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1. Knowledge Database
• Slide Presentation for the lecture of: Dido Green
Oxford Brookes University, UK
• Topic of lecture: Expectations for Therapy and Relationship to
Confidence and Competence and Intervention Outcomes for
Children with Unilateral Cerebral Palsy
• The lecture was given at Beit Issie Shapiro’s 6th International
Conference on Disabilities – Israel
• Year: 2015

2. HOPE
EXPECTATIONS FOR THERAPY AND RELATIONSHIP
TO CONFIDENCE AND COMPETENCE AND
INTERVENTION OUTCOMES FOR CHILDREN WITH
UNILATERAL CEREBRAL PALSY.
Dido Green
Unity and Diversity in Action
BIS 6th Conference, Tel Aviv 2015
With thanks to Sophie White, MSc
Student, Oxford Brookes Univ.
© Breathe Arts Health Research

3. “They won’t sit next
to me (at school) as
they don’t want to
catch my disease!”
“Games at school – they
always chose me last and
then the other side gloats
when they win.”
About new Friends
…” P (older boy)
because he’s grown
up and he’s OK”
I am a one handed
boy – I don’t want to
be associated with
‘them’.
What do the children say? Are we listening?

4. © Breathe Arts Health Research

5. • Psychosocial factors may influence development of movement
efficacy in children with UCP (Curtain & Clarke 2005,Gilmore etal
2010, Skold etal 2007, Green et al 2013),
• Up to 61% of children with UCP may have persistent mental health
problems affecting perceptions of confidence, competence and
positivity (Goodman & Graham 1996; Parkes et al 2008).
• Therapeutic outcomes from interventions for children with UCP are
influenced by children’s engagement which may be linked to
mastery motivation (Miller et al, 2014).
• Yet few studies investigate psychosocial factors
Background to current study

6. Aims and Objectives
A Mixed methods study to:
Explore the expectations and experiences of children
with UCP participating in an intensive 60 hour day-
camp using a magic-themed hand-arm bimanual
intensive therapy (Magic-HABIT).
Explore the perspectives of
children through
semi-structured interviews
© Breathe Arts Health Research

7. Intervention
• 2 week (60 hours) therapy camp for UCP
• Integrating magic tricks
and performing into
Occupational Therapy
and the Hand Arm
Bimanual Intensive
Therapy (HABIT)
protocol.
© Breathe Arts Health Research

8. Methodology
• Children participating in Magic camps
• Within-study
repeated measures
design.
• Assessments, pre,
post camp and 3-
month follow-up
© Breathe Arts Health Research

9. Outcome measures
• The Children’s Hope Scale (Snyder, 1997)
o Self report of positiveness and resilience
o 6 questions of goal achievement behaviours
• Jebsen Taylor Test of Hand Function
o timed test of grasp and release across 6 tasks.
• Children’s Hand Experience Questionnaire (CHEQ)
(Skold et al. 2011)
• Semi-Structured Interviews with children (&parents)

10. 29 activities children
commonly do in daily life
www.cheq.se Skold et al. 2011
Questions:
1) Are the activities performed independently?
2) Are one or two hands are used in the activities?
3) The experience of doing activities according to
• grip efficacy
• time taken in comparison to peers
• experience of feeling bothered
Negative 1----2----3----4 Positive

11. Sample characteristics
2011-2013 (White, 2014)
Sample
size
Age months
Mean (SD)
MACS
Mean (range)
MAS
Mean (range)
Behaviour Problems
Mild(opting out) to
significant (affecting
own + others
participation).
n=34 125.2 (32) 2.1 (1-3) 1.9 (0-4)
Mild n=10
Moderate n=3
Significant n=1
SD=standard deviation; MACS=Manual Ability Classification
System; MAS=Modified Ashworth Scale;

12. Results (White 2014)
Hand Skill
JTTHF
F(2,31) 8.11
p=0.001
eta2 0.344
 Changes in performance
400
420
440
460
480
500
520
540
560
1 2 3
TotalSpeedinSeconds
Independence
CHEQ
F(2,26) 23.27,
p<0.001 eta2
0.642
Positivity of
thinking HOPE*
F(2,32) 13.23,
p=0.001
*=Friedman
0
10
20
30
40
50
60
70
80
1 2 3
Percentage
22
23
24
25
1 2 3
MeanTotalScore

13. The effect of positivity on initial perceptions of
Competence and Feeling Bothered n=34 (White, 2014)
Correlations Pre
intervention
CHEQ
independent
CHEQ
grip
CHEQ
time taken
CHEQ
bothered JTTHF
Positivity (HOPE) .734 .084 .047 .186 .071
.001 .648 .799 .308 .674
34 34 34 34 39
Percentage of Independent Activities
HOPETotalScore
R² = 0.0391
15
17
19
21
23
25
27
29
31
33
35
0 20 40 60 80 100

14. The effect of positivity on changes in perceptions of
competence and worry n=34 (White, 2014)
Initial positivity to
% Change pre to
Follow up
CHEQ Grip
% change
Pre to FU
CHEQ Time
% Change
Pre to FU
CHEQ Bothered
% change Pre to
FU
CHEQ Independ
% Change Pre to
FU
Positivity (HOPE)
pre
.480 .491 .437 .685
.028 .015 .033 .007
R² = 0.2091
15
17
19
21
23
25
27
29
31
33
35
-60 -40 -20 0 20 40 60 80
HOPETotalScore
Percentage change in Feeling Bothered

15. Correlations between positivity and perceptions of
confidence & competence and hand skill (White, 2014)
HOPE
Post intervention hand skill
3 month FU CHEQ
Bothered
Post intervention
Positivity
-0.34 ns
0.049 ns
3 month FU positivity ns 0.484
ns 0.008
HOPETotalScore
Feeling Bothered at 3-mfu
R² = 0.1324
15
17
19
21
23
25
27
29
31
33
35
0 1 2 3 4 5

16. What do the children say?
 Experiences and self-identity
 Abilities – competitive or playful
 Friendships
 Therapy and exercises
 What does having a hemiplegia mean to them
 Positive or negative statements
 Expectations versus Experience*
 What were perceived benefits to the child?
 Capacity for change?
* (2013 &2014 camps were delivered by Breathe Arts
Health Research and the essence of feedback had been
moved to extrinsic and external rewards via Magicians)

17. What do the children say?
Experiences and self-identity
A bit weird, Because I didn’t know that
they had a hand like me. This is my first
time in the magic camp….. It felt a bit
funny. (….Because) …I feel like, umm fine
with my friends now. My new friends and
getting to know them … I’d sit with them
at lunch time and play with them and do
lots of magic tricks and have fun and all
that kind of stuff.

18. How do they feel about their
hemiplegia before?
Good and Bad.
 Pre camp
 Bit annoying a bit annoying, it doesn't do what I want it to do
all of the time. I want it to be exactly like this hand (showing)
 Annoying, I have to do them (exercises) every time and ,….
stretches and things and annoying. I have to go outside of the
class with 3 others every day. Annoying lasting for months. (too
much?) Yea four months ..12 months we have to do them of
months - very annoying (again animated). (every year?) Yea,
every year
 It is just a bit weird, kid of just weird: Um I don't, (pause) I
can't really, because, um I have the right because. The right
hand’s got all the goodness in it and all the strongness in it but
this hand hasn’t really thing in it because it’s kind of got a bit of
weak in it, it’s got weak stuff in it.

19. How do they feel about their
hemiplegia after?
 Post camp
 Umm I just ignore it. I don’t really feel bad about it. I don’t
really talk about anything from it. I don’t really think about
it unless I have to, I just ignore it. I think it’s just normal.
 It’s cool because you’re different and the things you do, to
actually make your hemiplegia easier, are actually really
fun. I like being different, so I like having hemiplegia,
because you’re different, you’re not the same. You’re
different in your own way*
 It’s a bit like hands, when you have one hand that is weaker
than the other, but then do a bit of practising and will get
better probably (so it will get better you think with practice)

20. Expectations versus Experience
I really liked this camp …..So like today
they were going to be a bit strict because
it was the magic camp that wanted you to
do your magic show that stuff that make
sure that you can do all the stuff that you
want and like do your magic tricks. Yeh so
you get better and the magic trick because
they want you to get it straight on so you
don’t fail the magic trick. So that you can
be a great magician!

21. Discussion
 The relationship between perceptions of confidence &
competence is complex.
 Higher initial positivity showed greater positive changes in
perceptions of competence and feeling less bothered by
difficulties.
 Children with lower initial degree of positivity still made
improvement in hand skill.
 Children report different experiences from those elicited in
questionnaire
 Consider whether expectations or perceptions of confidence
& competence may influence progress in movement skills

22. ‫אותנו‬ ‫דוחפת‬ ‫שאת‬ ‫לך‬ ‫תודה‬,
‫עלינו‬ ‫מוותרת‬ ‫לא‬ ‫שאת‬ ‫תודה‬
‫עלינו‬ ‫מרחמת‬ ‫לא‬ ‫שאת‬ ‫תודה‬
What are Clinically Meaningful Research Outcomes?
“It has been
fantastic and it
has helped me to
grip for the first
time…”
“My hand is feeling
much better now
and the hemiplegia
is coming away!”
‫את‬ ‫שהפכת‬ ‫תודה‬
‫ליכולת‬ ‫שלי‬ ‫הנכות‬

23. © Breathe Arts Health Research

24. Maya Weinstein,
Dr Mitchell Schertz,
Dr Shelly Shiran,
Vicky Myers,
Moran Artzi,
Becca Krom
Dr Lian Ben-Sira,
Dr Ronni Geva,
Dr Varda Gross-Tsur,
Dr. Aviva Fattal-Valevski
Dr. Dafna Ben Bashat,
Dr. Benni Hozmi
Dr Dana Roth
Sophie White
Prof Bert Steenbergen
Dr Maritije Jongsma
Amarlie Moore,
David Owen,
Richard McDougall,
Dr Will Houston,
Dr Verity McClelland,
Dr Gareth Barker,
Dr Geoff Charles-Edwards,
Prof Andrew Gordon

25. A BIG thank you to our funders, partners
and supporters…
Marnie Kimelman Trust

26. Dido.Green@brookes.ac.uk
For Films and more information on Breathe Magic
www.breatheahr.org

27. Curtin M, Clarke G. (2005) Living with impairment: learning from disabled young peoples’ biographies. British
Journal of Occupational Therapy. 68, 401-408.
Gilmore, R., Ziviani, J., Sakzewski, L., Shileds, N., & Boyd, R. (2010). A balancing act: children’s experience of
modified constraint-induced movement therapy. Developmental Neurorehabilitation.13(2), 88-94.
Goodman, R. and Graham, P. (1996) Psychiatric problems in children with hemiplegia: a cross sectional
epidermalogical study. British medical journal. 312, 1065-1069.
Green, D., Scherz, M., Gordon, A., Moore, A., Schejter- Margalit, T., Bashat, D., Weinstein, M., Lin, J-P. and
Fattal-Valevski, A. (2013) A multi-site study of functional outcomes following a themed approach to harnd-arm
bimanual intensive therapy for children with hemiplegia. Developmental medicine and child neurology. 55(6),
527-533.
Majnemer, A. Shevell, M. Law, M. Poulin, C. Rosenbaum, P. (2010) Level of motivation in mastering challenging
tasks in children with cerebral palsy. Developmental medicine and child neurology. 52(12): 1120-1126.
Parkes, J. White-Koning, M. Dickinson, H. Thyen, U. Arnaud, C. Beckung, E. Fauconnier, J. Marcelli, M.
Macmanus, V. Michelsen, S. Parkinson, K. Colver, A. (2008) Psychological problems in children with cerebral
palsy: a cross-sectional European study. Journal of child psychology and psychiatry. 49(4): 405-413.
Skold, A., Josephsson, S., Fitinghoff, H. and Elliasson, A. (2007) Experiences of use of the cerebral palsy
hemiplegic hand in young persons treated with upper extremity surgery. Journal of hand therapy. 20, 262-273.
Skold, A., Hermansson, L., Krumlinde-Sundholm, L. and Eliasson, A-C. (2011) Development and evidence of
validity for the children’s hand-use experience questionnaire (CHEQ).
Snyder, R. C., Hoza, B., Pelham, W., Rapoff, M., Ware, L., Danovsky, M., Highberger., Rubunstein, H. and Stahl, K.
(1997) The development and validation of the Children’s Hope Scale. Journal of Paediatric Psychology. 22(3),
349-421.
White, S. (2014) Perceptions of Confidence and Competence in children with unilateral Cerebral Palsy.
Unpublished MSc Thesis, Oxford Brookes University
References

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