The basic conceprs of a profession should be reAeered rhrough rhe

Occupation-Centered rem and measuremenrs used in irs pracrice. (Gillerre, 1991. p. 565)

Assessment of Children
I
n 1991, the Symposium on Measurement and As-
sessment: Directions for the Future in Occupational
Therapy was held in Chicago and sponsored jointly
by the American Occupational Therapy Foundation, the
Wendy Coster American Occupational Therapy Association (AOTA),
and the Center for Research and Measurement at the
University of Illinois at Chicago. This landmark meeting
Key Words: human activities and occupations
of occupational therapy researchers and scholars generat-
• pediatric occupational therapy • school based ed a series of articles and recommendations for future
occupational therapy directions in the field that were published in The Ameri-
can journaL of OccupationaL Therapy (Aj07) in March
and April of 1993. Collectively, these articles called for a
reexamination of the extent co which our assessmenr
processes and insuumenrs are, or are not, congruem with
the basic focus of our profession on occupation and our
philosophy of individualized and holistic intervention
The past 5 years have seen increasing caLLs to reexamine (Fisher & Shon-DeGraff, 1993).
our assessment and intervention practices to ensure that Trombly (1993), among others, arriculated a con-
they reflect the professions basic focus on occupation. cern that roo often our standard approach ro assessment
ALthough a number ofnoteworthy efforts in this direction
does not convey adequately ro our cliems either the im-
have been presentedfor aduLt practice areas, impLementa-
porrance or the relevance of what we do. She described
tion ofoccupation-centered assessment in pediatrics has
been hampered by the Lack ofa consistent framework to this typical approach as "bottom-up," meaning that the
guide this process. primary target of assessmeor is the level of discrete com-
This articLe wiLL present an adaptation ofthe func- poneor abilities that the therapist anticipates may be
tionaL assessment modeL proposed by TrombLy (1993) affected by the clieor's idenrifled condition. The poten-
designed to better reflect the unique needs and situations tial functional impact of these componenr deficits may
ofchiLdren. It is a muLtiLeveL modeL that examines the pat- be inferred but is often not assessed direcdy or in as great
tern ofa chiLd's occupations in a particuLar environment depth. As a consequence, the link between deficits in
as weLL as the perftrmance ofimportant tasks and activi- basic abilities and the functional problems the clienr
ties that are part ofthese occupations. It is proposed that
experiences in daily tife may never become clear to him
this modeL can serve as an organizing framework for an
or her, which, in rum, may raise doubts abom the mean-
occupation-centered assessment process by heLping to iden-
tifY the criticaL questions that need to be addressed at each ingfulness of the inrervenrion. As Mathiowetz (1993)
LeveL ofanaLysis and the kinds ofmemures that might be poinred out, a furrher problem is dlat the assumptions
used to obtain reLevant infOrmation. The newLy compLeted underlying This bottom-up approach to assessmenr and
SchooL Function Assessment wiLL be used to iLLustrate inrervenrion have been challenged strongly by recenr
appLication ofthe framework to examine occupationaL research, especially the expectation that normalizing per-
perfOrmance ofchiLdren in eLementary schoof. formance components will necessarily result in indepen-
dence in occupational performance.
The alternative recommended by the symposium
group is to adopt a top-down assessment process in
occupational therapy (Fisher & Shorr-DeGraff, 1993).
This top-down approach begins by gathering informa-
Wendy Coster, PhD, OTRJL, FAOTA, is Chair, Departmenr of
tion about what the person needs or wants to do, the
Occupational Therapy, Boston Universiry, Sargenr College of
Health and Rehabilitation Sciences, 635 Commonwealth
Avenue, Bosron, Massachusetts 02215. Author's Nore: ]n rhis paper, I use the rerm assessment ro refer ro rhe
process of informarion gathering ro better understand a given child.
This article was acceptedfor publication September 5, 1991. Wben a specific insuumem is being teferred ro, I use rhe term aJsess-
l'nen/ inJtrurnent, tl5.ieS.lrnent tool, or measure.

The American Journal ofOccupational Therap/ 337

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 context in which he or she typically engages in these val- distinction between the terms fimction and occupation.
ued occupations, and current limitations fulfilling these The term jUnction is often applied quite narrowly in reha-
personal expectations. This approach includes identifying bilitation so that it encompasses only the most basic daily
both the critical roles the person needs or wishes to fulfiJl actions or activities, for example, the standard set ofADL
and the particular tasks and contexts that define the ex- (eating, dressing, bathing, grooming, toileting) and sim-
pectations of these roles for that person. More discrete ple physical actions (reaching, sitting, standing, walking).
abilities (i.e., performance components) are assessed only Unfortunately, this narrow use of the term may mislead
to the extent that is needed to help clarify the possible some to believe that what is in reality only a cursory evalu-
sources of observed limitations in important daily tasks ation of the person's needs and occupational performance
and to help determine the most viable option for over- has addressed the demand for more "functional" evalua-
coming these functional limitations. tion Gette, 1995). Similarly, incorporation of a "real" ob-
It is argued that the top-down approach to informa- ject into an exercise program does not automatically make
tion gathering will result in improved communication the intervention more functional and more relevant for the
about the nature of occupational therapy as well as particular client's occupational performance (Nelson,
assessment results that better support truly occupation- 1988; Trombly 1995). Bits and pieces of function do not
centered intervention (Fisher & Short-DeGraff, 1993). make an occupation-centered assessment and intervention
However, the ability to implement this approach critical- process.
ly depends on the availability of assessment tools that are A broader perspective that recognizes not only the
congruent with an occupation focus, consider the person "doing" component denoted by function, but also the
in context, and are psychometrically sound. Several arti- social, symbolic, spiritual, and temporal elements encom-
cles in the two special issues of AjOT devoted to func- passed by occupation has been articulated in a number of
tional assessment examined assessment instruments and places in our literature (e.g., AOTA, 1995; Christiansen,
issues that pertain to adults (e.g., Law, 1993; Mathi- 1991; Clark et al., 1991). However, the instantiation of
owetz, 1993; Velozo, 1993). However, only two articles this framework in actual assessment practices and tools
directed their attention to children (Bundy, 1993; Miller has been slow. Adult clinical practice has a number of
& Roid, 1993), and none directly took up the unique examples of systematic efforts to develop new measures,
issues that pertain ro the assessment of children. For such as the Canadian Occupational Performance Measure
example, how should a client-centered approach be im- (Law et al., 1991), the Assessment of Motor and Process
plemented when the client of focus is a child? One meth- Skills (Fisher, 1993), the Occupational Performance His-
od is to take the family members or caregivers as the tory Interview (Kielhofner, Henry, & Whalens, 1989),
focus; however, at what age should the child himself or and discussions of the application of ethnographic (Spen-
herself begin to have some autonomy in defining needs cer, Krefting, & Mattingly, 1993) and narrative (Clark,
and goals, especially in a context such as school where the Ennevor, & Richardson, 1996) methods, for information
family is not present? As developing persons, children, far gathering and goal setting. To date, pediatrics has seen
more than adults, are measured against age-based expecta- few examples of or proposals for systematic occupation-
tions and standards. The impact of these assessments can centered assessment approaches (although see Madill,
be far ranging, from determining critical features of the Tirrul-Jones, & Magill-Evans, 1990). One reason for this
child's daily environment (e.g., school placement deci- discrepancy between adult and pediatric practice may be
sions) to eligibility for services such as occupational thera- that the methods proposed for client-centered assessment
py. Increasingly, occupational therapy services for children of adults are not readily applied with children. As noted
are provided in the context of school and, thus, are deter- earlier, children are often in environments where the stan-
mined by educational rather than medical policies. Is it dards are set by others, which leads to uncertainty about
possible to create assess men t tools that address these whether and how the child should be involved in the
unique features of pediatric practice while remaining true determination of his or her needs or goals. Traditionally,
to our professional focus on occupation? professionals have been reluctant to engage children in
As is clear from Trombly's (1993) discussion, imple- their own assessment, especially in domains of high
mentation of an occupation-centered assessment process importance, such as school. It is commonly believed that
requires more than adding on another instrument (e.g., children cannot reliably assess their own performance and
an activities of daily living [ADL] questionnaire) to an that their ability to identify and express their personal
existing battery. Shifting to occupation-centered assess- meanings and values may be limited.
ment requires adoption of a different framework altogether, The most important obstacle to changing assessment
one organized around our understanding of occupation. practices with children has been the dominance of the
This shift in framework also requires that we clarify the developmental model. Like the medical model, tradition-

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 al developmental models have been hierarchical and lin- lack of tools that are congruent with such a focus. In the
ear, emphasizing underlying performance components or absence of appropriate tools, therapists must rely on in-
abilities as the critical determinants of behavior. Thus, adequate measures designed for other purposes or on
underlying impairments (e.g., sensory processing deficits, untested measures of their own invention. Both the infor-
perceptual deficits, motor control deficits) are presumed mation-gathering process and effective communication
to explain the extent and form of functional difficulties among ourselves and with other professionals are hin-
seen in children with clinical disorders. The context, both dered in such a situation.
immediate and larger, and other characteristics of the per- To address these concerns, it is proposed that the
son, if considered at all, are typically viewed as moderators top-down model articulated by Trombly (1993) and by
of the effects of impairments but not as direer contribu- the symposium participants be used as a starting point for
tors to the observed behavior. This emphasis has support- building a pediarric assessment framework that can guide
ed a bottom-up approach to assessment that relies heavily the process of information gathering and the develop-
on developmental tests and an approach to intervention ment of new measures that support an occupation-cen-
that emphasizes normalizing the underlying processes as tered assessment process. The remainder of this article will
the best means to achieve greater function (Coster, 1995). illustrate how this proposal could be implemented. It will
Many of the same criticisms of bottom-up models in begin by describing a modified version of Trombly's
adult rehabilitation can, and have been, applied to pedi- model of occupational performance that was developed
atrics (e.g., Heriza, 199 I). More recent research and theo- with the special situation of children in mind. Then the
ry suggest that multiple factors simultaneously determine application of this framework to develop appropriate as-
the structure of behavior at a given moment in time sessment questions will be discussed. The School Function
(Fischer & Wozniak, 1993). In addition to component Assessment (Coster, Deeney, Haltiwanger, & Haley, 1998)
abilities, as well as other characteristics of the person (e.g., will be used to illustrate how the different assessment ques-
muscle strength, body proportions), features of the task; tions can be operationalized into scales that are psychome-
the emotional, social, and physical context; and personal tricaJly sound and preserve the essential focus on the child
goals have been identified as potential critical determi- in context. Direerions for future research and instrument
nants (Bronfenbrenner, 1992; Dunn, Brown, & McGui- development will also be suggested.
gan, 1994; Rogoff, 1990). Although they challenge the
traditional developmental model, these new views sup- An Occupation-Centered Top-Down Model for
porr an occupation-centered approach because they Children
emphasize the primacy of the task in the organization of a In the adult top-down model outlined by Trombly
person's behavior. (1993), assessment begins with an inquiry into the roles
Some areas of pediatric practice have shifted to a the person needs and wishes to perform and current abili-
broader perspective for assessment and intervention. Most ty to perform these roles to his or her own satisfaction.
notably, practice in early intervention has emphasized a This formulation is problematic for children for several
family-centered approach in which the family members' reasons. The most significant difficulty is the awkwardness
concerns are the starting point for defining needs and pri- of uying to fit the occupations of children into the defini-
orities (e.g., Meisels & Fenichel, 1996). Home-based in- tion of a roLe, that is, a culturally defined set of physical,
tervention may be more grounded in the typical family social, emotional, and cognitive expectations involving the
occupations, and writings in this area have emphasized performance of specified tasks. What role is the child ful-
the importance of embedding therapeutic aerivities in the filling when he or she is playing on the playground at
child's regular routines. Practice in school environments recess? Is this part of the same role he or she is fulfiJling in
has also confronted therapists with the need to consider the classroom or hallway? How would one define the
the context of the child both in trying to understand his expectations of these roles, and how would one assess
or her behavior and in designing meaningful interven- whether the child is performing the role successfuJly? The
tions (e.g., Clark & Miller, 1996; Griswold, 1994). The term appears to have little communicative usefulness in
federal regulations under which school-based services are these contexts.
provided mandate that these services be education related, An alternative approach to defining the most global
which requires that therapists identify the specific func- level of assessment concern is to focus on the child's over-
tional outcome their services for a child are designed to aJl pattern of occupational engagement in relation to a
help achieve (Giangreco, 1995). particular context of importance. A focus on the orches-
Despite these changes, pediatric practitioners are still tration of activities to improve or support quality of life
hampered by the lack of a consistent occupation-cen- was proposed by Frank (1996) in a discussion of the
tered framework to guide the assessment process and by a meaning of adaptation. If we apply this defillition to chil-

The American Journal ofOccupational Therapy 339

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 dren, we would focus our assessment on the extent to identified as a context of concern because of the child's
which a child is able to orchestrate engagement or partici- very limited participation in playground occupations.
pation in occupations in a given context that is positive Further assessment revealed that the child had greatest
(which, for a developing child, would often include growth difficulty with tasks that involved group interaction and
enhancing), personally satisfYing, and acceptable to the physical games. The next focus of assessment will be to
adults in society who are responsible for children (e.g., par- identify the key activity limitations: The source of diffi-
ents, teachers). For example, to what extent is the child culty may range from limited skills to initiate and sustain
able to select and carry out valued play and peer group peer interactions; to inability to remember and follow
activities during his or her free time on the playground! basic game rules; to physical difficulty, such as running or
This formulation acknowledges the importance of indi- kicking a ball; to limited endurance during sustained
vidual activities that are part of a particular occupation, as physical activity. The result of each of these activity limi-
well as of the context, but is most concerned with the tations may be limited participation in playground occu-
overall process of participation. pations, but the potential intervention avenues to support
Though the formulation is different, this definition more successful engagement may be quite different. Fur-
of the "top" or most global level of assessment shares thermore, consideration of activities in which the child is
many features with that described by Trombly (1993). In performing well may highlight areas of strength that can
particular, it suggests that what matters most is not indi- be tapped to help facilitate the desired changes.
vidual abilities and disabilities with regard to particular In turn, the pattern of activity limitations identified
tasks, but the extent to which the person is able to con- previously may also suggest underlying impairments that
struct a pattern of occupational engagement that meets are affecting the child's performance. The pattern may
individual needs and goals as well as societal expectations. suggest sensory processing difficulties, motor coordina-
Likewise, it is congruent with an approach to further tion difficulties, or emotional regulation difficulties. To
assessment that is directed at uncovering the obstacles devise the most effective intervention program, further
impeding successful occupational engagement and, thus, assessment may be needed to evaluate whether these im-
is individualized and oriented to problem solving. pairments are possible contributors to the limitations seen.
The next level in Trombly's (1993) top-down model In this case, the therapist may use the familiar standardized
focuses on identifYing the critical tasks that compose the tests already common in practice. The difference in the
client's key roles and on assessing whether performance present approach, however, is that these assessments would
difficulties with any of those tasks are impeding satisfYing be used to help determine how to intervene, not what the
role or occupational performance. Again, some modifica- goals of intervention will be. A child who has sensory
tions are needed to fit this model to children. Because defensiveness that is contributing to playground difficul-
participation or pattern of engagement replaced roles as ties will need an intervention that addresses, or at least
the key organizing concept in the previous level, the con- takes into account, this factor. However, the measure of
structs of this level need to be congruent with this revised successful outcome of intervention for this child is not
formulation. The focus on performance of critical tasks whether there has been a change in sensory processing,
still appears appropriate as a way to narrow down the focus but whether there is a change in his or her occupational
of assessment to specific aspects of occupational en- engagement to a pattern that is more personally satisfYing
gagement that pose difficulties for the child. Because many and more gtovvth supporting.
of children's environments have a defined set of task A summary of the modified tOp-down model is
expectations or possibilities, the tasks to be assessed could given in Table 1. Readers familiar with the disablement
be defined in relation to the expectations of the typical classifications proposed by the World Health Organiza-
child's environment. Thus, the assessment process may be tion (1980), National Center for Medical Rehabilitation
somewhat less individualized than with an adult, though Research (U.S. Department of Health and Human Ser-
it still takes into account the particular context. vices, 1993), and others (Coster & Haley, 1992) will note
The third assessment level seeks to identify the spe- the close parallel in the levels of analysis included in each
cific aspects of task performance, or activities, that are of these models. One important difference in the model
most limiting the person's engagement in important discussed here is that it is organized around the positive
occupations. Because a particular task may involve a vari- concept of occupational engagement of the individual
ety of activities, closer scrutiny of an area of iden tified child rather than concepts oflimitation. Despite these dif-
difficulty is needed to understand which particular activi- ferences in emphasis and language, many of the positive
ty limitations are having the greatest impact and, there- features of the disablement framework also apply to the
fore, should be targeted for intervention. To use an occupation framework, in particular, the clarification of
example for children, the playground may have been the different levels of analysis that need to be considered

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 Table 1
Conceptual Framework for Assessment
..J::evel of Analysis Disablement Term Assessmen:. Questi.':.'l . School Funcrion Assessment ScaJe
Participation Societal disadvantage To what extent is the child included Participation
in or restricted from panicipating in
the occupations rypicaJly expected of
or available to a child of this age and
culture'
Complex task petformance Disability To what extent is the child currently Task suppom:
meeting expectations for the perfor- Assistance
mance of imponant (complex) tasks Adap[a[ions
expected of his Ot her same age peers
in this culrure and context!
Aeriviry performance Functional limitations What are the child's current strengths Activiry performance
and limi[a[ions in performance of
specific activities required to accom-
plish [he major tasks expecred of or
desired by him or her'
Component processes Impoirments What is the Sta(Us (intactness, devel-
opment level) of the basic processes
or components necessary for the per-
formance of daily tasks and activities'
Note. Copyrighr 1997 by Wendy Cosrer. Printed with permission.

to understand the child's overall pattern of behavior to translate, or operationalize, the construe of interest
(McEwen & Shelden, 1995). into a measurement construct. How might adaptation, as
defined by pattern of occupational engagement (Frank,
Application of the Top-Down Approach to
1996), be translated into measutable terms? One possible
Developing Assessment Instruments
approach is to consider the context mat one is interested
The top-down model was proposed as a guide for the in and examine whether there are aspects of engagement
assessment process. Can it also help guide the develop. that might be used to gauge success in mis process. As we
ment of assessment instruments that are more suited to considered the context of elementary school for our as-
our purposes? Is it possible to construct standardized sessment, we selected social participation as our first mea-
assessment tools that maintain a focus on occupational surement construct and defined it as active engagement in
engagement? The issue is particularly critical for pediatric the typical activities available to and expected of peers in
occupational thetapists because pediatric practice is gov- the same context. We then identified six important envi-
erned by regulations and traditions that emphasize stan- ronments in which all elementary school children partici-
dardized assessment procedures. Thus, maintaining our pate: classroom, playground, transportation, transitions,
credibility in this practice arena may depend on use of cafeteria or eating area, and bathroom. Each environment
sound quantitative measures to document both the need (which we termed activity setting) was defined in terms of
for and outcomes of our services. Yet, as indicated earlier, the important tasks (i.e., physical, cognitive, social) that
to date we have not seen many standardized assessment are typically expected in the setting. For example, partici-
tools that are grounded in, and communicate to others, pation in transitions involves tasks such as moving from
our focus on occupation. One might conclude that the one area of the school to another and following school
absence of suitable assessment tools reflects a fundamen- rules regarding bOth movement and Other behavior. Parti-
tal difference between the focus and philosophy of occu- cipation on the playground involves a different set of tasks,
pational therapy and the demands of standardized tests. such as playing games and communicating with peers.
However, almough no standardized test may be able to The choice of participation reflects the focus of the
reflect the full richness of a child's occupational being, I tOp level of the assessment model on the child's overall
believe that we can go much farther than we have to cap- patrern of occupations. It is also congruent with the lan-
ture and communicate an occupation perspective in our guage and intent of the Individuals With Disabilities Edu-
assessment tools. In this next section, I will describe the cation Act of 1990 (IDEA; Public Law 101--476) under
approach taken during the development of the School which school-based therapists provide services. One of the
Function Assessment (Coster et aI., 1998) to illustrate goals of IDEA is securing the opportunity for children
how we might proceed and to suggest other avenues for with disabilities to participate in education in the least
future work. restrictive environment. We believed that once both the
To develop a standardized assessment tool, one needs meaning and the context of reference were defined clearly,

The American Journal ofOccupational Therapy 341

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 participation could be rated reliably by persons who have tasks to be included for the School Function Assessment,
observed the child frequently. we examined school curricula and other literature to iden-
Assigning numbers to children's participation to gen- tify the most consistenr expectations for elementary school
erate a score is only meaningful if the numbers retain children. For example, in all typical elementary schools,
some clear connection with the different patterns of chil- children need to move from one place to another, need to
dren's behavior. To do so, we designed a six-point scale care for basic physical needs, need to participate in group
whose rating points each reflect a different pattern of lessons and other peer group activities, need to be able to
engagement from complete lack of active engagement follow school routines and rules, and need some way to
(e.g., a child who cannot access the setting at al!), to en- communicate what they have learned. Difficulty with any
gagement that depends on the suPPOrt of constant super- of these tasks might affect the child's participation in
vision or guidance, to engagement comparable to same school life, and, thus, they were appropriate candidates
age-same grade peers. for inclusion in the test. Obviously, in another context,
A child's pattern of engagement in a critical environ- such as the home, a different set of essential tasks might
ment such as school can be considered from at least two be identified.
levels of analysis. The first just described looks at the pat- At the point where scores must be devised for task
tern in a specific environment, such as the playground, performance, one is confronted again with how to assign
the classroom, or during transitions from one area of the numbers to children's behavior in a meaningful (i.e., help-
school to another. The other important pattern emerges ful) way. Many existing scales do not support an occupa-
as one looks across these different ratings to identify areas tional therapy perspective that recognizes and values diver-
of greater or lesser participation. Questions may arise such sity of methods, including supported performance. For
as: Why is this child participating so little on the play- example, on the Scales of Independent Behavior-Revised
ground when he or she is more engaged elsewhere? What (Bruininks, Woodcock, Weatherman, & Hill, 1996), a
accounts for this discrepancy? Does he or she want to be child cannot obtain a score above 0 for a task if he or she
more a pan of peer activities, or does he or she like some requires any degree of physical help from another person.
time to be on his or her own? Sometimes the critical issues Rating scales like these also do not acknowledge the ex-
highlighted by a review of the child's participation are not tent to which children's activities are routinely supported
the ones that prompted the referral but may turn out to by adult involvemenr (Rogoff, 1990). This kind of scor-
be those most in need of consideration. In this way, use of ing system will be insensitive to the achievements of chil-
the School Function Assessmenr articulates an occupation
dren who may make importanr gains in their ability to do
perspective for the child's educational team and helps
a task interdependently with others but may never per-
keep the focus on the whole child (Florey, 1996).
form without some assistance.
There may be other ways that this first level of the
What are some alternatives for measuring task perfor-
top-down model can be operationalized. One would like
mance? We chose to measure the supports (assistance and
some way to obtain the children's own perspective on
adaptations) needed by the child to perform each major
their occupations in school, especially with older students.
task. We reasoned that this approach would encourage
Perhaps a combination of self-assessment and assessment
consideration of the important contextual factors that sup-
by others could be used. Discrepancies between the two
port children's occupational engagement. Furthermore, a
perspectives could serve as the starting place for further
collaborative assessment and problem solving. Contexts reduction in inrensity of supports (which would parallel
other than school may require a different measurement the child's increasing capacity for autonomous engage-
construct or approach to assessment. How might we ob- ment) is a meaningful outcome for services in the school
tain a measure of the child's pattern of engagement in the setting. In other environments, other types of ratings might
occupations of his or her community? A time-use record be appropriate. For example, in the home environment, the
is one relatively simple way that has been used to record extent to which a child can complete necessary daily tasks
the impact of disability on children's free-time pursuits with socially acceptable quality within reasonable time
(Brown & Gordon, 1987). However, differences in time limits may be relevant. In the play environment of home,
use may reflect personal choices and preferences as well as the extent to which the child can initiate and sustain a
limited opportunities. How else might we obtain a more variety of personaUy satisfying play activities may be a rele-
individual portrait of occupational engagement? vant focus for measurement.
The second assessment level is that of tasks. As noted The third level of the assessment framework is activity
earlier, children's tasks are often dictated by others, depend- perfOrmance. This level moves beyond global consideration
ing on the particular environment, and this is certainly the of task performance to idenrify which of the variety of
case in elementary school. Thus, to identify the essential activities in that task area can be completed satisfactorily

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 and which may be limiting successful task accomplish- planning.
ment. As was true with the previous levels, to design an The fourth level, that of component processes, is already
assessment instrument for this level, one must specifY the addressed by many of the currently available standardized
context because the context determines not only which ac- tests, including developmental tests and tests of compo-
tivities are likely to be expected or desired, but also what nent performance ability, such as the Bruininks-Oseretsky
features of the context are likely to affect the form and (Bruininks, 1978), the Peabody Developmental Motor
ptocess of the activity. For example, carrying a tray of food Scales and Activity Cards (Folio & Fewell, 1982), and the
from a counter to a table may be a necessary activity for Sensory Integration and Praxis Tests (Ayres, 1989). How-
eating in the school cafeteria but is unlikely to be part of ever, there is a pressing need for more research that tests the
eating at home. Thus, for the School Function Assessment, many assumptions in our lirerature about links between
we needed to identifY the essential activities that occur underlying performance abilities measured by these tests
during a school day in most elementary schools. Devel- and occupational performance (Jette, 1995; Trombly,
opment of a similar assessment instrument for community 1995). This important research agenda will be difficult to
participation would require identification of the essential implement until we have more occupation-centered mea-
activities that a child typically performs when in the com- sures suitable for such purposes.
munity.
Looking to the Future
As Florey (1989, 1996) eloquently pointed out on
several occasions, our professional philosophy is clear that, The top-down model offers a valuable guide for future
as occupational therapists, we should be concerned with work in pediatric assessment. It provides a structure to
the full range of a child's daily activities and with alJ of help articulate assessment questions that are more congru-
their various demands. Nevertheless, our texts and assess- ent with our focus on occupation and helps to clarify the
ment tools have often fallen short of this ideal by includ- different levels of analysis that need to be considered as we
ing only selected areas of performance. Sensory, physical, try to understand a child's overall pattern of engagement
cognitive, and basic ADL functioning have received far in occupations. Instruments framed in these terms help
more attention than the social and emotional aspects of a communicate the occupational therapy perspective to the
child's daily life. We cannot implement an occupation- children, family members, and other professionals we
centered assessment unless our tools and approach recog- work with and help identify the areas of a child's life where
nize, as Florey (1996) stated, that children have '''play- our services could make a meaningful contribution.
mate disorders' ... 'best friend disorders,' 'no one to eat Future work will require close creative collaboration
lunch with disorders'" (p. 428). The need for attention to between clinicians and researchers. The conceptual frame-
social and emotional aspects of occupation among chil- work of the School Function Assessment was transformed
dren with disabilities is reiterated in the literature (Hirst, into the final version of the instrument through the ef-
1989; Resnick, 1984). It is part of our professional role to fortS of hundreds of clinicians and educators who volun-
identify, try to understand, and assist with these difficul- teered their time to provide feedback about the content,
ties; thus, we took care to address psychosocial concerns rating scales, and practical applications of the instrument;
when constructing the School Function Assessment. to educate the project staff about constraints on assess-
To develop standardized measures at the activity level, ment time and activities imposed by their school systems;
we also had to find meaningful ways to assign numbers to and to assess more than 700 children with disabilities to
patterns of performance. For the School Function Assess- test the instrument's quality. This kind of linkage will
ment, we constructed a rating scale whose wording em- continue to be critical in ordet to develop assessment
phasizes the extent of the child's own contribution to the practices and instruments that are not only good in con-
performance of the activity (rather than the extent of his cept, but also meaningful in practice...
or her limitation). Each rating point represents an incre-
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