AOTA’S EVIDENCE EXCHAGE
CRITICALLY APPRAISED PAPER (CAP) WORKSHEET
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CITATION AND DOI NUMBER
Golos, A., Sarid, M., Weill, M., & Weintraub, N. (2011). Efficacy of an Early Intervention
Program for At-Risk Preschool Boys: A Two-Group Control Study. American Journal of
Occupational Therapy, 65(4), 400-408. doi:10.5014/ajot.2011.000455
DOI Number:
CLINICAL BOTTOM LINE
Briefly discuss how the evidence can be used to inform and guide occupational therapy practice (i.e.,
within the scope of traditional or emerging practice) AND how practitioners can use the evidence
relative to the target population and practice setting. Implications need to be reported in consideration
of the strength of the evidence (i.e., type of study design, level of evidence, identified study limitations,
internal validity rating, to what population results may generalize).
A multidisciplinary and multi-model intervention involving a two group control study
was used to target improvement in the performance skills and participation of pre-
schoolers in the classroom environment. The reasoning behind using a multi-model
intervention is that it would enable OTs to confront the variety of difficulties that children
may have. Also, the goal in this study was to improve participation not daily activities, not
only a specific skill. Since daily activities encompass an integration of many different
skills, the complex nature of this study requires multidisciplinary intervention. The
evidence shows that after intervention, there was a decrease in the percentage of children
at risk or with delays across most of the performing skills including manual dexterity
from pretest to posttest. Similar trends were apparent for preschool participation. This
evidence may prove to be useful for the preschooler with delays such as 48 month old
Brynn because it may be beneficial to create improvement in engaged participation in the
classroom and well as enhance specific performance skills involving manual dexterity.
RESEARCH OBJECTIVE(S)
To evaluate the efficiency of a multidisciplinary and multi model early intervention
program in improving children's performance skills and participation in preschool
activities. The questions that were raised were specifically if preschool boys who were
identified as at risk for or having delays significantly improve in their performance of and
participation in daily activities after intervention. As well as if the performance of these
children would be significantly better than those children in a control group.
DESIGN TYPE AND LEVEL OF EVIDENCE
Randomized control trial, level one. A pretest-posttest, two-group control study design was
used. The study took place in two IOU
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educational settings. The children in both settings were from the same cultural and SES
background. A combination of intervention models were used including modelling (to address
the children's unique difficulties) and collaborative consultation (to facilitate the transfer of
newly learned skills to the classroom).
PARTICIPANT SELECTION
How were participants recruited and selected to participate?
Participants were selected from two IUO educational settings in the same city. The two
settings were randomly assigned to an intervention or control group. In each setting, all
preschool boys participated with the exception of those who received OT in the
community during the study period and those who have not been granted permission from
their parents.
Inclusion criteria:
Children identified as at risk in the following areas: visual-motor integration as indicated
in the VMI subscale for inclusion into the graphomotor monitoring group; manual
dexterity, ball, and balance skills as indicated by the M-ABC for inclusion into the
manual dexterity and gross motor monitoring groups. In order to identify preschool
children with mild to moderate developmental delays, a screening instrument called the
Miller Assessment for Preschoolers was used. This study included two of the five
subscales: complex tasks and nonverbal abilities, which served as the criteria for inclusion
into the cognitive monitoring group. The structured preschool observation (SPO) was
used to evaluate performance and participation in different areas of daily activities in the
preschool setting.
Exclusion criteria:
Exclusion from the intervention group consisted of being a typically developing child who
performed as expected or above their age group
PARTICIPANT CHARACTERISTICS
N= 81
#/ % Male: 81 #/ % Female: 0
Ethnicity: Ultra Orthodox Jews
Disease/disability diagnosis: At risk for or having developmental delays
INTERVENTION AND CONTROL GROUPS (Add groups if necessary)
Group 1:
Brief description of the Using the monitoring model, small-group intervention (three to five
intervention children) was provided to children who were at risk or with delays in
four areas: manual dexterity, gross motor skills,
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graphomotor skills, and cognitive skills. Separate protocols were
developed for each of the four monitoring groups in the study group.
Each protocol included ten to twelve sessions, and groups met for 30
min/wk. These children also participated in the general collaborative
model which was exposed to the entire class, including typically
developing children in their class
How many participants 27 preschool boys
in the group?
Where did the Two IUO educational settings
intervention take place?
Who delivered? Developmental aid who was trained by a pediatric OT. Bimonthly
collaborative consultation sessions took place between the teacher
and OT where intervention goals were created and intervention was
planned out in coordination with the activities practiced in the
monitoring groups. The therapist modeled application of the
intervention program, and the teacher continued the program during
the week.
How often? 30 minutes a week
For how long? 8 months ( between Nov. and Jun. of the school year)
Group 2:
Brief description of the A control group that consist of typically developing children that
intervention were exposed only to the collaborative consultation model
How many participants 54 boys
in the group?
Where did the In the school setting
intervention take place?
Who delivered? Pediatric OT and school teacher
How often?
For how long? 8 months
Group 3:
Brief description of the A control group consisted of children who are at risk of or with
intervention delays who would have been included in specific monitoring groups
if they had been in the intervention group
How many participants 49 boys
in the group?
Where did the N/A because they did not receive intervention
intervention take place?
Who delivered? N/A
N/A
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How often?
For how long? N/A
INTERVENTION BIASES (Check yes or no, and include a brief explanation)
Contamination:
YES ☐ Explanation:
NO ☐ No mention of contamination in the section talking about limitations. Control
group has not accidentally received intervention.
Co-intervention:
YES ☐ Explanation:
NO ☐ Children receiving other forms of intervention such as OT at the community
center were excluded from the study.
Timing of intervention:
YES ☐ Explanation:
NO ☐ Improvements seen with the preschoolers overall and especially the
intervention group over the eight months may partially be due to maturation.
Site of intervention:
YES ☐ Explanation:
NO ☐ Intervention was provided in a school setting, specifically in classrooms with
the hope that the intervention performed in this setting would facilitate the
transfer of new skills into the classroom.
Use of different therapists to provide intervention:
YES ☐ Explanation:
NO ☐ It is not clear if the same or different OTs worked with both the control and
intervention groups. However, it was stated that OTs modeled application of
the intervention program and that the teachers or aides would continue the
program during the week.
Baseline equality:
YES ☐ Explanation:
NO ☐ Between the control and intervention group there were differences in pretest
measure scores. Overall, the intervention group had scores that placed them
at greater risk of or with delays compared to the control group. Also, in the
intervention group 85.2% of children were at risk of or with delays. In the
control group, that figure was 68.5%.
MEASURES AND OUTCOMES (Report only on measures relevant to occupational therapy
practice)
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Measure 1:
Name/type of Developmental test of visual- motor integration
measure used:
What outcome is Visual-motor integration in children between ages 2-18 (copying
measured? geometric shapes of increasing difficulty).
Is the measure YES ☐ NO ☐ Not Reported ☐
reliable (as reported
in the article)?
Is the measure valid YES ☐ NO ☐ Not Reported ☐
(as reported in the
article)?
When is the When identifying children at risk in this specific area both pretest and
measure used? postest
Measure 2:
Name/type of Movement Assessment Battery for Children
measure used:
What outcome is Evaluates manual dexterity, ball, and balance skills
measured?
Is the measure YES ☐ NO ☐ Not Reported ☐
reliable as reported
in the article?
Is the measure valid YES ☐ NO ☐ Not Reported ☐
as reported in the
article?
When is the When identifying children at risk in this specific area both pretest and
measure used? posttest.
Measure 3:
Name/type of Millers Assessment for Preschoolers
measure used:
What outcome is Used to identify preschool children with mild to moderate developmental
measured? delays. The study incorporated 2 of the 5 subscales used in this measure:
complex tasks and nonverbal abilities.
Is the measure YES ☐ NO ☐ Not Reported ☐
reliable as reported
in the article?
Is the measure valid YES ☐ NO ☐ Not Reported ☐
as reported in the
article?
When is the When identifying children at risk in this specific area both pretest and
measure used? posttest.
MEASUREMENT BIASES (Check yes or no, and include a brief explanation)
Were the evaluators blind to treatment status?
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YES ☐ Explanation:
NO ☐ Evaluators were blind to treatment status. A pediatric OT who was not
involved in pretesting developed separate protocols for each of the four
monitoring groups in the study group.
Was there recall or memory bias?
YES ☐ Explanation:
NO ☐ No indication of recall or memory bias was mentioned.
Other measurement biases: (List and explain)
RESULTS
List key findings based on study objectives:
Results showed that the intervention group scored significantly higher that the control group in
terms of graphomotor and cognitive skills. There were no significant difference between the two
groups in the other skills. Among all the children that participated in at least one monitoring
group, the intervention group scored significantly higher than the control group in participation.
Was this study adequately powered (large enough to show a difference)? (Check yes or no, and
include a brief explanation)
YES ☐ Explanation:
NO ☐ Improvement in all performance skills of the children at risk for or with
delays was better in the intervention group than in the control group.
However, the difference was only significant in relation to the balance
subscale. This fact might be because the groups were too small to reach
significance.
Were the analysis methods appropriate? (Check yes or no, and include a brief explanation)
YES ☐ Explanation:
NO ☐ The analysis methods were appropriate for this study. Analysis as performed
using SPSS Version 15. For each outcome measure, a difference mean score
was calculated. When comparing the intervention and control groups, a
separate one way analysis of variance for each measure was performed,
except for MAP.
Were statistics appropriately reported (in written or table format)? (Check yes or no, and include
a brief explanation)
YES ☐ Explanation:
NO ☐ Statistics were reported in both written and table format.
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Was participant dropout less than 20% in total sample and balanced between groups? (Check
yes or no, and include a brief explanation)
YES ☐ Explanation:
NO ☐ No dropout
What are the overall study limitations?
The study focused on children from one IUO community that have unique cultural
characteristics. Further studies must be performed and proven to be effective in other cultures.
Also, long term effects of the intervention were not evaluated in this study. Another limitation is
that parents were not involved as a part of the intervention program.
CONCLUSIONS
State the authors’ conclusions related to the research objectives.
Intervention programs administered in the educational setting for preschool children at risk for
or with developmental delays as a result of environmental deprivation or cultural beliefs may be
effective in improving their performance and participation in preschool daily activities.
CAP AUTHOR INFORMATION
List full name(s) of all participants (i.e., students, faculty advisor) and credentials.
Anat Golos, MSc, OT, Miri Sarid PhD, Michal Weill MD, Naomi Weintraub PhD, OTR
CAP Worksheet adapted from “Critical Review Form--Quantitative Studies.” Copyright 1998, by M. Law, D. Stewart, N. Pollack, L.
Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission.
For personal or educational use only. All other uses require permission from AOTA.
Contact: www.copyright.com
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