Research in Developmental Disabilities 31 (2010) 87–96

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Research in Developmental Disabilities

Movement Assessment Battery for Children (M-ABC): Establishing construct validity for Israeli children Batya Engel-Yeger *, Sara Rosenblum, Naomi Josman Department of Occupational Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, Mount Carmel, Haifa 31905, Israel

A R T I C L E I N F O

A B S T R A C T

Article history: Received 4 August 2009 Accepted 5 August 2009

The Movement Assessment Battery for Children (M-ABC) is one of the most accepted tools, both in clinical practice and in research, for the diagnosis of Developmental Coordination Disorders (DCDs) in children. The present study aimed to: (1) establish the construct validity of M-ABC in Israel by comparing the motor performance of typically developed children in four age groups (ranging from 6 to 12 years) and (2) examine the impact of socio-demographic parameters on children’s motor performance. Participants were 249 typical children, between 4.1 and 12.08 years old, whose motor performance was evaluated by the M-ABC. The results showed that age, gender, mother’s education level, and socioeconomic status had an impact on children’s motor performance. Thus, the M-ABC may serve as a suitable tool for examining the motor performance of children in Israel. This examination should also refer to socio-demographic factors in order to shed light on the contribution of environmental disadvantages to children’s motor performance. ß 2009 Elsevier Ltd. All rights reserved.

Keywords: Developmental Coordination Disorder Children Movement Assessment Battery for Children

1. Introduction Skilled movement is a fundamental component of human life (Henderson & Sugden, 1992), allowing human beings to meet their basic needs, to communicate, and to learn (Summers, Larkin, & Dewey, 2008). The impact of motor competence on children’s lives in general, and on academic performance in particular, is gaining increasing recognition (Chow, Hsu, Henderson, Barnett, & Lo, 2006; Henderson & Sugden, 1992). Difficulty in movement, expressed as a marked impairment in the development of motor

* Corresponding author. Tel.: +972 4 8240816; fax: +972 4 8249753. E-mail address: [email protected] (B. Engel-Yeger). 0891-4222/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.ridd.2009.08.001

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coordination, is labeled as Developmental Coordination Disorder (DCD; American Psychiatric Association, 1994). Although DCD negatively affects the functional performance of daily motor activities or academic achievement, it is not the result of any medical condition or intellectual impairment (American Psychiatric Association, 2000). DCD is a significant problem for approximately 6– 13% of school-aged children (American Psychiatric Association, 1994; Kadesjo¨ & Gillberg, 1999) and is known to be more prevalent among boys (Cairney, Hay, Flouris, Mandigo, & Faught, 2005). One of the most commonly used tools for evaluating DCD in children is the Movement Assessment Battery for Children (M-ABC; Henderson & Sugden, 1992). The M-ABC was developed as a clinical and educational tool to provide an indication of motor functioning across a range of fine and gross motor tasks among children 4–12 years old. Although the M-ABC norms are based on samples of children from the USA, the tool is widely used in other countries as well. Therefore, it is important to evaluate its sensitivity to the level of motor performance in discriminating between various age groups, geographical areas, and cultural backgrounds. This perspective is in accordance with the International Classification of Functioning, Disability and Health (ICF) model, which emphasizes the need to refer to meaningful environmental and contextual factors that either hinder or facilitate children’s participation (Dunn, Brown, & McGuigan, 1994; Law, 2002; Newell, 1986). Previous studies have described how the impacts of DCD on the activities of daily living are moderated by the context in which these activities are performed, particularly country of residence and cultural background (Rodger et al., 2003; Summers et al., 2008). Moreover, studies examining the validity of the M-ABC norms in other countries suggest that these norms may need to be adjusted to different contexts (e.g., Chow, Henderson, & Barnett, 2001; Miyahara et al., 1998; Rosblad & Gard, 1998). The examination of environmental context should also take into account the fact that children’s motor development is known to be affected by various socio-demographic factors, such as age, gender, parents’ education level and socioeconomic status. Examining the relationship between these sociodemographic parameters and children’s motor performance is of utmost importance when examining the validity of a specific evaluation tool (Henderson & Sugden, 1992). When referring to age, it is well established that motor development undergoes continuous changes and that coordination improves dramatically throughout childhood due to a better integration of sensory and motor systems (Gallahue & Ozmun, 2002; Roncesvalles, Schmitz, Zedka, Assaiante, & Woollacott, 2005; Smits-Engelsman, Sugden, & Duysens, 2006; Smyth, Katamba, & Peacock, 2004). For example, balance, which is the ability to maintain a weight-bearing posture or to move through a sequence of postures (Burton & Davis, 1992), improves largely linearly from ages 2 to 18 (Demura, Kitabayashi, Noda, & Aoki, 2008; DeOreo, 1971, unpublished doctoral dissertation; Geuze, 2003). Manual dexterity typically develops during the period from birth through mid-primary school, progressing from a reliance on fingers to the use of ‘school tools,’ such as pencils and scissors, in order to manipulate and explore things during the early childhood years (Case-Smith & Shortridge, 1996; Edwards, Buckland, & McCoy-Powlen, 2002; Exner, 2001). Preschool children steadily gain increasing feelings of success about their motor activities (Kurtz, 2003; Liddle & Yorke, 2003; Smith, 2003) so that by the time school age is reached, most children possess a sufficient repertoire of skills for coping with the basic demands of both home and school environments (Henderson & Sugden, 1992). A debate exists in the literature regarding the impact of gender on children’s motor development and performance. In general, across three stages of development, boys have shown better motor performance than girls (e.g., Davies & Rose, 2000). According to the M-ABC manual, non-significant differences were found between boys and girls in motor performance, but boys in most age bands in the 4–12 age range showed better motor performance than their female peers, and at the age of 9 this difference approached significance (Henderson & Sugden, 1992). Some studies have claimed that gender differences in pre-pubescent school-aged children can be attributed more to social and environmental factors than to biological factors (Garcia, 1994; Thomas, Nelson, & Church, 1991). Thus, the impact of gender on children’s motor performance should receive further attention (Henderson & Sugden, 1992), especially in countries outside the USA (e.g., Chow et al., 2001; Miyahara et al., 1998). Familial socioeconomic status was also found to be a possible factor affecting motor performance. According to the M-ABC manual, the higher the family’s socioeconomic status (as estimated by mother’s education), the better the child’s performance on the M-ABC, though the relationship was not significant.

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The M-ABC is increasingly used in Israel, where there is a growing interest in children with DCD and where a relatively high percentage of children with DCD are referred to intervention programs, such as occupational therapy. Based on the above, the present study aimed to establish the construct validity of the M-ABC in Israel and to determine the relationship between motor performance and children’s sociodemographic factors as: age, gender, parents’ educational level, residence and socioeconomic status. 2. Materials and methods 2.1. Participants Participants were 249 typical children, between 4.1 and 12.08 years old (mean = 8.27  = 2.34), who were enrolled in regular kindergartens and mainstream public schools in Israel. The children were divided into four age groups: 4–6 years; 7–8 years; 9–10 years; and 11–12 years, according to the four age bands of the M-ABC. All children had IQ in normal range. Exclusion criteria were a known low IQ level of performance; neurological, developmental, or learning disabilities; and DCD (children who scored at the 15th percentile and under in the M-ABC). The 15th percentile cut-off on the M-ABC has been widely used for the assessment and identification of children in risk for having DCD (Rodger et al., 2003; Sugden, 2006), while performance below the 5th percentile is indicative of definite motor difficulties (Henderson & Sugden, 1992; Sugden, 2006). All this information was based on school records and on parent’s reports. As presented in Table 1, participants’ familial socioeconomic level ranged from low to high, according to parents’ reports of their mean income level per month. The level of income as low, average or high was determined according to the values published by the Israel Central Bureau of Statistics (2007). Parents’ education level ranged from non-academic (i.e., up to 12 years of education through high school) to academic (i.e., 15 years of education and above at university level). 2.2. Instruments Demographic questionnaire. This questionnaire was composed by the authors and included data on family socio-demographic status, child’s health status, medications, treatment, and other health care interventions, such as para medical therapies. Specifically, parents’ educational level was measured by two categories (academic and nonacademic), and the socioeconomic status was measured by three categories (low, middle and high) Table 1 Participants’ demographic data. General sample (%)

4–6 age band (%)

7–8 age band (%)

9–10 age band (%)

11–12 age band (%)

Residence

City Kibbutz Village Missing

55.4 9.6 24.5 10.4

47.4 14 9.3 29.1

44.7 17 38.3 0

62.3 1.6 34.4 1.6

69.1 5.5 25.5 0

Gender

Male Female

83.9 16.1

77.9 22.1

74.5 25.5

91.8 8.2

92.7 7.3

Father’s education level

Academic Non-academic Missing

43.4 34.5 22.1

33.7 22.1 44.2

40.4 34 25.5

39.3 59 1.6

25.5 67.3 7.3

Mother’s education level

Academic Non-academic Missing

41.4 36.9 21.7

40.7 15.1 44.2

59.6 14.9 25.5

41 59 0

27.3 65.5 7.3

Familial socioeconomic status

Low Middle High Missing

6.8 14.1 11.2 67.9

1.2 17.4 12.8 68.6

17 19.1 63.8

18 8.2 9.8 63.9

9.1 12.7 3.6 74.5

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according to the values published by the Israel Central Bureau of Statistics (2007). Residence was measured by three categories of the most frequent form of residence in Israel (city, kibbutz and village). Movement Assessment Battery for Children (M-ABC; Henderson & Sugden, 1992). The M-ABC was developed as a clinical and educational tool to provide an indication of motor functioning across a range of fine and gross motor tasks among children 4–12 years old. There are four age-related item sets, each consisting of eight items measuring manual dexterity, ball skills, and static and dynamic balance. Children can score between 0 and 5 on each item, so the total score will vary from 0 to 40. The total score can be transformed to a percentile score. According to the Dutch standardization of the MABC, the American norms are valid for the Dutch population (Smits-Engelsman, 1998). The M-ABC is found to have acceptable validity and reliability (Henderson & Sugden, 1992). 2.3. Procedure The study was approved by the institutional review board (IRB) of the University of Haifa, and all parents signed a consent form allowing their children to participate. The parents also completed the demographic questionnaire. The M-ABC was administered by occupational therapy research assistants to each child individually in a quiet room at the children’s schools. Data collection took about 30 min to complete with each child. 2.4. Data analysis MANOVA was performed to examine the significance of the differences in M-ABC scores between age bands and genders. Age X gender interaction was not examined because of the low number of girls in each age band. MANOVA was also used to examine the significance of the differences in all the MABC scores between children from different places of residence and between children of parents with different education levels. ANOVA was performed to examine the significance of the differences in the total M-ABC scores between age bands and different places of residence. T-tests were performed to examine the significance of the differences in the total M-ABC scores between both genders and between children of parents with different education levels. Spearman correlations were used to examine the significance of the correlations between the children’s socioeconomic status and their MABC scores. The level of significance was set at .05 for all statistical tests. 3. Results 3.1. Age bands A general difference was found between the age bands (F9,581) = 8.15, p  .0001. Table 2 depicts the significance of the differences between the age bands in regard to the M-ABC scores. A significant Table 2 Means and standard deviations of M-ABC scores in each age band and the significance of differences between age bands (lower score represents better motor performance). M-ABC

Mean Manual Dexterity Mean Ball Skills Mean Balance Total M-ABC SD = standard deviation. ** p .01. *** p .001.

Age band 1 (4–6 years) (n = 86)

Age band 2 (7–8 years) (n = 47)

Age band 3 (9–10 years) (n = 61)

Age band 4 (11–12 years) (n = 55)

Mean

SD

Mean

SD

Mean

SD

Mean

SD

.86 .64 .26 4.6

.76 .81 .46 2.82

1.16 .96 .17 5.94

.94 .91 .28 2.74

1.56 .38 .39 6.61

.72 .63 .38 2.25

.94 .45 .63 5.63

.71 .81 .65 2.78

F

10.28*** 5.44** 10.07*** 6.96***

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difference between age bands was reflected in the total M-ABC scores (F3,244) = 6.96, p  .0001). Scheffe post hoc revealed that the only significant difference was found between age band 4–6 and age band 9– 10, where the younger age band scored significantly better than the older one (mean difference = 2.01; p  .0001). As for the Manual Dexterity subscale, the 4–6 age band scored significantly better than the 9–10 age band (mean difference = .71, p  .0001), and the 9–10 age band scored significantly lower than the 11–12 age band (mean difference = .62, p = .001). In the Ball Skills subscale, the 7–8 age band scored significantly lower than the 9–10 age band (mean difference = .58, p = .02) as well as the 11–12 age band (mean difference = .51, p = .012). In the Balance subscale, the 4–6 age band scored significantly better than the 11–12 age band (mean difference = .37, p  .0001), but the difference was found only in static balance (mean difference = .84, p  .0001). The 7–8 age band scored significantly better than the 11–12 age band (mean difference = .46, p  .0001) in static balance (mean difference = .83, p = .002) and in dynamic balance (mean difference = .27, p = .046). It should be noted that when comparing the present sample to the American sample described in the M-ABC manual, Israeli children aged 9–10 performed significantly worse than their American peers (see Table 3). 3.2. Gender In comparing both genders, a general difference was found between the age bands (F3,241) = 8.08, p  .0001. Table 4 depicts the significance of the differences between the genders in regard to the M-ABC scores. As shown in Table 4, the boys performed significantly better than the girls in the Ball Skills

Table 3 Comparison of means and standard deviations of total impairment scores of standardization sample in America and in Israel, by gender and age. Age

American

Israeli

t

N

Mean

SD

N

Mean

SD

4 5 6 7 8 9 10 11 12

211 146 136 124 140 130 127 117 103

5.3 5.2 5.1 5.1 5.0 5.2 5.0 5.7 5.1

5.7 5.6 4.5 4.1 4.1 4.4 4.8 4.2 4.4

14 41 31 30 17 8 50 47 7

4.0 4.8 4.6 5.9 6.0 7.4 6.5 5.8 4.5

2.6 3.1 2.7 3.1 2.2 1.9 2.3 2.7 3.1

1.84 .87 .102 1.42 1.87 3.11* 4.56*** .24 1.75

SD = standard deviation. * p .05. *** p .001.

Table 4 Means and standard deviations of M-ABC scores in each gender and the significance of differences between genders (lower score represents better motor performance). M-ABC scores

Boys (n = 209) Mean

SD

Mean

SD

Mean Manual Dexterity Mean Ball Skills Mean Balance

1.14 .49 .38

.84 .77 .51

.91 1.11 .21

.73 .83 .38

SD = standard deviation. * p .05. *** p .001.

Girls (n = 40)

F

ES-h2

2.75 21.39*** 4.15*

.01 .08 .02

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subscale. However, the girls performed significantly better than the boys in the Balance subscale. No significant difference was found between the genders in the total M-ABC scores. The effect sizes were lower than 0.1. 3.3. Parent’s education level No significant difference was found between the children of mothers with an academic education and the children of mothers with a non-academic education in the total M-ABC scores. However, in the Balance subscale, the children of mothers with an academic education performed significantly better (mean = .31  .43) than the children of mothers with a non-academic education (mean = .45  .54) (F1,189 = 4.26, p = .04). No significant difference was found between the children of fathers with an academic education and the children of fathers with a non-academic education in the total M-ABC scores or in the scores of each subscale. 3.4. Residence Although significant differences were found between children from different places of residence on several items, no significant differences were found between these groups when referring to the total M-ABC scores or to the scores of each subscale. 3.5. Socioeconomic level A significant correlation was found between socioeconomic status and the Manual Dexterity subscale scores, as follows: The higher the socioeconomic status, the better the Manual Dexterity scores (r = .39, p  .0001). 4. Discussion The present study aimed to establish the construct validity of M-ABC among typically developed Israeli children and also to examine the relationship between children’s motor performance and sociodemographic parameters. This study focused on children 4–12 years old, an age range when most DCD cases are recognized and treated (Cermak, Gubbay, & Larkin, 2002; Miller, Polatajko, Missiuna, Mandich, & Macn, 2001; Missiuna, Rivard, & Bartlett, 2003). Moreover, in this age range, children’s gain of daily living skills to function independently is enhanced. Since DCD is known to have immediate adverse effects on children’s day-to-day functioning (both academic and daily living skills) and significantly impacts on academic, psycho-social and vocational outcomes (American Psychiatric Association, 2000), it is important to study the motor abilities of preschoolers as they develop throughout their school years. Studies such as this one may provide both practical and theoretical insights regarding the relationship between motor abilities, school readiness, academic achievement, and performance in ADL—insights that are significant for screening DCD among children with disabilities, as well as for children with typical development. Although there is no gold standard for the diagnosis of DCD (Crawford, Wilson, & Dewey, 2001), the M-ABC was chosen for this study since it is one of the most accepted tools, both in clinical practice and in research, for the diagnosis of DCD. 4.1. The relationship between motor performance and socio-demographic parameters 4.1.1. Age In the total impairment score, Israeli children 9–10 years old performed significantly worse than children from the American sample. It is not clear what cultural factors can account for this result. It may be speculated that the difference is attributable to the specific sample of participants in this age band. However, it should be noted that this finding is supported by the few studies examining the motor performance of Israeli children in relation to American norms, even in other age bands. These studies also found the performance of Israeli children to be lower than that delineated by American norms (e.g., Schneider, Parush, Katz, & Miller, 1995). Yet, in studies conducted in other geographical

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areas, better performance was exhibited in comparison to the American samples (Chow et al., 2001, 2006; Livesey, Coleman, & Piek, 2007). These contradictory results highlight the need to standardize or modify developmental tests within specific cultures before using them and point to the need for modifications to the M-ABC norms when used with children from different countries and cultural backgrounds. In the present study, the impact of age on motor performance was expressed in the Ball Skills subscale, in which the older age bands performed significantly better than the younger age band. However, surprisingly, opposite results were demonstrated in the Manual Dexterity and Balance subscales, in which the younger age band scored higher than the older age bands. This finding is opposite to those on which the standardization of the M-ABC was based, indicating that older children are more proficient on average than younger children. It may be suggested that in the specific sample of this study, the Balance and Manual Dexterity subscales were not sensitive to age effects. Rather, they may reveal cross-cultural differences between this sample and those on which the M-ABC norms were based, as found in previous reports (e.g., Chow et al., 2001; Miyahara et al., 1998; Rosblad & Gard, 1998). The results of the present study supports the report found in the M-ABC manual (page 202) according to which no age differences in total impairment scores are expected given the way in which the test is normed: the impairment scores in each age band are based on percentiles within that band. Further studies should be performed in Israel as well as in other countries in order to explore this issue in greater depth. Although the M-ABC refers to manual dexterity, ball skills, and balance abilities and notes specific performance norms for each age band, it does not provide normative data for these subscale scores. This issue creates a dilemma for therapists in their need to determine whether the scores received on the subscales are significant (Junaid & Fellowes, 2006). 4.1.2. Gender Although the initial standardization processes of M-ABC revealed no significant differences between boys and girls in motor performance, the present study found significant differences between genders in the Ball Skills and the Balance subscale scores. In regard to Ball Skills, the boys scored significantly higher than the girls, as in line with previous reports (Chow et al., 2006; Dunn & Watkinson, 1996; Fischman, Moore, & Steele, 1992; Junaid & Fellowes, 2006; Miyahara et al., 1998). In regard to the Balance subscale scores, the findings of the present study support those of Nolan, Grigorenko, and Thorstensson (2005), who examined gender and age differences in balance control among children aged 9–16. They also found that boys may lag behind somewhat in terms of developing postural control and recommended that the genders be evaluated separately when investigating balance in children. While some authors have suggested that separate norms be established for boys and girls (e.g., Larkin & Cermak, 2002), the lower effect sizes associated with gender differences reported in the present study as well as in other studies (e.g., Chow et al., 2006) indicate that the gender differences are not of great consequence. As Chow et al. (2006) noted, the M-ABC’s primary purpose is to identify children with impaired motor performance. To date, there is no reliable published evidence regarding the shape of the gender distributions at the critical, lower edge of motor performance (Cairney et al., 2005). 4.1.3. Parents’ education In the present study, children of mothers with an academic education performed significantly better in the Balance subscale than children of mothers with a non-academic education. Mother’s education level is known to positively affect a child’s performance and to predict the child’s school readiness (Ferguson, Jimerson, & Dalton, 2001; Ramey & Ramey, 1999). This study strengthens other reports according to which parents’ education was shown to be relevant in regard to motor performance (e.g., Ong, Boo, & Chandran, 2001). 4.1.4. Residence In the present study, no significant differences in M-ABC scores were found between children from rural areas and those from urban areas. The literature is controversial in regard to this issue. For

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example, Cappellini et al. (2008) found that children who grew up in an urban environment showed a delay in balance development as compared to children of the same age from rural areas. The authors suggested that such a delay may be regained by means of a targeted psychomotor education program. The M-ABC norms were based on a sample that consisted of both urban and rural areas, which may explain why children from both areas showed similar motor performance in the present study. 4.1.5. Socioeconomic status In the present study, children from higher socioeconomic status showed better performance in the Manual Dexterity subtest. Children’s motor performance has been previously correlated with environmental variables (Ratzon, Greenbaum, Dulitzky, & Ornoy, 2000). Parents from a higher socioeconomic level may be more aware of the importance of exposing their children to aftercurricular activities and a variety of games that focus on fine motor development, thereby increasing their school readiness. Indeed, socioeconomic status has been found to predict fine motor performance at school age (Piek, Dawson, Smith, & Gasson, 2008). This study has some limitations that should be considered in the interpretation of the results. First, we used a convenience sample without total matching between the number of children according to age, gender, and socioeconomic status in general or in each age band. Furthermore, some of the measures were generalized and not divided into several sub-levels (e.g., parents’ education level had only two sub-divisions: academic and non-academic). Therefore, the sample may not adequately represent the general population. Additional studies on more representative samples with a broader distribution of participants from different socioeconomic levels and a more detailed sub-division of socio-demographic factors should be conducted among typical children, as well as among children with DCD. The negative emotional and other developmental outcomes of DCD call for early screening and intervention in order to prevent the development of secondary academic, social, and emotional problems. The fact that DCD is often not identified until the child reaches school age stresses the need to screen children’s motor abilities in the preschool years. While the present study suggests that the M-ABC may serve as a suitable tool for examining children’s motor abilities, their scores in M-ABC subtests should be further examined, also by using the new version of the M-ABC (add ref) and in relation to children with DCD. Motor assessment should also refer to socio-demographic factors, such as gender and mother’s education, in research and in practice. This perspective may provide insight into the contribution of environmental disadvantages and the ways in which to promote children’s optimal functioning and participation at school and in daily living. Such an understanding will allow therapists to better meet children’s needs, maximize their involvement in treatment, and improve treatment efficacy. Acknowledgments Thanks are extended to the following Occupational Therapists: Ayelet Goffer, M.Sc., Jumana AsssyMarjieh M.Sc., Nirit Lifshitz, Ph.D., Amani Hanna Kasis M.Sc. and Daphna Weissman M.Sc., who helped with data collection. References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. American Psychiatric Association. (2000). DSM-IV-TR. Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: American Psychiatric Association. Burton, A. W., & Davis, W. E. (1992). Assessing balance in adapted physical education: Fundamental concepts and applications. Adapted Physical Activity Quarterly, 9, 14–46. Cairney, J., Hay, J., Flouris, A., Mandigo, J., & Faught, B. (2005). Developmental Coordination Disorder, self efficacy toward physical activity and play: Does gender matter? Adapted Physical Activity Quarterly, 22, 67–82. Cappellini, A. C., Mancini, S., Zuffellato, S., Bini, F., Polcaro, P., Conti, A. A., et al. (2008). Environmental effects on school age child psychomotricity. Minerva Pediatrica, 60, 277–284. Case-Smith, J., & Shortridge, S. D. (1996). The developmental process: Prenatal to adolescence. Occupational therapy for children, St. Louis, MO Mosby. pp. 46–66. Central Bureau of Statistics–Israel. (2007). Retrieved June 2007 from http://www1.cbs.gov.il/reader/cw_usr_view_Folder?ID=141.

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