Content uploaded by Karen Dobyns
Author content
All content in this area was uploaded by Karen Dobyns on Mar 21, 2018
Content may be subject to copyright.
Running head: INCREASING AWARENESS
Increasing Awareness and Acceptance of Children with Disabilities through Children’s Picture
Books
Karen Dobyns
Rocky Mountain University of Health Professions
INCREASING AWARENESS
2
Table of Contents
!
Abstract(....................................................................................................................................................(3(
Introduction(...........................................................................................................................................(4(
Importance(of(Participation(........................................................................................................................(5(
Occupational(Identity(and(Deprivation(...................................................................................................(7(
Occupational(Justice(....................................................................................................................................(12(
Social(Inclusion(..............................................................................................................................................(13(
Disability(Awareness(Programs(...............................................................................................................(22(
Children’s(Picture(Books(..................................................................................................................(25(
Promoting(Literacy(......................................................................................................................................(27(
Developmental(Growth(...............................................................................................................................(27(
Acceptance(of(Self(.........................................................................................................................................(35(
Transfer(of(Knowledge(................................................................................................................................(36(
Current(Status(of(Picture(Books(....................................................................................................(41(
OT(and(Picture(Books(..................................................................................................................................(44(
Occupational(Justice(....................................................................................................................................(45(
Unique(Focus(..................................................................................................................................................(46(
Habilitative(Services(....................................................................................................................................(50(
Co-occupations(..............................................................................................................................................(51(
Diversity(and(Identity(.................................................................................................................................(52(
Knowledge(Translation(..............................................................................................................................(53(
Centennial(Vision(...........................................................................................................................................(54(
Entrepreneurialism(...........................................................................................................................(55(
Possibilities(.....................................................................................................................................................(57(
The(Process(of(Writing(Children’s(Books(...................................................................................(59(
Needs(Assessment(........................................................................................................................................(60(
Questionnaire(Results(.................................................................................................................................(61(
Writing(..............................................................................................................................................................(63(
Illustrations(....................................................................................................................................................(64(
Publishing(........................................................................................................................................................(65(
Marketing(........................................................................................................................................................(66(
Innovation,(Implementation(.....................................................................................................................(68(
Sample(Manuscript(.......................................................................................................................................(70(
Conclusion(.......................................................................................................................................................(71(
References(............................................................................................................................................(73(
Note:!Appendixes!+!Self-Reflection!removed!from!Public!version.!!
(
INCREASING AWARENESS
3
Abstract
Children with disabilities often demonstrate reduced participation in social occupations such as
recess play, due to exclusion by others. Children without disabilities are often lacking
understanding or awareness about a child’s disability and are therefore less likely to be
accepting. Disability awareness simulation programs are often helpful in increasing level of
inclusion and acceptance, but are costly and time-intensive (Hurst, Corning, & Ferrante, 2012).
Children’s picture books can serve as educational tools to increase awareness and acceptance
that are cost and time efficient (Turner, 2006). However, picture books featuring children with
disabilities are vastly underrepresented, and there is a push within the publishing field to increase
diversity (We Need Diverse Books, 2014). Occupational therapists, due to their expertise in
analyzing needs and barriers, their skills in knowledge translation, and ability to promote health
and wellness, are well equipped to write, publish, and/or disseminate children’s books about
children with disabilities. Such books can promote wider recognition of occupational therapy,
furthering the goals of the Centennial Vision (AOTA, 2007). There is also a multitude of non-
traditional entrepreneurial possibilities and marketing opportunities associated with the writing
or distribution of children’s books featuring children with disabilities. In addition to such books
helping promote awareness and acceptance of children with disabilities, occupational therapists
and clinics could directly and indirectly profit from the selling or distribution of these books.
Keywords: disability, children, picture books, diversity, occupational therapy, entrepreneurial
INCREASING AWARENESS
4
Increasing Awareness and Acceptance of Children with Disabilities through Children’s Picture
Books
Children with disabilities face barriers to occupational participation, whether related to
client factors, performance skills, or contexts and environments (American Occupational
Therapy Association [AOTA], 2014). Some barriers are easily addressed, such as modifications
of physical environments, while others, particularly pertaining to social environment and cultural
context, require nuanced navigation, sometimes at a community level. For example, many
people without disabilities in the community are lacking awareness, understanding, and
acceptance of children with disabilities, and therefore exclude them, whether inadvertently or
deliberately (Hurst, Corning, & Ferrante, 2012). This social exclusion leads to occupational
deprivation of children with disabilities, negatively affecting their quality of life, self-acceptance,
developmental growth, and more (Dahan-Oliel, Shikako-Thomas, & Majnemer, 2012; Houtrow,
2012; Lawlor, 2003).
Occupational therapists (OTs) have an ethical and moral imperative to address this
injustice, considering that the OT profession is based on the fundamental belief that occupational
participation is a basic human right (AOTA, 2010; World Health Organization [WHO], 2011).
One of the main interventions currently used to promote awareness and acceptance of children
with disabilities (hopefully leading to social inclusion and occupational participation) is
disability awareness programs or events (Ison et al., 2010; Rillotta & Nettelbeck, 2007).
However, such programs are typically costly, time-intensive, and local affairs. There may be
similarly effective approaches that are inexpensive, require less time, and can more efficiently
reach a broader audience. For example, bibliotherapy, or the use of books as a therapeutic tool,
has been completely ignored within the field of occupational therapy, at least based the absence
INCREASING AWARENESS
5
of literature. Yet there is a wealth of evidence in other fields that supports the use of children’s
picture books as educational tools that can promote emotional competency and increase
understanding of various issues (Gebarski et al., 2013; Turner, 2006).
One could argue, based on synthesis of the literature, that the collaborative reading and
discussing of carefully chosen children’s picture books could be an effective tool for OTs to use
for increasing awareness and acceptance of children with disabilities. Unfortunately, there are
limited books out there that appropriately portray children with disabilities (Brenna, 2008;
Dyches, Prater, & Leininger, 2009). Therefore one could also argue that occupational therapists
are uniquely suited to write children’s books that cover these gaps in the literature. By writing
and reading books about children with disabilities, it helps promote awareness and acceptance,
leading to social inclusion, which leads to increased participation in occupation. In addition, use
of children’s books as a tool, whether through creation or curating, could provide a non-
traditional, entrepreneurial stream of income or value-added service that can increase referrals
and place occupational therapy in the public eye.
Importance of Participation
The WHO’s International Classification of Functioning, Disability and Health (2007)
defines participation as ‘involvement in life situations’ ([3], p. 1). AOTA defines participation as
“engagement in desired occupations in ways that are personally satisfying and congruent with
expectations within the culture” (AOTA, 2014b, p. 35). In 2010, Hoogsteen and Woodgate
performed a concept analysis of the term “participation,” finding that the term was not well
defined for the purposes of measurement or even understanding. The researchers, through an
exhaustive literature review, determined that for true participation, the child must feel a sense of
inclusion, be engaged either with “something or with someone” (p. 326), feel some level of
INCREASING AWARENESS
6
control, and be working toward a goal or something that enhances quality of life, which can
refer to something as simple as play, something children value. In a systematic review of
nineteen studies, compiled by Dahan-Oliel et al. (2012), they found that children’s level of
participation in leisure activities, whether structured or unstructured, were positively correlated
with quality of life. This was a Level 1 study per the Oxford 2011 levels of evidence (OCEBM
Levels of Evidence Working Group, 2011). Please note that all levels of evidence discussed in
this paper were determined from the same resource.
Yet multiple studies have found that children with special needs demonstrate decreased
levels of occupational participation (Hurst et al., 2012; Masse, Miller, Shen, Schiariti, &
Roxborough, 2013) due to barriers related to mismatches between occupation and necessary
performance skills, client factors, and/or contexts and environments. In 2013, Masse et al.
retrospectively analyzed the survey data from over 7,000 interviews with Canadian parents who
had children between the ages of five- to fourteen-years-old with activity limitations, as
determined during a 2006 census. The researchers reviewed patterns of participations in children
with neurodevelopmental disabilities, finding that results varied dramatically by environment
and specific subtype of disability, but that children with social interaction or psychological
disorders had the lowest participation within educational activities. Also in 2013, Coster et al.
had 576 parents fill out a Participation and Environment Measure for Children and Youth
questionnaire in order to compare patterns of social participation by children with disabilities
versus those without. Their results showed that parents reported their children with disabilities
participating far less in school activities, and that one major reason was a socio-environment
barrier.
In an even more recent systematic review by Shields, King, Corbett, and Imms (2014),
INCREASING AWARENESS
7
the investigators determined that children with intellectual disabilities were significantly less
likely to participate in community-based activities (social, recreational, formal, etc.). Thus,
participation restrictions are consistently noticed in a wide variety of contexts and environments
with children who have a wide variety of diagnoses. Considering that the U.S. Census Bureau
(2010) reports that at least 19% of non-institutionalized individuals have a disability, and that
major laws such as the Americans with Disabilities Act of 1990 and Individuals with Disabilities
Education Improvement Act of 2004 have been in place for over a decade, this is a disturbing
finding. Unfortunately, despite the laws that state it is illegal to exclude someone based on
disability, social exclusion is still common in most settings, such as schools and recreational
areas (Coster et al., 2013; Dahan-Oliel et al., 2012). This social exclusion has massive effects on
the construction of occupational identity, an extremely important component of early
development (Lawlor, 2003).
Occupational Identity and Deprivation
Occupations are central to a person’s identity and sense of self-efficacy, and different
occupations will have different meanings to different people (AOTA, 2014b; Bandura,
Barbaranelli, Caprara, & Pastorelli, 2001). According to developmental frames of reference, the
construction of occupational identity begins early in childhood, as children began to take on
different roles and engage in occupations that can provide them with experience, the mastering
of tasks, knowledge, and experimentation. This helps children discover what does and does not
interest them, enforces values that he or she applies to self and others, and builds (or destroys)
self-esteem (Bandura et al., 2001; Sokol, 2009). Erikson (Sokol, 2009) looked at identity
construction from an individualistic perspective, while other theorists have preferred a more
sociocultural perspective (Phelan and Kinsella, 2013). Yet very little research has been done on
INCREASING AWARENESS
8
occupational identity in children with disabilities. Phelan and Kinsella (2013) were curious to
know how occupation at a sociocultural level shapes identity in this population. The researchers
used a Level IV collective case study methodology to explore perspectives on identity with six
children and their parents through three different methods: assessment, photoelicitation
interviews, and semi-structured interviews. The children were between the ages of ten to twelve
and had a variety of disabilities, including cerebral palsy and spina bifida. Purposeful sampling
was used to capture data from children both in rural and urban areas. The major theme that arose
was that of relational identity, with the children having and/or wanting relationships with their
peers, being very aware of these relationships, and identifying themselves through those
relations.
Other themes that arose that affected occupational identity were whether the children had
feelings of success when accomplishing occupations such as swimming, and whether the
children were able to keep up with their peers. Based on the children’s narratives and their
analysis, using grounded theory methods, researchers determined that the overarching theme was
one of a desire and focus on “sameness” (p. 349) due to the children’s (with disabilities) desire to
fit in with their peers on a sociocultural level. The researchers also found that occupational
identity was far more dynamic than realized and that sociocultural dimensions had significant
impacts, sometimes on a day-to-day basis on the types of occupations chosen to participate in,
level of participation in occupation, and how the child defined him or herself (Phelan & Kinsella,
2013). This dynamism could be argued to be a good thing, as it speaks to the ability of positive
external influences, such as that of an occupational therapist, being able to help reconstruct a
child’s occupational identity. Considering the developmental interplay between construction of
occupational identity and how heavily it’s affected by participation, children who have restricted
INCREASING AWARENESS
9
participation (focusing on social barriers for the purpose of this paper) are at extreme risk of
occupational deprivation. Considering how rarely the occupational identity of children with
disabilities has been studied, the trustworthiness of this study is vital.
While the adult participants were not asked to review the data for credibility purposes,
the researchers included many quotes from both the children and parents, were in prolonged
engagement with the participants, and triangulated the data, which all contributes to credibility.
The thick description, content, and thorough overview of the methodology was also helpful in
addressing dependability, as it appears the study could easily be replicated. Confirmability was
strong, as the two researchers were in constant contact and left a strong audit trail, as well as
wrote reflexive field notes after each interaction. Limitations of their study included that five of
the six participants were female, and four of them had either cerebral palsy or spina bifida, which
can hypothetically affect transferability as it was primarily based off female perspectives and two
specific disabilities. However, the authors’ provision of thick description and context somewhat
counteracts that issue. Based on the trustworthy findings of identity construction, it does appear
valid to say that occupational deprivation could lead to significant dysfunction (Phelan &
Kinsella, 2013).
Deprivation occurs when one is not able to engage in occupations that one wants or needs
to participate in (van Bruggen, 2014). Risk factors for social exclusion are similar to those of
occupational deprivation, as they feed off each other. The more a child is socially excluded, the
more the child can be occupationally deprived, leading to a decreased quality of life (van
Bruggen, 2014). In 2014, Spilt, van Lier, Leflot, Onghena, and Colpin conducted one component
of a longitudinal study with 570 Belgian children, examining how self-concept was affected by
peer rejection. They found that the higher the levels of peer rejection, the lower the self-concept
INCREASING AWARENESS
10
and the higher risk of psychopathology. Children with disabilities are typically rejected more
than their peers (Dahan-Oleil et al., 2012; Hurst et al., 2012) and are thus at high risk for
internalizing their problems and having poor self-esteem. Considering young children are in the
thick of the developmental necessity of identity construction and task mastery (Sokol, 2009),
social exclusion and occupational deprivation are extremely harmful. Thus, health and wellness
are inextricably linked with participation and inclusion in occupation (Hocking, 2013).
Occupational deprivation is often an issue of deprivation from social occupations, such as
playing a game. Lawlor (2003) argues that children are “…socially occupied beings, doing
something with someone else that matters” (p. 432), meaning that meaningful participation
requires social interaction as a part of basic human development. Lawlor (2003) also points out
that children are innately wired from birth to seek out connection. Thus the developmental
importance of participation, social inclusion and engagement in occupation cannot be
understated.
Developmental and occupational theorists, operating under developmental frames of
reference, have long noted that through participation and engagement in tasks, activities, and
occupations, children establish feelings of task mastery and competence, learn a sense of self-
efficacy, develop/refine motor, cognitive, and socioemotional skills, and construct their
occupational identity (AOTA, 2014b; Lawlor, 2003; Phelan & Kinsella, 2013; Sokol, 2009).
Within each life stage, to achieve competence, children must be provided with “just-right”
challenges that facilitate their growth in each of these areas (Bandura et al., 2001; Sokol, 2009).
Developmental theorist Piaget stated that young children (ages two to seven) are in a
preoperational and then concrete operational stage (ages seven to eleven), acquiring new
knowledge through their hands-on manipulation of objects, such as learning about mass and
INCREASING AWARENESS
11
volume during water play, implying that children who do not participate in these activities are
reducing their chances of acquiring new knowledge about how their world works (Blake & Pope,
2008). Freud argued children between the ages of six to eleven-years-old are in their latency
stage in which they focus on learning new skills and forming defense mechanisms based on their
interactions with peers (Smith-Osborne, 2007). Erikson based his theories off social interaction,
arguing that at different ages, certain conflicts had to be resolved for developmental health. In
“middle childhood,” roughly the same ages as in Freud’s latency stage, Erikson theorized that
children have to resolve feelings of “accomplishment versus inferiority,” through focusing on
learning skills, comparing self to others, and competing. Children began to gain a sense of
competence and identity from these experiences (Sokol, 2009). Gesell notes that socioculturally,
children in early and middle childhood are looking for friends, wanting to play with other
children, and starting to form groups and teams. Vygotsky also believed that social interaction
and the sociocultural environment was critical for developing self (Blake & Pope, 2008).
Children prevented from participating in these phases of growth due to barriers, with a
focus on social barriers in this case, are at a massive developmental disadvantage. While these
children may have been able to remain somewhat developmentally on par with their peers had
they been allowed the same experiences, their lack of participation can cause a learned, or
perhaps “unlearned-induced” developmental delay. From a motivational standpoint, most
children are motivated to continue learning due to success in previous learning experiences.
Children who are repeatedly excluded or are unable to complete tasks like their peers are likely
to lose motivation, which hinders their progress even more (Bandura et al., 2001).
In other words, children who are occupationally deprived due to social exclusion
(ignoring physical barriers for the purpose of this paper), which is often the case with children
INCREASING AWARENESS
12
with disabilities, are less likely to participate in the very activities that help them
developmentally, leading them to fall farther behind their peers. The growing developmental
disparity perpetuates the social exclusion, leading to ever-increasing chances of exclusion and
therefore restricted participation or occupational participation. It’s a vicious cycle, and a reason
why it is so important to address the concept of social inclusion as early as possible.
In 2013, Anaby et al. performed a scoping review of the effect of environment on
participation of children with disabilities. The researchers reviewed thirty-one studies written
between 1990 and 2011, having to do with children between the ages of five- to twenty five-
years of age in non-school environments. They determined that different domains of the
environment could act as a facilitator or barrier, but that social support was one of the most
important for increasing participation.
Occupational Justice
While there are unlimited reasons to promote social inclusion of children with disabilities
within all environments, one of the ethical reasons to do so is due to the concept of occupational
justice, which addresses the fundamental right of all people, regardless of differences such as a
disability, to have full inclusion in daily life participation, within any context and environment
(AOTA, 2014a). The AOTA emphasizes the importance of occupational justice in its
Occupational Therapy Practice Framework: Domain and Process, 3rd ed., ([Framework-III],
AOTA, 2014b), Code of Ethics (AOTA, 2015), and Standards of Practice (AOTA, 2010).
AOTA notes that it is a professional responsibility and ethical imperative for occupational
therapists to be aware of and address occupational disparities, which can often be done via
intervention. Van Bruggen (2014) notes that occupational injustice is a huge factor contributing
to social exclusion, thus addressing injustice can help reduce social exclusion. In addition,
INCREASING AWARENESS
13
AOTA (2014a) has a specific policy statement on nondiscrimination and inclusion, noting that
society as a whole benefits from the inclusion of all individuals, and that the profession’s
interventions are expected to be facilitators of occupational engagement. However, as Nilsson
and Townsend (2010) point out, there is a difference between occupational therapists
understanding and valuing the concept attitudinally, versus actually incorporating the concept
into practice. A bridge must be found to link attitude and behavior, and intervention can vary by
therapist and situation.
Occupational therapists must remember that intervention for occupational justice does not
always have to occur at an individual level. There is growing awareness and calls for action
within the profession of occupational therapy to promote and encourage inclusion and
participation at a community and population level as well (Hildenbrand & Lamb, 2013; Leclair,
2010). However, the first step for an occupational therapist to take is to explore the literature on
social inclusion and exclusion in order to gain a clearer understanding of the barriers and
perceptions of the phenomena.
Social Inclusion: Addressing Lack of Awareness and Understanding
Addressing social inclusion can seem deceptively simple. One could conjecture that all it
takes is an adult requiring social interaction between children with and without disabilities. For
example, an adult could force children playing kickball to include a child with a disability in the
game. For all intents and purposes, one could look at a snapshot of the scene and it would appear
the child with a disability is being included. However, in order for social inclusion to
authentically take place in social environments such as the classroom, the children without
disabilities must be accepting of inclusion. This can be very challenging as many children
without disabilities have negative attitudes/feelings/behaviors/thoughts towards children with
INCREASING AWARENESS
14
disabilities (Nowicki & Brown, 2013). The level of negativity can vary by type of disabilities,
level of children’s contacts with children with disability, and amount of accurate disability
knowledge/understanding (Anaby et al., 2013; Hurst et al., 2012). How to address these attitudes
can take many approaches, and children have differing views on inclusion than adults.
Children with and without disabilities are typically well aware of the difference between
forced inclusion and desired inclusion, as discovered in a phenomenological Level IV study by
Spencer-Cavaliere and Watkinson (2010). These researchers explored the concept of inclusion
from the point of view of the children with disabilities, which has rarely been done. Typically
inclusion is studied from the perspective of how it impacts others, versus analyzing the feelings
of children with disabilities. The researchers were interested in learning more about the
subjective experiences of children with disabilities because it has important implications for how
adults should approach the encouragement of inclusion.
Researchers performed semi-structured interviews with eleven children total: nine boys
and two girls with an age range from eight to twelve years old. All had disabilities that varied
dramatically in impact/type, from asthma to cerebral palsy. The researchers utilized purposeful
sampling with a goal of maximum variation, in order to explore individual perspectives from a
wide range of ages, gender, and type of disability, and find similarities among the participants’
experiences as well. After each recorded interview, the researcher also wrote reflective field
notes. After transcription of the interviews had taken place, researchers used content analysis to
extract and tag major themes, and then analyzed line-by-line to sort the information into more
specific groupings. This continued until data saturation took place. Three major themes about
inclusion, from the perspective of children with disabilities, emerged from analysis: gaining
entry to play, feeling like a legitimate participant, and having friends.
INCREASING AWARENESS
15
Regarding entry to play, children with disabilities talked about feeling included when
other children invited and/or allowed them to play, and felt excluded when other children either
said no or ignored them. Regarding feeling like a legitimate participant, it was affected by
whether a teacher or parent initiated/forced the participation, whether the child felt capable of
performing the task, whether the other children treated them differently for having a disability,
and whether the other children seemed to want their participation. Children talked about the
difference between being included and feeling included, a rather profound distinction. Regarding
having friends, children felt that having friends was a bridge/opportunity to feel included and/or
invited to play, leading to an increased chance of participation. Overall, the three feelings of
inclusion seemed to be “acceptance, belonging, and value,” and that “peer support, social
isolation, and negative emotions” also corresponded with the three themes (p. 287). The concept
of social acceptance by others was extremely important to feelings of inclusion, and being asked
to play was particularly important, although the most salient factor seemed to be the perception
of having friends (Spencer-Cavaliere & Watkinson, 2010).
Overall, the children’s feelings of inclusion were heavily influenced by how others
treated them, and a feeling of inclusion went far beyond the actual “act” of inclusion, i.e. where
for all intents and purposes the child appears to be included. While adults could contribute (or
not) to feelings of inclusion, ultimately it was the actions of peers that made the most
comprehensive differences in children’s perceptions of inclusion (Spencer-Cavaliere &
Watkinson, 2010). None of these results is surprising, although many studies are undertaken in
order to accumulate evidence for a seeming fact. Based on these results, adults who push
inclusion and help children participate need to realize that the child may still not feel included,
and that it makes sense to work on inclusion from a peer level rather than from an adult level. (In
INCREASING AWARENESS
16
other words, work on increasing children’s willingness and self-initiated desire to include
others in play, as children with disabilities are sensitive to the difference between what’s
mandated and what’s desired.)
The researchers addressed major components of trustworthiness, allowing readers to feel
more confident about using and applying the provided information. The researchers discussed
the 20+ years of experience of the researcher/interview, their use of two pilot studies, and use of
two types of data to demonstrate credibility/corroboration. In addition, a second person
independently coded the data to establish dependability and confirmability. The researchers
explained their audit trail so one could follow their reasoning (Spencer-Cavaliere & Watkinson,
2010). While transferability was slightly limited because nearly half their participants had
cerebral palsy, and only two girls were included, they provided such thorough coverage of the
context these statements were made in that they appear transferable to the general population of
children with disabilities. While this study examined the perception of social inclusion and
exclusion from the point of view from children with disability, there are also studies that
examine the perception from the point of view of children without disabilities.
In a qualitative phenomenological Level III study, Nowicki, Brown, and Stepien (2014)
performed semi-structured interviews with 36 Canadian school children in grades five and six
(mean age = 10.42 years), exploring the children’s views on why social exclusion of peers with
intellectual or learning disabilities took place. The researchers then transcribed the interviews,
sorted out the unique information, and then collaboratively concept mapped the emerging themes
with the students. They found that most of the concepts fit into one of four clusters, including
“thoughts and actions of other children,” “differences in learning ability and resource allocation,”
INCREASING AWARENESS
17
“differences in affect and physical characteristics,” and “negative behavior and thoughts” (p.
351).
For the first cluster of thoughts and actions of other children, the concept of social
selectivity emerged, where children choose to play with others like themselves (for example
smart or cool), and dismissing other students as dumb or less cool. For the second cluster of
differences in learning ability and resource allocation, there was the concept that children with
disabilities would cause issues that disturbed a game, or would not have the same abilities or
interests. In addition, children were bothered with the perception or idea that the children with
disabilities got paid more attention and took up too much of the teacher’s time, which was
frustrating. For the third cluster of differences in affects and physical characteristics, children
discussed fear, anger, and frustration as possible feelings of either the child with a disability or
the child without. In addition, physical differences or other types of problem such as a hearing,
visual, or speech issue was a cause for social exclusion. Finally, within the cluster of negative
behaviors and thoughts, children noted that sometimes children with disabilities were mean or
weird or caused issues, and/or that children without disabilities didn’t know what to do or are
ignorant, which leads to social exclusion. All of the information in the clusters above was
suggested as possible reasons for social exclusion.
The study appeared trustworthy. The interviewer was an experienced teacher, which
raises credibility. In addition, the three researchers performed independent reviews, with
discussion to resolve any differences in process, contributing to confirmability and credibility.
They utilized thick description to help with transferability and confirmability. They also shared
their audit trail, and used evidence to back up their rationale for using or modifying certain types
of data, which contributes to all aspects of trustworthiness. A limitation of the study was that
INCREASING AWARENESS
18
while students readily provided reasons for social exclusion, none admitted to practicing those
reasons. Therefore the students were likely not fully truthful in their interviews as the students
did not want to appear as if they were practicing social exclusion. However, the reasons the
students provided appeared legitimate, even if they did not own them as their own. Overall, the
researchers felt that the unifying theme of reasons for social exclusion was difference. Children’s
perception of self, versus their perception of children with disabilities as “others” due to their
differences, coupled with the children’s often-inaccurate perceptions of children with disabilities
due to lack of awareness and understanding, is a recipe for social exclusion. This perception of
self versus other due to differences is in alignment with socio-developmental theories, as
children in their early and middle childhood years, are in the process of learning “theory of
mind,” defining themselves in relation to others and learning how others feel may be different
than their own feelings (Korkmaz, 2011).
In addition, children with and without disabilities have ideas on strategies for
social inclusion. In a phenomenological Level III study that took place in 2012, Lindsay and
McPherson explored the views of fifteen children with cerebral palsy in regards to social
inclusion, interviewing the children either individually or via group discussion. These children
with disabilities came up with a variety of strategies to increase inclusion, and several had to do
with increasing awareness of the disabilities. Insert sentence here. In 2013, Nowicki and Brown
performed semi-structured interviews with thirty-six children in junior high school (nine to
twelve years of age), without disabilities, in a phenomenological study examining the children’s
ideas for social inclusion of children with intellectual and/or learning disabilities in their school
environment. Seven major themes arose from the children’s strategies, one of which was a need
to focus on similarities, not the differences, between children with and without disabilities. This
INCREASING AWARENESS
19
in alignment with the findings of Phelan and Kinsella (2013), as one of the themes that
emerged from the researcher’s interviews with children with disabilities is that the children
desired fitting in with their peers/being similar.
In 2014, Macmillan, Tarrant, Abraham, and Morris performed a Level I narrative
systematic review on thirty-five quantitative studies that were observational in nature, examining
the associations between contact with a child with a disability and attitude. All studies measured
children’s attitudes towards disability, and consisted primarily of Level IV studies, correlational
using multiple school sites. The majority of studies had samples of over 100 students, increasing
both internal and external validity. Overall, significant positive association and correlation was
found between children who have contact with people with disabilities and their attitudes
towards disability, in 16 of 35 studies. Six studies found no association if a full attitude measure
was in place (overall score), but five of those studies did show significant results on some
subscales. Eleven studies found no association at all, and two found a negative association.
However, one of those two had a small effect size, and an effect size was not noted in the other.
Interestingly, when looking only at the twenty-two articles with school-level contact, there was a
positive association in twelve studies, two negatives, and no association in eight. On the other
hand, in the self-report studies, eleven out of thirteen of them found positive associations and
only two studies found no association. Researchers noted that in general, self-report measures
were found to be more reliable for these types of studies, pointing out a possibility that there is
maybe a stronger positive association than it appears when looking at school-level studies.
Overall, based on the number of studies that found a positive association, it does seem to confirm
that the more contact a child had with someone who had a disability, the more likely they were to
have an more accepting attitude. Also, thirteen out of the thirty-five studies were from the 1980s,
INCREASING AWARENESS
20
which may not reflect attitudes of current times, considering all the legal and social changes
that have occurred in the past thirty years. One would cautiously and hopefully assume that
attitudes have continued to improve since then. There were some issues with the systematic
review, including that out of thirty-five studies, there were twenty-six different measures used,
which can make it very hard to compare. The instrument widely considered the most reliable was
only used in five of them. Some of the studies focused on a specific disability, and some more
generally, and there is possibly differences in contact attitudes depending on the type of
disability. In addition, the majority of the studies were lacking vital information, meaning they
were relatively poor quality.
The systematic review was overall well done, explaining in detail their methods, results
and including tables of information for all studies, as well as including a quality appraisal. One
cannot have contact without simultaneously being exposed, and exposure by itself, via the
reading of children’s books, could potentially be considered a priming factor for contact. It
stands to reason, with studies like this one backing it up, that if children are exposed and have
new knowledge about a child with disabilities, they are more likely to have a positive association
with children with disabilities. This was true over 75% of the time in the self-report studies,
which are considered more valid than school-contact studies. The more likely the child is to
have a positive association with a child with disabilities, the more likely the child may reach out
to the child with disability due to an increase in awareness. The strategies provided by children,
with and without disabilities, regarding social inclusion, all included increasing awareness of
disability, and contact is certainly one method to do so.
One major component of awareness and reason for its effectiveness is that awareness is
often coupled with an increase in understanding. Lawlor (2003) discusses the concept of
INCREASING AWARENESS
21
intersubjectivity, or the capacity to understand the viewpoints of others, which first requires
awareness, leading to the next potential step of understanding. Hong, Kwon, and Jeon (2014)
found that the more understanding of disabilities that children without disabilities had (for any
reason, such as previous exposure, adult discussion, etc.), the more likely the children were to
have positive feelings and the higher the probability these children would socially include
children with disabilities in play. The researchers performed semi-structured interviews with a
staggering ninety-four preschoolers and their parents to come to this conclusion, which is in
alignment with the results of other studies discussing children with disabilities and social
inclusion (Nowicki, Brown, & Stepien, 2014; Spencer-Cavaliere & Watkinson, 2010). The
researchers highly recommended promoting awareness and understanding of children with
disabilities starting as young as possible, while children were developmentally most malleable
and therefore most receptive to attitudinal change (Hong, Kwon, & Jeon, 2014).
Many types of programs have been implemented, formally or informally, in order to
address social inclusion in the schools, with varying but typically positive levels of success
(Hurst et. al, 2012; Nowicki & Brown, 2013). Some schools have special events or programs,
others rely on their teachers, and some do not address it at all except through having socially
inclusive classrooms (which is typically not enough to actually have social inclusion). Those
environments that actually address participation and social inclusion typically attempt to do so
via awareness, understanding, knowledge, contact, and discussion. Via literature review, it
appears that disability awareness programs of varying lengths and complexity, undertaken by
schools, camps, or other environments, were the most common approach to promoting social
inclusion.
INCREASING AWARENESS
22
Disability Awareness Programs
Many disability awareness programs have been attempted in schools and the community,
with the aim of increasing awareness and acceptance of children with disabilities. Those that
succeed attribute the increased level of acceptance and inclusion among teachers and peers as
being due to increased awareness and education (Hurst et al., 2012; Ison et al., 2010; Rillotta &
Nettelbeck, 2007). In 2010, Ison et al. researched a two-session disability awareness program
with 147 Australian students from nine to eleven years of age. Multiple educational modalities,
primarily cognitive-behavioral in approach, were used in these sessions, and included writing,
simulations, and demonstrations. In this mixed-method study, children filled out pre-post
questionnaires and participated in focus groups to provide measures of change. Researchers
found significant improvements in knowledge, attitude, and acceptance, even after just two
sessions.
In 2012, Hurst et al. examined how a disability-simulation program would impact
children’s acceptance of children with disabilities, using a Level III one-group pretest-posttest
study with a convenience sample of 231 second- and third-graders. As a pre-test, researchers first
administered an adapted version of Voeltz’s Acceptance Scale, which is a survey with Likert-
scale questions asking students about others with a disability, to measure acceptance levels. All
participants then participated in a one-time disability awareness event in which the children
rotated to four different stations in which they could simulate various disabilities as well as
observe and discuss. Afterwards, the children once again filled out the same survey, in order for
researchers to measure the change in students’ acceptance of children with disabilities from
pretest to posttest (with the pretest serving as a control for comparison). Researchers compared
the group means of the pre-and post-survey questions, finding an expected increase in students’
INCREASING AWARENESS
23
acceptance, as measured by the survey, on seven of the eight questions. (The one question that
showed a decrease appeared to be an outlier due to the researcher’s scale adaptation versus a true
decrease). The results were only statistically significant for five of the questions, p < 0.05,
although the increase was clinically meaningful in the seven questions. Investigators also found
that students who knew someone with a disability were significantly more likely to be accepting,
and students who had exposure to other students with disability, regardless of frequency, were
more accepting than those who had not been exposed, which was clinically meaningful even the
result was not statistically significant. This finding is in alignment with multiple other studies on
contact (Ison et al., 2010; Papaioannou, Evaggelinou, Barkoukis, & Block, 2013.). The
researchers posited that there may have been a ceiling effect on some scores since 70% of
students had shown high acceptance rates even on the pre-test, so there were limits to how much
further the scores could go up, making it harder for there to be statistical significance.
Limitations included the fact that both schools were over 70% Caucasian, which makes it
potentially hard to generalize the results to minority populations. However, they did use both
genders and explained their process and shared the questions asked, which helps with external
validity. Another limitation was that investigators adapted a validated version of the Voeltz
Acceptance Scale, and based on their description, modified it so extensively that it would not be
recognizable as the original. Therefore its internal validity is in question (although they do note
correlations between questions such as it appeared to have good construct validity). Another
concern was how the researchers worded their question, which appeared confusing. For example,
children had to agree or disagree on the following. “At lunch, I would not like to sit next to
someone who had no arms.” Even though there were threats to both internal and external
validity, their results were overall in alignment with the expected hypothesis, which is that a
INCREASING AWARENESS
24
disability awareness program leads to increased acceptance. This study helps demonstrate that
awareness is a major factor in acceptance.
In a Level II randomized controlled trial by Papaioannou et al. (2013), 387 adolescents
without disabilities (mean age = 13) in a summer camp were divided into an experimental and
control group. Those in both groups had typical programming, although those in the
experimental group also attended a full-day disability awareness program, participating in a
variety of modified sports, reading books, watching videos, and taking part in discussions.
Participations completed a scale addressing attitudes towards inclusion both before and after the
programming, and there was a significant increase in positive attitude towards inclusion in the
experimental group, whereas the control group remained stable in attitude. Noticeably, the
children’s attitudes changed from the program even in the absence of any children with
disabilities. The researchers discuss the importance of awareness in promoting understanding,
and therefore attitude shifts. While this study did not follow-up after a period of time to
determine attitude stability, a very similar study completed by Moore and Nettelbeck (2013)
found that the improvement in attitude was still present at a one-month follow up.
Lindsay and Edwards (2013) performed a Level I systematic review of forty-two studies
to examine the characteristics of successful disability awareness interventions. Thirty-four of the
studies found an increase in awareness and therefore acceptance, eight studies found an increase
in knowledge, and only five studies reported negative or neutral results, suggesting strong
evidence that these programs can be effective. However, the researchers found that nobody had
analyzed the programs to determine the most effective methods. Methods can include
simulations, theater, children’s books, discussions, videos, and more. Researchers found that the
most effective programs included a wide variety of multi-media and interaction, and virtually all
INCREASING AWARENESS
25
the successful programs noted that the increase in awareness and knowledge of disabilities led
to positive attitude changes.
In 2014, De Boer, Pijl, Minnaert, and Post performed a quasi-experimental longitudinal
study with an experimental and control group consisting of 271 children in school between the
ages of four- to twelve-years-old. Children in the experimental group underwent six educational
sessions on children with disabilities, and completed pre-test, post-test, and one-year follow up
surveys on attitudes and acceptance. The sessions included picture books, videos, discussions,
and simulations. The youngest children demonstrated the most dramatic positive results.
A common theme in the results of all these disability awareness programs, all of which
had mostly positive results, was that the students had more knowledge and understanding of
children with disabilities, recognizing that they weren’t so different after all, or how their
disabilities worked. Thus the programs were valuable in in creasing awareness and acceptance
due to increased understanding, after education. These programs are valuable in minimizing
sociocultural barriers, which can lead to increase in participation in occupation. However, these
programs require time, cost, resources, and there may be a method that can have similar results,
with far less resources, which would be through the use of children’s picture books.
While peer-reviewed studies on the topic are minimal, one could argue, based on the synthesis of
evidence from above and below, another less invasive, less time, cost, and resource-intensive
method to increase awareness is potentially through use of children’s picture books.
Children’s Picture Books
Children’s picture books are typically a total of 32 pages, geared at children four- to
eight-years-old and are less than 1000 words, with illustrations telling as much of the story as the
text (Backes, 2012). The protagonist is typically a child and the story is told from a child’s point
INCREASING AWARENESS
26
of view. High-quality children’s picture book literature does not seem overtly didactic and
does not have a concretely-stated theme, leaving it up to the reader/adult facilitator to determine
its lessons rather than have it fed to them. Typically the child fails a task, fails again trying an
alternative route, then succeeds and changes over the course of the book due to this experience,
for example being shy then learning that sometimes being outgoing isn’t so bad. In this process,
the child protagonist is empowered. He or she must solve the problem his or herself rather than
having an adult or someone else solve it for them. There are also other types of picture books,
such as concept books, where the child is taught or has a concept reinforced, such as opposites or
colors. Again, a high-quality concept book is engaging and not overly didactic even while getting
the concept across. Regardless of the type of picture book, the pictures must tell as much of the
story as the text (Backes, 2012).
Pantaleo (2005, as cited in Mantei & Kervin, 2014) describes a synergistic effect in the
picture book combination of text and pictures, and Keifer (2008, as cited in Mantei & Kervin,
2014) argue the combination, when done well, can be an art form with its intricate dance of text
and pictures combining to tell a story. Such stories are engaging and motivating. A few famous
examples include “If You Give a Mouse a Cookie,” “Where The Wild Things Are,” and “Stella
Luna.” Any library, bookstore, daycare, house, and most waiting rooms are filled with children’s
picture books. As the following paragraphs will attest, there is a strong evidence to support the
ability of children’s picture books to promote literacy, promote the development of knowledge,
strengthen caregiver-children relationships, provide many types of socioemotional education
(including emotional competence, empathy and theory of mind), and be useful for bibliotherapy
(Montgomery & Maunders, 2015). Thus children’s picture books can transform attitudes and
INCREASING AWARENESS
27
behaviors and serve as jumping points for other activities and/or discussion, all of which can
ultimately promote social inclusion.
Promoting Literacy
The importance of children’s literature and reading out loud to young children for the
purpose of developmental skills is nearly uncontested by researchers (American Academy of
Pediatrics [AAP], 2014; Zuckerman & Augustyn, 2011). The majority of parents agree to its
importance, and over 60% of parents above the poverty line report reading books out loud to
their children on a daily basis (AAP, 2014). There are many early intervention and charities out
there that focus entirely on providing children’s books to children with limited or no access
(Zuckerman & Augustyn, 2011). According to a policy statement by the American Academy of
Pediatrics (2014), promoting literacy is an “essential component” of pediatric care, as reading
out loud stimulates brain development, relationships between the reader/child (typically a
caregiver or teacher), language, fine motor skills, and emerging academic skills. In addition,
reading promotes the learning of joint attention and provides awareness and labeling of feelings
(Zuckerman & Augustyn, 2010). Primary care physicians are encouraged to promote literacy
within their practice (Khandekar, Augustyn, Sanders, & Zuckerman, 2010) with programs such
as “Reach Out and Read,” where the physicians discuss with caregivers the benefits of reading
aloud, and also provide developmentally appropriate books for high-risk families (Zuckerman &
Augustyn, 2011).
Developmental Growth and Education
There is a wealth of evidence to support the influence of children’s picture books as
vessels of knowledge, providing children with awareness and understanding of topics, new
perspectives, motivation, and vocabulary, and more (Kumschick et al. 2014; Pardeck, 2005).
INCREASING AWARENESS
28
Children’s books can serve as diverse educational tools, including motivating and aiding
children in the learning of early mathematical concepts (Flevares & Schiff, 2014) and affecting
whether children had an anthropomorphic versus biological perspective of animals (Waxman,
Hermann, Woodring, & Medin, 2014).
While children’s picture books by themselves can have the power to change a child’s
attitude and behaviors, often times the magic lies in the aftermath of reading a book. The child
ideally first becomes engaged in a topic on a cognitive-knowledge level as well as a more
emotional level, allowing for far more increased learning than if the child felt no ties to the
information (Mantei & Kervin, 2014; Pardeck, 2005). During the process, the children can begin
making connections between what they are reading and how it relates to their own lives. Often
this link is facilitated by an adult, such as a teacher, and can take place through discussion during
and after reading the text. In a study by Kara, Aydos, and Aydin (2015) on changing the
ecological attitudes of preschoolers into behaviors, the researchers used children’s books as the
starting points for other activities and discussion. In a study by Kumschick et al. (2014),
children’s books were used as a starting point to improve emotional competence, with activities
and discussions based off the book. Thus stories and discussion have the ability to help children
with task mastery on a variety of levels, including emotionally and cognitively. Bettelheim
(1976, as cited in Montgomery & Maunders, 2015) captures the sentiment clearly:
When all the child's wishful thinking gets embodied in a good fairy; all his destructive
wishes in an evil witch; all his fears in a voracious wolf; all the demands of his
conscience in a wise man encountered on an adventure; all his jealous anger in some
animal that pecks out the eyes of his archrivals — then the child can finally begin to sort
INCREASING AWARENESS
29
out his contradictory tendencies. Once this starts, the child will be less and less
engulfed by unmanageable chaos. (p. 66)
Developmentally, based on how children use picture books as a reflection and method of their
own internal struggles, they are using the books in a way to gain emotional competence by
learning to identify, sort, and manage their emotions on a sociocultural/socioemotional level.
In 2006, Turner analyzed the contents of 119 children’s picture books that had themes of
injury, illness, and/or health. Turner wanted to determine how often causation was addressed,
what themes arose most frequently, and how characters in the book such as parents and providers
are presented. Turner noted that picture books, due to their structure, often did not delve into
detail on causation, the majority of the books focused on illness (67.2%) and caregiving most
frequently was depicted as taking place by multiple caregivers (52.9%). Turner discusses the
socioemotional importance of these books, noting that most of the picture books on illness had a
positive tone (72.4%) and an emphasis on the caregiving, providing children with a sense of
comfort and safety. The focus on caregiving may also help the caregivers reading them out loud
and encouraging interaction. In addition, 24.4% of the sample had an educational tone, providing
age-appropriate information on illness that could be utilized by healthcare providers as a patient
resource due to the books’ abilities to increase awareness and understanding. All the books,
whether with an educational focus or a story with information, were useful. When Turner’s
(2006) study noted the socioemotional impact of books about illness and how they provide
information to the child on caregiving or with important knowledge, it was demonstrating that
the picture books were being used to reduce socioemotional distress
In 2013, using a Level II randomized controlled trial, Gebarski et al. explored whether
children who were read a specialized picture book about an upcoming medical procedure, called
INCREASING AWARENESS
30
a voiding cystourethrogram (VCUG), had less distress during the procedure than children who
did not read the storybook. Researchers recruited the parents of 232 children who were between
the ages of 2-14 years of age. Half the parents received the storybook (experimental), and half
did not (control), based on random assignment. Those that received the storybook were
encouraged to read the book with their child in the weeks leading up to the child’s procedure.
After the child’s actual procedure, the parent rated their perception of their child’s distress levels
on an anonymous questionnaire. In addition, the VCUG technologist, blinded to who received
the storybook, rated the child’s tolerance using an adapted Groningen Distress scale, for
comparative purposes. Researchers noted that the score provided by the parent and technologist
were 80% of the time concordant within one grade, meaning that both caregivers and the
technologist were reasonably congruent in their appraisal of the child’s distress level.
Researchers received a usable 100 questionnaire responses, and 50% of them had read the
storybook. Researchers found a statistically significant difference between the two groups, p =
.0092, with children who had read the storybook performing better on the procedure (less
distress), meaning that the storybook was an effective method for reducing distress levels. This is
likely due to the previewing of the procedure in advance, helping children prepare
psychologically as they knew what to expect. In this case, the storybook served as a basic
educational tool for providing information about a procedure, yet also had a socio-emotional
effect, as Turner (2006) had discussed in the content analysis of picture books on illness.
Some limitations of the study included that no instructions were provided with the VCUG
storybook, with details such as when to read it, how often to read it, or how to approach the
storybook, thus intervention was poorly controlled (at survey conclusion, investigators only
knew, based on caregiver response, if the book had been read or not, but without helpful details.
INCREASING AWARENESS
31
This slightly endangered both internal and external validity. Also, the storybook was the same
whether children were two or fourteen years of age. In addition, the storybook may have been a
catalyst to discuss emotions/other issues surrounding the upcoming procedure, so it may just be
the discussion that helped (or the combination), rather than just the storybook. The researchers
note that in other studies, children’s anxiety is reduced when parental anxiety is reduced, so it’s
possible that the storybooks were helpful to the parental anxiety more so than the child (perhaps
they could just have the parent read it only for themselves in a future study). There was at least
one numerical typo, which slightly decreases the reliability as it signifies an inattention to detail.
There was also a relatively small sample size within each age group. A major limitation is that
the researchers used their own adapted version of the Groningen Distress Scale, meaning their
version’s reliability and validity were unknown. However, researchers noted the high
concordance rate likely helped confirm its reliability. There was a corroboration of scores
between blinded VCUG technologist and caregiver that demonstrates good interrater reliability.
While there were limitations, the most egregious related to the intervention not being
standardized or providing instructions on method to the experimental group, the results were still
clear that the experimental group experienced less distress, which answers the question of
whether it was an effective method, and the limitations did not appear to dramatically affect the
reliability and validity of the study to the point that one would have serious doubts.
This study on reducing distress by Gebarski et al. (2013) has important implications for
the use of children’s books as a tool for increasing acceptance and awareness of children with
disabilities. For children’s books to serve as an effective tool, there must be evidence to prove
that children are able to learn from the material provided and apply it to the real world, raise their
emotional awareness of others, and increase their tolerance of others’ differences, among other
INCREASING AWARENESS
32
things. This study looked at children’s books as a tool that could increase, decrease, or not
affect the probabilities of a future action or emotion. If a child can gain understanding and
increase tolerance/reduce distress (a form of emotional dysregulation) for a stressful medical
procedure by reading a children’s book, which the evidence does support, it bolsters support that
a child can take away important information from a book and apply it to the real world situations,
and that the books can both relay information and have an effect on emotional states.
In a Level III controlled quasi-experimental study by Kumshick, et al. (2014),
investigators explored “emotional competence” in second and third grade children, as children
with high competence (which includes intersubjectivity, empathy and awareness of emotions) are
more likely to be socially included and socially inclusive, as well as perform better academically
and have a decreased likelihood of psychopathology. In an effort to determine whether it was
possible to use children’s literature as a primary tool to increase emotional competence,
researchers developed a program called “READING and FEELING” and enrolled 104 students
in an afterschool daycare for intervention as the experimental group, with an additional 104
students in a control group. The children in the intervention group participated in twice-weekly
sessions for eight weeks, where they first read a carefully chosen children’s book before
participating in discussions, group and individual activities. The researchers tested the children
on components of emotional competence both before and after the 9-week program, finding that
the intervention group had significant improvements in three of the four variables the researchers
used to test for emotional competence, including emotional vocabulary (p < .001), explicit
emotional knowledge (p < .05), and recognition of masked feelings (p < .001). There was a
gender effect, as boys demonstrated higher improvement than girls in recognizing masked
feelings. No significant improvement was noted in recognition of mixed feelings. While the
INCREASING AWARENESS
33
outcome measures used in this quantitative study had relatively questionable reliability and
validity due to use of unstandardized assessments, the researchers did discuss item homogeneity
and inter-rater reliability, as well as noting (without detail) that the reliability and validity of the
assessments had been explored during pilot studies. However, considering the use of a control
group and that the authors provide a thorough overview of the intervention and outcome
measures, the results appear valid.
These results were promising and positive in supporting the use of children’s books as an
effective tool for increasing emotional competency in children, which is associated with
increased likelihood of awareness, acceptance, and social inclusion of children of diverse
backgrounds. Lawlor (2003) discussed the importance of intersubjectivity in occupation and
development, and social beings. When children develop increased emotional competence, they
are more likely to be aware of the perspectives of others, understand feelings, i.e., “maybe that
child with a disability feels left out.” While the study did not address the use of this program
with children with disabilities, these children could theoretically benefit as well, as many
children with disabilities are found to be lacking social skills (Masse et al., 2013; Phelan &
Kinsella, 2013), which of course affects likelihood of social inclusion and participation.
In 2015, Montgomery and Maunders performed a Level I systematic review on the use of
creative bibliotherapy as a means of affecting internalizing, externalizing, or prosocial behaviors
in children between the ages of five and sixteen. They defined creative bibliotherapy as “the
guided reading of fiction and poetry relevant to therapeutic needs” (p. 37). They accurately
operationalized internalizing behaviors as behaviors such as depression, externalization as
behaviors such as aggression, and prosocial behaviors as attitudes or intent. They noted that
prosocial behaviors include self-regulative abilities and emotional competence, which are
INCREASING AWARENESS
34
correlated with empathy. The researchers noted that there is minimal research on the effects of
creative (versus self-help) bibliotherapy on “psychosocial outcomes” (p. 37). They started with
over nine thousand articles and ended up with forty-six potential articles, although only eight met
their inclusion criteria. Their rationale of inclusion criteria was clear. Of these eight studies, the
authors note that all lacked important information, even though all were randomized controlled
trials. However, they found that overall, there were small to moderate helpful effects of the
bibliotherapy on the prevention and treatment of internalizing and externalizing behaviors, and
strengthening of prosocial behaviors. Montgomery & Maunders (2015) hypothesized that the
bibliotherapy worked along the same lines as cognitive behavioral therapy.
Some of the disability awareness programs utilize a cognitive-behavioral approach as
well (Ison et al., 2010). It makes sense that the bibliotherapy works along similar mechanisms as
cognitive-behavioral therapy, because both work on cognitive and emotional planes, working to
shift attitudes and behaviors from negative to positive. Contact and exposure is a form of
recognizing that previously held beliefs (children with disabilities/differences are scary) are not
necessarily accurate, and revising those attitudes (Macmillan et al., 2014). The researchers
recommended bibliotherapy as a low-cost tool that at the very least, if using high-quality age-
appropriate books, did not harm. Considering even small shifts in behavior can affect an
interaction or event, there is great promise in bibliotherapy as a tool to promote awareness and
acceptance of children with disabilities (Montgomery & Maunders, 2015). This in turn can lead
to attitudinal and therefore behavioral changes (Kara et al., 2015) and an increase in social
inclusion (Spencer-Cavaliere & Watkinson, 2010). This leads to higher probability of
occupational participation, which is vital to the development of occupational identity (Lawlor,
2003). Within occupational identity, children not just defined by their actual occupations, but
INCREASING AWARENESS
35
sense of self, sense of belonging, self-concept, etc. (Bandura et al., 2001; Phelan & Kinsella,
2013). Children’s books have the power to affect this development.
Acceptance of Self and Occupational Identity
In an article by Mantei and Kervin (2014), the authors discussed how children’s picture
books allow the children to make connections between themselves and that of the book. While
there will be similarities and differences no matter what, a sense of self-recognition or mirroring
can help with helping a child feel a sense of identity or validation. From a developmental
standpoint, young children are finding their place in the world in relation to others, and are
reifying sociocultural norms and determining hierarchies and sense of self (Blake & Pope, 2008;
Sokol, 2009). A major component of this time period is the sense of fitting in, of belonging to a
particular group, as the children continue forming their identity. Phelan and Kinsella (2013)
examine the concept of creation of occupational identity being a dynamic process, thus easily
reconstructed on even a daily basis as new information is received, such as when a children’s
picture book is read that resonates with the child.
In the following anecdote relayed by a pediatric occupational therapist (K. Holt, personal
communication, July 2, 2015) the power of self-recognition is noted. She had worked with a
five-year-old child who had a congenital deformity of her right arm, rendering it unusable. This
little girl was self-conscious and often did not participate in play with her peers. After she saw
the movie Finding Nemo, however, something shifted in her. She approached her mother several
days later and spoke about the character Nemo and his similar challenges, and how he still had
friends and could do many things like the other children. The little girl began incorporating
herself into class nearly immediately (K. Holt, private communication, July 2, 2015). When
children hear or read stories that resonate with them or that they can identity with, it can have a
INCREASING AWARENESS
36
powerful impact on their attitude, which in turn can affect their participation in occupation.
For example, a child who has belief in his or her ability to accomplish a task will have more
motivation and therefore more likelihood of participating in a task than a child who has a sense
of despair, fear, or belief of inability (Bandura et al., 2001).
For a child with a disability, self-recognition in a children’s picture book can sometimes
be quite rare. Reading a book about a child with his or her own disability or a similar one, who is
(ultimately) successful in their attempts to complete an action, can provide inspiration for the
child with a disability. This can help a child feel better as he or she is constructing a more
positive occupational identity, and can potentially contribute to increasing self-esteem. In
addition, completing actions successfully can allow children to feel more similar to other
children, again increasing motivation to feel similarly in the future through continuing to attempt
tasks.
Transfer of Knowledge
One could question whether young children have the capacity to transfer information
learned from picture books into the real world. The general consensus is “of course,” although in
truth there have been few peer-reviewed studies published that verify it. Most of the evidence is
purely anecdotal and considered “common sense.” Ganea, DeLoache, and Ma (2011) took a
more evidence-based approach and explored this capacity with a set of two experiments, both on
teaching preschoolers about how animals and camouflage abilities. In the first pretest posttest
experiment, 3- and 4-year-olds (N=104) were tested with pictures to pick which predators were
most at risk (depending on whether camouflaged or not), then read a picture book on the topic
(either purely factual or factual story-based), and were tested again. The children were more
likely to choose the correct answer (72.6%) posttest versus pretest (56.9%) after reading the
INCREASING AWARENESS
37
picture books. Type type of picture book (factual or story-based factual) did not have an
effect. In the second experiment of similar design, 4-year-olds (N=32) were asked the questions
using real animals as well as pictures. Researchers found that children were more than 84%
likely to get the right answer after reading the picture books, and that type of picture book did
not matter. At post-test children were significantly more likely to answer correctly on the
pictures versus real animal questions, although the difference had only marginal significance, p
<.01. Overall, these results demonstrate that children were able to generalize knowledge learned
from picture books into real world scenarios (Ganea et al., 2011). Considering children would be
learning about children with disabilities via the use of picture books, it’s important to establish
that children can, in fact, transfer the knowledge from the printed page to their 3-D environment.
More studies, using more populations, more subjects, and other types of knowledge (less
concrete), for more generalizability, are encouraged.
Another important question to address is not only whether children can transform their
knowledge or attitude post-intervention, but whether that in turn can shift their behaviors. As
Townsend (2011) noted, there is not always a bridge between theory and practice. Sometimes
there is also not a bridge between attitude and behavior. In 2015, Kara et al. addressed this topic,
performing a collaborative action research study with a teacher and her preschool students aged
60-72 months in an early childhood education program. The teacher had contacted them
regarding ecological issues, noting that her students were aware of environmental issues such as
the need to recycle, yet the children did not necessarily demonstrate “ecocentric” behavior (p.
46). In other words, their behaviors were not congruent with their attitudes. The researchers
aimed to create and research a protocol that would help the children’s attitudes link to their
behaviors, thus become more authentically ecocentric. The researchers implemented a protocol
INCREASING AWARENESS
38
that focused heavily on the use of children’s picture books about environmental issues as a
starting point to other interactive activities. Behavioral data was collected via teacher reports
both before and after the action plan had been implemented. In addition, the fourteen students,
half male and half female, underwent individual semi-structured picture interviews, all
administered by their familiar teacher. The questions asked had to do with four areas:
consumption patterns, environmental protection, recycling and reusing, and living habits. After
the researchers transcribed each audio recording of the interviews, they coded the children’s
responses to each question and extracted detailed examples for each coding type. They then
analyzed the teacher’s observation reports and extracted examples from there as well. They
analyzed data both before and after the implementation of protocol, as their protocol was based
off the teacher’s and students’ initial responses.
The teacher noted before protocol implementation, via her observation reports, that while
children were mostly demonstrating ecocentric attitudes, their behaviors did not show it, for
example they would waste paper. After implementation, which was a series of sessions that
started with reading a children’s picture book and then discussing and participating in activities
having to do with the book, the review of the new observation reports showed a marked
improvement in the children’s abilities to behave in an ecocentric manner, such as being more
aware of the need to save paper. Researchers noted the importance of providing the children with
many diverse activities, including children’s picture books, while teaching lessons about
environmental issues. Overall, researchers concluded that their protocol was successful in the
transforming of preschoolers’ attitudes into behaviors within the topic of environmental issues,
and that targeting the children in early childhood education was a developmentally and
environmentally appropriate thing to do.
INCREASING AWARENESS
39
Data was coded into themes by two independent and experienced researchers, with
excellent interrater reliability of .89. Their data was validated using triangulation methods,
confirming that observation data corroborated with interview data, which demonstrates
confirmability. Limitations of this study include the specificity of using only one topic
(environmental issues), which can challenge generalizability. In addition, they utilized only one
classroom and one teacher, so results could vary depending on teacher. Demographic makeup
was not discussed beyond gender and age. In addition, their interventions, while quite detailed,
had so many diverse activities that it was impossible to truly pinpoint what aspect of the
interventions was the most helpful in transforming their attitudes into behavior. The researchers
did not explain what the teacher was doing beforehand, activity-wise, and why their new plan
worked when the old one didn’t. Considering that the participants were primarily young children,
credibility of their results is not possible to measure, although the teacher did report credibility
and the behavior/observations appeared to match the results. Even though this study took place
in a single classroom in Turkey, there appears to be reasonable transferability, as the underlying
problem (attitude versus behavior) seemed quite universal in nature, and their explanations were
quite in-depth/thick. Finally, because their description of the population and their protocols were
so detailed, there was reasonable dependability. Replication would be relatively easy. The
researchers did address change and since it was action research, there were somewhat constant
adjustments, which were explained. Thus the investigators addressed all aspects of
trustworthiness in some manner.
It was overall clear the children’s picture books served as a strong vehicle of knowledge
and were always the starting points. While one must be cautious with generalizing this study to
other non-environmental topics, especially considering that this study used only one extremely
INCREASING AWARENESS
40
cooperative and motivated teacher, it can be reasonably inferred that a similar action plan, this
time pertaining to disability issues rather than environmental, would similarly help transform
behavior. For example, instead of picture books being read about environmental issues and
follow-up activities with recycling, the children would read books that have disabilities within
them, and then engage in activities such as disability simulation.
In addition, the study overall provided evidence that it’s possible to transform a child’s
attitude into a behavior, and that children’s books can serve as a strong starting point for leading
into other relevant activities. The study was clear that the children’s picture books served as a
strong vehicle of knowledge for every lesson plan within their protocol. Investigators provided
detailed information of how they utilized the children’s books, and how attitudes morphed into
behaviors. This is evidence supporting the argument that children’s books serve as a vessel for
knowledge and exposure into the topic of children with disabilities, so having proof that
children’s books can do so is important to prove. In addition, showing that young children can
make behavioral changes based on attitudes is very helpful, as increasing awareness and
understanding of children with disabilities via picture books is one component, but acceptance
and subsequent behavior change is what’s ultimately most important.
In an anecdote demonstrating how children’s behaviors can be changed via the reading of
children’s picture books, a mother talked about her preschooler getting in trouble at school for
hitting other children. Her mother read her child a book entitled “Hands are not for Kicking,” and
then the mother brought the book to the child’s daycare and asked them to read it both with her
daughter and the rest of the class. The back of the book had several pages of suggestions for
caregivers on how to handle hitting. The mother reported her daughter’s incidents of hitting
INCREASING AWARENESS
41
others went down dramatically after this occurred (K. Czech, personal communication, June
20, 2015).
Current Status of Picture Books
While children’s picture books can have powerful effects, some of their power lies in
accurate portrayal and representation of many types of people in many types of situations, ideally
with universal themes. While there are many books featuring young white children, there are far
fewer books geared at minority populations (We Need Diverse Books [WNDB], 2014). There is
luckily a currently a large push in children’s literature to increase its representation of diversity
of color, sexual orientation, gender, and disability, as well as intersections of those areas, due to
their massive under-representations (WNDB, 2014). The famed Scholastic Books has recently
announced a pairing with the non-profit organization “We Need Diverse Books” in response to
the increasing requests by teachers, parents, and students for more diverse books, which is a big
deal. In addition, Sesame Street has just come out with a new character, Julia, who has autism
(Barajas, 2015). Sesame Street has also provided a digital children’s picture book entitled
“We’re Amazing! 1, 2, 3!” However, children of diversity are underrepresented in children’s
picture books, with less than 10% having children of color, and a smaller but unknown
percentage having children with disabilities as protagonists (Kirch, 2013; WNDB, 2014). Yet
according to the U.S. Census Bureau, as of 2010 at least 19% of non-institutionalized people had
some form of disability.
Many forward-thinking librarians and educators of children with special needs are
beginning to address diversity and disability, curating/recommending books that have to do with
specific issues (Tan & Campbell, 2014). Many are also writing articles on the matter discussing
rationale for inclusion and exclusion and the extreme importance of choosing books wisely,
INCREASING AWARENESS
42
providing guidelines as to how to do so, considering stereotypes/learning process and ability to
harm. Several peer-reviewed research articles have been written on the topic.
Dyches et al. (2009) analyzed forty-one children’s books written between 2004-2007 to
examine the portrayals of children with developmental disabilities (DD). In this case, they
defined DD as ones that limit the child in at least three out of seven major life areas. Examples
include intellectual disabilities and autism. The researchers note that many children will have
their first encounter with children with DD via children’s literature, and thus it’s important the
child with DD is portrayed in an accurate manner rather than a stereotypical one. In this case,
accuracy doesn’t have to mean positively so much as “multi-dimensional” (p. 304). Of the forty-
one books, thirteen were picture books. Many of the books analyzed were rather instructional,
educating on the disability. These are appropriate at times, but ideally there would also be books
that just have the child with DD be a character in the story, without a focus on the impairment.
Researchers note that the number of children’s books that feature children with DD are
increasing, and simultaneously there is an increase in ethnic or other types of diversity in
combination, such as a black child with Down syndrome.
In addition, they found that certain types of disabilities were becoming over-represented
in the literature, while others were under-represented, and hypothesized this was due to increases
in media attention of certain disabilities, such as autism. The researchers noted a trend towards
books portraying more inclusive environments and with the character with DD demonstrating an
increase in initiation and success, rather than being dependent or a static character. They
recommend that future authors actively work to accurately portray children with DD as multi-
dimensional and participate in self-directed activities. They also encourage that educators
INCREASING AWARENESS
43
carefully choose high-quality literature, essentially meaning in this case that the values of the
book are positive.
Koc, Koc, and Ozdemir (2010) explored forty-six picture books that had a child character
with a physical or sensory impairment, analyzing the types of relationships taking place between
the characters without impairments and the characters with impairments. The researchers
determined eleven different types of relationships found within these books, and that the
relationships could be positive, negative, or neutral in nature. Oftentimes, the relationship
evolved over the course of book, such as starting out negative [child with impairment is
misunderstood, shunned] and transitioning into a positive relationship once the action of the
story has taken place and the child with impairment is now better understood by others.
Considering that picture book characters often serve as role models for children, educators,
researchers, and others are concerned about the possibility for harm in such books, such as when
stereotypes are used. The researchers provide a large list of things to look out for as well as
recommendations, such as having the child with impairment be a main character without the
story actually being about the impairment.
After exhaustive literature review, Pardeck (2005) has one of the only articles on the use
of children’s books specifically to teach others about disabilities. He specifically looks at
“developmental interactive bibliotherapy” (p. 79) used to promote children’s development and in
this case, awareness and appreciation of children with disabilities. He notes that fiction,
nonfiction, self-help books, fairy tales, and picture books can be useful in bibliotherapy. In the
case of picture books, children can learn different way to solve conflicts and can gain self-
recognition, self-reflection, and new perspectives through the reading of such books. However,
bibliotherapy does not stop at the reading of the book. Pardeck (2005) notes that follow-up,
INCREASING AWARENESS
44
through a variety of activities and discussion with peers and ideally an adult facilitator, is also
an important component. Finally, these books must contain characters that are portrayed
realistically, without stereotypical personalities, with legitimate and appropriate methods of
reaching their goals.
Occupational Therapy and Picture Books
Where there are currently not any peer-reviewed studies within any professional field that
address the use of bibliotherapy as an intervention specifically intended to increase occupational
engagement in children, there is plenty of evidence to suggest the strong likelihood of its efficacy
(Gebarski et al., 2013; Montgomery & Maunders, 2015). Yet there are no articles about
children’s books within the occupational therapy literature, with exception of a brief mention by
Jacobs (2012), who noted that children’s books are a “powerful tool” (p. 662) that engage
children in learning and can potentially be used to promote occupational therapy. When evidence
of the role of occupational therapy in promoting engagement is combined with the role of
bibliotherapy in promoting awareness of children with disabilities and therefore acceptance, it
becomes evident that bibliotherapy can be a powerful modality that OT should consider
adopting. OTs could be the first to demonstrate the power of children’s books to promote social
inclusion and occupational participation within a public health and wellness arena. Other positive
points are that children’s books are typically inexpensive in comparison to most therapy toys,
compact and therefore transportable, and easily accessible in stores and libraries. In addition,
there are carefully curated lists of books on children with disabilities that have been compiled by
librarians and others, so an OT would not have to spend the time doing the curating. However,
considering the gaps and other issues in the current literature (Dyches et al., 2009; Koc et al.,
2010), OTs should consider not just utilizing bibliotherapy but actually creating the books
INCREASING AWARENESS
45
themselves.
Occupational therapists are uniquely suited to write children’s books featuring strong and
ultimately empowered protagonists that happen to be a child with disability, ultimately
increasing representation of children with disabilities in children’s literature, increasing
awareness and acceptance of children with disabilities, and therefore social inclusion and then
occupational participation. Occupational therapists have a holistic perspective, and a strong
understanding of how the lives of children with disabilities are impacted on many levels. In
addition, OTs are aware of the basic needs of children with varying types of disability which can
at times be subtle. OTs are also strong in knowledge translation (Cramm, White, & Krupa,
2013), breaking down complicated topics into chunks of information that are easier to digest.
Even though there are already increasing numbers of authors writing about diverse topics, many
of the children’s books out there on children with disabilities are low quality, promote
stereotypes, have the children with disabilities as secondary characters, and/or focus on the
disability rather than plot (Brenna, 2008; Dyches et al., 2009). In addition, from a proportionality
standpoint, children with disabilities are extremely underrepresented in children’s literature
(Dyches et al., 2009; WNDB, 2014). To address this is a form of occupational justice, and can
simultaneously serve as a platform to promote the contributions of OT in disability awareness
and acceptance. The creation and use of bibliotherapy can also be considered a new opportunity
for OT, in alignment with both AOTA’s Framework-III (2014b) and the Centennial Vision
(2007). These concepts will be explored further in the following pages, and in addition the
process of writing children’s books and the business and financial aspects will be provided.
Occupational Justice
Educating individuals and communities on children with disabilities, and removing
INCREASING AWARENESS
46
barriers to occupational participation, are areas that occupational therapists (OTs) can and
should address (Christiansen, 1999; Hildenbrand & Lamb, 2013). One reason to utilize or write
children’s books is that it can serve as an intervention that promotes occupational justice,
addressed in depth earlier in this paper (p. 2). The OT profession takes this seriously, as the very
foundation of occupational therapy is based off the concept that participation in occupation is a
basic and necessary human right (AOTA, 2014b). The World Health Organization (2011) agrees
that the exclusion from life activities is a human rights concern. AOTA (2014) pushes therapists
to become advocates for their clients as a means of encouraging occupational justice. Hocking
(2013) discusses the need for therapists to pinpoint societal factors that affect people’s health,
and intervene at a societal level in the areas that can be changed via skillful intervention, to
prevent exclusion. There is luckily a growing awareness within the profession of occupational
therapy that occupational justice (which includes promoting inclusion/participation) can take
place at the societal level, which can be extremely efficient. (Hildenbrand & Lamb, 2013;
Leclair, 2010). If children’s books about children with disabilities are being dispersed at a
societal level in order to increase awareness and acceptance of children with disabilities (which
promotes inclusion), then occupational justice is being served. Simultaneously, considering that
this type of intervention could take place on a grand scale, it’s also a wide-reaching promotion of
OT.
Unique Focus
Occupational therapy can be considered a science and an art, as is writing picture books.
To skillfully weave a short yet engaging and age-appropriate story with nuanced characters, in a
way that teaches a child about the world and provides words to his or her experiences, while
simultaneously avoiding a didactic approach, is not easy. Yet OTs have undergone holistic
INCREASING AWARENESS
47
training that bolsters their abilities to tackle children’s books. For example, the domain of OT
encompasses five areas, including occupations, client factors, performance skills, performance
patterns, and contexts and environments (AOTA, 2014b). These areas have a transactional
relationship in which each affects the others in a dynamic manner, and occupational performance
is the output of this constant and complicated interplay (AOTA, 2014b). This is reflected in a
model of practice called People-Environment-Occupation (PEO) model (Law et al., 1996).
Because OTs are trained to notice and analyze the transactional relationship between these areas
in order to determine a client’s or society’s barriers to occupational participation, OTs can
accurately capture the whole picture of a child with a disability in their natural contexts and
environments (Heah, Case, McGuire, & Law, 2006).
For example, perhaps the OT who creates a children’s book can ask the illustrator to
show specific adaptations in the environment that have been made. Also, the OT can emphasize
the child’s strengths, abilities, and areas of sameness as studies show this awareness helps with
social inclusion (Phelan & Kinsella, 2013) because it of it “bridging the gap between the
different parties involved.” (Sharp, Dunford, & Seddon, 2012, p. 493). In addition, it helps the
focus be not on the disability itself but on the child, with the disability present yet not the issue.
An example would be to show a child in a wheelchair who is leading a scavenger hunt. The
protagonist has a disability and adaptations/modifications are present and woven into the story,
yet the focus is not on the child’s differences/need for a wheelchair. Instead the focus could be a
typical age-appropriate issue, such as arguments with another child as to who should be the
leader.
Developmental Frame of Reference and Person-Occupation-Environment (PEO) model of
practice
INCREASING AWARENESS
48
One of the unique advantages that occupational therapists have in writing children’s
books is an ability to understand and capture the children characters from both from a
developmental standpoint and an interactive sociocultural standpoint, giving the characters more
depth. In addition, OTs understand the vital importance of children participating in occupations
from a developmental growth standpoint. It is through participation in tasks, activities, and
occupations, that children work towards achieving task mastery, a major component of the
developmental frames of reference (Sokol, 2009). Intervention focuses on the child’s life stage
and provides “just-right” challenges that facilitate a child’s growth, while also acknowledging
the role of context (AOTA, 2014b). Developmental age rather than chronological age is the focus
as a 7-year-old with a mental disability could be at a very different stage than a 7-year old child
without a disability. Various theorists have looked at stages in a different way. For example,
Erikson looked at a child’s development from an individualistic view (Sokol, 2009), while
Vygotsky looked at it from a sociocultural view (Blake & Pope, 2008). Occupational therapists,
on the other hand, are holistic and examine not just a developmental life stage but how this stage
plays out in every day life, meaning en vivo within various contexts and environments (AOTA,
2014b).
For example, a child in a concrete operational stage is learning about tangible items, and
requires a lot of exploratory play, such as manipulation of sand or water. His or her caregivers
need to be providing lots of opportunities in a variety of environments for the child to make
developmental progress and achieve task mastery. A child who is in the concrete operational
stage and yet is given minimal opportunities for exploratory and experimental play or in limited
settings (potentially for social reasons) is not going to have the same foundational learning
experiences and may subsequently struggle to gain certain types of skills, due to a mismatch
INCREASING AWARENESS
49
between what the child needs at a particular stage versus what the child is receiving. OTs can
pinpoint the mismatches that can lead to pathology or at the very least cause some developmental
stunting. Children with disabilities may face a variety of barriers to appropriate developmental
exploration, typically done through play, and one of those reasons is social exclusion (Hurst et
al., 2013).
For example, if three preschoolers are playing a game in the sandbox, they are learning
cause and effect, conservation of mass and volume, etc., and building cognitive, motoric, and
social knowledge. The child who they have socially excluded is not able to participate in this
activity and is therefore deprived of opportunities to master skills. The act of building the perfect
sand castle is in itself not a necessary skill of course, but the factors that go into it – the ability to
gradate movement, turn over items, carefully sculpt, and negotiate the steps with another child,
are useful in a variety of settings. Social inclusion and developmental progress are therefore
closely tied. An OT is able to address this issue at individual and societal levels after looking at
the interaction of individuals, environments/contexts, and activities (AOTA, 2014b). In the
Framework-III, AOTA (2014b) notes that OTs use analysis of these combinations in order to
determine intervention, which can affect client factors, skills, performance patterns, and any
other area of occupation. The PEO model of practice addresses these interactions as well, noting
there is a transactive and dynamic relationship between person, environment, and occupation,
and there must be a good fit between all three areas for an occupation to be completed
successfully (leading to task mastery and developmental progress) (Heah et al., 2006; Law et al.,
1996). A child’s developmental stage and age affects all three areas, as the areas change
constantly over the course of the lifespan. The occupations a child participates in will vary by
age and stage. The child’s client factors, performance skills, and performance patterns will also
INCREASING AWARENESS
50
change by age and stage, as will contexts/environments (AOTA, 2014b; Heah et al., 2006;
Strong et al., 1999).
This dynamic relationship is often modeled in children’s books. The protagonist faces a
conflict, often fueled by a mismatch between what’s expected, what the child can do, and what
resources are available. Resolution occurs when the different components are addressed, and
occupational performance commences. OTs have a much stronger understanding than other
professions as to the complexity of the transactive relationship, and are therefore more likely to
capture the nuances within children’s books if writing them. The PEO model has primarily been
utilized at an individual level, yet Watson and Wilson (2003, as cited in LeClair, 2010) discuss
use of the model at a community level, arguing that OTs could perform task analysis of the
person-environment-occupation by looking at the population, contexts/environments, and
occupations at a community level. The model as it stands is not quite intended for that task, so it
is up to the OTs to modify approach, but LeClair (2010) points out that it’s a first step leading
towards new models that function at a community level. When OTs are able to look at barriers
from a community level, OTs can either select children’s books that address such barriers, or can
even choose to write them if none exist for a particular community-level issue.
Habilitative Services
In the Framework-III (AOTA, 2014b) and a policy statement by AOTA entitled OT
Promotion of Health and Wellbeing (2013), it is noted that it is within the scope of practice for
OTs to perform habilitative services as well as rehabilitative services, and therefore OTs have the
capacity to promote health and wellbeing. The public health necessary of preventative measures
is an area that OTs have not seemed to be fully comfortable with (Hildenbrand & Lamb, 2013).
Yet OTs have the ability to analyze barriers whether at an individual or societal level, analyzing
INCREASING AWARENESS
51
performance patterns, activity demands, contexts and environments, etc. (Hildenbrand &
Lamb, 2013). OTs can implement measures that aid in the creation and promotion of healthy
behaviors, enhancement of existing healthy behaviors, reduction of unhealthy behaviors, and
overall championing for preventative measures that nip problems before they can even start
(AOTA, 2013).
One measure of health is the amount of participation a person has in occupations
meaningful to him or her (AOTA, 2011). The primary interest of OTs is in helping people
engage in occupation, although the approach to that final goal can vary dramatically. The process
can start with something as simple as sitting down in a general education classroom and reading
the children a book about children with disabilities, and afterwards discussing the story. This
increase in awareness on the part of children without disabilities, leading to increased acceptance
of children with disabilities, leading to more likelihood of social inclusion, can lead ultimately to
increased participation in occupation in children with disabilities. Thus even the reading of
carefully chosen children’s books can be considered a form of habilitative service (Brown,
2014).
Co-occupations
OTs are aware of the importance of social inclusion (AOTA, 2014b). When writing or
reading children’s books having to do with children with disabilities, OTs must also be cognizant
of capturing the complexity of social relations. In the Framework-III (AOTA, 2014b), the
authors acknowledge the importance of co-occupations, in which an occupation involves more
than one individual. For example, the child playing a social interactive game of “Castle” in a
sandbox with three peers is involved in co-occupation. OTs must recognize that at an individual
or societal level, children and people in general are by nature social beings in an interactive
INCREASING AWARENESS
52
world, and thus co-occupations in many different contexts must be addressed (AOTA, 2014b;
Lawlor, 2003). LeClair (2010) discusses the role of OT in the community, noting that OTs must
always self-reflect, “Are we enhancing participation in shared occupations?” (p. 19). This goes
back to the Person-Environment-Occupation model at a community level, acknowledging the
transactive relationship occurs not just with the individual but at a more macro level (Law et al.,
1996; LeClair, 2010). In addition it falls under the developmental frames of reference in that it
acknowledges the importance of social relations in the construction of identity and the various
stages children go through that rely heavily on social participation in co-occupations (Blake &
Pope, 2008; Lawlor, 2003).
Diversity and Identity
Disability can be considered a form of cultural diversity (Pardeck, 2005). Clark (2013)
points out in a lecture on connectivity and diversity that there are two types of diversity,
demographic and embodied, which go hand-in-hand. The first has to do with a category such as
age or ethnicity or disability, while embodiment has more to do with the personal consequences
of these demographic realities. Many writers do not have a nuanced understanding of disability
and may therefore oversimplify matters by focusing more on the sociocultural typicality of any
one type of demographic diversity, whereas OTs have an appreciation for the complexity of each
individual and how embodiment is essentially a recognition that the person-environment-
occupations of each person leads to each of us being as unique as our fingerprints (AOTA,
2014b; Clark, 2013). Therefore OTs may be more likely to write children’s books that capture
and celebrate the individuality of each book character. In the capture of individuality, the
featured child with a disability will show both similarities and differences to their peers, versus
only differences. Phelan and Kinsella (2013) note after their qualitative study exploring the
INCREASING AWARENESS
53
perspectives of children with disabilities on their identity, that children with disabilities desire
“sameness,” to be similar to their peers. There is a famous quote by comedian Steven Wright that
says, “Always remember you are unique – just like everybody else.” When an OT writer is able
to give a child with disability character a nuanced and layered personality, just like any other
child, the OT is recognizing and honoring the sameness as well as the diversity. In addition,
children can be diverse in many ways – a child may be from India and have cerebral palsy and
have a peanut allergy, for example. OTs would also be able to understand how each of these
components affects a child differently and reflect that in the text, while still staying true to the
concept that the focus is the sameness. This reflection can be helpful to children with and
without disabilities.
In addition, children with disability who recognize a character similar to him or herself,
may feel a sense of pride, validation, and community. At the very least, the relief to discover he
or she is not alone. In an anecdote provided earlier (p. 17), about a little girl with one hand who
identified with a one-finned character of Finding Nemo, the little girl subsequently participated
more in her community. When children are able to identify with their disability as a positive or at
least neutral entity versus a negative one, they are more likely to participate in occupation (Sharp
et al., 2012). Providing an intervention (such as the reading of an appropriate children’s book)
for the purpose of acquisition of a more positive occupational identity is an area that the
Framework-III endorses in the OT profession (AOTA, 2014b).
Knowledge Translation
Another area where OTs excel is in knowledge translation and transfer. The importance
of knowledge translation is becoming increasingly recognized as our healthcare system grows
(Metzler & Metz, 2010). Communicating complicated/complex concepts between disciplines or
INCREASING AWARENESS
54
between healthcare providers and clients can be challenging, yet vital for health and wellness
(Cramm et al., 2013). For example, if a person with diabetes does not understand the information
provided to him or her, then he or she is less likely to follow through with instructions, and may
become sicker. Occupational therapists are quite aware of the capacities and abilities of their
clients, and after an occupational profile and analysis, are able to determine the health literacy
level of a client, and manipulate any information accordingly, so that the person can understand.
In terms of children’s books, occupational therapists are aware of and well versed in prominent
healthcare topics and needs, and also understand how to educate a person at any level, child or
adult. An OT can take a complicated concept and boil it down to the level that even a toddler can
understand. Therefore an OT can likely take a concept such as empathy or fear and write a story
where even a 5-year-old can extract information about the concept, which can garner awareness.
Centennial Vision
Since 2007, AOTA has espoused the following goal to be met by 2017: “We envision
that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based
profession with a globally connected and diverse workforce meeting society’s occupational
needs.” (AOTA, 2007, p. 613). Leaders of the profession discuss their desire for OTs to seek out
new areas in order to help advance the OT profession (Anderson & Nelson, 2011). The writing
and/or use of children’s books as socioemotional and educational tools for promoting awareness
and acceptance of children with disabilities, falls perfectly in alignment with this vision. The
books can be powerful because they help children’s attitudes change, thereby potentially
changing behaviors (Kara et al., 2015), which can have positive and far-reaching consequences.
The books written by OTs can potentially become widely recognized if they’re distributed to a
large audience, which can help put OTs in the public eye as experts in health promotion and
INCREASING AWARENESS
55
providers of public health needs. Clark (2011) notes that OTs should be sharing their
innovative efforts, so writing and dispersing these children’s books would allow society to
become aware of our abilities, value, and potential (AOTA, 2007). The writing of children’s
books could somewhat be considered evidence-based in that there is a large quantity of literature
pointing to the efficacy of children’s literature as a tool for learning (Gebarski et al., 2013; Hurst
et al. 2013). It is globally connecting in that children and OTs all over the world can become
familiar with a single book, as many books have been translated into multiple languages, and
often have a universal message. This is “fostering global connections,” as Clark (2013, p. 627)
espouses. And finally, the books can most certainly meet some of society’s occupational needs as
it can provide social inclusion in a world with a rapidly increasing rate of children with
disabilities. For all these reasons, writing and disseminating children’s books furthers the goals
of the Centennial Vision (AOTA, 2007).
Entrepreneurialism
A leader is often a pioneer, one who sees an area of need, analyzes what is happening,
and decides he or she can make a difference in meeting that need. Leaders by their very nature
are often entrepreneurial thinkers, which is something the profession of OT appreciates and
desires (AOTA, 2009, 2014). In a 2009 policy statement by AOTA entitled Specialized
Knowledge and Skills of OT Educators of the Future, AOTA notes that OTs must be innovators,
that “as social concerns evolve”…they “must understand occupational implications of issues”
and must be proactive (p. 804). This is in agreement with Hinojosa (2007) who argues the
existence of hyperchange in the healthcare environment and the necessity of OT to evolve to
meet the changes head-on. In 2012, Clark noted in a presidential address for AOTA that “we
must evolve in order to survive” and “push beyond comfort zones to expand influence, visibility,
INCREASING AWARENESS
56
and power.” (p. 645-646). In a 2013 presidential address for AOTA, Stoffel notes we must
“lift our eyes to see the openings…” (p. 635) in a variety of areas, from construction sites to day
care centers, using our creativity to find innovative new ways to meet society’s occupational
needs, which is one of the tenets of the Centennial Vision (AOTA, 2007). In 2014, Holmberg and
Ringsberg note that OTs must “innovate” in order to expand emerging niche areas as well as
brand new areas. It’s clear that innovation and evolution are constantly urged within the
healthcare environment of OT, and that far more work needs to be done in order for the field of
OT to meet its Centennial Vision in 2017 (AOTA, 2007).
In fact, Anderson and Nelson (2011) note that entrepreneurialism is a necessity within the
profession in order to meet the goals of the Centennial Vision to be more “powerful” and “widely
recognized” (AOTA, 2007). Braveman and Metzler (2012) also point out that the Patient
Protection and Affordable Health Care Act also provides the OT profession with new
opportunities that further the Centennial Vision. Habilitative services including prevention and
wellness are becoming more prominent in the general healthcare environment, although OTs
must advocate in order to play their part in the public health arena. Anderson and Nelson (2011)
discuss the important of experimentation and how entrepreneurs are willing to take risks when
they see valid opportunities. Anderson and Nelson (2011) also note that two of ten emerging
practice areas recognized within OT are in the area of “health and wellness consulting” and
“psychosocial needs of children and youth.” The writing and or/sharing of picture books that
promote social inclusion of children with disabilities (through increasing awareness and
acceptance) can fit under both those categories, and it’s also low risk and manageable, which is
important when first entering the realm of entrepreneurialism (Anderson & Nelson, 2011).
There is a push in occupational therapy to find alternative streams of revenue that are not
INCREASING AWARENESS
57
insurance- or direct service-based (LeClair, 2010), as old models of reimbursement are
changing, and innovative methods of making money for our professional expertise are being
sought out (Hildenbrand and Lamb, 2013; Hinojosa, 2007). Earning income through the
publishing of children’s picture books that promote awareness and inclusion of children with
special needs, and simultaneously inform consumers of the value of occupational therapy is an
alternative form of revenue that has barely been explored (Jacobs, 2012). As of 2015, there
appear to be only three occupational therapists with children’s books linked to them. Karen
Jacobs (2012) has written two, How Full is Sophia’s Backpack? And Three Bakers and a Loon.
Paulette Bourgeois is a Canadian OT who has written You, Me, and My OT per request by the
Canadian Occupational Therapy Association, as well as a famous but unrelated series of
children’s books about a turtle character called Franklin. In addition, Nicole Poplos Thompson
wrote a book called Sophia Discovers Occupational Therapy. While others may exist, those were
the only three with known links. Therefore those who enter the business of bibliotherapy and
writing children’s books now are at an advantage, as the market is not saturated.
Possibilities
One can think of a multitude of possibilities on how to approach both sharing and/or
writing children’s books. It first depends on what type of children picture book one is sharing
and/or creating. One can consider writing social stories, disability education-based books, fiction
with children with disabilities as main characters, books that have occupational therapists in
them as characters, and/or have a glossary in the back with OT-related information. Social stories
and those with OT characters would likely need to be marketed only in the OT arena, while the
others would have potential in mainstream audiences. Based on the type of book, one can then
look at the entrepreneurial opportunities.
INCREASING AWARENESS
58
The first opportunities arise in product development and product management. Writing
and publishing a book requires multiple steps of development, ending with a need to set a price
point that will allow for profit. Once a profitable price has been established, the OT will work in
product management and can attempt to sell his or her books to catalogs, schools, libraries,
parents, teachers, bookstores, clinics and even set up booths at local health fairs or even a
Farmer’s Market to sell his or her own books or other carefully curated books on disabilities. E-
mails, postal mail, and social media could also be used to promote the books. The books could be
sold as either e-books, print-on-demand, or paper books, depending on the OT’s desires, which
would affect where the OT could market. This type of entrepreneurialism would be the selling of
goods. Alternatively, the OT could use the books as a starting point for services, such as
consultation.
Consultation is when an OT advises others based on their knowledge and experience
base, for example when an OT consults with a teacher to show him or her some methods to calm
down a student (AOTA, 2014b). In addition, after the children’s books are created, their very
presence/use can almost be considered a form of permanent consultation, in which the data is
permanently available. An OT could consult with daycares, doctor’s offices, libraries, and more,
to discuss the use of children’s books and how particular ones can be used within a particular
setting to prevent bullying and promote social inclusion. The OT could also promote and provide
any of his or her own books he or she has written (Anderson & Nelson, 2011). The OT could
also offer to run story-time at a library or a community center, with discussion, interaction, and
activities afterwards based off the story.
After becoming familiar with the process of selling and/or creating children’s books,
other opportunities arise in this emerging area. An OT could offer continuing education courses
INCREASING AWARENESS
59
on the process of writing children’s books, as it is relatively complex. An OT could offer
mentorship, either paid or as a volunteer, to OTs starting the process. An OT could offer
presentations or workshops to parents, teachers, or other OTs on how to use bibliotherapy within
OT, or write their own books. In addition, an OT could obtain a grant or permission to do a
research study in which the use of bibliotherapy in OT is in someway researched, as there is
currently no OT literature on the topic, so the current evidence comes from other fields.
Considering there is no research at all that demonstrates how bibliotherapy can be used with the
end goal of occupational engagement, this would be a pioneering effort. Even the use of
bibliotherapy to promote social inclusion (awareness and acceptance) has not been specifically
done. One advantage to this type of entrepreneurial work with its endless possibilities is that
there is flexibility in approach and relatively minimal risk to income. One can continue a full-
time job while working on writing children’s books, or selling them.
The Process Of Children’s Book Writing
The amount of work needed to write a children’s book, publish it, and market it, is daunting and
seemingly endless. One might think the hardest part would be the creative process, which can
take a surprisingly long time considering the book should be less than 1,000 words long (Backes,
2012). One must note, however, that there is always a learning curve, and the first book will
therefore likely take the longest. It becomes easier, especially if writing e-books and marketing
only a very specific population. The cost of writing, publishing and marketing a children’s book
is extremely variable and depends on the amount of support one desires or requires, what type of
publishing route taken (self, hybrid, or traditional), how much marketing takes place, and
whether one needs an illustrator. An OT with reasonable illustration skills who wrote and
illustrated a book by him or herself for the purpose of selling to other therapists and parents, then
INCREASING AWARENESS
60
self-published as an e-book only, could potentially spend less than $100. The majority,
however, will require some outside support and an illustrator. If an OT primarily depends on
outside support to guide the process, hires a high-quality illustrator, and wishes to print on paper,
the final cost of a single book could run easily over a thousand dollars. The process of writing a
children’s picture book, for the purpose of increasing awareness and acceptance of children with
disabilities, will be briefly covered in conjunction with the financial component for each stage.
Needs Assessment
Before starting the children’s book writing process, one should conduct a needs
assessment, informally or formally (Anderson & Nelson, 2011). It may be that one notes a gap in
the literature in a particular area. Or one might hear the lament of a parent who wishes there were
more books that featured children with ankle-foot orthoses. Many parents, children, and OTs can
gladly share what types of books they wish were out there, and not surprisingly, the suggested
books likely have to do with the child’s own struggles. One can also consider sending out a
questionnaire through surveymonkey.com or a similar site, which allows one to create a specific
questionnaire. The results of a questionnaire can help guide the next step. For minimal usage of
surveymonkey.com, there is no fee. For assistance with analysis or for a large-scale
questionnaire, one can pay a one-time monthly fee of $25.00 (Survey Monkey Inc., 2015). By
completing a needs assessment of some sort, one can get a better sense of what is most likely to
be marketable (Anderson & Nelson, 2011).
In addition, one can research data trends via the website Google Trends, which is part of
a search engine run by Google. This site allows one to explore how often a particular search term
has been made, and how the number of searches for that word or phrase has changed over time
(Google, 2015). For example, if one types “autism” into the search box at Google Trends,
INCREASING AWARENESS
61
Google will provide a graph of the overall trend from 2004 to 2015, based off how often
people have searched for that term. The website provides suggested related searches, options to
search by region, and even a forecast option. Multiple fields have run studies using Google
Trends and found that there are correlations between Google Trends data and economic shifts or
flu cases, for example (Preis, Moat, & Stanley, 2013). Essentially studies are demonstrating that
the exploration of a large aggregation of data that shifts over time (a temporal context) provides
inquirers with valuable information as to the attitudinal or behavioral shifts of a market. If one
searches “autism” and finds there is increasing interest in the term based off how often it has
been searched, it’s an indicator that a children’s book about this topic may be pertinent to current
consumer interest (Preis, Moat, & Stanley, 2013).
Questionnaire Results
This author used surveymonkey.com to create a one-page, nine-question questionnaire
entitled “Children’s Books as an Occupational Therapy Tool” (see Appendix A for the list of
questions). It would likely take participants (occupational therapists) a maximum of five to ten
minutes to fill out. I distributed the questionnaire electronically on my personal Facebook page,
Facebook business page, a Pediatric Occupational Therapists Facebook group of over 15,000
members, OT Twitter account, and to my doctoral student cohort. I received a total of 36
responses. A response rate is not possible to calculate as it is unknown how many people actually
saw these requests.
The following is a brief analysis of the results, provided as an example. Twenty-four of
the thirty-six respondents worked in the schools. Twenty-five percent of the thirty-six
respondents frequently used books in their practice, 53% used them rarely, 14% had never
thought about it, and 8% had never used them in practice. Forty-seven percent would prefer a
INCREASING AWARENESS
62
picture book that is fictional with a main character that has a disability as the focus. Sixty-
seven percent would prefer that the disability was not the focus. And 39% would prefer
nonfiction, about a disability, for educational purposes. From this data, I note that I should
consider focusing on a fictional book without disability as a focus, since that is what the majority
preferred. Therapists would like to see more children’s books about a variety of diagnoses
covering essentially any and all disabilities or skills, such as social skills. Twelve therapists
would like to see more books about autism, while all of the other specific categories received
less than six votes. Most therapists provided a list of diagnoses or issues they would like covered.
When asked if therapists would use children’s books in their therapy setting if available, 95%
said yes, and 5% said maybe. No one responded with a no. This data tells me that marketing
children’s books to other OTs would be smart, as nearly 100% of them are potentially interested
in utilizing such books.
In addition, 28% of therapists replied that yes, they consider writing their own children’s
books. 47% said no, and 25% said maybe. Those who declined stated reasons such as not being
creative enough or too busy. Those who replied positively were quite enthusiastic about the
possibility. Based on this data, I would note that the 28% of therapists who were interested may
be willing to take a continuing education course on writing children’s books as an OT, so from
an entrepreneurial standpoint, I could use this data to develop one.
When asked if therapists would consider spending their own money on a book to use with
clients, 78% said yes, 3% said no, and 19% said maybe. From a financial standpoint, this is
lucrative news in conjunction with the news that nearly 100% of therapists would consider using
books in practice. When therapists were asked if they felt children’s books could be used to
increase awareness and acceptance of children with disabilities, 94% said yes, and 6% said not
INCREASING AWARENESS
63
sure. Nobody said no. The results of this survey were promising, as it confirmed that therapists
were already using or open to the idea of incorporating children’s books into their practice. Not
only that, they are willing to spend their own money. Therefore OTs writing children’s books, or
selling those of others, should strongly consider marketing to other OTs as their primary base.
Once the needs assessment is complete, the next step is to approach the writing of the book.
Writing
The actual writing of the story may be the hardest part of all. One should consider first
writing an outline or coming up with a general story arc, then filling in the gaps. Searching the
Internet will provide one with literally thousands of pages of advice on how to go about this
process. One can join a critique group or send a draft to colleagues and family for feedback,
although ideally one searches for unbiased critiques by those in the children’s book business.
Manuscript mentors advise going to a library or bookstore and looking at popular books written
within the last five years, as word count and style have changed dramatically over the decades
(L. Backes, personal communication, August 4, 2015). One should strongly consider researching
the community one wants to write about, both online and in person. For example, if wanting to
write a book about a child with cerebral palsy, speak to children with cerebral palsy and their
parents, review the literature, and search online communities/forums to accurately capture voices
and get ideas.
If one uses critique groups, this writing process can be free of direct costs, although there
are indirect costs associated with the large amount of time required for acquiring the initial
concept, actually writing it, then revising it multiple times. From this author’s personal
experience, it’s highly recommended that a beginning writer spend money on a critique from a
children’s book professional, or consider a mentoring relationship. While prices vary, a critique,
INCREASING AWARENESS
64
which includes a review of one’s work, written comments and a thirty-minute phone call, can
cost $150 (Backes, n.d). However, in an agreed-upon ongoing mentoring relationship, prices
may be lowered substantially.
Illustrations
Occupational therapists interested in publishing traditionally would not hire an
illustrator, as that is the job of a publishing house if a manuscript is accepted. However, OTs
interested in self-publishing would need to procure their own illustrator. An OT’s job when using
an illustrator would include ensuring the pictures accurately capture the environment of a child
with a disability. For example, for a child with cerebral palsy, one might see some ankle-foot-
orthoses strewn across a children’s bedroom floor, or the child completing an activity of daily
life using a modified approach due to use of one-hand. One uses art notes in brackets throughout
the manuscript to explain to the illustrator the desired pictures. Illustrations can be the most
costly aspect of the process, yet are a requirement for picture books. While many OTs are
creative and artistic, illustrating children’s books is quite specialized and challenging (Art Career
Project, n.d.), and the majority of OTs, even those with artistic backgrounds, will likely not have
the ability. One can search for an illustrator through a search engine, with the more heavily used
sites showing up first. Depending on the type of illustrations wanted, complexity of the
drawings, resolution, and speed desired, a reasonably high quality yet unknown children’s book
illustrator on a site such as Fiverr.com can easily charge $40 for a page. There are typically
approximately 28 pages of pictures in a picture book (Backes, 2012), so that would be $1120 for
a book. Prices can be dramatically higher if the illustrator is known, with total cost running into
the thousands (Society for Children’s Book Writers and Illustrators [SCBWI], n.d.). (Added
March 2018 for those who request text: To hire an actual illustrator of children’s books,
INCREASING AWARENESS
65
$5,000 is on the cheaper end. There are some websites that have “student” illustrators
who have taken a course in children’s book illustrations but it will still potentially run in
the thousands. If you decide to use a friend/family member who is a good artist and do it
informally, encourage them to actually read up on picture book illustrations on the
Internet or take a course, as it’s much more specialized than most people realize.)
Publishing
The question of whether an OT should attempt to traditionally publish a book or self-
publish a book is an extremely complicated one, and the nuances are beyond the scope of this
paper. The following is an extremely broad overview with brief description of the financial
differences. Traditional publishing is what most people think of when they think about
publishing a book. It’s when an individual writes a manuscript and then submits it to either a
small independent press, or a small, medium, or large publishing company, with the goal of
having the publishing company take on the book and the process from that point on, which
would include illustrations, sales and marketing. While this method is still widely considered the
most respectable, it’s also extremely difficult to have a manuscript accepted, and the process can
take years (SCBWI, n.d). On the other hand, self-publishing is becoming increasingly accepted,
and this is where an OT author would perform all the steps by his or herself (with paid support as
needed) in order to get his or her book out to the public. There are no gatekeepers in self-
publishing, so if one goes through the process, the book can exist. However, whether or not
anyone reads the book is another story, as sales and marketing are extremely important
(Zimmerman, n.d.).
While there is controversy as to whether one is more financially better off attempting to
INCREASING AWARENESS
66
publish traditionally or self-publishing, there are trade-offs. In traditional publishing, the house
is responsible for procuring and paying an illustrator as well as marketing, which saves the
author money. An advance is typically given, which can range from hundreds to many
thousands, depending on the market and desirability. That is a financial advantage to traditional
publishing. However, the royalty rate will likely be 10%. Therefore, for every $20 book sold, the
author may only receive $2 of that, while the publishing house could receive $5. Whereas in self-
publishing, the author may be able to keep approximately 80% of net proceeds, selling an e-book
for $5 and gaining $4 of those dollars (Zimmerman, n.d). Thus self-publishing is a lucrative
method if successful.
Realistically, the chance of writing a children’s book that is financially lucrative is slim.
If an OT chooses to write quick e-books with minimal investment in illustrations, and
successfully markets them to other OTs and clinic consumers or through various websites such
as Teachers Pay Teachers, then there is a chance for hundreds of dollars a month, possibly more.
Yet an OT who wants to write a high-quality children’s book with high-quality illustrations and
self-publish, may spend thousands and therefore have to recoup those costs before ever making
any profit. There is certainly a chance for profit and success, but one must understand that it will
most likely not become a significant source of income. However, there are other types of value
besides cash. Relatively customized children’s books that are linked with a therapist or clinic can
be helpful in promotions, advertisements, word of mouth, prestige, and recognition, and can
therefore increase or encourage referrals (Gronroos & Ojasalo, 2004).
Marketing
The marketing possibilities when writing children’s books are endless. Whether an OT
works as an independent contractor, private clinic owner, or staff therapist in a setting such as a
INCREASING AWARENESS
67
clinic, his or her services and OT skills can be promoted through such a book. One important
step is to prominently feature the logo of the clinic, or brand of the OT, on the front of each
book. This is especially important for waiting rooms, or if giving away books for free as a value-
added service. Books with this marketing information on them can also be donated to local
auctions, local libraries, school districts, bloggers in exchange for reviews, medical waiting
rooms, daycares, and more. If one writes a book about a child with cerebral palsy, then locations
that cater to this population (such as a doctor who specializes in cerebral palsy) would be ideal
places to send book copies. In addition, one can submit to sites such as littleparachutes.com,
which is a search engine that parents can use to find books on particular developmental topics.
The tagline of Little Parachutes is “picture books to help children with life’s challenges,” and
children’s books written by OTs on children with disabilities would be appropriate in this setting.
An OT author could also consider submitting the book to catalogs and to AOTA, listing it on
sites such as GoodReads.com and Amazon Lists, advertising it on Facebook groups such as
Pediatric Occupational Therapists which has over 20,000 members, and more. All of these
actions will contribute to the distribution and dissemination of information about children with
disabilities, helping place the books in the hands of those who will learn more about disabilities
and therefore awareness and acceptance, while simultaneously learning more about the power of
occupational therapy.
In addition, the books can serve as marketing vessels for other services. If a particular
book is associated with an OT’s company or clinic, readers will become more familiar with that
company and clinic, and may be more likely to purchase other services. For example, if two
clinics are in a town and a parent of a child with cerebral palsy is trying to decide which of the
two to attend, the parent may be more likely to choose the one that has published a children’s
INCREASING AWARENESS
68
book about a child with cerebral palsy. In addition, it allows an OT to serve as an expert in a
topic. If a news outlet decides to write a story about a child with cerebral palsy, he or she may do
some Internet searching and reach out to the OT who has written stories on the topic. Whether
selling the children’s books of others, or creating one’s own books, figuring out the
implementation is an important factor to consider.
Innovation, Implementation, and Customer Satisfaction
Having the idea to write and publish children’s books, or sell them in various settings, is
an important first and innovative step. However, “seeding innovation into practice” is potentially
complicated, if an OT is not the person responsible for making decisions at their treatment
setting (Burke & Gitlin, 2012, p. e86). The following information is based on the hypothetical
intent to implement the selling of children’s books within a pediatric clinic setting. Getting
managers, owners, administration, and fellow OTs to buy into a new idea can be difficult.
Sudsawad (2005) discusses Diffusion of Innovation theory, and how the adoption rate of a new
product or process is affected by relative advantage, compatibility, complexity, trialability, and
observability [these are the exact terms used for this theory]. Essentially, is the innovation
perceived as better than other options, is it consistent with the needs and values of those who will
use it, how easy is it to use, how easily can it be experimented with without risk, and how
obvious are the results of the use of this innovation? In the case of children’s books and selling
them in the clinic, one would to prove to those in charge that the selling the product can be
reasonably implemented in an efficient manner, is client-centered, applicable and relevant to
intervention, and provides benefit. Pointing out that the use of bibliotherapy is evidence-based
may also further one’s argument.
INCREASING AWARENESS
69
Another evidence-based argument is from a business perspective. By providing clients
with customized book recommendations and offers, the client can realize that their healthcare
provider is providing attention to the client’s needs and values, strengthening the client-
practitioner relationship and therefore customer satisfaction. In addition, this innovative practice,
the selling of these customized goods, is relatively unique as a value-added service that the client
may not be able to get at other clinics. This customer satisfaction can lead to increased loyalty,
increased word-of-mouth referrals, and increased standing in the community (such as rating
higher on Yelp.com reviews and therefore more prominently). The evidence shows that loyalty
and satisfaction can lead to higher profit margins, and the referrals lead to decreased advertising
costs (Gronroos & Ojasalo, 2004).
However, ultimately in businesses the management and owners are concerned with
financial feasibility, examining both indirect and direct costs (Dickerson, 1990) in its relation to
profit. Direct costs would be related to the pricing point of a book, including tax and shipping. A
clinic could look into the possibility of buying wholesale or receiving discounts for buying in
bulk. The indirect costs would primarily be related to storage and time. For example, is there a
place to display or store these books that would not be inconveniencing or lead to crowding out
of other more lucrative products? Does an OT or administrative staff have to take time out of
their schedule to discuss the books and complete transactions with parents, and if so is that
feasible given a particular OT’s schedule or an administrator’s frenzied duties? If so, perhaps the
selling of children’s books is not reasonable in that environment. One possibility would be to
have one or two books for waiting room or for use by therapist, and then cautiously build up a
stock of only a few books of the most common diagnoses for the most minimal financial risk.
One can experiment with price point, considerably raising the resale price since this obviously
INCREASING AWARENESS
70
leads to increased profit, to explore whether parents will buy the book at the clinic for
convenience, or find the price too high and order online or elsewhere.
The entire process is a learning experience at first, so after a period of time, one can
assess whether it was a successful endeavor from a financial performance perspective and if it’s
worth it to continue, expand, or discontinue the attempt. It’s important to remember that even if
profit is negligible or even causing a small amount of financial loss, the selling of books may
continue to be worth it if it leads to higher customer satisfaction and loyalty, because referrals
and continued treatment bring in the revenue (Gronroos & Ojasalo, 2004). Therefore, for
example, losing $2 for each book sold may be worth it if a child continues to come in at $125 an
hour due to satisfaction and loyalty (Gronroos & Ojasalo, 2004).
Sample Manuscript
An example of an 809-word manuscript is included (see Appendix B – NOTE: not
included in this public version of the capstone). The manuscript is formatted per industry
standards (Sherman, n.d.) with 1” inch margins, size 12-font Times New Roman or Ariel, and
double-spaced. This sample manuscript, written by this author, is entitled “The Centipede Who
Can’t Tie His Shoes,” and its protagonist is Ben, a centipede starting second grade. He is having
trouble learning to tie his shoes, as he can’t differentiate the laces due to his low vision disability.
He is bullied by a peer for his inability to tie his shoelaces, which causes Alex distress. An
occupational therapist aids him by providing high-contrast shoelaces and reviewing the steps.
Ben must then decide whether he feels brave enough to go to school with the new laces, which
will cause him to stand out from his peers. He ultimately learns how to tie his shoes, thanks to
his own perseverance in practice, his willingness to stand out, and his assistance from an OT.
Children who are read this story will learn a little bit about low vision, and how that disability
INCREASING AWARENESS
71
can affect a child’s ability to tie his or her own shoes. In addition, the children learn of
alternative shoelaces, both the type that tie and do not tie. This new knowledge can lead to
understanding, awareness, and acceptance, which is the purpose of these books. A glossary is
provided at the end to provide more information about occupational therapy and shoe tying,
which increases the usability and value of the book for parents and educators. (Updated March
2018: It’s finally about to be in print. Check out missawesomeness.com/books for more
info, and/or if you read this after April 2018 you can likely find it on Amazon!)
Conclusion
In conclusion, children’s engagement in occupations is vital to their health and well-
being, but children with disabilities are less likely to participate in occupations, often due to
social exclusion (Dahan-Oleil et al., 2012; Masse et al., 2013). Children’s books can be used as
bibliotherapy (Turner, 2006), and a synthesis of evidence from other professions, combined with
evidence within occupational therapy on the health benefits of occupational participation, leads
one to conclude that children’s bibliotherapy can be used to promote awareness and acceptance
of children with disabilities, leading to social inclusion, which can lead to occupational
participation (Hong et al., 2014; Hurst, et al., 2012; Montgomery & Maunders, 2015; Phelan &
Kinsella, 2013). In addition, OTs are well-suited to write children’s books about disabilities due
to OTs’ ability to transfer knowledge, holistically analyze situations, and understand the
transactive relationships between person, environment, and occupation (Heah, et al., 2006;
LeClair, 2010). Occupational therapists who choose to sell or write children’s books can market
the books to a variety of populations, including other occupational therapists, which can
hopefully bring in a small nontraditional source of income, and additionally serve as a value-
INCREASING AWARENESS
72
added service that promotes loyalty and increases customer satisfaction within the consumer
base. This loyalty and satisfaction can have an effect of increasing future revenue (Gronroos &
Ojasalo, 2004). The process of writing children’s books can be daunting, but the benefits, both
for the author and for society, are large. In addition, the goal of the Centennial Vision for OT to
have wider recognition is partially fulfilled by the writing and dissemination of children’s picture
books about children with disabilities (AOTA, 2007). Occupational therapists are encouraged to
start the process of utilizing bibliotherapy within their practice, and to consider the creative and
rewarding process of writing their own children’s books to help promote awareness and
acceptance of children with disabilities.
INCREASING AWARENESS
73
References
American Academy of Pediatrics. (2014). Literacy promotion: An essential component of primary
care pediatric practice. Pediatrics, 134(2), 1–6. http://doi.org/10.1542/peds.2014-1384
American Occupational Therapy Association. (2007). American Occupational Therapy
Association’s Centennial Vision and executive summary. American Journal of
Occupational Therapy, 61, 613-614.
American Occupational Therapy Association. (2009). Specialized knowledge and skills of
occupational therapy educators of the future. American Journal of Occupational Therapy,
63(6), 804-818.
American Occupational Therapy Association. (2010). Standards of practice for occupational
therapy. American Journal of Occupational Therapy, 64(Suppl.), S106–S111.
http://dx.doi.org/10.5014/ajot.2010.64S106
American Occupational Therapy Association. (2013). Occupational therapy in the promotion of
health and well-being. American Journal of Occupational Therapy, 67(Suppl.), S47–S59.
http://dx.doi.org/10.5014/ajot.2013.67S47
American Occupational Therapy Association. (2014a). Occupational therapy’s commitment to
nondiscrimination and inclusion. American Journal of Occupational Therapy, 67(6), S23-
24.
American Occupational Therapy Association. (2014b). Occupational therapy practice framework:
Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1),
S1-S48.
American Occupational Therapy Association. (2015). Occupational therapy code of ethics and
ethics standards. American Journal of Occupational Therapy, 69(Suppl. 3), S1- 10.
INCREASING AWARENESS
74
Americans With Disabilities Act of 1990, Pub. L. 101–336, 42 U.S.C. § 12101.
Anaby, D., Hand, C., Bradley, L., DiRezze, B., Forhan, M., DiGiacomo, A., & Law, M. (2013).
The effect of the environment on participation of children and youth with disabilities: A
scoping review. Disability and Rehabilitation, 35(19), 1589–1598.
http://doi.org/10.3109/09638288.2012.748840
Anderson, K. M., & Nelson, D. L. (2011). Wanted: Entrepreneurs in occupational therapy.
American Journal of Occupational Therapy, 65(2), 221–228.
http://doi.org/10.5014/ajot.2011.001628
Art Career Project. (n.d.). Bring stories to life as a book illustrator. Retrieved from
http://www.theartcareerproject.com/bring-stories-to-life-with-a-book-illustration-
career/358/
Backes, L. (2012). Picture Books 101. Retrieved from http://cbiclubhouse.com/clubhouse/picture-
books-101/
Backes, L. (n.d.) Get a Professional Critique. Retrieved from
http://cbiclubhouse.com/clubhouse/get-a-personalized-critique/
Barajas, J. (2015). ‘Sesame Street’ debuts Julia, its first character with autism. Retrieved from
http://www.pbs.org/newshour/rundown/sesame-street-debuts-julia-first-character-autism/
Blake, B., & Pope, T. (2008). Developmental Psychology : Incorporating Piaget’s and Vygotsky’s
theories in classrooms. Writing, 1(1), 59–67.
Bandura, A., Barbaranelli, C., Caprara, G.V., & Pastorelli, C. (2001). Self-efficacy beliefs as
shapers of children’s aspirations and career trajectories. Child Development, 72(1), 187–
206. http://doi.org/10.1111/1467-8624.00273
INCREASING AWARENESS
75
Braveman, B., & Metzler, C. (2012). Health care reform implementation and occupational
therapy. American Journal of Occupational Therapy, 66(1), 11–14.
Brenna, B. (2008). Breaking stereotypes with children’s fiction: Seeking protagonists with special
needs. International Journal of Special Education, 23(1), 100–102.
Brown, D. (2014). Health policy perspectives—Habilitative services: An essential health benefit
and an opportunity for occupational therapy practitioners and consumers. American Journal
of Occupational Therapy, 68, 130–138. http:// dx.doi.org/10.5014/ajot.2014.682001
Burke, J. P., & Gitlin, L. N. (2012). The issue is—How do we change practice when we have the
evidence? American Journal of Occupational Therapy, 66, e85–e88.
http://dx.doi.org/10.5014/ajot.2012.004432
Clark, F. (2011). High-definition occupational therapy’s competitive edge: Personal excellence is
the key. American Journal of Occupational Therapy, 65(6), 616–622.
http://doi.org/10.5014/ajot.2011.656001
Clark, F. (2012). Beyond high definition: Attitude and evidence bringing OT in HD–3D
(presidential address). American Journal of Occupational Therapy, 66, 644–651.
http://dx.doi.org/10.5014/ajot.2012.666002
Clark, F. (2013). As viewed from above: Connectivity and diversity in fulfilling occupational
therapy’s Centennial Vision (farewell presidential address). American Journal of
Occupational Therapy, 67, 624–632. http://dx.doi.org/ 10.5014/ajot.2013.676003
Christiansen, C. H. (1999). Defining lives: Occupation as identity: An essay on competence,
coherence, and the creation of meaning, 1999 Eleanor Clarke Slagle lecture. American
Journal of Occupational Therapy, 53, 547–558.
INCREASING AWARENESS
76
Coster, W., Law, M., Bedell, G., Liljenquist, K., Kao, Y., Khetani, M., & Teplicky, R. (2013).
School participation, supports and barriers of students with and without disabilities. Child:
Care, Health and Development, 39(4), 535–543. http://doi.org/10.1111/cch.12046
Cramm, H., White, C., & Krupa, T. (2013). The Issue Is—From periphery to player: Strategically
positioning occupational therapy within the knowledge translation landscape. American
Journal of Occupational Therapy, 67, 119–125. http://dx.doi.org/10.5014/ajot.2013.005678
Dahan-Oliel, N., Shikako-Thomas, K., & Majnemer, A. (2012). Quality of life and leisure
participation in children with neurodevelopmental disabilities: A thematic analysis of the
literature. Quality of Life Research, 21, 427–439. http://doi.org/10.1007/s11136-011-0063-9
De Boer, A., Pijl, S. J., Minnaert, A., & Post, W. (2014). Evaluating the effectiveness of an
intervention program to influence attitudes of students towards peers with disabilities.
Journal of Autism and Developmental Disorders, 44(3), 572–583.
http://doi.org/10.1007/s10803-013-1908-6
Dickerson, A. (1990). Evaluating productivity and profitability in occupational therapy contractual
work. American Journal of Occupational Therapy, 44(2), 33–37.
Dyches, T. T., Prater, M. A., & Leininger, M. (2009). Juvenile literature and the portrayal of
developmental disabilities. Education and Training in Developmental Disabilities, 44(3),
304–317.
Flevares, L. M., & Schiff, J. R. (2014). Learning mathematics in two dimensions: A review and
look ahead at teaching and learning early childhood mathematics with children’s literature.
Frontiers in Psychology, 5, 1–12. http://doi.org/10.3389/fpsyg.2014.00459
Ganea, P. A., Pickard, M., & DeLoache, J. S. (2008). Transfer between picture books and the real
world by very young children. Journal of Cognition and Development, 9, 46–66.
INCREASING AWARENESS
77
Gebarski, K. S., Daley, J., Gebarski, M. W., Keshavarzi, N., Hernandez, R. J., Ivanzic, V., &
Gebarski, S. S. (2013). Efficacy of a cartoon and photograph montage storybook in
preparing children for voiding cystourethrogram. Pediatric Radiology, 43(11), 1485–1490.
http://doi.org/10.1007/s00247-013-2713-2
Google. (2015). Google Trends. Retrieved from https://www.google.com/trends/
Grönroos, C., & Ojasalo, K. (2004). Service productivity - Towards a conceptualization of the
transformation of inputs into economic results in services. Journal of Business Research,
57(4), 414–423. http://doi.org/10.1016/S0148-2963(02)00275-8
Heah, T., Case, T., McGuire, B., & Law, M. (2007). Successful participation: The lived experience
among children with disabilities. Canadian Journal of Occupational Therapy, 74(1), 38–47.
http://doi.org/10.2182/cjot.06.10
Hildenbrand, W. C., & Lamb, A. J. (2013). Occupational therapy in prevention and wellness:
Retaining relevance in a new health care world. American Journal of Occupational
Therapy, 67(3), 266–71. http://doi.org/10.5014/ajot.2013.673001
Hinojosa, J. (2007). Becoming innovators in an era of hyperchange [Eleanor Clarke Slagle
Lecture]. American Journal of Occupational Therapy, 61, 629–637.
Hocking, C. (2013). Occupation for public health. New Zealand Journal of Occupational Therapy,
60(1), 33–37.
Holmberg, V., & Ringsberg, K. C. (2014). Occupational therapists as contributors to health
promotion. Scandinavian Journal of Occupational Therapy, 21(2), 82–89.
http://doi.org/10.3109/11038128.2013.877069
INCREASING AWARENESS
78
Hong, S., Kwon, K., & Jeon, H. (2014). Children’s attitudes towards peers with disabilities:
Associations with personal and parental factors. Faculty Publications from CYFS, 30, 170-
193. Retrieved from http://digitalcommons.unl.edu/cyfsfacpub/30
Hoogsteen, L., & Woodgate, R. L. (2010). Can I play? A concept analysis of participation in
children with disabilities. Physical & Occupational Therapy in Pediatrics, 30(4), 325–339.
http://doi.org/10.3109/01942638.2010.481661
Houtrow, A.P. (2012). Participation of children with special health care needs in school and the
community. Academic Pediatrics, 12(4), 326–334.
Hurst, C., Corning, K., & Ferrante, R. (2012). Children’s acceptance of others with disability: The
influence of a disability-simulation program. Journal of Genetic Counseling, 21(6), 873–
883. doi:10.1007/s10897-012-9516-8
Individuals With Disabilities Education Act, 20 U.S.C. § 1400 (2004)
Ison, N., McIntyre, S., Rothery, S., Smithers-Sheedy, H., Goldsmith, S., Parsonage, S., & Foy, L.
(2010). “Just like you”: A disability awareness programme for children that enhanced
knowledge, attitudes and acceptance: Pilot study findings. Developmental
Neurorehabilitation, 13(5), 360–368. http://doi.org/10.3109/17518423.2010.496764
Jacobs, K. (2012). PromOTing occupational therapy: Words, images, and actions (Eleanor Clarke
Slagle Lecture). American Journal of Occupational Therapy, 66, 652–671.
http://dx.doi.org/10.5014/ajot.2012.666001
Kara, G. E., Aydos, E. H., & Aydin, Ö. (2015). Changing preschool children’s attitudes into
behavior towards selected environmental issues: An action research study. International
Journal of Education in Mathematics, Science, and Technology, 3(1), 46–63.
INCREASING AWARENESS
79
Khandekar, A., Augustyn, M., Sanders, L., & Zuckerman, B. (2011). Improving early literacy
promotion: A quality-improvement project for Reach Out and Read. Pediatrics, 127(4),
e1067–e1072. http://doi.org/10.1542/peds.2010-2290
Kirch, C. (2013). First Book tackles lack of diversity in children’s books. Retrieved from
http://www.publishersweekly.com/pw/by-topic/childrens/childrens-industry-
news/article/57867-first-book-tackles-lack-of-diversity-in-children-s-books.html
Koc, K., Koc, Y., & Ozdemir, S. (2010). The portrayals of individuals with physical and sensory
impairments in picture books. International Journal of Special Education, 25(1), 145-161.
Korkmaz, B. (2011). Theory of mind and neurodevelopmental disorders of childhood. Pediatric
Research, 69(5 Pt 2), 101R–8R. http://doi.org/10.1203/PDR.0b013e318212c177
Kumschick, I. R., Beck, L., Eid, M., Witte, G., Klann-Delius, G., Heuser, I., & Menninghaus, W.
(2014). READING and FEELING: The effects of a literature-based intervention designed to
increase emotional competence in second and third graders. Frontiers in Psychology, 5(10),
1–11. http://doi.org/10.3389/fpsyg.2014.01448
Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). Person–Environment–
Occupation Model: A transactive approach to occupational performance. Canadian Journal
of Occupational Therapy, 63, 9–23. http://dx. doi.org/10.1177/000841749606300103
Lawlor, M. C. (2003). The significance of being occupied: The social construction of childhood
occupations. American Journal of Occupational Therapy, 57, 424-434.
Leclair, L. L. (2010). Re-examining concepts of occupation and occupation-based models:
Occupational therapy and community development. Canadian Journal of Occupational
Therapy. Revue Canadienne D’ergotherapie, 77(1), 15–21.
http://doi.org/10.2182/cjot.2010.77.1.3
INCREASING AWARENESS
80
Lindsay, S., & Edwards, A. (2013). A systematic review of disability awareness interventions for
children and youth. Disability and Rehabilitation, 35(8), 623–646.
http://doi.org/10.3109/09638288.2012.702850
Lindsay, S., & McPherson, C. (2012). Strategies for improving disability awareness and social
inclusion of children and young people with cerebral palsy. Child: Care, Health and
Development, 38(6), 809–816. http://doi.org/10.1111/j.1365-2214.2011.01308.x
Macmillan, M., Tarrant, M., Abraham, C., & Morris, C. (2014). The association between children’s
contact with people with disabilities and their attitudes towards disability: A systematic
review. Developmental Medicine and Child Neurology, 56(6), 529–546.
http://doi.org/10.1111/dmcn.12326
Mantei, J., & Kervin, L. (2014). Interpreting the images in a picture book: Students make
connections to themselves, their lives, and experiences. English Teaching: Practice and
Critique, 13(2), 76-92.
Masse, L. C., Miller, A. R., Shen, J., Schiariti, V., & Roxborough, L. (2013). Patterns of
participation across a range of activities among Canadian children with neurodevelopmental
disorders and disabilities. Developmental Medicine & Child Neurology, 729-736.
http://doi.org/10.1111/dmcn.12167
Metzler, M. J., & Metz, G. (2010). Analyzing the barriers and supports of knowledge translation
using the PEO model. Canadian Journal of Occupational Therapy. Revue Canadienne
D’ergotherapie, 77(3), 151–158. http://doi.org/10.2182/cjot.2010.77.3.4
Montgomery, P., & Maunders, K. (2015). The effectiveness of creative bibliotherapy for
internalizing, externalizing, and prosocial behaviors in children: A systematic review.
INCREASING AWARENESS
81
Children and Youth Services Review, 55, 37–47.
http://doi.org/10.1016/j.childyouth.2015.05.010
Moore, D., & Nettelbeck, T. (2013). Effects of short-term disability awareness training on attitudes
of adolescent schoolboys toward persons with a disability. Journal of Intellectual &
Developmental Disability, 38(3), 223–31. http://doi.org/10.3109/13668250.2013.790532
Nilsson, I., & Townsend, E. (2010). Occupational justice - Bridging theory and practice.
Scandinavian Journal of Occupational Therapy, 17, 57–63. http://dx.doi.
org/10.3109/11038120903287182
Nowicki, E., & Brown, J. D. (2013). “A kid way”: Strategies for including classmates with learning
or intellectual disabilities. Intellectual and Developmental Disabilities, 51(4), 253–262.
http://doi.org/10.1352/1934-9556-51.4.253
Nowicki, E., Brown, J.D., & Stepien, M. (2014). Children’s thoughts on the social exclusion of
peers with intellectual or learning disabilities. Journal of Intellectual Disability Research,
58(4), 346–357. http://doi.org/10.1111/jir.12019
OCEBM Levels of Evidence Working Group. (2011). The Oxford 2011 levels of evidence. Oxford
Centre for Evidence-Based Medicine. Retrieved from
http://www.cebm.net/index.aspx?o=5653
Papaioannou, C., Evaggelinou, C. Barkoukis, V., & Block, M. (2013). Disability awareness
program in a summer camp. European Journal of Adapted Physical Activity, 6(2), 19-28.
Pardeck, J. (2005). Using children's books as an approach to enhancing our understanding of
disability. Journal of Social Work in Disability & Rehabilitation, 4:1-2, 77-85.
INCREASING AWARENESS
82
Phelan, S. K., & Kinsella, E. A. (2013). Occupation and identity: Perspectives of children with
disabilities and their parents. Journal of Occupational Science, 21(3), 334–356.
http://doi.org/10.1080/14427591.2012.755907
Preis, T., Moat, H. S., & Stanley, H. E. (2013). Quantifying Trading Behavior in Financial Markets
Using Google Trends. Scientific Reports, 3, 1–6. http://doi.org/10.1038/srep01684
Rillotta, F., & Nettelbeck, T. (2007). Effects of an awareness program on attitudes of students
without an intellectual disability towards persons with an intellectual disability. Journal of
Intellectual & Developmental Disability, 32(1), 19–27.
http://doi.org/10.1080/13668250701194042
Sharp, N., Dunford, C., & Seddon, L. (2012). A critical appraisal of how occupational therapists
can enable participation in adaptive physical activity for children and young people. The
British Journal of Occupational Therapy, 75(11), 486–494.
http://doi.org/10.4276/030802212X13522194759815
Sherman, P. (n.d.).Writing picture books for children: Formatting your manuscript. Retrieved from
http://www.writingpicturebooksforchildren.com/manuscript-formatting.html
Shields, N., King, M., Corbett, M., & Imms, C. (2014). Is participation among children with
intellectual disabilities in outside school activities similar to their typically developing
peers? A systematic review. Developmental Neurorehabilitation, 17(1), 64–71.
http://doi.org/10.3109/17518423.2013.836256
Smith-Osborne, A. (2007). Life span and resiliency theory: A critical review. Advances in Social
Work, 8(1), 152–168. Retrieved from
http://journals.iupui.edu/index.php/advancesinsocialwork/article/view/138
INCREASING AWARENESS
83
Society for Children’s Book Writers and Illustrators. (n.d.) Illustrator Gallery. Retrieved from
https://www.scbwi.org/illustrator-gallery/
Sokol, J.T. (2009). Identity development throughout the lifetime: An examination of Eriksonian
theory. Graduate Journal of Counseling Psychology, 1(2). Retrieved from:
http://epublications.marquette.edu/gjcp/vol1/iss2/14
Spencer-Cavaliere, N., & Watkinson, E. J. (2010). Inclusion understood from the perspectives of
children with disability. Adapted Physical Activity Quarterly, 27(4), 275–293.
Spilt, J.L., van Lier, P., Leflot, G., Onghena, P., & Colpin, H. (2014). Children’s social self-concept
and internalizing problems: The influence of peers and teachers. Child Development, 85(3),
1248–1256. http://doi.org/10.1111/cdev.12181
Stoffel, V. C. (2013). From heartfelt leadership to compassionate care (inaugural presidential
address). American Journal of Occupational Therapy, 67, 633–640.
http://dx.doi.org/10.5014/ajot.2013.676001
Strong, S., Rigby, P., Stewart, D., Law, M., Letts, L., & Cooper, B. (1999). Application of the
Person-Environment-Occupation Model: A practical tool. Canadian Journal of
Occupational Therapy, 66(3), 122–133.
Sudsawad, P. (2005). Concepts in clinical scholarship: A conceptual framework to increase
usability of outcome research for evidence-based practice. American Journal of
Occupational Therapy, 59, 351–355.
SurveyMonkey Inc. (2015). Plans and Pricing. Retrieved from
https://www.surveymonkey.com/pricing/
INCREASING AWARENESS
84
Tan, M., & Campbell, S. (2014). Selecting fiction books for a children’s health section.
Researchgate, p. 1-18. Retrieved from:
http://www.researchgate.net/publication/268215263_Selecting_Fiction_Books_for_a_Child
ren's_Health_Collection
Turner, J. C. (2006). Representations of illness, injury, and health in children’s picture books.
Children’s Health Care, 35(2), 179–189. http://doi.org/10.1207/s15326888chc3502_5
U.S. Census Bureau. (2010). Americans with disabilities: 2010. Retrieved from
https://www.census.gov/newsroom/releases/archives/miscellaneous/cb12-134.html
We Need Diverse Books. (2014). Annual report 2014. Retrieved from
http://weneeddiversebooks.org/annualreport2014/
Van Bruggen, H. (2014). Turning challenges into opportunities: How occupational therapy is
contributing to social, health, and educational reform. WFOT Bulletin, 70, 41-46.
Waxman, S. R., Herrmann, P., Woodring, J., & Medin, D. L. (2014). Humans (really) are animals:
Picture-book reading influences 5-year-old urban children’s construal of the relation
between humans and non-human animals. Frontiers in Psychology, 5, 1–8.
http://doi.org/10.3389/fpsyg.2014.00172
World Health Organization. (2011). World report on disability. Geneva: World Health
Organization. Retrieved from www.who.int/disabilities/world_report/2011/report/en/
World Health Organization. (2007). International Classification of Functioning, Disability, and
Health: Children & Youth version. Geneva: World Health Organization.
Zimmerman, C. (n.d.). Getting Published: Children’s Books. Retrieved from
http://www.businessknowhow.com/startup/emma.htm
INCREASING AWARENESS
85
Zuckerman, B., & Augustyn, M. (2011). Books and reading: Evidence-based standard of care
whose time has come. Academic Pediatrics, 11(1), 11–17.
http://doi.org/10.1016/j.acap.2010.09.007
(
