Scandinavian Journal of Occupational Therapy

ISSN: 1103-8128 (Print) 1651-2014 (Online) Journal homepage: https://www.tandfonline.com/loi/iocc20

Child and parent perspectives of life quality of

children with physical impairments compared with
non-disabled peers

Linda Björk Ólafsdóttir, Snaefrídur Thóra Egilson, Unnur Árnadóttir & Stefan
C. Hardonk

To cite this article: Linda Björk Ólafsdóttir, Snaefrídur Thóra Egilson, Unnur Árnadóttir &
Stefan C. Hardonk (2019) Child and parent perspectives of life quality of children with physical
impairments compared with non-disabled peers, Scandinavian Journal of Occupational
Therapy, 26:7, 496-504, DOI: 10.1080/11038128.2018.1509371

To link to this article: https://doi.org/10.1080/11038128.2018.1509371

© 2018 The Author(s). Published by Informa Published online: 20 Nov 2018.

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SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY
2019, VOL. 26, NO. 7, 496–504
https://doi.org/10.1080/11038128.2018.1509371

ORIGINAL ARTICLE

Child and parent perspectives of life quality of children with physical

impairments compared with non-disabled peers
Linda Bjo 
€rk Olafsdottira ra Egilsona
, Snaefrıdur Tho 
, Unnur Arnadottirb and Stefan C. Hardonka
a
Centre of Disability Studies, School of Social Sciences, University of Iceland, Reykjavık, Iceland; bThe State Diagnostic and
Counselling Centre, Kopavogur, Iceland

ABSTRACT ARTICLE HISTORY

Background: Life quality has become a widely used concept within rehabilitation and occupa- Received 4 April 2018
tional therapy practice. Revised 5 July 2018
Aim: This study explored child and parent perspectives of life quality of children with physical Accepted 30 July 2018
impairments compared with a group of non-disabled children.
KEYWORDS
Method: Data were collected with the Icelandic self- and proxy-reported versions of the Life quality; children;
KIDSCREEN-27. For children with physical impairments, reports from 34 children and 40 parents physical impairment;
were included in the analyses, and in control group reports from 429 children and 450 parents KIDSCREEN-27; self- and
were included. proxy report
Results: Children with physical impairments evaluated their life quality within the average range
on four out of five life quality dimensions. The lowest scores were within the physical well-being
dimension. Self-reported scores of children with physical impairments were higher than those of
their parents on all dimensions except autonomy and parent relations. Thus, the parents consid-
ered more environmental and personal factors to negatively influence their child’s life quality
than children did themselves.
Conclusion: Children with physical impairments experience their life quality similarly to non-dis-
abled children.
Significance: Focus on life quality can help occupational therapists to identify what circumstan-
ces positively or negatively influence client well-being and to focus more on contextual factors
that contribute to disablement.

Introduction barriers that hinders their full and effective participa-

tion in society’ [6]. Within occupational therapy stud-
For the last two decades, children’s rehabilitation has
ies, children’s well-being is said to be impacted by
made great strides in moving away from ‘medical
their daily participation and the occupations in which
model’ and impairment-based interventions that focus
they engage [9], and improving children’s life quality
on changing children’s body functions and structures,
is a pervasively stated goal of occupational therapy
to focusing more on contextual factors in disablement
programs worldwide [3,10].
[1,2], as well as children’s life quality [3–5]. This
Life quality is a multidimensional concept intended
important shift is partly related to the advent of the to capture children’s own subjective sense of well-
International Classification of Functioning, Disability being [5,11]. By focusing on circumstances that enable
and Health for children and youth (ICF-CY) [2] and or constrain children’s participation and prosperity –
is also in line with the United Nations Convention on e.g. in regard to health, standard of living, parental
the Rights of Persons with Disabilities (UN-CRPD) guidance, privacy, education, play and leisure – the
[6], both of which offer a relational understanding of concept relates closely to children’s rights [6,12].
the multiple mediators of disablement [7,8]. However, in health research some conceptual confu-
Accordingly, disability is considered to be the result sion abounds in term of relevant domains and how
of the dynamic interactions between children with these interact [8], with different measures having
impairments and ‘attitudinal and environmental


CONTACT Linda Bj€ork Olafsd 
ottir [email protected] Centre of Disability Studies, School of Social Sciences, University of Iceland, Saemundarg€
otu 2, 101
Reykjavık, Iceland
ß 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-
nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed,
or built upon in any way.
 SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 497

different understandings [13]. Also, the concept is quality of children with physical impairments with
‘subjective’ insofar as it is typically assessed using self- life quality of children in the Icelandic population.
report measures that produce measurable scores
across predetermined domains. Nevertheless, judicious
Methods
use of generic life quality measures like the
KIDSCREEN can help identify what circumstances Participants
positively or negatively influence children’s well-being
Participants were recruited from the registry of the
and thus provide valuable insights into how best to
State Diagnostic and Counselling Centre (SDCC),
support their rights as outlined by the UN-CRPD [6]
which keeps diagnostic records of the vast majority of
by focusing on contextual factors that contribute to
disabled children in Iceland. Eligible for participation
disablement.
were all children with physical impairments and IQ
Children with physical impairments often report
above 80, aged between 8-18 years at the time of the
levels of life quality similar to children in the general
study. The inclusion criteria were set to increase
population [14–17]. Most related studies focus on
children’s capacity to read and respond to a question-
children with Cerebral Palsy (CP) while a few have
included children with different diagnoses (e.g. chil- naire. Altogether 80 children and their parents were
dren with Spina Bifida or neuromuscular disorders) invited to participate in the study. Additionally, a ran-
compared with non-disabled children. For children dom sample of 429 non-disabled children from the
with CP, quantitative studies indicate that type and national registry (aged 8-18 years) and 450 parents
severity of impairment are seldom associated with participated in the study (control group).
perceptions of life quality [14,15,18]. Nevertheless, For children with physical impairments the
children having walking difficulties tend to report response rate was 42.5% (n ¼ 34) (self-reports). More
lower levels of physical well-being [15] and children parents than children answered the questionnaire and
experiencing frequent pain often report lower scores the response rate for parents (proxy-reports) was 50%
of overall life quality than other children [14,15,19]. (n ¼ 40). According to the records of the SDCC, most
Furthermore, studies provide conflicting evidence children had CP, others Spina Bifida (four children) or
about how life quality of children with other types of Neuromuscular disorders (six children). The children
physical impairments than CP compares with that of with CP were all classified at Level I or II in the Gross
children in general [20–22]. Thus, more studies are Motor Function Classification System (GMFCS) [28],
needed to shed further light on this topic. meaning that they were capable of walking in most set-
This study is part of a larger research project tings but uneven terrains, inclines and long distances
focusing on the life quality, participation and environ- might influence their mobility choices. Table 1 shows
ments of disabled and non-disabled children living in the sample characteristics of the participating children.
Iceland (LIFE-DCY) [23–27]. Our present objectives The majority of proxy respondents were mothers
are to 1) describe the life quality of children with (95% for children with physical impairments and
physical impairments as reported by the children 83.8% for control group). The mean age of proxy
themselves and their parents and 2) compare life respondents was 42 (SD ¼6.7) for children with

Table 1. Characteristics of the participating children and the children of participating parents.
Children with physical impairment Children in control group
Children self-report, n (%) Parent-proxy report, n (%) Children self-report, n (%) Parent-proxy report, n (%)
Gender
Boy 17 (50) 22 (55) 240 (55.9) 260 (57.8)
Girl 17 (50) 18 (45) 189 (44.1) 190 (42.2)
Age range (years)
8-11 11 (32.4) 12 (30) 151 (35.2) 170 (37.8)
12-18 23 (67.6) 28 (70) 278 (64.8) 280 (62.2)
Type of impairment
Cerebral Palsy 24 (70.6) 30 (75.0) – –
Spina Bifida 4 (11.8) 4 (10.0) – –
Neuromuscular disorders 6 (17.6) 6 (15.0) – –
Residence
Capital region 24 (70.6) 27 (67.5) 245 (57.1) 257 (57.1)
Small towns and rural areas 10 (29.4) 13 (32.5) 184 (42.9) 193 (42.9)
Type of school setting
Mainstream 30 (88.2) 35 (87.5) 416 (97.0) 437 (97.1)
Special education class 4 (11.8) 5 (12.5) 13 (3.0) 13 (2.9)
498 
L. B. OLAFSD 
OTTIR ET AL.

physical impairments and 44 (SD ¼6.6) for control

group, and most of them held a university degree;
62.5% for parents of children with physical impair-
ments and 69.3% for control group.

Measure
Data were collected with the Icelandic self- and proxy-
reported versions of the KIDSCREEN-27 [29]. The
measure is a generic health-related life quality instru-
ment for children and adolescents aged 8-18 years. It
was developed simultaneously in 13 European coun-
tries by appraising views of children and emphasising
perception of psychosocial aspects of well-being rather
than functioning or symptoms. The measure includes
27 items covering five life quality domains: physical
well-being (five items), psychological well-being (seven
items), autonomy and parent relations (seven items),
social support and peers (four items) and school envir-
onment (four items) (see Figure 1). Each question or
item is rated on a 5-point Likert response scale ranging
from ‘not at all’ to ‘extremely’ or from ‘never’ to
‘always’. The recall period is one week [29].
For this study, an electronic version of the
KIDSCREEN-27 was used that allowed questions to be
presented one at a time. Additionally, the children had Figure 1. Conception of the KIDSCREEN-27 dimensions [29].
the option of listening to pre-recorded questions. Before
answering, both children and parents were asked to
think about the last week and the parents were also regular mail to prospective participants in an enve-
given the instructions to answer how they thought their lope addressed to parents. The letters contained a
child felt. These instructions were in concordance with link to the study website and a password that
guidelines from the KIDSCREEN manual [29]. enabled participants to answer the life quality meas-
The KIDSCREEN measure has been shown to have ure electronically. Approximately one week later all
good psychometric properties [30,31]. In the current parents received a phone call as a reminder. This
study, the internal consistency (Cronbach’s alpha) for also gave them an opportunity to seek more infor-
self-report measures was in the range of 0.71 (physical mation about the study. It was considered as a con-
well-being) and 0.93 (psychological well-being) for chil- sent for participation if the parents responded to
dren with physical impairments and 0.79 (social sup- the measure and delivered the introductory letter to
port and peers) and 0.89 (psychological well-being) for their child. The child then decided to take part in
children in control group. For the proxy-versions the the study by answering or not. This arrangement
range was 0.70 (autonomy and parent relations) and was described in the introductory letters to parents
0.92 (social support and peers) for parents of children and children.
with physical impairments and 0.79 (autonomy and Participation was anonymous, ensuring that no
parent relations) and 0.88 (social support and peers) personal information was attached to the electronic
for parents of children in control group. Hence, all measure. A professional with a long experience work-
alpha values met or exceeded the threshold of 0.70 ing with children with physical impairments and their
that is required for group comparisons [32]. families at the SDCC was responsible for all commu-
nication with the research group while professionals
at the University of Akureyri Research Centre con-
Procedure
tacted the control group. The study was approved by
A cross-sectional descriptive comparative design the Icelandic National Bioethics Committee (VSN-13-
was used. Initially, introductory letters were sent by 081-V3).
 SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 499

Table 2. Comparison of children’s and parents’ ratings: Independent sample t-tests and effect sizes.
Independent
Children self-report Parent proxy-report sample t-test
Effect sizeb
a a
n Mean (SD) n Mean (SD) T P î2
Children with physical impairments
Physical well-being 33 45.97 (9.67) 37 36.85 (7.41) 4.451 0.001 0.23
Psychological well-being 33 52.46 (12.73) 39 42.14 (11.40) 3.628 0.001 0.16
Autonomy and parent relations 33 52.13 (7.89) 39 50.14 (7.23) 1.119 0.267 0.02
Social support and peers 34 50.19 (10.21) 38 44.53 (13.09) 2.029 0.046 0.06
School environment 34 52.91 (12.16) 39 47.35 (10.80) 2.070 0.042 0.06
Children in control group
Physical well-being 426 53.34 (10.81) 446 50.20 (10.15) 4.423 0.001 0.02
Psychological well-being 418 53.69 (10.47) 433 50.85 (9.90) 4.057 0.001 0.02
Autonomy and parent relations 400 52.75 (10.05) 410 51.15 (8.98) 2.392 0.002 0.01
Social support and peers 424 50.14 (8.99) 422 49.22 (9.93) 1.408 0.159 0.01
School environment 420 52.78 (10.11) 426 51.56 (9.61) 1.793 0.073 0.01
a
n may vary due to unanswered questions.
b
Interpretation of î2: 0.01 ¼ small effect; 0.06 ¼ medium effect; 0.14 ¼ large effect.

Analyses threshold of 53.34 þ/ (0.510.81) and t-test showed

significant difference between the scores of children
All analyses were conducted using IMB SPSS Statistics
with physical impairments and children in control
24. Total raw scores from each KIDSCREEN-27
group (t(457) ¼ 3.800, p < 0.001) although the effect
dimension were converted into Rasch scores and then
size was small (î2 ¼ 0.03).
into T-values by using SPSS syntaxes provided in the
Parents of children with physical impairments eval-
manual [29]. The threshold for classifying life quality
uated their children’s life quality below the average
scores as ‘within the average range’ or ‘below the
threshold on two KIDSCREEN dimensions; on physical
well-being (50.20 þ/ (0.510.15)) and psychological
average’ was set at a value of the mean life quality
well-being (50.85 þ/ (0.59.90)). On the physical
score of children in control group, plus or minus half
a standard deviation. For example, if the mean of the well-being dimension the proxy-mean score fell below
control group was 50 and SD was 10 the resulting one standard deviation from the control group’s mean
range was 45 to 55 (50 þ/ (0.510)). (<40.05) and t-test showed significant difference
Independent sample t-tests were conducted to (t(48) ¼ 10.190, p < 0.001) with high effect size
compare the means between different groups (95% (î2 ¼ 0.18). For the psychological well-being dimension
significance level) and effect sizes (eta (î2)) were cal- the difference was also significant (t(470) ¼ 5.201,
culated and classified as a small effect (î2 ¼ 0.01), p < 0.001) but the effect size was small (î2 ¼ 0.05).
moderate effect (î2 ¼ 0.06), or large effect (î2 ¼ 0.14) Additionally, significant differences were found on
(Cohen, 1988). Consistent with guidelines from the social support and peers (t(41) ¼ 2.156, p ¼ 0.037,
KIDSCREEN manual [29], the children were divided î2 ¼ 0.01) and school environment (t(463) ¼ 2.591,
into younger (8-11 years) and older (12-18 years) age p ¼ 0.010, î2 ¼ 0.01) both with small effect sizes.
groups. Additionally, in keeping with the guidelines, a The self-reported life quality scores of children with
dimension score was not calculated if more than one physical impairments were significantly higher than the
question remained unanswered. parent-proxy reported scores on the physical well-being
and psychological well-being dimensions with high
Results effect sizes, and on social support and peers and school
environment where the effect sizes were moderate. No
Table 2 provides mean T-values and SD, along with difference was found between the ratings of children
independent sample t-tests and effect sizes when com- with physical impairments and parents on autonomy
paring self- and proxy-reported scores (see also and parent relations (see also Table 2).
Figure 2). The mean self-reported life quality scores
of children with physical impairments were within
the average range in four out of five life quality Differences in age and gender
dimensions; psychological well-being, autonomy and For children with physical impairments, significant
parent relations, social support and peers, and school gender differences with moderate effect sizes were
environment. On the physical well-being dimension found on two life quality dimensions; on psychological
the children’s mean score fell below the average well-being (t(31) ¼ 2.086, p ¼ 0.045, î2 ¼ 0.12) and
500 
L. B. OLAFSD 
OTTIR ET AL.

Figure 2. Life quality scores based on self- and proxy-reports in both groups of children.

school environment (t(32) ¼ 2.174, p ¼ 0.037, In contrast, the ratings of the parents of children
î ¼ 0.13), with boys reporting higher levels of life
2
with physical impairments were less positive toward
quality than girls. No gender differences were found their children’s life quality. On two dimensions, phys-
when analysing the parent-proxy reported scores. ical well-being and psychological well-being, they eval-
Other background factors, like the children’s age and uated their children’s life quality below the average
residence did not influence self- or proxy-reported threshold. Thus, the parents were clearly concerned
scores among children with physical impairments. about their child’s physical activity and energy, as
Similar gender differences were not found in self- well as their self-esteem and happiness.
nor proxy-reported life quality scores among the control For children with physical impairments, the self-
group. Nevertheless, girls in the control group reported reported mean scores were higher than those of their
lower levels of life quality regarding physical well-being parents on four out of five life quality dimensions; on
than boys (t(332) ¼ 2.882, p ¼ 0.004) but with small effect physical well-being, psychological well-being, social sup-
size (î2 ¼ 0.02). In the control group older children port and peers and school environment. Medium to
reported lower life quality than younger children on all large effect sizes were found in these four dimensions.
dimensions except for autonomy and parent relations Despite these differences in ratings, the children with
with small effect sizes (p < 0.01, î2 < 0.06). physical impairments and their parents seemed to
agree about which area was most problematic, as
apparent in the lowest mean scores and high effects
sizes for the physical well-being dimension. Similar
Discussion
differences between self- and proxy reported scores
According to their ratings, children with physical were evident between children with autism spectrum
impairments were quite positive about many aspects of disorder and their parents in our larger study [24,27].
their lives. On the KIDSCREEN-27 the children eval- These findings are also in concordance with studies
uated their life quality within the average range on showing that parents of children with physical impair-
four out of five life quality dimensions. The results ments tend to rate their child’s life quality lower than
revealed their overall positive emotions and satisfaction the child’s own ratings, especially in domains that are
with life, fulfilment with their relationships with their more subjective than objective (or observable) in
parents and friends, and positive feelings about school. nature [33–36].
In fact, the self-reported scores for both groups of chil- The study results suggest it is important for occu-
dren were quite similar in all dimensions except for pational therapists and other professionals working
physical well-being where the mean score of children with disabled children and their families to recognize
with physical impairments was below half a standard that children and parents are likely to have different
deviation from the control group’s average. perspectives of the childrens life quality and consider
 SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 501

abilities, constrains and their implications differently physical well-being dimension perhaps contains the
when answering measures like the KIDSCREEN [24]. most ‘performance based’ items with questions such
It is not unlikely that parents are concerned with as ‘have you been able to run well?’ The study by
their child’s well-being and future prospects, and that Erhart et al. [41] shows that children with CP are less
their own normative ideas of what constitutes a good likely than children in general to obtain a high score
life may affect their answers even though they are on that item. Nevertheless, it can be argued that chil-
asked to answer just as their child would. However, dren with physical impairments can experience a high
the good news is that the children were generally level of physical well-being without being able to run,
positive towards their lives as evident on the psycho- walk or cycle well or the same way as other children
logical well-being dimension where the children’s do. It also raises the question what it means for them
mean scores were relatively high. to do things well, which is highly open to individual
Among children with physical impairments, gender interpretation, and if the children may instead be
differences were found on two life quality dimensions; responding to an imagined question of ‘can you run?’
psychological well-being and school environment with It can be argued that life quality measures that
girls reporting lower levels of life quality than boys. offer such set options of what constitutes a good life
These results revealed lower self-esteem, more sadness have major shortcomings, especially since they do not
and more negative feelings about school life among take into account the child’s unique perspective on
girls than boys. This is noteworthy in light of recent the relevant significance of each of these options in
concerns about the effect of the impairment on iden- relation to his or her life [8]. Nonetheless, we suggest
tity and masculinity of boys with physical impair- that such measures when used judiciously, are still
ments, and how it may affect their lives [37]. important in enabling the comparison between the
Nevertheless, little research is available on the inter- ratings of disabled and non-disabled children as well
section of gender and disability with school aged chil- as that of their parents [4], like we have done in this
dren and the effects of life quality. study. Historically, disabled children have been por-
For Icelandic children in general, recent findings trayed as incompetent and/or vulnerable in research,
from the 2015 OECD PISA research about well-being and although there is a growing tendency to include
of school-aged children showed higher satisfaction children’s perspectives, it is has mainly applied to
with life among boys than girls [38]. Furthermore, non-disabled children. Disabled children were, and
European studies report more decline of life quality still are, much less commonly involved, perhaps
of girls than boys with increasing age, especially because of perceived difficulties with access, the need
regarding ‘general moods and feelings about self’ and for some accommodations, and/or negative assump-
‘physical activities and health’ [39,40]. These differen- tions about their capabilities [42,43]. Therefore, it is
ces may be due to diverse social expectations, harsh important that disabled children are given the oppor-
self-criticism (e.g. related to body-image) and puberty tunity to participate in large-scale studies along with
being a more significant experience for girls than other children. The results of such research can be
boys [38,39]. Interestingly, this was not the case in used to identify specific challenges faced by disabled
our control group; although girls scored significantly children compared with other children; to influence
lower than boys on the physical well-being dimensions public policy decisions in order to support disabled
the effect size was only small and in other life quality children’s participation and well-being, and ultimately
dimensions gender differences were not found. to challenge oppressive social, cultural, legal, institu-
The KIDSCREEN measure has previously been tional, and other barriers that hinder participation
used in several studies to examine life quality of chil- and opportunities for disabled children [44].
dren with physical impairments [15,19,34] and it has When children with physical or other types of
been shown to give compatible results with children impairments report that their lives are of diminished
with CP and in the general population [41]. Most quality, there is a cultural assumption – frequently
items in the KIDSCREEN-27 concern how the chil- shared by practitioners and researchers – that this is
dren feel rather than what they do (e.g. ‘have you an inevitable consequence of their impairments [44].
been happy at school?’) and thus focus on feelings Much of our time as occupational therapists is spent
like pleasure and purpose in life, as well as the child- on evaluating and classifying children’s bodily struc-
ren’s sense of belonging - reflecting ‘subjective’ well- tures and function, and consequently we often work
being which is increasingly considered to be an towards changing the child’s body so it more closely
important strength for life quality measures [11]. The adheres to valued social norms of wholeness and
502 
L. B. OLAFSD 
OTTIR ET AL.

normalcy. However, the ICF-CY [2] promotes a more working with disabled children to understand and
expansive view of the role of rehabilitation providers, identify what factors might influence the children’s
one that looks more broadly at children’s lives by well-being e.g. with help from life quality measures
focusing on the interplay between their social partici- like the KIDSCREEN [29]. Nevertheless, further
pation and relevant environmental factors. investigation is needed to understand more fully how
The concept of life quality has the potential to help the key issues of life quality are understood, applied
us identify and address the qualities of meaningful by disabled children and relate to one another – as
living that are valued contributors to children’s rights well as how the constructs of life quality and partici-
and well-being [45]. That is where our focus should pation interrelate in the lives of disabled children and
be directed. youth. The complexities of different interpretations of
life quality by disabled children and their parents, and
the relations of life quality with other concepts such
Strengths and limitations as participation are the heart of our on-going study
A strength of this study is the large control group LIFE-DCY in Iceland. The findings presented here
based on population-based sample that allowed us to provide a starting point for further quantitative and
compare data from children with physical impairments qualitative analysis, on which we will report in add-
to that of Icelandic children in general. Another itional publications.
strength is that we stressed accessibility issues such as
providing the option of listening to pre-recorded ques- Acknowledgements
tions to children in both groups to enable more chil-
We would like to thank the families who participated in the
dren to participate. Also, a professional working at
study. We would also like to thank Professor Barbara E
SDCC was in contact with the research group and pro- Gibson at the University of Toronto who contributed to the
vided extra information about the study whenever research. The study was supported by the Icelandic Research
necessary. Not all children with physical impairments Fund under Grant number 174299-051; and the Doctoral
living in Iceland are listed in the registry of SDCC and Grants of The University of Iceland Research Fund.
it is a limitation to the study that only 34 children par-
ticipated. Also, information on background characteris- Disclosure statement
tics of non-responders was not available. Another
The authors report no conflicts of interest.
limitation is that mothers constituted a great majority
of respondents, with overrepresentation of parents with
university degrees, although the latter factor was not ORCID
found to be associated with differences between child Linda Bj€ 
ork Olafsd
ottir http://orcid.org/0000-0001-
and proxy ratings. No information was gathered about 9591-2798
other factors related to the children’s impairment, like Snaefrıdur Th
ora Egilson http://orcid.org/0000-0002-
possible co-morbidities and services received other 7578-5207
than special education services. Also, information was
not gathered about financial resources, social-economic
status and marital status of the participating families. References
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