necessary component to ensure success. The developed resource binder increases efficiency within the clinic and allows clinicians to maximize therapeutic time within the hour provided. Additionally, clinicians indicated that the parent handout section was essential to create parent buy-in and improve follow-through at home. Family support and continuation of interventions at home are critical components of learning, emphasized in the relevant literature. A detailed explanation of the goals and procedures used within the clinic as well as suggestions to practice at home are believed to improve rapport with parents and increase follow-through which has limited success in the past. The provided resources also hold parents accountable as there is a strong communication method already developed. Previously, therapists struggled to communicate with each parent regarding progress within the session in a timely manner. The pre-printed handouts eliminate the need to verbalize daily interactions and ensure that each parent/guardian receives relevant information and expected homework assignments. This leaves time for therapists to address individualized questions that may arise within the limited time provided. The group process was also considered to be effective because of the social component that individualized therapy lacks. The novel environment breaks up the mundane routine that some families find themselves in when children require extensive therapy services. Children often respond with increased drive and motivation when presented with peers performing the same tasks. Communal interaction and planned interventions to promote teamwork provide a unique aspect to the learning process that increases incentive and participation efforts. Likewise, parents appear to display increased follow-through at home when they are aware children will be compared to peers. Therapists report families exhibit increased ambition to meet objectives and expectations when they see progression and successes in others. Furthermore, clinicians indicated that basing the group on a specific curriculum (Handwriting Without Tears) is an essential component to ensure success. All OTs within the clinic have at least a basic understanding of the popular program and do not require any additional training to utilize the group plans. Therapists agreed it was vital that the interventions are evidence based with supporting research. While the staff all have extensive experience with children and FM delays, the procedures in place ensure interventions are not based on individual therapist’s perceptions or interpretations of writing competency. Additionally, clinicians indicated they believed this program was sustainable due to the uniformity and organization of pre-made handouts. All 5 OTs agreed they could step in and teach a weekly session at any point in the group process without prior experience. The detailed explanations of each activity ensure that no additional training is necessary to participate. Easily accessible supplies along with a strong foundation in OT fundamentals such as fine motor coordination, sensory processing, and self-regulation ensure feasibility and provide a practical approach to the implementation process. Finally, clinicians identified perceived barriers to the execution of the program. The two recurrent themes were coordinating times within the clinic to accommodate the group, as well as reimbursement procedures. After a discussion regarding the best methods to organize the schedule, clinicians identified their opinions on the best methods to address these concerns. First, therapists could coordinate a specific one-hour time slot to keep open in preparation for the group, or place temporary clients in these slots to allow for openings during the summer months. Next, it was determined the services would be billed through insurance with the exception of the out-of-pocket purchase of the workbook ($11.50). The hospital may be able to offer a waiver for families that cannot afford this expense. Both issues will be brought to the attention of the department manager for further consideration and finalization. Discussion Data interpretation and impact The results from the M-FUN assessment suggest excellent rates of validity and interrater reliability among all five therapists. Both subsections tested by all 5 clinicians resulted in excellent scores and suggest a cohesive assessment team that can work together to identify deficits and develop appropriate interventions. This is one of the main project goals developed in collaboration among site clinicians. Attending an in-depth seminar was a critical component in the development of a virtual education platform. Advanced instruction with provided examples assisted in the construction of both the PowerPoint and official competency. The M-FUN is now in continual use within the clinic and all therapists have administered the assessment independently. All therapists passed the competency evaluation for the hospital and were accredited required units of education. The PDMS-2 remains an option to utilize however, the OTs have indicated they prefer the M-FUN for a more accurate and occupation-based evaluation. After a discussion regarding the administration and scoring procedures, clinicians stated they felt confident in their ability to both utilize and interpret the assessment results. This is a vital component of the project objectives as a consistent and reliable evaluation is required in order to develop goals, create interventions, and measure progress. The high reliability and validity ensure that therapists are using best practice methods in conjunction with evidence-based interventions. After evaluation of the data, it is evident that project goal one and all four related objectives were met. Despite the fact that the handwriting group was not implemented during my capstone experience, the development of an evidence-based curriculum along with relevant resources was completed within the time provided. I compiled a detailed binder with a weekly syllabus, along with parent resources, communication notes, homework, and any additional resources needed for the group. After a qualitative interview including all OTs at the clinic, recurrent themes regarding their opinion of the group were compiled. Overall, therapists felt the materials effectively achieved the purpose of reducing additional time spent researching and collecting materials. The organization provided by the binder ensures efficiency within the clinic which was a major concern identified by the therapists. Following a conversation regarding remaining barriers to implementation, the involved parties developed a plan to address both scheduling and monetary obstacles. As a result of these efforts, the clinic now has a fully developed program targeting a common skill deficit in clients seen by the OTs. Clinicians will not be burdened with additional research or pressure to collect supplies between sessions. Additionally, children will have the opportunity to improve an important skill using evidence-based research with clinicians who utilize best-practice methods. After a review of the initial plan, I concluded the modified project goal two along with all related objectives were met within the second half of the capstone experience. Throughout the fourteen weeks on-site, I worked with clients daily, developing a full caseload. This opportunity assisted in my understanding of the genuine needs of the clinic. I assessed and treated children with a variety of diagnoses including ASD, sensory processing disorder, fine motor delay, Noonan syndrome, agenesis of the corpus callosum, and cerebral palsy. Interventions focused on addressing deficits in handwriting, fine motor, problem-solving, sensory, and self-regulation, among other skills. Generally, the children responded well to the incorporation of HWT components as well as sensory exploration with materials such as shaving cream. Major factors related to providing client-centered care were made evident when working directly with families. Parent communication, therapeutic use of self, clear expectations, and occupation-based activities were all vital in contributing to successful patient care and encouraging good participation efforts from the children. I was able to administer and score the M-FUN multiple times while using the results to develop targeted and individualized intervention plans. Throughout this process, I have gained a heightened understanding of both evaluation and treatment methods. I recognize the need to treat each client and their family with respect while addressing personal concerns in a professional manner. Additionally, the opportunity to work with an interdisciplinary team and provide co-treatments has helped me to view the client in a holistic manner while addressing how physical, social, and emotional factors can contribute to performance and participation. I feel well equipped to utilize this knowledge to further grow and advocate for clients as a more informed clinician. Project goal three as well as all related objectives were met by the end of the experience. Sustainability It is essential that the components developed during this experience are maintained and adapted to meet the needs of the clinic as it grows. Although all OTs are educated in the administration and scoring of the M-FUN, it is likely they may need a reminder regarding certain procedures as time passes. Additionally, it is possible new staff members hired in the future may be unfamiliar with this assessment. The modifications to develop an electronic seminar that is easily accessible to all clinicians was a carefully considered adaptation to ensure the knowledge and skills were sustained over time. Therapists can open the PowerPoint on any clinic computer and skip to desired information with the option of narration. Clinicians can quickly ascertain a small detail needed or study the entire assessment procedures. This ensures all clinicians can maintain their knowledge and continue to assess clients using best practice methods in the future. Maintaining the sustainability of the handwriting group was a major goal because this was a challenge for previously implemented feeding groups. In order to increase the longevity of materials, all papers are included in a hard binder with individualized sheet covers. To ensure the program could be easily repeated, clinicians received all resources in an electronic form. This provides the therapists with the opportunity to edit or modify the resources in any way to adapt to the needs or concerns of the current clients and their families. The provided curriculum focuses on improving handwriting formation using evidence-based research that is not specific to a certain diagnosis. Thus, a variety of children with varying backgrounds and experiences can participate within the group in the future. The ability to adapt the interventions and activities was an important component when planning the syllabus to account for any additional needs of the children. Because the group is seven weeks, it can be replicated annually during the typical summer break to allow for increased scheduling opportunities. However, as long as therapists and clients are available, the group session can take place throughout the year to accommodate any schedule. Sustainability is also incorporated by choosing the HWT program as the foundation of the group. Four of the five clinicians have attended at least one HWT course and after analyzing the weekly goals, all five therapists agreed they felt confident teaching the material. To ensure any new therapists who join the rehab team in the future do not need additional training, all instructions are clearly provided, eliminating the need to participate in individual research. Any care provider can easily step in and assist with running the session at any point in the groups process. The schedule of each week is similar to provide stability and consistency for both clients and staff. Additionally, all resources were individually chosen because of their ability to be re-used, or their consistent presence within the clinic. For example, the sensory bins and chalkboards will not need to be reordered for each group and are ecologically and financially conservative. Other resources such as shaving cream are cheap items that the clinic regularly keeps in stock and will not contribute an added burden to the ordering process. Overall, dedication to ensuring this program is sustainable has been successful and clinicians indicate they believe it will be efficient and effective when implemented in the future.   Conclusion The ultimate goal of this capstone experience was to address the needs of the clinic by providing ways to incorporate evidence-based research into group services and assessment strategies to meet the changing needs of a busy outpatient pediatric clinic. Throughout the fourteen weeks, I completed both of these goals as well as a third objective related to personal clinical growth. Through hands-on experience, I was able to understand and move forward to address the concerns related to the newly expanded clinic. A lack of time and resources were both prominent issues limiting the clinicians’ abilities to further develop a desired group procedure as well as implement a new assessment tool. After completion of both these tasks quantitative and qualitative data was collected to measure the effectiveness of my efforts. Results from a statistical analysis indicated that clinicians were both valid and reliable in their administration and scoring procedures of the M-FUN, and this assessment is now consistently used in the pediatric clinic. A detailed interview process also indicated that therapists viewed the handwriting program as efficient, effective, and sustainable. The program will be ready to be implemented as COVID-19 related health restrictions decrease. Both the therapy staff and I view this capstone as a successful effort to improve the function of the clinic through the application of practices with foundations in the profession of occupational therapy. References Alaniz, M. L., Galit, E., Necesito, C. I., & Rosario, E. R. (2015). Hand strength, handwriting, and functional skills in children with autism. American Journal of Occupational Therapy, 69(4), p1-p9. https://doi.org/10.5014/ajot.2015.016022 Baldi, S., Caravale, B. A.-O., & Presaghi, F. (2018). Daily motor characteristics in children with developmental coordination disorder and in children with specific learning disorder. (1099-0909 (Electronic)). Barnett, A. L., Prunty, M., & Rosenblum, S. (2018, Jan). Development of the Handwriting Legibility Scale (HLS): A preliminary examination of Reliability and Validity. Res Dev Disabil, 72, 240-247. https://doi.org/10.1016/j.ridd.2017.11.013 Cantin, N., & Hubert, J. (2019, Dec). A description of teachers' approach to handwriting instruction in primary schools. Can J Occup Ther, 86(5), 371-376. https://doi.org/10.1177/0008417419832480 Carlson, B., McLaughlin, T. F., Derby, K. M., & Blecher, J. (2009, 04/08/). Teaching Preschool Children with Autism and Developmental Delays to Write. Electronic Journal of Research in Educational Psychology, 7(1), 225-238. https://www.ulib.iupui.edu/cgi-bin/proxy.pl?url=https://search.ebscohost.com/login.aspx?direct=true&db=eric&AN=EJ836585&site=eds-live Case-Smith, J. (2002, Jan-Feb). Effectiveness of school-based occupational therapy intervention on handwriting. Am J Occup Ther, 56(1), 17-25. https://doi.org/10.5014/ajot.56.1.17 Chang, S.-H., & Yu, N.-Y. (2010). Characterization of motor control in handwriting difficulties in children with or without developmental coordination disorder. Developmental Medicine & Child Neurology, 52(3), 244-250. https://doi.org/10.1111/j.1469-8749.2009.03478.x Chien, C. W., & Bond, T. G. (2009). Measurement properties of fine motor scale of Peabody developmental motor scales-second edition: a Rasch analysis. (1537-7385 (Electronic)). Denton, P. L., Cope, S., & Moser, C. (2006, Jan-Feb). The effects of sensorimotor-based intervention versus therapeutic practice on improving handwriting performance in 6- to 11-year-old children. Am J Occup Ther, 60(1), 16-27. https://doi.org/10.5014/ajot.60.1.16 Donica, D. K. (2015, Nov-Dec). Handwriting Without Tears(®): General Education Effectiveness Through a Consultative Approach. Am J Occup Ther, 69(6), 6906180050p6906180051-6906180058. https://doi.org/10.5014/ajot.2015.018366 Feder, K. P., & Majnemer, A. (2007, Apr). Handwriting development, competency, and intervention. Dev Med Child Neurol, 49(4), 312-317. https://doi.org/10.1111/j.1469-8749.2007.00312.x Goyen, T.-A., & Duff, S. (2007). Kinaesthetic training was no more effective than handwriting practice or no treatment in improving kinaesthesis or handwriting speed and legibility in grade-one students. Australian Occupational Therapy Journal, 54(3), 240-242. https://doi.org/10.1111/j.1440-1630.2007.708_2.x Grindle, C. F., Cianfaglione, R., Corbel, L., Wormald, E. V., Brown, F. J., Hastings, R. P., & Carl Hughes, J. (2017, 11//). Teaching handwriting skills to children with intellectual disabilities using an adapted handwriting programme [Article]. Support for Learning, 32(4), 313-336. https://doi.org/10.1111/1467-9604.12178 Holloway, J. A.-O., Long, T., & Biasini, F. (2019). Concurrent Validity of Two Standardized Measures of Gross Motor Function in Young Children with Autism Spectrum Disorder. (1541-3144 (Electronic)). Howe, T. H., Roston, K. L., Sheu, C. F., & Hinojosa, J. (2013, Jan-Feb). Assessing handwriting intervention effectiveness in elementary school students: a two-group controlled study. Am J Occup Ther, 67(1), 19-26. https://doi.org/10.5014/ajot.2013.005470 Hoy, M. M. P., Egan, M. Y., & Feder, K. P. (2011). A systematic review of interventions to improve handwriting. Canadian Journal of Occupational Therapy / Revue Canadienne D'Ergothérapie, 78(1), 13-25. https://doi.org/10.2182/cjot.2011.78.1.3 Kushki, A., Chau, T., & Anagnostou, E. (2011). Handwriting difficulties in children with autism spectrum disorders: A scoping review. Journal of Autism and Developmental Disorders, 41(12), 1706-1716. https://doi.org/10.1007/s10803-011-1206-0 Lust, C. A., & Donica, D. K. (2011, Sep-Oct). Effectiveness of a handwriting readiness program in head start: a two-group controlled trial. Am J Occup Ther, 65(5), 560-568. https://doi.org/10.5014/ajot.2011.000612 Miller Function & Participation Scales (2017). Shirley Ryan Ability lab. https://www.sralab.org/rehabilitation-measures/miller-function-participation-scales Novak, I., & Honan, I. (2019, Jun). Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review. Aust Occup Ther J, 66(3), 258-273. https://doi.org/10.1111/1440-1630.12573 Occupational Therapy Practice Framework: Domain and Process—Fourth Edition. (2020). American Journal of Occupational Therapy, 74(Supplement_2), 7412410010p7412410011-7412410010p7412410087. https://doi.org/10.5014/ajot.2020.74S2001 Pade, M., Liberman, L., Sopher, R. S., & Ratzon, N. Z. (2018). Pressure distributions on the chair seat and backrest correlate with handwriting outcomes of school children. Work, 61(4), 639-646. https://doi.org/10.3233/wor-182831 Patton, S., & Hutton, E. (2016, Aug). Parents' perspectives on a collaborative approach to the application of the Handwriting Without Tears(®) programme with children with Down syndrome. Aust Occup Ther J, 63(4), 266-276. https://doi.org/10.1111/1440-1630.12301 Racine, M. B., Majnemer, A., Shevell, M., & Snider, L. (2008, Apr). Handwriting performance in children with attention deficit hyperactivity disorder (ADHD). J Child Neurol, 23(4), 399-406. https://doi.org/10.1177/0883073807309244 Review of the Miller Function & Participation Scales (M-FUN). (2011). Roberts, G. I., Derkach-Ferguson, A. F., Siever, J. E., & Rose, M. S. (2014). An examination of the effectiveness of Handwriting Without Tears® instruction. Canadian Journal of Occupational Therapy / Revue Canadienne D'Ergothérapie, 81(2), 102-113. https://doi.org/10.1177/0008417414527065 Rosenblum, S., & Gafni-Lachter, L. (2015, May-Jun). Handwriting Proficiency Screening Questionnaire for Children (HPSQ-C): Development, Reliability, and Validity. Am J Occup Ther, 69(3), 6903220030. https://doi.org/10.5014/ajot.2015.014761 Saleem, G. T., & Gillen, G. (2019, Feb). Mental practice combined with repetitive task practice to rehabilitate handwriting in children. Can J Occup Ther, 86(1), 19-29. https://doi.org/10.1177/0008417418824871 Schwellnus, H., Carnahan, H., Kushki, A., Polatajko, H., Missiuna, C., & Chau, T. (2012). Effect of pencil grasp on the speed and legibility of handwriting in children. American Journal of Occupational Therapy, 66(6), 718-726. https://doi.org/10.5014/ajot.2012.004515 Seo, S. M. (2018, Feb). The effect of fine motor skills on handwriting legibility in preschool age children. J Phys Ther Sci, 30(2), 324-327. https://doi.org/10.1589/jpts.30.324 Shen, I. H., Lee, T. Y., & Chen, C. L. (2012, Jul-Aug). Handwriting performance and underlying factors in children with Attention Deficit Hyperactivity Disorder. Res Dev Disabil, 33(4), 1301-1309. https://doi.org/10.1016/j.ridd.2012.02.010 van Hartingsveldt, M. J., Cup Eh Fau - Oostendorp, R. A. B., & Oostendorp, R. A. (2005). Reliability and validity of the fine motor scale of the Peabody Developmental Motor Scales-2. (0966-7903 (Print)). Weintraub, N., Yinon, M., Hirsch, I. B.-E., & Parush, S. (2009, Sum 2009). Effectiveness of sensorimotor and task-oriented handwriting intervention in elementary school-aged students with handwriting difficulties. OTJR: Occupation, Participation and Health, 29(3), 125-134. https://doi.org/10.3928/15394492-20090611-05 Zwicker, J. G., & Hadwin, A. F. (2009, Win 2009). Cognitive versus multisensory approaches to handwriting intervention: A randomized controlled trial. OTJR: Occupation, Participation and Health, 29(1), 40-48. https://doi.org/10.3928/15394492-20090101-06 Appendix A *All interviews were conducted in person or over the phone. No recording device was used. Questions asked during interview 1 What is your mission statement? Do you agree that it aligns with your personal and professional goals? What is currently working well at this site? Who do you consider stakeholders for this organization? What assets does your organization bring stakeholders? What gaps do you see in your site? What aspects are not working well? What would you like to see improved? What goals do you feel you are not achieving and why? How do you think OT can support the stakeholders in this project to achieve their goals? Questions asked during interview 2 What ages do you see? Which ages are the most commonly seen? What are the most common diagnoses seen at the clinic? What is the average socioeconomic status of your clients? Do the children you treat usually come from nuclear families or more complex family units? Do you usually see clients weekly? Do they show up at the same day and time? Do you spend the same amount of time with each client? What are barriers and supports already in place within the clinic? What is your vision for a handwriting program? Do you have a specific program in mind? Would multiple children be seen at once? Would this be at the clinic and billed time? Would other therapists be involved? Etc… We discussed creating educational materials regarding OT. Who would you like this to target? Families? Physicians? Etc… You mentioned possibly finding a new assessment tool to observe fine motor deficits. Can you elaborate on your expectations of this task? What tools do you currently use? Appendix B Appendix C Table 1: Visual MOtor Percent agreement Item OT 1 OT 2 OT 3 OT 4 OT 5 % Agreement Mean Stdev 1 12 11 11 11 10 60 11 0.71 2 0 0 0 0 0 100 0 0 3 4 4 4 4 4 100 4 0 4 4 4 4 4 4 100 4 0 5 9 10 9 11 7 40 9.2 1.48 6 9 9 9 9 9 100 9 0 7 5 5 5 5 5 100 5 0 8 2 2 2 2 2 Provided answers N/A N/A Total 45 45 44 46 41 40 44.2 1.92 scaled score 8 8 7 8 7 60 7.6 0.55 Table 2: Visual MOtor Average error Item Mean observed Expected Average % error 1 11 10 10 2 0 0 0 3 4 4 0 4 4 4 0 5 9.2 9 2.2 6 9 9 0 7 5 5 0 8 N/A N/A Provided Answers Total 44.2 43 2.8 Scaled Score 7.6 7 8.57 Table 3: Fine motor percent agreement Item OT 1 OT 2 OT 3 OT 4 OT 5 % Agreement Mean stdev 1 11 11 11 11 11 100 11 0 2 14 14 14 12 13 60 13.4 0.89 3 11 11 11 11 11 100 11 0 4 9 9 9 9 9 100 9 0 5 21 21 21 21 21 100 21 0 6 6 6 6 6 6 Provided answers N/A N/A Total 72 72 72 70 71 60 71.4 0.89 Scaled score 8 8 8 8 8 100 8 0 Table 4: Fine motor average error Item Mean observed Expected Average % error 1 11 11 0 2 13.4 13 3.08 3 11 11 0 4 9 9 0 5 21 21 0 6 N/A N/A Total 71.4 71 0.56 Scaled score 8 8 0 Appendix D *Interview was conducted in person following a presentation on the development of the handwriting group. No recording device was used. Group Interview Questions: What aspects of this project seem most beneficial to you? How efficient do you perceive this program to be? Why? Do you view this group as sustainable, why or why not? How do you feel parents will respond to the group? Why? How have they responded to similar groups in the past? Do you feel as though having a specific curriculum/program is beneficial? Why or why not? What barriers do you still perceive in the implementation of this group?