Florence Clark, Ph.D., OTR/L, FAOTA

Professor, Associate Dean and Division Chair of Occupational Science and Occupational Therapy

Room: CHP 133
Phone: (323) 442-2875
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Biography

Dr. Florence Clark is a widely published and noted scholar. She earned her BA in English and Drama at SUNY Albany, her MS in OT from SUNY Buffalo, and her PhD in Education from USC, and she was awarded an honorary doctorate from the University of Indianapolis. Her PhD focus was in the area of psychometrics. Appointed as a charter member of the Academy of Research of the American Occupational Therapy Association, she has served as special consultant to the US Army Surgeon General, been on the board of the National Center for Medical Rehabilitation Research and been the recipient of an Eleanor Clarke Slagle Lectureship, the highest academic honor of the American Occupational Therapy Association. In 1999, the American Occupational Therapy Association honored her with its Award of Merit and in 2001 she received a lifetime achievement award from the Occupational Therapy Association of California. In 2004, she received the Presidential Medallion from the president of the University of Southern California, the ultimate honor for those who have brought honor and distinction to the university. She is currently President-Elect of the American Occupational Therapy Association (AOTA) and in July 2010 will begin her term as President.

Research Interests

Pressure Ulcer Prevention Study; Well Elderly Study; Active Research; Recent Research
Since 1985, Dr. Florence Clark has attracted more than $10 million in extramural funding from NIH, NIDRR, and other federal agencies for research and training in the areas of healthy aging and the secondary conditions that impede the flourishing of people with disabilities in their real life circumstances. Dr. Clark’s research programs in healthy aging and in the prevention of pressure ulcers in persons with spinal cord injury have followed a blueprint for translational research which she first developed with colleagues in connection with the USC Well Elderly Study. Initiated in 1993, the Well Elderly Study (RO1 AG11810) was a randomized clinical trial which demonstrated that preventative occupational therapy forestalls the declines associated with aging and improves the health of independently living elders. In the translational research blueprint, qualitative research is employed first to systematically identify the needs and concerns of consumers. This information is translated into an intervention approach, which is then tested by launching randomized clinical trials to ascertain efficacy, effectiveness, and cost-effectiveness of the intervention. In 2004, Dr. Clark received a second large research award (RO1 AG11810) to conceptually replicate the original Well Elderly results and document the mediating mechanisms responsible for the intervention’s positive effects. In 2003, Dr. Clark, in collaboration with colleagues from Rancho Los Amigos National Rehabilitation Center, received a NIDRR field-initiated research grant to identify the contextual factors that led to recurrent pressure ulcers in people with spinal cord injury. At the end of the study, the following products were produced: a rehabilitation professional’s manual and companion manual, an online consumer manual (www.usc.edu/pups) and a manualized intervention. This study completed the first step in the application of the blueprint to a specific life-threatening problem for people with spinal cord injury. In continuing this research program, in 2008 Dr. Clark received a $3.6 million NIH-funded grant (1RO1 HD056267-01A1) to conduct a randomized clinical trial of the efficacy and cost-effectiveness of the intervention and products that were developed through NIDRR funding. Clark's specific research expertise is in the use of qualitative research methods to build interventions and in randomized clinical trial (efficacy, effectiveness, cost-effectiveness) methodology.

Education

Doctor of Philosophy (Ph D) in Educational Psychology
University of Southern California
1982

Master of Science (MS) in Occupational Therapy
SUNY - Buffalo State College
1970

Bachelor of Arts (BA) in English
SUNY - University Center at Albany
1968

Publications

Books

Mandel, D., Jackson, J. M., & Clark, F. A. (1999). Lifestyle Redesign: Implementing the Well Elderly Program. Bethesda, MD: American Occupational Therapy Association.

Zemke, R., & Clark, F. A. (1996). Occupational science: The evolving discipline. Philadelphia, PA: F. A. Davis.

Book Chapters

Clark, F. A., & Lawlor, M. C. (2008). The making and mattering of occupational science. In E. Crepeau, E. Cohn, & B. Schell (Eds.), Willard & Spackman’s occupational therapy (11th ed.). Philadelphia, PA: J. P. Lippincott Co.

Clark, F. A. (2005). Occupation embedded in a real life: Interweaving occupational science and occupational therapy. In R. Padilla (Ed.), A professional legacy: The Eleanor Clarke Slagle lectures in occupational therapy, 1955-2004 ( 2nd ed.). Bethesda, MD: AOTA Press. Abstract →← Abstract

This lecture presents an example of research in the genre of interpretive occupational science and demonstrates how occupational science can inform clinical practice. The innovative qualitative methodology used blended elements of the anthropological tradition of life history ethnography, ethnomethodology, the naturalistic methods used by Mattingly and Schön to study practice, and especially narrative analysis as described by Polkinghorne. The bulk of the paper is presented in the form of a narrative analysis that provides an account of a stroke survivor's personal struggle for recovery, a story that emerged from transcription, coding, and analysis of transcripts from approximately 20 hours of interview time. First, this narrative analysis provides an example of how the occupational science framework can evoke a particular kind of storytelling in which childhood occupation can be related to adult character. Storytelling of this kind is later shown to be therapeutic for the stroke survivor. Next, the narrative illustrates how rehabilitation can be experienced by the survivor as a rite of passage in which a person is moved to disability status and then abandoned. Finally, a picture is given of how occupational story making and occupational storytelling embedded in real life can nurture the human spirit to act and can become the core of clinical practice.

Clark, F. A., Jackson, J. M., & Carlson, M. E. (2004). Occupational science, occupational therapy and evidence-based practice: What the well elderly study has taught us. In M. Molineux (Ed.), Occupation for occupational therapists. Oxford: Blackwell Publishing.

Larson, E., Wood, W., & Clark, F. A. (2003). Occupational science: Building the science and practice of occupation through an academic discipline. In E. Crepeau, E. Cohn & B. Schell (Eds.), Willard & Spackman's occupational therapy (10th ed.). Philadelphia, PA: J. P. Lippincott Co.

Clark, F. A. (2000). Occupational science perspective. In P. Crist, C. Royeen, & J. Schkade (Eds.), Infusing occupation into practice: Comparison of three clinical approaches in occupational therapy (2nd ed.). Bethesda, MD: American Occupational Therapy Association.

Clark, F. A. (1998). Occupational science: Occupational therapy's legacy for the 21st century. In E. Crepeau & M. Neistadt (Eds.), Willard & Spackman’s occupational therapy (9th ed.). Philadelphia, PA: J. P. Lippincott Co.

Clark, F. A. (1997). Foreword. In L. D. Parham and L. S. Fazio (Eds.), Play in occupational therapy for children. St. Louis, MO: C. V. Mosby.

Clark, F. A., Larson, B., & Richardson, P. (1996). A grounded theory of techniques for occupational storytelling and occupational story making. In R. Zemke & F. Clark (Eds.), Occupational science: The evolving discipline. Philadelphia, PA: F. A. Davis.

Clark, F. A., & Larson, E. (1993). Developing an academic discipline: The science of occupation. In H. L. Hopkins & H. D. Smith (Eds.), Willard & Spackman's occupational therapy (8th ed.). Philadelphia, PA: J. P. Lippincott Co.

Mailloux, Z., Knox, S., Burke, J., & Clark, F. A. (1985). Pediatric dysfunction. In G. Kielhofner (Ed.), A model of human occupation: Theory and application. Baltimore, MD: Williams & Wilkins.

Clark, F. A. (1984). Evaluating the instrumentation used in research. In J. Morse (Ed.), New dimensions in research for health professionals. Laurel, MD: Ramsco Press.

Clark, F. A., Mailloux, Z., & Parham, L. (1984). Sensory integration and children with learning disabilities. In A. S. Allen & P. N. Clark (Eds.), Occupational therapy for children. St. Louis, MO: C. V. Mosby.

Clark, P., Florey, L., & Clark, F. A. (1984). Developmental principles and theories. In A. S. Allen & P. N. Clark (Eds.), Occupational therapy for children. St. Louis, MO: C. V. Mosby.

Clark, F. A. (1980). Right and left hemisphere specialization and the laterality and hemispheric dysfunction hypotheses of learning disabilities. In N. B. Tyler (Ed.), Sensory integration topics: Faculty review. Pasadena, CA: CSSID.

Clark, F. A. (1975). APT: Assessment program tool. In J. Brody & R. E. Similowitz (Eds.), APT: Assessment program tool. Spring City, PA: Department of Public Welfare Publications.

Journal Articles

Jackson, J. M., Mandel, D., Blanchard, J., Carlson, M. E., Cherry, B. J., Azen, S. P., Chou, C. P., Jordan-Marsh, M., Forman, T., White, B. A., Granger, D., Knight, B. G., & Clark, F. A. (2009). Confronting challenges in intervention research with ethnically diverse older adults: The USC Well Elderly II Trial. Clinical Trials, 6, 90-101.

Dunn, C., Carlson, M. E., Jackson, J. M., & Clark, F. A. (2009). Response factors surrounding progression of pressure ulcers in community-residing adults with spinal cord injury. American Journal of Occupational Therapy, 63, 301-309. Abstract →← Abstract

This study examined how community-dwelling adults with spinal cord injury (SCI) respond in real-life circumstances after detecting a low-grade (Stage 1 or Stage 2) pressure ulcer. We performed a secondary analysis of personal information profiles obtained in a previous qualitative research study. Profiles were examined to explore how individualized lifestyle considerations affected pressure ulcer risk in 19 adults with SCI who responded to an early ulcer that later progressed to a medically serious level. On the basis of a total of 46 pressure ulcer events, we identified a typological framework that described eight primary response categories and seven subcategories. The findings have significant practice implications for occupational therapists who provide services for adults with SCI living in the community. The importance of combining an initial individualized preventive intervention with structured follow-up within a person's unique everyday life setting is further explored.

Clark, F. A., Sanders, K., Carlson, M. E., Blanche, E. J., & Jackson, J. M. (2007). Synthesis of habit theory. Occupational Therapy Journal of Research, 27(4), 7-23. Abstract →← Abstract

During the past century, numerous researchers and theorists have argued that human lives are largely shaped by the nonreflective realm of habit. Beyond this observation, however, scholarly conceptualizations of habit are widely divergent, ranging from neural-level to culturally saturated macro-level constructs. To clarify the multiple ways that habit has been construed and is related to rehabilitation, the authors present a typology of nine categories of habits: habit as tic; habit as neural networks; habit as conditioned responses; habit as addiction; habit as single, everyday activities; habit as routine; habit as custom, ritual, rite, or ceremony; habit as character; and habit as habitus. Although these categories overlap and share common properties, their conceptual features differ along several dimensions. Each category offers a distinct perspective from which to understand the role of habit in the lives of clients undergoing rehabilitation, which the authors illustrate using examples from the Pressure Ulcer Prevention Study (PUPS), a qualitative study on the contextual factors that lead to serious recurrent pressure ulcers in people with spinal cord injuries. The authors argue that habit is a ubiquitous, protean force that presents itself in many interlinking forms, steering the course of human lives in both health-promoting and destructive directions. To have the greatest effect on health and participation, rehabilitation professionals must examine the nuanced ways that habit may operate both in the lives of clients and in professional practice.

Xie, B., Chou, C. P., Spruijt-Metz, D., Reynolds, K. D., Clark, F. A., Palmer, P. H., Gallaher, P., Sun, P., Guo, Q., & Johnson, C. S. (2007). Socio-demographic and economic correlates of overweight status in Chinese adolescents. American Journal of Health Behavior, 31(4), 339-352.

Clark, F. A., Jackson, J. M., Scott, J., Carlson, M. E., Atkins, M., Uhles-Tanaka, M., & Rubayi, S. (2006). Data-based models of how pressure ulcers develop in daily-living contexts of adults with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 87(11), 1516-1525. Abstract →← Abstract

Objective To examine the daily-lifestyle influences on the development of pressure ulcers in adults with spinal cord injury (SCI).

Design Qualitative investigation using in-depth interviewing and participant observation.

Setting Participants were studied in their homes and other naturalistic contexts.

Participants Twenty men and women of diverse ethnicities with paraplegia or tetraplegia who were recruited at a pressure ulcer management clinic in a large rehabilitation facility.

Interventions Not applicable.

Main Outcome Measures Detailed descriptive information pertaining to the development of recurring pressure ulcers in relation to participants’ daily routine and activity, personal choices, motivating influences, lifestyle challenges, and prevention techniques and strategies.

Results The daily-lifestyle influences on pressure ulcer development in adults with SCI can be described through various models that vary in complexity, depending on whether they incorporate individualization, interrelations among modeled elements, situational specificity, and/or temporal comprehensiveness. Ulcers are most likely to develop when a person with a relatively high-risk background profile is exposed to an equilibrium-disrupting change event that culminates in a specific pressure ulcer risk episode.

Conclusions The results underscore the significant degree of complexity and individualization that characterize the emergence of pressure ulcers in daily-life contexts. Prevention efforts should therefore incorporate attention to the unique constellation of circumstances that comprise a person’s everyday life.

Clark, F. A. (2006). One person’s thoughts on the future of occupational science. Journal of Occupational Science, 13(3), 167-179. Abstract →← Abstract

In its 16 years of existence, occupational science has achieved noteworthy success. However, to continue to thrive, the discipline must remain responsive to the changing times and environment. This paper assesses the current health of occupational science based on the plight of other academic disciplines such as sociology and geography whose future is presently threatened. The intellectual vitality of occupational science is strong, yet the discipline must continue to solidify its interdisciplinary commitment, increase the number of publications, and expand its research scope. Beyond this, strategic planning to keep occupational science alive and well in the future will require nurturing the symbiotic relationship between the discipline and the occupational therapy profession. To the extent that occupational therapy thrives, occupational science must be better positioned, with the resource base and links to practice it needs to flourish. Finally, viewing occupational science as a kind of living organism whose survival can be described through principles of evolutionary biology can also help with the formulation of strategic initiatives. In this paper, I use this framework to identify long-term survival strategies for occupational science. I then present an heuristic model for developing customized survival plans for occupational science programs within the US and for the discipline in general. The occupational science program at the University of Southern California is used to illustrate the implementation of the heuristic model in terms of: national and global priorities; university/institutional culture, mission and values; university colleagues, networks, and programs; and departmental research and education programs. I believe occupational science will thrive in the future if occupational scientists develop and implement customized survival plans for their educational programs that are responsive to the opportunities and challenges present in their respective settings.

Clark, F. A., Carlson, M. E., Jackson, J. M., & Mandel, D. (2003). Lifestyle Redesign: Improves health and is cost-effective. OT Practice, 9-13.

Hay, J., LaBree, L., Luo, R., Clark, F. A., Carlson, M. E., Mandel, D., Zemke, R., Jackson, J. M., & Azen, S. P. (2002). Cost-effectiveness of preventive occupational therapy for independent-living older adults. Journal of the American Geriatrics Society, 50(8), 1381-1388. Abstract →← Abstract

OBJECTIVES:To evaluate the cost-effectiveness of a 9-month preventive occupational therapy (OT) program in the Well-Elderly Study: a randomized trial in independent-living older adults that found significant health, function, and quality of life benefits attributable to preventive OT.

DESIGN:A randomized trial.

SETTING:Two government-subsidized apartment complexes.

PARTICIPANTS:One hundred sixty-three culturally diverse volunteers aged 60 and older.

INTERVENTION:An OT group, a social activity group (active control), and a nontreatment group (passive control).

MEASUREMENTS:Use of healthcare services was determined by telephone interview during and after the treatment phase. A conversion algorithm was applied to the RAND 36-item Short Form Health Survey to derive a preference-based health-related quality of life index, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio for preventive OT relative to the combined control group.

RESULTS:Costs for the 9-month OT program averaged $548 per subject. Postintervention healthcare costs were lower for the OT group ($967) than for the active control group ($1,726), the passive control group ($3,334), or a combination of the control groups ($2,593). The quality of life index showed a 4.5% QALY differential (OT vs combined control), P < .001. The cost per QALY estimates for the OT group was $10,666 (95% confidence interval = $6,747–$25,430). For the passive and active control groups, the corresponding costs per QALY were $13,784 and $7,820, respectively.

CONCLUSION:In this study, preventive OT demonstrated cost-effectiveness in conjunction with a trend toward decreased medical expenditures.

Clark, F. A. (2001). Editorial. Scandinavian Journal of Occupational Therapy, 8(1), 3-6.

Jackson, J. M., Mandel, D., & Clark, F. A. (2001). Promoting quality of life in elders: An occupation based occupational therapy program. World Federation of Occupational Therapy Bulletin, .

Clark, F. A., Azen, S. P., Carlson, M. E., Mandel, D., LaBree, L., Hay, J., Zemke, R., Jackson, J. M., & Lipson, L. (2001). Embedding health-promoting changes into the daily lives of independent-living older adults: Long-term follow-up of occupational therapy intervention. Journal of Gerontology: Psychological Sciences and Social Sciences, 56B, 60-63. Abstract →← Abstract

The Well Elderly Study was a randomized trial in independent-living older adults that found significant health, function, and quality of life benefits attributable to a 9-month program in preventive occupational therapy (OT). All participants completing the trial were followed for an additional 6 months without further intervention and then reevaluated using the same battery of instruments. Long-term benefit attributable to preventive OT was found for the quality of interaction scale of the Functional Status Questionnaire and for six of eight scales on the RAND SF-36: physical functioning, role functioning, vitality, social functioning, role emotional, and general mental health (p < .05). Approximately 90% of the therapeutic gain observed following OT treatment was retained in follow-up. The finding of a sustained effect for preventive OT is of great public health relevance given the looming health care cost crisis associated with our nation's expanding elderly population.

Clark, F. A., Rubayi, S., Jackson, J. M., Uhles-Tanaka, D., Scott, M., Atkins, M., Gross, K., & Carlson, M. E. (2001). The role of daily activities in pressure sore development. Skin and Wound Care, 14(2), 52-54. Abstract →← Abstract

Pressure ulcers are a serious complication of spinal cord injury (SCI).1 Although pressure ulcers are often assumed to be preventable,2 research suggests that more than three fourths of individuals with an SCI will develop a pressure ulcer over the course of their lifetime.1-3 The total annual cost to treat these ulcers is nearly $1.5 billion.1-3 Not only can pressure ulcers be potentially life-threatening, but they can also impede the rehabilitation process and significantly disrupt the quality of life of persons with an SCI.1

Because the pressure ulcer problem among persons with an SCI is so severe, it is important for clinicians to develop a full understanding of the underlying contributing factors in attempting to reduce pressure ulcer risk. Research has demonstrated that in the realm of lifestyle choices, factors such as poor fitness, inadequate nutrition, unemployment, decreased social involvement, substance abuse, and emotional stress can increase the risk for developing pressure ulcers.4-8 By focusing on generalizable quantitative relationships between variables, these researchers have demonstrated that, on average, individuals with an SCI who manifest a particular risk factor have a greater likelihood of developing a pressure ulcer.

Clark, F. A., Sato, T., & Iwama, M. (2000). Towards the construction of a universally acceptable definition of occupation: Occupational science perspective. The Japanese Journal of Occupational Therapy, 34(1), 9-14.

Jackson, J. M., Kennedy, B. L., Mandel, D., Carlson, M. E., Cherry, B., Fanchiang, S., Ding, L., Zemke, R., Azen, S. P., LaBree, L., & Clark, F. A. (2000). Derivation and pilot assessment of a health promotion program for Mandarin-speaking Chinese older adults. The International Journal of Aging & Human Development, 50(2), 127-149. Abstract →← Abstract

Describes methods used to adapt a health care program so that it would better meet the needs of a group of well, older Mandarin-speaking Chinese residents of Los Angeles. Outcomes from a pilot experiment are presented that are consistent with the notion that the adapted program was effective in reducing health-related declines among participants.

Clark, F. A. (2000). The concepts of habit and routine: A preliminary theoretical synthesis. The Occupational Therapy Journal of Research, 20(Supplement 2000), 123-137.

Azen, S. P., Palmer, J., Carlson, M. E., Jackson, J. M., Cherry, B., Fanchiang, S., & Clark, F. A. (1999). Psychometric properties of a Chinese translation of the SF-36 Health Survey Questionnaire in the well elderly study. Journal of Aging and Health, 11(2), 240-251. Abstract →← Abstract

This study seeks to evaluate the psychometric properties of a Chinese translation of the 36-item Short Form Health Survey (SF-36) in the Well Elderly Study: a randomized clinical trial designed to evaluate the effectiveness of preventive occupational therapy services specifically tailored for multiethnic, independent-living, older adults. Translation and back-translation procedures were used to obtain appropriate meanings for the SF-36 survey questions and to ensure face, functional, and conceptual equivalence. Statistical analyses demonstrated satisfactory reliability and validity, with the results generally similar to those reported for older Anglo adults. As the percentage of older adults of diverse ethnicity increases, the need for health care research and service strategies that can effectively include multiple ethnicities becomes paramount. The results of this study suggest that a Chinese translated SF-36 can be used to assess multiple dimensions of health in a Mandarin-speaking population of older adults.

Jackson, J. M., Carlson, M. E., Mandel, D., Zemke, R., & Clark, F. A. (1998). Occupation in lifestyle redesign: The well elderly study occupational therapy program. American Journal of Occupational Therapy, 52(5), 326-336. Abstract →← Abstract

This article describes an innovative preventive occupational therapy intervention for well older adults, the Well Elderly Treatment Program. In a previously reported large-scale randomized effectiveness study, this intervention was found to be highly successful in enhancing the physical and mental health, occupational functioning, and life satisfaction of multicultural, community-dwelling elders. In this article, the philosophical background, manner of development, topical content, methods of program delivery, and mechanisms underlying the program's positive effects are discussed, along with implications for occupational therapy practice. The treatment was based on application of occupational science theory and research and emphasized the therapeutic process of lifestyle redesign in enabling the participants to actively and strategically select an individualized pattern of personally satisfying and health-promoting occupations. The wide-ranging effectiveness of the program supports the occupational therapy profession's emphasis on occupation in affecting health and positions practitioners to extend their services to the realm of preventive interventions.

Carlson, M. E., Young, B., & Clark, F. A. (1998). Practical contributions of occupational science to the art of successful aging: How to sculpt a meaningful life in older adulthood. Journal of Occupational Science, 5(3), 107-118. Abstract →← Abstract

Given that the longevity revolution has already arrived and will continue to flourish in the upcoming decades, Western societies are confronted with the urgent challenge of promoting the goal of successful ageing for untold millions of citizens. With regard to this goal, current thinking points to the optimistic conclusion that potentially controllable lifestyle factors play a crucial role in enabling people to experience health and satisfying lives well into older adulthood. In this paper, the importance of occupation as providing a fundamental, personally relevant context for the enactment of sustainable lifestyle choices that foster successful ageing is described. This stress on the significance of occupation is supported by the successful outcome of an experimental test of a preventive occupational therapy intervention designed to promote health and psychosocial well-being in community dwelling elders. Based on the theory and research that is discussed, a practically oriented synthetic overview is provided of the conditions conducive to successful ageing.

Snyder, C., Clark, F. A., Masunaka-Noriega, M., & Young, B. (1998). Los Angeles street kids: New occupations for life program. Journal of Occupational Science, 5(3), 133-139. Abstract →← Abstract

In the same sense that health intervention focused on the daily occupations of the well-elderly can promote successful ageing, programs aimed at the daily occupations of at-risk youth may act as a potential deterrent to street gang activity. In the city of Los Angeles, thousands of young people come under the influence of gang culture and in turn, lead lifestyles destructive to themselves and society. This paper begins with a few statistics which paint a grim picture of the existence of street gang members and the impact of street gang involvement. Following, there is a story of one youth’s path from immigration to the United States to his involvement with a street gang which eventually led to his participation in the New Occupations for Life Program. This pilot program, developed by the University of Southern California Department of Occupational Science and Occupational Therapy, targeted the harmful occupations of 100 Hispanic and African-American teenagers at-risk for gang involvement. The program provided a safe context for disestablishing gang allegiances, building community, and exploring socially acceptable, productive occupations. In this liminal space, these at-risk youth were given the opportunity to experience other “modes of being” within the context of meaningful and enjoyable occupations. Clark and her colleagues offer their interpretation of this transformative process and share their optimism about the power of occupation to change the lives of at-risk youth.

Clark, F. A. (1997). Reflections on the human as an occupational being: Biological need, tempo, and temporality. Journal of Occupational Science: Australia, 4(3), 86-92. Abstract →← Abstract

Global health through occupation is contingent upon our understanding of the human as an occupational being. In this paper, I reflect upon two aspects of the human as an occupational being: 1) the biological need for occupation, and 2) tempo and temporality as a way of beginning to generate a blueprint for global health. Wilcock’s theory on the human need for occupation proposes that people living in post industrial nations are diverted from engagement in occupations that function to meet biological needs. The theory largely addresses the issue of what kinds of occupations are likely to be health promoting, given a set of assumptions about the history of humans as occupational beings. On the surface it would appear that occupations that resemble those of prehistoric men and women would be optimal for promoting health and wellbeing, but these kinds of occupations are largely unsuitable for incorporation into contemporary lifestyles. Yet, there are elements of prehistoric occupations that can be recaptured in contemporary activity, and I speculate on the form such occupation might take as a way of addressing the general question of what kinds of occupations are likely to be health promoting . The beginning blueprint for global health through occupation must also take into account the nature of occupational beings in relation to tempo and temporality. I argue that there is an intersection between tempo and temporality. The tempo of occupation is simply defined as its pace and rhythm. Temporality, in contrast, has to do with how we understand occupation in relation to past, present, and future events. When life is rushed as it is in the fast lane of modernity, the result can be the forgetting-ofbeing, or stated otherwise, doing without being. I suggest that healthier people and a healthier world could result from a blueprint generated through occupational science research that identifies the patterns of occupation that are likely to be maximally health promoting and the pace at which they should be undertaken.

Clark, F. A., Azen, S. P., Zemke, R., Jackson, J. M., Carlson, M. E., Hay, J., Mandel, D., Josephson, K., Cherry, B., Hessel, C., Palmer, J., & Lipson, L. (1997). Occupational therapy for independent-living older adults: A randomized controlled trial. Journal of the American Medical Association, 278(16), 1321-1326. Abstract →← Abstract

Preventive health programs may mitigate against the health risks of older adulthood. OBJECTIVE: To evaluate the effectiveness of preventive occupational therapy (OT) services specifically tailored for multiethnic, independent-living older adults. Design.-A randomized controlled trial. SETTING: Two government subsidized apartment complexes for independent-living older adults. SUBJECTS: A total of 361 culturally diverse volunteers aged 60 years or older. INTERVENTION: An OT group, a social activity control group, and a nontreatment control group. The period of treatment was 9 months. MAIN OUTCOME MEASURES: A battery of self-administered questionnaires designed to measure physical and social function, self-rated health, life satisfaction, and depressive symptoms. RESULTS: Benefit attributable to OT treatment was found for the quality of interaction scale on the Functional Status Questionnaire (P=.03), Life Satisfaction Index-Z (P=.03), Medical Outcomes Study Health Perception Survey (P=.05), and for 7 of 8 scales on the RAND 36-Item Health Status Survey, Short Form: bodily pain (P=.03), physical functioning (P=.008), role limitations attributable to health problems (P=.02), vitality (P=.004), social functioning (P=.05), role limitations attributable to emotional problems (P=.05), and general mental health (P=.02). CONCLUSIONS: Significant benefits for the OT preventive treatment group were found across various health, function, and quality-of-life domains. Because the control groups tended to decline over the study interval, our results suggest that preventive health programs based on OT may mitigate against the health risks of older adulthood.

Clark, F. A., Carlson, M. E., & Polkinghorne, D. (1997). The legitimacy of life history and narrative approaches in the study of occupation. American Journal of Occupational Therapy, 51(4), 313-317. Abstract →← Abstract

Ina recent arricle published in this column, Duchek and Thessing (1996) expressed their belief that the use of life history and narrarive as research methodologies will not "completely meet the objectives" (p. 395) of occupational science. We feel that it is important to respond to the issues they raise.

Spitzer, S., Roley, S., Parham, D., & Clark, F. A. (1996). Sensory integration: Current trends in the United States. Scandinavian Journal of Occupational Therapy, 3(3), 123-138. Abstract →← Abstract

Abstract In this article, the current status of the theory and practice of sensory integration in the United States since the 1960s is described and analyzed. In order to characterize current issues in this growing field of practice, historical developments in sensory integration are examined. The following four topics are explored: theoretical constructs, research, assessment, and practice. The article identifies a trend toward understanding sensory integration within the context of an individual's daily occupations.

Carlson, M. E., Fanchiang, S., Zemke, R., & Clark, F. A. (1996). A meta-analysis of the effectiveness of occupational therapy for older persons. American Journal of Occupational Therapy, 50(2), 89-98. Abstract →← Abstract

Given the current health care debate, it is imperative to document the usefulness of various health services for older persons, a rapidly growing population at increased risk for a wide variety of physical and functional impairments. A meta-analysis was conducted to examine the degree of effictiveness of occupational therapy for older persons. For a sample of 15 distinct tests of occupational therapy, a positive unweighted mean effict size of .51 (54 when corrected for instrument unreliability) was obtained, along with a highly significant cumulative result for treatment success (p < .001). Beneficial treatment effects extended to activities of daily living--functional and psychosocial outcomes. The results for physical outcomes suggested a beneficial effect, although not every meta-analytic test yielded significant results. It was concluded that factors such as publication bias or poor study design are incapable of accounting for the positive meta-analytic result and that occupational therapy represents a worthwhile treatment option for older persons.

Clark, F. A., Carlson, M. E., Zemke, R., Frank, G., Patterson, K., Larson, B., Rankin Martinez, A., Hobson, L., Crandall, J., Mandel, D., & Lipson, L. (1996). A qualitative study of the llfe domains and adaptive strategies of the low income well elderly. American Journal of Occupational Therapy, 50(2), 99-108. Abstract →← Abstract

Older adults are at increased risk for a variety of physical and emotional limitations that threaten their ability to lead independent and fullfilling lives. Consequently, they stand to benefit from personalized strategies of adaptation that enable them to achieve successful outcomes in their daily activities and desired goals. In the current investigation, a qualitative descriptive methodology was used to document the perceived life domaim of importance and associated strategies of adaptation of 29 residents of Angelus Plaza, a federally subsidized apartment complex in downtown Los Angeles for low-income, well older adults. On the basis of interview data, 10 life domains were identified, and within each domain, a typology of adaptive strategies was derived. The domains were activities of daily living (ADL), adaptation to a multicultural environment, free time usage, grave illness and death-spirituality, health maintenance, mobility maintenance, personal finances, personal safety, psychological well-being and happiness, and relationships with others. Although the typology should not be generalized to a geriatric population, therapists may wish to refer to it to gain a sense of the extent to which certain adaptive strategies may be applicable to the lives of particular older adults to whom they deliver services. The teaching of these adaptive strategies could then be incorporated into an individualized treatment plan.

Clark, F. A., Zemke, R., Frank, G., Parham, D., Neville-Jan, A. M., Hedricks, C., Carlson, M. E., Fazio, L., & Abreu, B. (1993). Dangers inherent in the partition of occupational therapy and occupational science. American Journal of Occupational Therapy, 47(2), 184-186. Abstract →← Abstract

Occupational science, an outgrowth of occupational therapy, is an emerging basic science that has been defined as the systematic study of humans as occupational beings (Clark et aI., 1991; Yerxa et aI., 1989). The research and theory development that emanates from occupational science is intended to enhance both the scholarly foundation and professional practice of occupational therapy (Clark, 1991; Clark et aI., 1991). As occupational science expands, new insights concerning the nature of occupation and the manner in which it enriches people's lives are expected to emerge; such insights will spur the development of improved therapeutic techniques and thereby generate important yields both to the profession and to the clients whom it serves. In recognition of this rich potential, the American Occupational Therapy Foundation recently provided funding to establish an occupa[ional science-based Research Center at the University of Southern California to promote the study of occupation and its relationship to adaptation and the challenges of aging and disability.

Carlson, M. E., & Clark, F. A. (1991). The search for useful methodologies in occupational science. American Journal of Occupational Therapy, 45(3), 235-242. Abstract →← Abstract

Debate currently exists on the soundness of various research methodologies in the social sciences. In the present paper, this question is addressed in relation to the emerging discipline of occupational science. First, the discipline of occupational science is defined. Next, two competing methodologies--Paradigm 1, Positivistic, and Paradigm 2, Naturalistic--are contrasted. The criteria of genuineness and trustworthiness are proposed as crucial for the evaluation of the soundness of available research methodologies for the extension of occupational science. Next, exemplars of research methodologies that meet these criteria are described. In the conclusion, the role that nonscientific ways of knowing, such as art and literature, may play in the understanding of human occupation is discussed.

Clark, F. A., Parham, D., Carlson, M. E., Frank, G., Jackson, J. M., Pierce, D., Wolf, R., & Zemke, R. (1991). Occupational science: Academic innovation in the service of occupational therapy’s future. American Journal of Occupational Therapy, 45(4), 300-310. Abstract →← Abstract

Occupational science is a new scientific discipline that is defined as the systematic study of the human as an occupational being. A doctoral program in occupational science has been established at the University of Southern California, Los Angeles, with its emphasis on the provision of a multidimensional description of the substrates, form, function, meaning, and sociocultural and historical contexts of occupation, occupational science emphasizes the ability of humans throughout the life span to actively pursue and orchestrate occupations. In this paper, occupational science is described, defined, and distinguished from other social sciences. A general systems model is presented as a heuristic to explain occupation and organize knowledge in occupational science. The development of occupational science offers several key benefits to the profession of occupational therapy, including (a) fulfillment of the demand for doctoral-level faculty members in colleges and universities; (b) the generation of needed basic science research; and (c) the justification for and potential enhancement of practice.

Danner, P., & Clark, F. A. (1991). Effectiveness of sensory integrative procedures on four Finnish children with minimal brain dysfunction. Japanese Journal of Sensory Integration Dysfunction, 21(1), 7-16.

Wiss, T., & Clark, F. A. (1990). Validity of the Southern California Postrotary Nystagmus Test: Misconceptions lead to incorrect conclusions. American Journal of Occupational Therapy, 44(7), 658-659. Abstract →← Abstract

In her article entitled "Testing Vestibular Function: Problems With the Southern California Postrotary Nystagmus Test" (American Journal of Occupational Therapy, July 1989), Helen Cohen concluded: "Although postrotatory nystagmus is indicative of vestibular system function, the SCPNT [Southern California Postrotary Nystagmus Test] does not provide a valid measure of that behavior. Therefore, results from this test are not valid indicators of vestibular function" (p. 475). Although Dr. Cohen is to be applauded for providing an excellent review of some aspects affecting the testing of pure vestibular responses and for attempting to educate therapists on the validity of a widely used test, she has failed to recognize the distinction between the testing of pure vestibular responses and the purpose of the Southern California Postrotary Nystagmus Test (SCPNT) (Ayres, 1975). This distinction is central to the use and interpretation of results on the SCPNT.

Clark, F. A., & Jackson, J. M. (1990). The application of the occupational science negative. Occupational Therapy in Health Care, Special Issue on Occupational Science, 6(4), 69-91.

Primeau, L., Clark, F. A., & Pierce, D. (1989). Occupational therapy alone has looked upon occupation: Future applications of occupational science to the health care needs of parents and children. Occupational Therapy in Health Care, 6(4), 19-32. Abstract →← Abstract

Occupational therapy has been an invisible profession, largely because the public has had difficulty grasping the concept of occupation. The emergence of occupational science has the potential of improving this situation. Occupational science is firmly rooted in the founding ideas of occupational therapy. In the future, the nature of human occupation will be illuminated by the development of a basic theory of occupational science. Occupational science, through research and theory development, will guide the practice of occupational therapy. Applications of occupational science to the practice of pediatric occupational therapy are presented. Ultimately, occupational science will prepare pediatric occupational therapists to better meet the needs of parents and their children.

Hamilton-Dodd, C., Kawamoto, T., Clark, F. A., Burke, J., & Fanchiang, S. (1989). The effects of a maternal role preparation program on mother/infant pairs: A pilot study. American Journal of Occupational Therapy, 43(8), 513-521. Abstract →← Abstract

This quasi-experimental pilot study examined the association of a maternal preparation program with womens' competence in maternal care behaviors, self-perceived adaptation to the maternal role, and satisfaction with the maternal preparation received in conjunction with obstetric and delivery care. Sixteen subjects participated in the program. A cost-benefit questionnaire was completed by the program participants to examine whether the availability of such a maternal preparation program would influence future selections of a hospital for delivery. Our occupational therapy maternal role preparation program was provided to the subjects in four sessions. The program included material on physiological changes in the new mother, orchestration of activities of daily living, infant development and individual differences, and the mother-infant relationship. Results were statistically significant only for the factor of the mothers' satisfaction with their obstetric care and preparation for the maternal role, in favor of the treatment group. In addition, all 8 members of the treatment group reported that they thought the program was helpful and would recommend it to other mothers.

Clark, F. A., & Jackson, J. M. (1989). Contemplative occupational therapy: Thoughts on the application of the occupational therapy negative heuristic in the treatment of persons with human immunodeficiency infection. Occupational Therapy in Health Care, 6(4), 69-91.

Yerxa, E., Clark, F. A., Frank, G., Jackson, J. M., Parham, D., Pierce, D., Stein, C., & Zemke, R. (1989). An introduction to occupational science: A foundation for occupational therapy in the 21st century. Occupational Therapy in Health Care, 6(4), 1-17. Abstract →← Abstract

Occupational science is an emerging basic science which supports the practice of occupational therapy. Its roots in the rich traditions of occupational therapy are explored and its current configuration is introduced. Specifications which the science needs to meet as it is further developed and refined are presented. Compatible disciplines and research approaches are identified. example's of basic science research questions and their potential contributions to occupational therapy practice are suggested.

Jackson, J. M., Rankin, A., Siefken, S., & Clark, F. A. (1989). Options: A high school transition program for adolescents with developmental delays. Occupational Therapy in Health Care, 6(2/3), 197-214. Abstract →← Abstract

This article discusses a grant-funded occu~ational therapy independent living skills transition program for adoiesccnts with develo~mental disabilities on a non-mainstreamed high school campus. The Options Program was designed to provide intensive transition services through its emphasis on exploring and broadening the range of individuals' choices' about employment, living arrangements, and social activities. The assessment procedure, program model, curriculum goals, and intervention strategies are presented.

Parush, S., & Clark, F. A. (1988). A study of reliability and validity of a sensory developmental expectation questionnaire for mothers of newborn infants. American Journal of Occupational Therapy, 42(1), 11-16. Abstract →← Abstract

The purpose of this study was to construct and conduct preliminary reliability and validity studies on a questionnaire designed to measure a mother's ability to provide an adequate sensory environment for her newborn child. The questionnaire was conceptualized as an extension and application of sensory integrative theory into the domain of maternal role preparation. The instrument assessed (a) a motber's knowledge of the sensory capacity of the newborn and (b) a mother's perception ofher ability to influence tbe development of her child. The subjects were 55 primaparas of newborn infants who responded to the questionnaire within 3 days postpartum. The findings demonstrated that the questionnaire measured tbe two traits reliably. Additionally, they indicated that knowledge of the sensory capacity of the newborn correlated positively with perceived influence on deuelopment. Maternal age did not correlate with tbe mothers' knowledge of the sensory capacity of tbe child, but did correlate with perceived influence of mothers on development. Educational level of the respondent correlated with scores on both subscales. With further research, it is foreseen that this questionnaire may be used by occupational therapists as a part of a screening interview for identifying mothers who may be at risk for failure to provide adequate sensory experiences for their children.

Clark, F. A., Mack, W., & Pennington, V. (1988). Transition needs assessment of severely disabled high school students and their parents and teachers. Occupational Therapy Journal of Research, 8(6), 323-344. Abstract →← Abstract

A survey of 45 severely disabled high school students and their parents and teachers found that students and parents perceived that the students' greatest need was for social development and vocational competence. Teachers indicated that some independent living skills were not adequately covered in existing courses.

Clark, F. A., & Primeau, L. (1988). Obfuscation of sensory integration: A matter of professional predation. Commentary. American Journal on Mental Deficiency, 92(5), 415-422. Abstract →← Abstract

In a response to a critique of studies on the use of sensory integration therapy with mentally retarded persons, the article provides a detailed chart of mistakes, selective statements, distortions, and evidence of poor scholarship on the part of the authors of the critique.

Burke, J., Clark, F. A., Hamilton, C., & Kawamoto, T. (1987). Maternal role preparation: A program using sensory integration, infant-mother attachment and occupational behavior perspectives. Occupational Therapy in Health Care, 4(2), 9-21. Abstract →← Abstract

The Maternal Role Preparation project utilizes an occupational therapy approach to increasing maternal competence in first-time mothers. The four-session program covers topics concerning infants (attachment, sensory systems, developmental abilities) and mothers (the mothering role, physiological changes after childbirth, physical and psychological needs of the new mother, and infant care skills).

Clark, F. A. (1986). The foundation--A new concept: Apprenticeships for occupational therapy researchers. American Journal of Occupational Therapy, 40(9), 639-641. Abstract →← Abstract

Occupational therapy needs people who are trained to do research and are willing to commit a major part of their time to it. In urging the profession to become an academic discipline, Dr. Peter E. Tanguay (1985) warned that "a profession that neglects its academic base is in grave danger for several reasons. Unless you are constantly proving the worth of your new ideas or the effectiveness of your services and unless you are creating substantially new theoretical approaches to enliven your profession, the world will pass you by" (p. 467). Assuming we agree with Dr. Tanguay, we might ask the question, What mechanisms need to be put in place to ensure that productive researchers proliferate in occupational therapy?

Clark, F. A., Sharrott, G., Campbell, S., & Hill, D. (1985). A comparison of the impact of undergraduate and graduate occupational therapy education on professional productivity. American Journal of Occupational Therapy, 39(3), 155-162. Abstract →← Abstract

This article presents an account of the evolutionary changes in occupational therapy graduate education at the University of Southern California (USC) in response to the increasing professional demands and the expanding knowledge base of the field. The contention that undergraduate and graduate education represented by these changes would result in different student products was tested. A questionnaire survey was used to assess the responses of 189 former undergraduate and graduate occupational therapy students of USC on issues relating to professionalism,leadership, attitudes, and scholarly contributions. Results of this study support the theory that graduate education of a specific kind and quality enhances the professionalization of occupational therapy more so than does undergraduate education.

Saeki, K., Clark, F. A., & Azen, S. P. (1985). Performance of Japanese and Japanese-American children on the Motor Accuracy Revised and Design Copying Test: A cross-cultural study. American Journal of Occupational Therapy, 39(2), 103-109. Abstract →← Abstract

This study investigates whether cultural differences affect childrens' performances on the Design Copying (DC) and Motor Accuracy-Revised (MAC-R) Tests of the Southern California Sensory Integration Tests. The DC and the MAC-R were administered to 98 children who were born in Japan and lived there at least during the first year of life and to 82 children who were of Japanese descent but who were born in America. Average test scores of the Japanese and Japanese-American children were compared with those of the American children, on whom the tests were standardized. Results of the tests requiring right-hand performance revealed that both groups of Japanese-descent children performed better than the standardization group of American children; the Japan-born children performed the best. We base these findings on the influence that culture has on the development of a child.

Clark, F. A., & Sharrott, G. (1984). Commentary. Toward an image of one's own: Sources of variation in the role of occupational therapists in psychosocial practice. Occupational Therapy Journal of Research, 4, 24-36.

Bissell, J., & Clark, F. A. (1984). Dichotic listening performance in normal children and adults. American Journal of Occupational Therapy, 38(3), 176-186. Abstract →← Abstract

The purpose of this study was to investigate normative expectations on the dichotic listening test in order to determine the influence of sex and development on development listening performance. Thirty 5- to 6-year-olds, thirty 11- to 12-year-olds, and 30 adults, 15 males and 15 females in each group, were tested by using conssonant- vowel dichotic stimuli. There were no significant differences between males and females except for the 11- to 12-year-old females who were significantly more accurate than the males. Degree of ear asymmetry did not differ among the three age goups; however, the adults and 11- to 12-year-olds were significantly more accurate than the 5- to 6-year-olds. Guidelines are suggested for the interpretation of dichotic listening test data.

Clark, F. A. (1983). Research on the neuropathophysiology of autism and its implications for occupational therapy. Occupational Therapy Journal of Research, 3, 3-22.

Clark, F. A., Gabrielli, W., Mednick, S., & Venables, P. (1982). Relationship of electrodermal activity in three-year-olds to their aggression at age eight. Psychophysiology, 19, 554.

Clark, F. A., & Steingold, L. (1982). A potential relationship between occupational therapy and language acquisition. American Journal of Occupational Therapy, 36(1), 42-44. Abstract →← Abstract

In the preceding, "Vestibular Stimulation Effect on Language Development in Mentally Retarded Children," the authors present results of their study on the relationship between vestibular stimulation and language acquisition. While their research question is of obvious interest to speech pathologists, its relevance to occupational therapists is not readily apparent. Without such a linkage, one could take the stand that there is insufficient justification to warrant publication in The American Journal of Occupational Therapy. However, we believe that a potential relationship between occupational therapy and language acquisition has been established by several empirical theoretical works discussed below. Further support for the relationship between occupational therapy and language acquisition derives from PL 94-142, and two frames of reference in occupational therapy practice.

Clark, F. A. (1982). The Illinois Test of Psycholinguistic abilities: Considerations of its use in occupational and physical therapy. Physical and Occupational Therapy in Pediatrics, 2(4), 29-41. Abstract →← Abstract

The psycholinguistic model of learning disabilities and with it the Illinois Test of Psycholinguistic Abilities (ITPA), are in widespread use in the fields of special education and speech pathology. As occupational and physical therapists have become more involved in sensory integrative procedures, they are sometimes expected to interpret the Southern California Sensory Integrative Tests in relation to results on the ITPA. This paper provides an overview of the ITPA, describing the psycholinguistic model from which it was developed and the research on its usefulness, reliability and validity. Since the majority of studies suggest that the validity of the ITPA is questionable when it is not used in conjunction with other tests and since the tests may not be sensitive enough to therapeutic changes as a consequence of therapy, a recommendation is made that therapists exercise considerable discretion in using this test for research purposes. At the same time, the test may be a useful supplement in clinical evaluation.

Benson, J., & Clark, F. A. (1982). A guide to instrument development and validation. American Journal of Occupational Therapy, 36(12), 789-800. Abstract →← Abstract

As occupational therapists become increasingly concerned with accountability, the paucity of adequate instrumentation available for documenting therapeutic effectiveness surfaces as a major problem. Therapists will need to construct new or refine existing instruments to satisfy the requirements of third-party payment. The purpose of this paper is to illustrate how a new instrument is planned, developed, and validated. A sequential step-by-step process is illustrated with a flowchart and applied in the hypothetical construction of an attitude scale to assess school administrators' valuing of the role of occupational therapists in the schools. This example is provided to show how general psychometric principles are applied within an occupational therapy context.

Shuer, J., Clark, F. A., & Azen, S. P. (1980). Vestibular function in mildly mentally retarded adults. American Journal of Occupational Therapy, 34(10), 664-670. Abstract →← Abstract

The purpose of this study was to compare the duration of nystagmus in mildly mentally retarded and normal adults as measured by the Southern California Postrotary Nystagmus Test. The results revealed that the retarded males demonstrated attenuated duration of nystagmus. These findings support the need for further investigation of possible sensory integrative deficits in this population so that proper treatment can be provided.

Clark, F. A., Miller, L., Thomas, J., Kucherawy, D., & Azen, S. P. (1978). A comparison of operant and sensory integrative methods on developmental parameters in profoundly retarded adults. American Journal of Occupational Therapy, 32, 86-92.

Clark, F. A., & Shuer, J. (1978). A clarification of sensory integrative therapy and its application to programming with retarded people. Mental Retardation, 16(3), 227-232. Abstract →← Abstract

The article clarifies the theoretical base of sensory integrative therapy as described by J. Ayres, discusses appropriate target populations (primarily learning disabled students with apraxia or vestibular problems), and reviews research with mentally retarded persons.

Conference Proceedings

Clark, F. A. (1988). Lessons to be learned: A history of sensory integration research. In Proceedings of the First International Conference of Sensory Integration and the Sixth Japanese Conference of Sensory Integrative Dysfunction.

Clark, F. A., & Pierce, D. (1986). Effectiveness studies in sensory integration. In Proceedings of conference: Occupational therapy for maternal and child health: Research and leadership development.

Clark, F. A. (1986). Leadership: Converting vision into positive action. In Proceedings of conference: Occupational therapy for maternal and child health: Research and leadership development.

Clark, F. A., Hammond, W., & Vulpe, S. (1986). Collaboration: Key to securing needed resources. In Proceedings of conference: Occupational therapy for maternal and child health: Research and leadership development.

Clark, F. A. (1986). Faculty-student research collaboration. In Proceedings of target 2000 conference: Occupational therapy education. Nashville, TN.

Manuals

Clark, F. A., Sharrott, G., & Jackson, J. M. (1987). Design of the model pupil personnel training program, Model program and guidelines for occupational therapist training in delivery of high school based transition services for students with disabilities. U.S. Department of Education Grant OSERS # G008400770.

Clark, F. A., Pennington, V., & Mack, W. (1987). The establishment and design of a model independent living skills training center, Model Program and guidelines for occupational therapist training in delivery of high school-based transition services for students with disabilities. U.S. Department of Education OSERS Grant #G008400770.