University of Southern California
Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy
Redesigning Lives Globally
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Faculty

Florence Clark PhD, OTR/L, FAOTA

Florence Clark

Associate Dean, Chair and Mrs. T.H. Chan Professor of Occupational Science and Occupational Therapy

Room: CHP 100D
Phone: (323) 442-2113
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Biography

Florence Clark is a widely published and noted scholar. She earned her BA degree in English from the State University of New York at Albany, her MS degree in Occupational Therapy from the State University of New York at Buffalo, and her PhD degree in Education from the University of Southern California, focusing in the areas of psychometrics and special education. She has been awarded honorary doctorate degrees from the University of Indianapolis and from The State University of New York Health Science Center at Brooklyn. Appointed as a charter member of the Academy of Research of the American Occupational Therapy Association (AOTA), she has served as special consultant to the United States Army Surgeon General, been on the board of the National Center for Medical Rehabilitation Research, and been the recipient of an Eleanor Clarke Slagle Lectureship, the occupational therapy profession's highest academic honor. In 1999, AOTA honored her with its Award of Merit and in 2001 she received a lifetime achievement award from the Occupational Therapy Association of California. In 2004, she received the Presidential Medallion from President Steven Sample of the University of Southern California, the ultimate honor for those who have brought honor and distinction upon USC. She held elected national office as AOTA Vice President from 2007-2010 and as AOTA President from 2010-2013.

Research Interests

Since 1985, Florence Clark has attracted more than $10 million in extramural funding from NIH, NIDRR, and other federal agencies for research and training in the areas of healthy aging and the secondary conditions that impede the flourishing of people with disabilities in their real life circumstances. Dr. Clark’s research programs in healthy aging and in the prevention of pressure ulcers in persons with spinal cord injury have followed a blueprint for translational research which she first developed with colleagues in connection with the USC Well Elderly Study. Initiated in 1993, the Well Elderly Study (RO1 AG11810) was a randomized controlled trial which demonstrated that preventive occupational therapy forestalls the declines associated with typical aging and improves the health of independently living elders. In the translational research blueprint, qualitative research is employed first to systematically identify the needs and concerns of consumers. This information is translated into an intervention approach, which is then tested by launching randomized controlled trials to ascertain efficacy, effectiveness and cost-effectiveness of the intervention. In 2004, Dr. Clark received a second large research award (RO1 AG11810) to conceptually replicate the original Well Elderly results and document the mediating mechanisms responsible for the intervention's positive effects.

In 2003, Dr. Clark, in collaboration with colleagues from Rancho Los Amigos National Rehabilitation Center, received a NIDRR field-initiated research grant to identify the contextual factors that led to recurrent pressure ulcers in people with spinal cord injury. At the end of the study, the following products were produced: a rehabilitation professional’s manual and companion manual, an online consumer manual (www.usc.edu/pups) and a manualized intervention. This study completed the first step in the application of the blueprint to a specific life-threatening problem for people with spinal cord injury. In continuing this research program, Dr. Clark received a $3.6 million NIH-funded grant (1RO1 HD056267-01A1) in 2008 to conduct a randomized clinical trial of the efficacy and cost-effectiveness of the intervention and products that were developed through NIDRR funding. Clark's specific research expertise is in the use of qualitative research methods to build interventions and in randomized controlled trial (efficacy, effectiveness, cost-effectiveness) methodology.

Education

Doctor of Philosophy (PhD) in Education
University of Southern California
1982

Master of Science (MS) in Occupational Therapy
State University of New York at Buffalo
1970

Bachelor of Arts (BA) in English
State University of New York at Albany
1968

Publications

Books

Mandel, D. R., Jackson, J. M., Zemke, R., Nelson, L., & Clark, F. A. (1999). Lifestyle redesign: Implementing the Well Elderly Program. Bethesda, MD: The American Occupational Therapy Association, Inc. Link to full text

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

Book Chapters

Clark, F. A., Jackson, J., & Pyatak, E. A. (2013). Developing an integrated occupational science research program: The USC Well Elderly and Pressure Ulcer Prevention studies. In D. Pierce (Ed.), Occupational science for occupational therapy. (pp. 291-310). Thorofare, NJ: Slack, Inc. Link to full text

Clark, F. A. (2011). Occupation embedded in a real life: Interweaving occupational science and occupational therapy [1993 Eleanor Clarke Slagle Lecture]. In R. Padilla & Y. Griffiths (Eds.), A professional legacy: The Eleanor Clarke Slagle lectures in occupational therapy, 1955-2010 (3rd ed.). Bethesda, MD: AOTA Press. Link to full text Abstract →← Abstract 

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

Clark, F. A. (2008). Foreword. In L. D. Parham & L. S. Fazio (Eds.), Play in occupational therapy for children (2nd ed.). (pp. ix-x). St. Louis, MO: Mosby Elsevier. Link to full text

Clark, F. A., & Lawlor, M. C. (2008). The making and mattering of occupational science. In E. B. Crepeau, E. S. Cohn, & B. A. B. Schell (Eds.), Willard & Spackman’s occupational therapy (11th ed.). (pp. 2-14). Philadelphia, PA: Lippincott Williams & Wilkins.

Clark, F. A., Jackson, J. M., & Carlson, M. E. (2004). Occupational science, occupational therapy and evidence-based practice: What the Well Elderly Study has taught us. In M. Molineux (Ed.), Occupation for occupational therapists. (pp. 200-218). Oxford, UK: Blackwell Publishing. Link to full text

Larson, E., Wood, W., & Clark, F. A. (2003). Occupational science: Building the science and practice of occupation through an academic discipline. In E. B. Crepeau, E. S. Cohn, & B. A. B. Schell (Eds.), Willard & Spackman's occupational therapy (10th ed.). (pp. 15-26). Philadelphia, PA: Lippincott Williams & Wilkins.

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

Clark, F. A., Wood, W., & Larson, E. A. (1998). Occupational science: Occupational therapy's legacy for the 21st century. In M. E. Neistadt & E. B. Crepeau (Eds.), Willard & Spackman's occupational therapy (9th ed.). (pp. 13-21). Philadelphia, PA: Lippincott.

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

Clark, F. A., Larson, B., & Richardson, P. (1996). A grounded theory of techniques for occupational storytelling and occupational story making. In R. Zemke & F. Clark (Eds.), Occupational science: The evolving discipline. (pp. 373-392). Philadelphia, PA: F. A. Davis.

Clark, F. A., & Larson, E. A. (1993). Developing an academic discipline: The science of occupation. In H. L. Hopkins & H. D. Smith (Eds.), Willard & Spackman's occupational therapy (8th ed.). (pp. 44-57). Philadelphia, PA: Lippincott.

Clark, F., Mailloux, Z., Parham, L. D., & Bissell, J. (1989). Sensory integration and children with learning disabilities. In P. N. Pratt & A. S. Allen (Eds.), Occupational therapy for children (2nd ed.). (pp. 457-509). St. Louis, MO: C. V. Mosby.

Mailloux, Z., Knox, S., Burke, J. P., & Clark, F. A. (1985). Pediatric dysfunction. In G. Kielhofner (Ed.), A model of human occupation: Theory and application. (pp. 306-351). Baltimore, MD: Williams & Wilkins.

Clark, F. A., Mailloux, Z., & Parham, L. D. (1984). Sensory integration and children with learning disabilities. In P. N. Clark & A. S. Allen (Eds.), Occupational therapy for children. (pp. 457-509). St. Louis, MO: C. V. Mosby.

Clark, P. H., Florey, L., & Clark, F. A. (1984). Developmental principles and theories. In P. N. Clark & A. S. Allen (Eds.), Occupational therapy for children. (pp. 18-47). St. Louis, MO: C. V. Mosby.

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

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

Journal Articles

Clark, F., Pyatak, E. A., Carlson, M., Blanche, E. I., Vigen, C., Hay, J., Mallinson, T., Blanchard, J., Unger, J. B., Garber, S. L., Diaz, J., Florindez, L. I., Atkins, M., Rubayi, S., & Azen, S. P. (2014). Implementing trials of complex interventions in community settings: The USC-Rancho Los Amigos Pressure Ulcer Prevention Study (PUPS). Clinical Trials, 11, 218-229. doi:10.1177/1740774514521904. Link to full text Abstract →← Abstract 

BACKGROUND: Randomized trials of complex, non-pharmacologic interventions implemented in home and community settings, such as the University of Southern California (USC)-Rancho Los Amigos National Rehabilitation Center (RLANRC) Pressure Ulcer Prevention Study (PUPS), present unique challenges with respect to (1) participant recruitment and retention, (2) intervention delivery and fidelity, (3) randomization and assessment, and (4) potential inadvertent treatment effects.
 
PURPOSE: We describe the methods employed to address the challenges confronted in implementing PUPS. In this randomized controlled trial, we are assessing the efficacy of a complex, preventive intervention in reducing the incidence of, and costs associated with, the development of medically serious pressure ulcers in people with spinal cord injury.
 
METHODS: Individuals with spinal cord injury recruited from RLANRC were assigned to either a 12-month preventive intervention group or a standard care control group. The primary outcome is the incidence of serious pressure ulcers with secondary endpoints including ulcer-related surgeries, medical treatment costs, and quality of life. These outcomes are assessed at 12 and 24 months after randomization. Additionally, we are studying the mediating mechanisms that account for intervention outcomes.
 
RESULTS: PUPS has been successfully implemented, including recruitment of the target sample size of 170 participants, assurance of the integrity of intervention protocol delivery with an average 90% treatment adherence rate, and enactment of the assessment plan. However, implementation has been replete with challenges. To meet recruitment goals, we instituted a five-pronged approach customized for an underserved, ethnically diverse population. In intervention delivery, we increased staff time to overcome economic and cultural barriers to retention and adherence. To ensure treatment fidelity and replicability, we monitored intervention protocol delivery in accordance with a rigorous plan. Finally, we have overcome unanticipated assessment and design concerns related to (1) determining pressure ulcer incidence/severity, (2) randomization imbalance, and (3) inadvertent potential control group contamination.
 
LIMITATIONS: We have addressed the most daunting challenges encountered in the recruitment, assessment, and intervention phases of PUPS. Some challenges and solutions may not apply to trials conducted in other settings.
 
CONCLUSIONS: Overcoming challenges has required a multifaceted approach incorporating individualization, flexibility, and persistence, as well as the ability to implement needed mid-course corrections.

Wilcox, R. R., Granger, D. A., Szanton, S., & Clark, F. (2014). Diurnal patterns and associations among salivary cortisol, DHEA and alpha-amylase in older adults. Physiology & Behavior, 129, 11-16. doi:10.1016/j.physbeh.2014.02.012. Link to full text Abstract →← Abstract 

BACKGROUND: Cortisol and dehydroepiandrosterone (DHEA) are considered to be valuable markers of the hypothalamus-pituitary-adrenal (HPA) axis, while salivary alpha-amylase (sAA) reflects the autonomic nervous system. Past studies have found certain diurnal patterns among these biomarkers, with some studies reporting results that differ from others. Also, some past studies have found an association among these three biomarkers while other studies have not. This study investigates these patterns and associations in older adults by taking advantage of modern statistical methods for dealing with non-normality, outliers and curvature. Basic characteristics of the data are reported as well, which are relevant to understanding the nature of any patterns and associations.
 
METHODS: Boxplots were used to check on the skewness and presence of outliers, including the impact of using simple transformations for dealing with non-normality. Diurnal patterns were investigated using recent advances aimed at comparing medians. When studying associations, the initial step was to check for curvature using a non-parametric regression estimator. Based on the resulting fit, a robust regression estimator was used that is designed to deal with skewed distributions and outliers.
 
RESULTS: Boxplots indicated highly skewed distributions with outliers. Simple transformations (such as taking logs) did not deal with this issue in an effective manner. Consequently, diurnal patterns were investigated using medians and found to be consistent with some previous studies but not others. A positive association between awakening cortisol levels and DHEA was found when DHEA is relatively low; otherwise no association was found. The nature of the association between cortisol and DHEA was found to change during the course of the day. Upon awakening, cortisol was found to have no association with sAA when DHEA levels are relatively low, but otherwise there is a negative association. DHEA was found to have a positive association with sAA upon awakening. Shortly after awakening and for the remainder of the day, no association was found between DHEA and sAA ignoring cortisol. For DHEA and cortisol (taken as the independent variables) versus sAA (the dependent variable), again an association is found only upon awakening.

Wilcox, R. R., Granger, D. A., Szanton, S., & Clark, F. (2014). Cortisol diurnal patterns, associations with depressive symptoms, and the impact of intervention in older adults: Results using modern robust methods aimed at dealing with low power due to violations of standard assumptions. Hormones and Behavior, 65, 219-225. doi:10.1016/j.yhbeh.2014.01.005. Link to full text Abstract →← Abstract 

Advances in salivary bioscience enable the widespread integration of biological measures into the behavioral and social sciences. While theoretical integration has progressed, much less attention has focused on analytical strategies and tactics. The statistical literature warns that common methods for comparing groups and studying associations can have relatively poor power compared to more modern robust techniques. Here we illustrate, in secondary data analyses using the USC Well Elderly II study (n=460, age 60-95, 66% female), that modern robust methods make a substantial difference when analyzing relations between salivary analyte and behavioral data. Analyses that deal with the diurnal pattern of cortisol and the association of the cortisol awakening response with depressive symptoms and physical well-being are reported. Non-significant results become significant when using improved methods for dealing with skewed distributions and outliers. Analytical strategies and tactics that employ modern robust methods have the potential to reduce the probability of both Type I and Type II errors in studies that compare salivary analytes between groups, across time, or examine associations with salivary analyte levels.

Wilcox, R. R., Erceg-Hurn, D. M., Clark, F., & Carlson, M. (2014). Comparing two independent groups via the lower and upper quantiles. Journal of Statistical Computation and Simulation, 84, 1543-1551. doi:10.1080/00949655.2012.754026. Link to full text Abstract →← Abstract 

The most common strategy for comparing two independent groups is in terms of some measure of location intended to reflect the typical observation. However, it can be informative and important to compare the lower and upper quantiles as well, but when there are tied values, extant techniques suffer from practical concerns reviewed in the paper. For the special case where the goal is to compare the medians, a slight generalization of the percentile bootstrap method performs well in terms of controlling Type I errors when there are tied values [Wilcox RR. Comparing medians. Comput. Statist. Data Anal. 2006;51:1934–1943]. But our results indicate that when the goal is to compare the quartiles, or quantiles close to zero or one, this approach is highly unsatisfactory when the quantiles are estimated using a single order statistic or a weighted average of two order statistics. The main result in this paper is that when using the Harrell–Davis estimator, which uses all of the order statistics to estimate a quantile, control over the Type I error probability can be achieved in simulations, even when there are tied values, provided the sample sizes are not too small. It is demonstrated that this method can also have substantially higher power than the distribution free method derived by Doksum and Sievers [Plotting with confidence: graphical comparisons of two populations. Biometrika 1976;63:421–434]. Data from two studies are used to illustrate the practical advantages of the method studied here.

Carlson, M., Jackson, J., Mandel, D., Blanchard, J., Holguin, J., Lai, M. Y., Marterella, A., Vigen, C., Gleason, S., Lam, C., Azen, S., & Clark, F. (2014). Predictors of retention among African American and Hispanic older adult research participants in the Well Elderly 2 randomized controlled trial. Journal of Applied Gerontology, 33, 357-382. doi:10.1177/0733464812471444. Link to full text Abstract →← Abstract 

The purpose of this study was to document predictors of long-term retention among minority participants in the Well Elderly 2 Study, a randomized controlled trial of a lifestyle intervention for community-dwelling older adults. The primary sample included 149 African American and 92 Hispanic men and women aged 60 to 95 years, recruited at senior activity centers and senior residences. Chi-square and logistic regression procedures were undertaken to examine study-based, psychosocial and health-related predictors of retention at 18 months following study entry. For both African Americans and Hispanics, intervention adherence was the strongest predictor. Retention was also related to high active coping and average (vs. high or low) levels of activity participation among African Americans and high social network strength among Hispanics. The results suggest that improved knowledge of the predictors of retention among minority elders can spawn new retention strategies that can be applied at individual, subgroup, and sample-wide levels.

Pyatak, E. A., Blanche, E. J., Garber, S. L., Diaz, J., Blanchard, J., Florindez, L., & Clark, F. A. (2013). Conducting intervention research among underserved populations: Lessons learned and recommendations for researchers. Archives of Physical Medicine and Rehabilitation, 94, 1190-1198. doi:10.1016/j.apmr.2012.12.009. Link to full text Abstract →← Abstract 

Randomized controlled trials (RCTs) are considered the criterion standard in research design for establishing treatment efficacy. However, the rigorous and highly controlled conditions of RCTs can be difficult to attain when conducting research among individuals living with a confluence of disability, low socioeconomic status, and being a member of a racial/ethnic minority group, who may be more likely to have unstable life circumstances. Research on effective interventions for these groups is urgently needed, because evidence regarding approaches to reduce health disparities and improve health outcomes is lacking. In this methodologic article, we discuss the challenges and lessons learned in implementing the Lifestyle Redesign for Pressure Ulcer Prevention in Spinal Cord Injury study among a highly disadvantaged population. These issues are discussed in terms of strategies to enhance recruitment, retention, and intervention relevance to the target population. Recommendations for researchers seeking to conduct RCTs among socioeconomically disadvantaged, ethnically diverse populations are provided.

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. doi:10.5014/ajot.2013.676003. Link to full text

Wilcox, R. R., Granger, D. A., & Clark, F. A. (2013). Modern robust statistical methods: Basics with illustrations using psychobiological data. Universal Journal of Psychology, 1, 21-31. doi:10.13189/ujp.2013.010201. Link to full text Abstract →← Abstract 

Psychological studies in general, and psychobiological studies in particular, routinely use a collection of classic statistical techniques aimed at comparing groups or studying associations. A fundamental issue is whether violating the basic assumptions underlying these methods, namely normality and homoscedasticity, can result in relatively poor power or miss important features of the data that have practical significance. In the statistics literature, hundreds of papers make it clear that under general conditions the answer is yes and that routinely used strategies for dealing with violations of assumptions can be unsatisfactory. Moreover, a vast array of new and improved techniques is now available for dealing with violations of assumptions, including more flexible methods for dealing with curvature. The paper reviews the major insights regarding standard methods, explains why some seemingly reasonable methods for dealing with violations of assumptions are technically unsound, and then outlines methods that are technically correct. It then illustrates the practical importance of modern methods using data from the Well Elderly II study.

Wilcox, R. R., Carlson, M. E., Azen, S. P., & Clark, F. A. (2013). Avoid lost discoveries, because of violations of standard assumptions, by using modern robust statistical methods. Journal of Clinical Epidemiology, 66, 319-329. doi:10.1016/j.jclinepi.2012.09.003. Link to full text Abstract →← Abstract 

OBJECTIVES: Recently, there have been major advances in statistical techniques for assessing central tendency and measures of association. The practical utility of modern methods has been documented extensively in the statistics literature, but they remain underused and relatively unknown in clinical trials. Our objective was to address this issue.
 
STUDY DESIGN AND PURPOSE: The first purpose was to review common problems associated with standard methodologies (low power, lack of control over type I errors, and incorrect assessments of the strength of the association). The second purpose was to summarize some modern methods that can be used to circumvent such problems. The third purpose was to illustrate the practical utility of modern robust methods using data from the Well Elderly 2 randomized controlled trial.
 
RESULTS: In multiple instances, robust methods uncovered differences among groups and associations among variables that were not detected by classic techniques. In particular, the results demonstrated that details of the nature and strength of the association were sometimes overlooked when using ordinary least squares regression and Pearson correlation.
 
CONCLUSION: Modern robust methods can make a practical difference in detecting and describing differences between groups and associations between variables. Such procedures should be applied more frequently when analyzing trial-based data.

Carlson, M., Kuo, A., Chou, C., & Clark, F. (2013). Relationship of global self-evaluations of activity to psychosocial and health-related aging outcomes. OTJR: Occupation, Participation, and Health, 33, 180-189. doi:10.3928/15394492-20130712-01. Link to full text Abstract →← Abstract 

The authors obtained older adults’ self-rated judgments about the quality of their activity engagement considered as a whole (global activity evaluation) and, using cross-sectional survey data, tested the ability of such judgments to predict well-being. Participants were 460 community-dwelling older adults who responded to (1) global activity evaluations, (2) activity participation frequency scales, and (3) indices of life satisfaction, depression, and physical and mental health-related quality of life. Regression analyses indicated that global activity evaluations had a stronger relationship to psychosocial outcome indices than did participation frequency ratings, although both measurement approaches were associated with statistically significant predictions. However, global evaluations and participation frequency ratings were approximately equal in their ability to predict physical health-related quality of life. These relationships were fairly consistent across ethnic groups. Overall, the results suggest that ideally the two strategies for assessing activity should be incorporated in future research on activity and occupational therapy practice.

Clark, F. A., Park, D. J., & Burke, J. P. (2013). Dissemination: Bringing translational research to completion. American Journal of Occupational Therapy, 67, 185-193. doi:10.5014/ajot.2013.006148. Link to full text Abstract →← Abstract 

Despite the availability of innovative health care research, a gap exists between research-generated knowledge and the utilization of that knowledge in real-world practice settings. This article examines the transition from research to implementation in the context of the dissemination of A. Jean Ayres' sensory integration procedures and of the challenges currently facing the University of Southern California Well Elderly Studies research team. Drawing from the emerging field of implementation science, this article discusses how researchers can develop an implementation plan to more easily translate evidence into practice. Such plans should address the intervention's reach (i.e., its capacity to penetrate into the intended target population), the settings for which it is applicable, the leaders who will encourage practitioner uptake, stakeholder groups, and challenges to dissemination. By taking action to ensure the more effective dissemination of research-generated knowledge, researchers can increase the likelihood that their interventions will lead to improvements in practice and more effective care for consumers.

Chang, M. C., Parham, L. D., Blanche, E. J., Schell, A., Chou, C. P., Dawson, M., & Clark, F. A. (2012). Autonomic and behavioral responses of children with autism to auditory stimuli. American Journal of Occupational Therapy, 66, 567-576. doi:10.5014/ajot.2012.004242. Link to full text Abstract →← Abstract 

OBJECTIVES: We examined whether children with and without autism spectrum disorder (ASD) differ in autonomic activity at rest and in response to auditory stimuli and whether behavioral problems related to sounds in everyday life are associated with autonomic responses to auditory stimuli.
 
METHOD: We measured skin conductance (SC) at rest and in response to auditory stimuli as well as behavioral responses using the Sensory Processing Measure (SPM) Home Form. Participants were 25 children with ASD and 25 typically developing (TD) children, aged 5–12 yr.
 
RESULTS: The ASD group had significantly higher resting SC and stronger SC reactivity to tones than the TD group. Correlations between SC and SPM indicated that more severe auditory behavioral difficulties were associated with higher sympathetic activation at rest and stronger sympathetic reactivity to sound.
 
CONCLUSION: High sympathetic reactivity to sound may underlie the difficult behavioral responses to sound that children with ASD often demonstrate.

Clark, F. A., Jackson, J. M., Carlson, M. E., Chou, C. P., Cherry, B. J., Jordan-Marsh, M., Knight, B. G., Mandel, D., Blanchard, J., Granger, D. A., Wilcox, R. R., Lai, M. Y., White, B. A., Hay, J. W., Lam, C., Marterella, A., & Azen, S. P. (2012). Effectiveness of a lifestyle intervention in promoting the well-being of independently living older people: Results of the Well Elderly 2 Randomised Controlled Trial. Journal of Epidemiology and Community Health, 66, 782-790. doi:10.1136/jech.2009.099754. Link to full text Abstract →← Abstract 

BACKGROUND: Older people are at risk for health decline and loss of independence. Lifestyle interventions offer potential for reducing such negative outcomes. The aim of this study was to determine the effectiveness and cost-effectiveness of a preventive lifestyle-based occupational therapy intervention, administered in a variety of community-based sites, in improving mental and physical well-being and cognitive functioning in ethnically diverse older people.
 
METHODS: A randomised controlled trial was conducted comparing an occupational therapy intervention and a no-treatment control condition over a 6-month experimental phase. Participants included 460 men and women aged 60-95 years (mean age 74.9±7.7 years; 53% <$12,000 annual income) recruited from 21 sites in the greater Los Angeles metropolitan area.
 
RESULTS: Intervention participants, relative to untreated controls, showed more favourable change scores on indices of bodily pain, vitality, social functioning, mental health, composite mental functioning, life satisfaction and depressive symptomatology (ps<0.05). The intervention group had a significantly greater increment in quality-adjusted life years (p<0.02), which was achieved cost-effectively (US $41,218/UK £24,868 per unit). No intervention effect was found for cognitive functioning outcome measures.
 
CONCLUSIONS: A lifestyle-oriented occupational therapy intervention has beneficial effects for ethnically diverse older people recruited from a wide array of community settings. Because the intervention is cost-effective and is applicable on a wide-scale basis, it has the potential to help reduce health decline and promote well-being in older people.

Carlson, M., Park, D. J., Kuo, A., & Clark, F. (2012). Occupation in relation to the self. Journal of Occupational Science, doi:10.1080/14427591.2012.727356. Link to full text Abstract →← Abstract 

Knowledge of the construct of occupation remains fragmented within traditional social science disciplines. In this paper, we aim to provide a theoretical synthesis by explicating the unique properties of occupation in relation to the self within social science discourse. Occupations relate to other social science constructs in three ways: (a) they recruit a set of associated changes into a person's life; (b) they serve a person's ability to achieve important goals; and (c) they act as a mirror by reflecting multiple dimensions of the self. Key characteristics of occupation such as its experiential salience and its repetitional flavor powerfully amplify its significant role in affecting self-relevant outcomes. Occupation represents a crucial playing field that profoundly affects the unfolding of human lives. Therefore, the continued pursuit of occupational science is warranted and can uniquely contribute to an improved understanding of the self.

Clark, F. A. (2012). Beyond high definition: Attitude and evidence bringing OT in HD–3D [Presidential address]. American Journal of Occupational Therapy, 66, 644-651. doi: 10.5014/ajot.2012.666002. Link to full text

Werner, J. M., Carlson, M. E., Jordan-Marsh, M., & Clark, F. A. (2011). Predictors of computer use in community-dwelling, ethnically diverse older adults. Human Factors, 53, 431-447. doi:10.1177/0018720811420840. Link to full text Abstract →← Abstract 

OBJECTIVE: In this study, we analyzed self-reported computer use, demographic variables, psychosocial variables, and health and well-being variables collected from 460 ethnically diverse, community-dwelling elders to investigate the relationship computer use has with demographics, well-being, and other key psychosocial variables in older adults.
 
BACKGROUND: Although younger elders with more education, those who employ active coping strategies, or those who are low in anxiety levels are thought to use computers at higher rates than do others, previous research has produced mixed or inconclusive results regarding ethnic, gender, and psychological factors or has concentrated on computer-specific psychological factors only (e.g., computer anxiety). Few such studies have employed large sample sizes or have focused on ethnically diverse populations of community-dwelling elders.
 
METHOD: With a large number of overlapping predictors, zero-order analysis alone is poorly equipped to identify variables that are independently associated with computer use. Accordingly, both zero-order and stepwise logistic regression analyses were conducted to determine the correlates of two types of computer use: e-mail and general computer use.
 
RESULTS: Results indicate that younger age, greater level of education, non-Hispanic ethnicity, behaviorally active coping style, general physical health, and role-related emotional health each independently predicted computer usage.
 
CONCLUSION: Study findings highlight differences in computer usage, especially in regard to Hispanic ethnicity and specific health and well-being factors.
 
APPLICATION: Potential applications of this research include future intervention studies, individualized computer-based activity programming, or customizable software and user interface design for older adults responsive to a variety of personal characteristics and capabilities.

Carlson, M. E., Wilcox, R. R., Chou, C. P., Chang, M., Yang, F., Blanchard, J., Marterella, A., Kuo, A., & Clark, F. A. (2011). Psychometric properties of reverse-scored items on the CES-D in a sample of ethnically diverse older adults. Psychological Assessment, 23, 558-562. doi:10.1037/a0022484. Link to full text Abstract →← Abstract 

Reverse-scored items on assessment scales increase cognitive processing demands and may therefore lead to measurement problems for older adult respondents. In this study, the objective was to examine possible psychometric inadequacies of reverse-scored items on the Center for Epidemiologic Studies Depression Scale (CES-D) when used to assess ethnically diverse older adults. Using baseline data from a gerontologic clinical trial (n = 460), we tested the hypotheses that the reversed items on the CES-D (a) are less reliable than nonreversed items, (b) disproportionately lead to intraindividually atypical responses that are psychometrically problematic, and (c) evidence improved measurement properties when an imputation procedure based on the scale mean is used to replace atypical responses. In general, the results supported the hypotheses. Relative to nonreversed CES-D items, the 4 reversed items were less internally consistent, were associated with lower item-scale correlations, and were more often answered atypically at an intraindividual level. Further, the atypical responses were negatively correlated with responses to psychometrically sound nonreversed items that had similar content. The use of imputation to replace atypical responses enhanced the predictive validity of the set of reverse-scored items. Among older adult respondents, reverse-scored items are associated with measurement difficulties. It is recommended that appropriate correction procedures such as item readministration or statistical imputation be applied to reduce the difficulties.

Clark, F. A. (2011). High-definition occupational therapy's competitive edge: Personal excellence is the key [Presidential address]. American Journal of Occupational Therapy, 65, 616-622. doi:10.5014/ajot.2011.656001. Link to full text

Blanche, E. J., Fogelberg, D., Diaz, J., Carlson, M. E., & Clark, F. A. (2011). Manualization of occupational therapy interventions: Illustrations from the Pressure Ulcer Prevention Research Program. American Journal of Occupational Therapy, 65, 711-719. doi:10.5014/ajot.2011.001172. Link to full text Abstract →← Abstract 

The manualization of a complex occupational therapy intervention is a crucial step in ensuring treatment fidelity for both clinical application and research purposes. Toward the latter end, intervention manuals are essential for ensuring trustworthiness and replicability of randomized controlled trials that aim to provide evidence of the effectiveness of occupational therapy. In this article, we review the literature on the process of intervention manualization. We then illustrate the prescribed steps through our experience in implementing the University of Southern California/Rancho Los Amigos National Rehabilitation Center's collaborative Pressure Ulcer Prevention Project. In this research program, qualitative research provided the initial foundation for manualization of a multifaceted occupational therapy intervention designed to reduce the incidence of medically serious pressure ulcers in adults with spinal cord injury.

Vaishampayan, A., Clark, F. A., Carlson, M. E., & Blanche, E. J. (2011). Preventing pressure ulcers in people with spinal cord injury: Targeting risky life circumstances through a community-based interventions. Advances in Skin and Wound Care, 24, 275-284. doi:10.1097/01.ASW.0000398663.66530.46. Link to full text Abstract →← Abstract 

OBJECTIVE: The objectives of the study were to sensitize practitioners working with individuals with spinal cord injury (SCI) to the complex life circumstances that are implicated in the development of pressure ulcers (PrUs) and to document the ways that interventions can be adapted to target individual needs.
 
METHODS: This study was a content analysis of weekly fidelity/quality control meetings that were undertaken as part of a lifestyle intervention for PrU prevention in community-dwelling adults with SCI.
 
RESULTS: Four types of lifestyle-relevant challenges to ulcer prevention were identified: risk-elevating life circumstances, communication difficulties, equipment problems, and individual personality issues. Intervention flexibility was achieved by changing the order of treatment modules, altering the intervention content or delivery approach, or going beyond the stipulated content.
 
CONCLUSION: Attention to recurrent types of individual needs, along with explicit strategies for tailoring interventions published in a manual, has the potential to enhance PrU prevention efforts for adults with SCI.

Eakman, A. M., Carlson, M. E., & Clark, F. A. (2010). Factor structure, reliability, and convergent validity of the Engagement in Meaningful Activities Survey for older adults. OTJR: Occupation, Participation and Health, 30, 111-121. doi:10.3928/15394492-20090518-01. Link to full text Abstract →← Abstract 

This study evaluated the psychometric properties of the Engagement in Meaningful Activities Survey (EMAS) (Goldberg, Brintnell, & Goldberg, 2002) in a sample of older adults living in the greater Los Angeles area. The EMAS evidenced moderate test-retest reliability (r = .56) and good internal consistency (α = .89). Exploratory factor analysis (principal components) discerned a two-component structure within the EMAS, indicative of Personal-Competence and Social-Experiential meaning. The EMAS demonstrated theoretically predicted zero-order correlations with measures of meaning and purpose in life, depressive symptomology, life satisfaction, and health-related quality of life. Regression analyses discerned that purpose and meaning in life consistently predicted the EMAS and its components. Furthermore, individuals reporting greater levels of Social-Experiential relative to Personal-Competence meaning had the lowest levels of physical health-related quality of life. This study offers initial evidence in support of the EMAS as a valid measure of meaningful activity in older adults.

Jackson, J. M., Carlson, M. E., Rubayi, S., Scott, M. D., Atkins, M. S., Blanche, E. J., Saunders-Newton, C. D., Mielke, S. E., Wolfe, M. K., & Clark, F. A. (2010). Qualitative study of principles pertaining to lifestyle and pressure ulcer risk in adults with spinal cord injury. Disability and Rehabilitation, 32, 567-578. doi:10.3109/09638280903183829. Link to full text Abstract →← Abstract 

PURPOSE: The aim of this article is to identify overarching principles that explain how daily lifestyle considerations affect pressure ulcer development as perceived by adults with spinal cord injury (SCI).
 
METHOD: Qualitative in-depth interviews over an 18-month period with 20 adults with spinal injury and a history of pressure ulcers were conducted using narrative and thematic analyses.
 
RESULTS: Eight complexly interrelated daily lifestyle principles that explain pressure ulcer development were identified: perpetual danger; change/disruption of routine; decay of prevention behaviors; lifestyle risk ratio; individualization; simultaneous presence of prevention awareness and motivation; lifestyle trade-off; and access to needed care, services and supports.
 
CONCLUSIONS: Principles pertaining to the relationship between in-context lifestyle and pressure ulcer risk underscore previous quantitative findings, but also lead to new understandings of how risk unfolds in everyday life situations. Pressure ulcer prevention for community-dwelling adults with SCI can potentially be enhanced by incorporating principles, such as the decay of prevention behaviors or lifestyle trade-off, that highlight special patterns indicative of elevated risk. The identified principles can be used to theoretically drive future research or to guide innovative lifestyle-focused intervention approaches. Public policies that promote short-term preventive interventions at critical junctures throughout a person's life should be considered.

Eakman, A. M., Carlson, M. E., & Clark, F. A. (2010). The Meaningful Activity Participation Assessment: A measure of engagement in personally valued activities. International Journal of Aging and Human Development, 70, 299-317. doi:10.2190/AG.70.4.b. Link to full text Abstract →← Abstract 

The Meaningful Activity Participation Assessment (MAPA), a recently developed 28-item tool designed to measure the meaningfulness of activity, was tested in a sample of 154 older adults. The MAPA evidenced a sufficient level of internal consistency and test-retest reliability and correlated as theoretically predicted with the Life Satisfaction Index-Z, the Satisfaction with Life Scale, the Engagement in Meaningful Activities Survey, the Purpose in Life Test, the Center for Epidemiologic Studies Depression Inventory and the Rand SF-36v2 Health Survey subscales. Zero-order correlations consistently demonstrated meaningful relationships between the MAPA and scales of psychosocial well-being and health-related quality of life. Results from multiple regression analyses further substantiated these findings, as greater meaningful activity participation was associated with better psychological well-being and health-related quality of life. The MAPA appears to be a reliable and valid measure of meaningful activity, incorporating both subjective and objective indicators of activity engagement.

Clark, F. A. (2010). Power and confidence in professions: Lessons for occupational therapy. Canadian Journal of Occupational Therapy, 77, 264-269. doi:10.2182/cjot.2010.01.77.5.2. Link to full text Abstract →← Abstract 

BACKGROUND: Powerful professions have the capacity to obtain leadership positions, advocate successfully in the policy arena, and secure the resources necessary to achieve their professional goals. Within the occupational therapy profession, cultivating power and confidence among our practitioners is essential to realize our full capacity for meeting society's occupational needs.
 
PURPOSE AND KEY ISSUES: Drawing from a historical analysis of the medical and nursing professions, this paper discusses the implications of power and disempowerment among health professions for their practitioners, clients, and public image. Theoretical perspectives on power from social psychology, politics, organizational management, and post-structuralism are introduced and their relevance to the profession of occupational therapy is examined.
 
IMPLICATIONS: The paper concludes with recommendations for occupational therapy practitioners to analyze their individual sources of power and evaluate opportunities to develop confidence and secure power for their professional work—in venues both in and outside the workplace.

Dunn, C. A., Carlson, M. E., Jackson, J. M., & Clark, F. A. (2009). Response factors surrounding progression of pressure ulcers in community-residing adults with spinal cord injury. American Journal of Occupational Therapy, 63, 301-309. doi:10.5014/ajot.63.3.301. Link to full text Abstract →← Abstract 

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

Jackson, J. M., Mandel, D., Blanchard, J., Carlson, M. E., Cherry, B. J., Azen, S. P., Chou, C. P., Jordan-Marsh, M., Forman, T., White, B. A., Granger, D., Knight, B. G., & Clark, F. A. (2009). Confronting challenges in intervention research with ethnically diverse older adults: The USC Well Elderly II Trial. Clinical Trials, 6, 90-101. doi:10.1177/1740774508101191. Link to full text Abstract →← Abstract 

BACKGROUND: Community-dwelling older adults are at risk for declines in physical health, cognition, and psychosocial well-being. However, their enactment of active and health-promoting lifestyles can reduce such declines.
 
PURPOSE: The purpose of this article is to describe the USC Well Elderly II study, a randomized clinical trial designed to test the effectiveness of a healthy lifestyle program for elders, and document how various methodological challenges were addressed during the course of the trial.
 
METHODS: In the study, 460 ethnically diverse elders recruited from a variety of sites in the urban Los Angeles area were enrolled in a randomized experiment involving a crossover design component. Within either the first or second 6-month phase of their study involvement, each elder received a lifestyle intervention designed to improve a variety of aging outcomes. At 4-5 time points over an 18-24 month interval, the research participants were assessed on measures of healthy activity, coping, social support, perceived control, stress-related biomarkers, perceived physical health, psychosocial well-being, and cognitive functioning to test the effectiveness of the intervention and document the process mechanisms responsible for its effects.
 
RESULTS: The study protocol was successfully implemented, including the enrollment of study sites, the recruitment of 460 older adults, administration of the intervention, adherence to the plan for assessment, and establishment of a large computerized data base.
 
LIMITATIONS: Methodological challenges were encountered in the areas of site recruitment, participant recruitment, testing, and intervention delivery.
 
CONCLUSIONS: The completion of clinical trials involving elders from numerous local sites requires careful oversight and anticipation of threats to the study design that stem from: (a) social situations that are particular to specific study sites; and (b) physical, functional, and social challenges pertaining to the elder population.

Fogelberg, D., Atkins, M., Blanche, E. J., Carlson, M. E., & Clark, F. A. (2009). Decisions and dilemmas in everyday life: Daily use of wheelchairs by individuals with spinal cord injury and the impact on pressure ulcer risk. Topics in Spinal Cord Injury Rehabilitation, 15(2), 16-32. doi:10.1310/sci1502-16. Link to full text Abstract →← Abstract 

Individuals with spinal cord injury (SCI) use wheelchairs for mobility and for full participation in their daily activities. The use of wheelchairs, however, can increase the risk of pressure ulcers. This study focused on wheelchair users’ perceptions of the interplay between their wheeled mobility and the development of pressure ulcers by performing a secondary analysis of data gathered during a 2-year ethnographic study of 20 community-dwelling adults with SCI. Data from a subset of these individuals are described; each of these stories contains a pressure ulcer risk episode related to wheeled mobility or cushion use. Identified risk episodes were associated with wheelchair selection, wheelchair adjustment, habituation to new equipment, lifestyle choices, and challenging life contexts. Examples highlighted the crucial relationship between individuals’ minute-to-minute decision-making and pressure ulcer risk.

Xie, B., Chou, C. P., Spruijt-Metz, D., Reynolds, K. D., Clark, F. A., Palmer, P. H., Gallaher, P., Sun, P., Guo, Q., & Johnson, C. S. (2007). Socio-demographic and economic correlates of overweight status in Chinese adolescents. American Journal of Health Behavior, 31, 339-352. doi:10.5993/AJHB.31.4.1. Link to full text Abstract →← Abstract 

OBJECTIVE: To investigate over-weight prevalence and socio-demographic and economic correlates in Chinese adolescents.
 
METHODS: Weight, height, waist circumference, and socio-demographic and economic variables of 6863 middle and high school students were measured.
 
RESULTS: 10% of girls and 17% of boys were overweight. Waist circumference and overweight risk were significantly associated with pubertal status (P<0.05). High levels of parental education and family income were significant risk factors for overweight (P<0.05).
 
DISCUSSION: Our findings underscore the need for development of evidence-based and culturally appropriate public health programs to prevent and treat pediatric obesity in China.

Clark, F. A., Reingold, F. S., & Salles-Jordan, K. (2007). Obesity and occupational therapy [Position paper]. American Journal of Occupational Therapy, 61, 701-703. doi:10.5014/ajot.61.6.701. Link to full text Abstract →← Abstract 

Obesity is a significant and wide-ranging health and social problem in the United States. Occupational therapy is a health care profession that is qualified to provide interventions with individuals, groups, and society to effect change to promote optimum health. Occupational therapy services are often used directly and indirectly to influence weight management and related health concerns through attention to lifestyle and engagement in fulfilling activities. The purpose of this paper is to explain to persons within and outside of the profession the role of occupational therapists and occupational therapy assistants in addressing the impact of obesity on people’s ability to engage in daily activities.

Clark, F. A., Sanders, K., Carlson, M. E., Blanche, E. J., & Jackson, J. M. (2007). Synthesis of habit theory. Occupational Therapy Journal of Research, 27(4), S7-S23. Link to full text Abstract →← Abstract 

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

Clark, F. A., Jackson, J. M., Scott, M. D., Carlson, M. E., Atkins, M. S., Uhles-Tanaka, D., & Rubayi, S. (2006). Data-based models of how pressure ulcers develop in daily-living contexts of adults with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 87, 1516-1525. doi:10.1016/j.apmr.2006.08.329. Link to full text Abstract →← Abstract 

OBJECTIVE: To examine the daily-lifestyle influences on the development of pressure ulcers in adults with spinal cord injury (SCI).
 
DESIGN: Qualitative investigation using in-depth interviewing and participant observation.
 
SETTING: Participants were studied in their homes and other naturalistic contexts.
 
PARTICIPANTS: Twenty men and women of diverse ethnicities with paraplegia or tetraplegia who were recruited at a pressure ulcer management clinic in a large rehabilitation facility.
 
INTERVENTIONS: Not applicable.
 
MAIN OUTCOME MEASURES: Detailed descriptive information pertaining to the development of recurring pressure ulcers in relation to participants' daily routine and activity, personal choices, motivating influences, lifestyle challenges, and prevention techniques and strategies.
 
RESULTS: The daily-lifestyle influences on pressure ulcer development in adults with SCI can be described through various models that vary in complexity, depending on whether they incorporate individualization, interrelations among modeled elements, situational specificity, and/or temporal comprehensiveness. Ulcers are most likely to develop when a person with a relatively high-risk background profile is exposed to an equilibrium-disrupting change event that culminates in a specific pressure ulcer risk episode.
 
CONCLUSIONS: The results underscore the significant degree of complexity and individualization that characterize the emergence of pressure ulcers in daily-life contexts. Prevention efforts should therefore incorporate attention to the unique constellation of circumstances that comprise a person's everyday life.

Clark, F. A. (2006). One person’s thoughts on the future of occupational science. Journal of Occupational Science, 13, 167-179. doi:10.1080/14427591.2006.9726513. Link to full text Abstract →← Abstract 

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

Xie, B., Chou, C. P., Spruijt-Metz, D., Reynolds, K. D., Clark, F. A., Palmer, P. H., Gallaher, P., Sun, P., Guo, Q., & Anderson, J. C. (2006). Weight perception, academic performance, and psychological actors in Chinese adolescents. American Journal of Health Behavior, 30, 115-124. doi:10.5993/AJHB.30.2.1. Link to full text Abstract →← Abstract 

OBJECTIVE: To investigate weight perception and related psychological factors in Chinese adolescents.
 
METHODS: A questionnaire on weight perception, academic performance, stress, hostility, and depression was completed by 6863 middle and high school students. Weight and height were measured.
 
RESULTS: Overweight perception was related to school-related stress and depression in both girls and boys (P<0.01) and to hostility in boys (P<0.01). Perceived over-weight was related to lower GPA in girls only (P<0.05).
 
CONCLUSIONS: Distorted weight perception has a detrimental psychological impact on Chinese adolescents. These findings may contribute to the obesity research and to the development of future effective intervention programs in China.

Xie, B., Chou, C. P., Spruijt-Metz, D., Reynolds, K. D., Clark, F. A., Palmer, P. H., Gallaher, P., Sun, P., Guo, Q., & Johnson, C. A. (2006). Weight perception and weight-related sociocultural and behavioral factors in Chinese adolescents. Preventive Medicine, 42, 229-234. doi:10.1016/j.ypmed.2005.12.013. Link to full text Abstract →← Abstract 

BACKGROUND: Rapid economic development accompanied by imported Western media, advertising, fashion, and lifestyle in mainland China has resulted in shifts in cultural beliefs and beauty ideals in adolescents. The present study focused on understanding relationships among weight perception and weight-related sociocultural and behavioral factors in Chinese adolescents.
 
METHODS: Data collected in 2002 from 6863 middle and high school students and their parents from four large cities in mainland China were used. Weight status was determined by measured weight and height. Weight perception, media exposure, attitudes, and health behaviors were assessed by a structured questionnaire survey.
 
RESULTS: Boys were more likely to describe themselves as either too thin or relatively thin than girls (37.32% vs. 18.79%), while girls more often considered themselves either relatively heavy or too heavy than boys (50.83% vs. 26.54%). Girls who were actually normal or underweight were more likely than boys to describe themselves as either relatively heavy or very heavy (41.6% vs. 11.6%), while boys who were actually normal or overweight were more likely than girls to believe themselves as underweight (30.9% vs. 15.7%). Girls who were frequently exposed to media from Japan, Korea, Hong Kong, and Taiwan, and placed high value on their physical appearance, were more likely to be dissatisfied with their body weight, which in turn were more likely to restrict consumption of certain foods, smoke cigarettes, and drink alcohol. Similar results were not observed in boys.
 
CONCLUSIONS: Weight dissatisfaction was prevalent in Chinese adolescents and was significantly related to media exposure, attitudes towards physical appearance, and adoption of certain health-risk behaviors in girls. Our findings underscore the importance of sociocultural influences in shaping realistic body image and have implications for prevention and early intervention for establishing health behavioral practices during adolescence

Hay, J., LaBree, L., Luo, R., Clark, F. A., Carlson, M. E., Mandel, D., Zemke, R., Jackson, J. M., & Azen, S. P. (2002). Cost-effectiveness of preventive occupational therapy for independent-living older adults. Journal of the American Geriatrics Society, 50, 1381-1388. doi:10.1046/j.1532-5415.2002.50359.x. Link to full text Abstract →← Abstract 

OBJECTIVES: To evaluate the cost-effectiveness of a 9-month preventive occupational therapy (OT) program in the Well-Elderly Study: a randomized trial in independent-living older adults that found significant health, function, and quality of life benefits attributable to preventive OT.
 
DESIGN: A randomized trial.
 
SETTING: Two government-subsidized apartment complexes.
 
PARTICIPANTS: One hundred sixty-three culturally diverse volunteers aged 60 and older.
 
INTERVENTION: An OT group, a social activity group (active control), and a nontreatment group (passive control).
 
MEASUREMENTS: Use of healthcare services was determined by telephone interview during and after the treatment phase. A conversion algorithm was applied to the RAND 36-item Short Form Health Survey to derive a preference-based health-related quality of life index, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio for preventive OT relative to the combined control group.
 
RESULTS: Costs for the 9-month OT program averaged $548 per subject. Postintervention healthcare costs were lower for the OT group ($967) than for the active control group ($1,726), the passive control group ($3,334), or a combination of the control groups ($2,593). The quality of life index showed a 4.5% QALY differential (OT vs combined control), P < .001. The cost per QALY estimates for the OT group was $10,666 (95% confidence interval = $6,747–$25,430). For the passive and active control groups, the corresponding costs per QALY were $13,784 and $7,820, respectively.
 
CONCLUSION: In this study, preventive OT demonstrated cost-effectiveness in conjunction with a trend toward decreased medical expenditures.

Clark, F. A., Azen, S. P., Carlson, M. E., Mandel, D., LaBree, L., Hay, J., Zemke, R., Jackson, J. M., & Lipson, L. (2001). Embedding health-promoting changes into the daily lives of independent-living older adults: Long-term follow-up of occupational therapy intervention. Journals of Gerontology: Series B, Psychological Sciences and Social Sciences, 56, P60-P63 doi:10.1093/geronb/56.1.P60. Link to full text Abstract →← Abstract 

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

Clark, F. A., Rubayi, S., Jackson, J. M., Uhles-Tanaka, D., Scott, M., Atkins, M., Gross, K. A., & Carlson, M. E. (2001). The role of daily activities in pressure ulcer development [Guest editorial]. Advances in Skin & Wound Care, 14, 52-54. Link to full text Abstract →← Abstract 

Pressure ulcers are a serious complication of spinal cord injury (SCI). Although pressure ulcers are often assumed to be preventable, research suggests that more than three fourths of individuals with an SCI will develop a pressure ulcer over the course of their lifetime. The total annual cost to treat these ulcers is nearly $1.5 billion.1-3 Not only can pressure ulcers be potentially life-threatening, but they can also impede the rehabilitation process and significantly disrupt the quality of life of persons with an SCI.
 
Because the pressure ulcer problem among persons with an SCI is so severe, it is important for clinicians to develop a full understanding of the underlying contributing factors in attempting to reduce pressure ulcer risk. Research has demonstrated that in the realm of lifestyle choices, factors such as poor fitness, inadequate nutrition, unemployment, decreased social involvement, substance abuse, and emotional stress can increase the risk for developing pressure ulcers. By focusing on generalizable quantitative relationships between variables, these researchers have demonstrated that, on average, individuals with an SCI who manifest a particular risk factor have a greater likelihood of developing a pressure ulcer.

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

Clark, F. A. (2001). Editorial. Scandinavian Journal of Occupational Therapy, 8(1), 3-6. doi:10.1080/11038120118826. Link to full text

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

Jackson, J. M., Kennedy, B. L., Mandel, D., Carlson, M. E., Cherry, B. J., Fanchiang, S. P., Ding, L., Zemke, R., Azen, S. P., LaBree, L., & Clark, F. A. (2000). Derivation and pilot assessment of a health promotion program for Mandarin-speaking Chinese older adults. The International Journal of Aging & Human Development, 50, 127-149. doi:10.2190/9V9H-E4L7-BTJP-9WMJ. Link to full text Abstract →← Abstract 

As the percentage of older adults of diverse ethnicities increases in the United States, the call for culturally sensitive health care service strategies that target the special needs of older people grows. The present report describes methods used to adapt a health care program so that it would better meet the needs of a group of well, older Mandarin-speaking Chinese residents of Los Angeles. The specific qualitative research procedures that we used to adapt the treatment program are described, along with the particular adaptations that emerged. Additionally, outcomes from a randomized pilot experiment are presented that are consistent with the notion that the adapted program was effective in reducing health-related declines among older Mandarin-speaking men and women. The overall outcome of this project is in agreement with other reports in the health care literature that address the importance of providing culturally sensitive health care service for elders.

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

Azen, S. P., Palmer, J. M., Carlson, M. E., Mandel, D., Cherry, B. J., Fanchiang, S. P., Jackson, J. M., & Clark, F. A. (1999). Psychometric properties of a Chinese translation of the SF-36 Health Survey Questionnaire in the Well Elderly Study. Journal of Aging and Health, 11, 240-251. doi:10.1177/089826439901100206. Link to full text Abstract →← Abstract 

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

Snyder, C., Clark, F. A., Masunaka-Noriega, M., & Young, B. (1998). Los Angeles street kids: New occupations for life program. Journal of Occupational Science, 5, 133-139. doi:10.1080/14427591.1998.9686441. Link to full text Abstract →← Abstract 

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

Carlson, M. E., Clark, F. A., & Young, B. (1998). Practical contributions of occupational science to the art of successful ageing: How to sculpt a meaningful life in older adulthood. Journal of Occupational Science, 5, 107-118. doi:10.1080/14427591.1998.9686438. Link to full text Abstract →← Abstract 

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

Jackson, J. M., Carlson, M. E., Mandel, D., Zemke, R., & Clark, F. A. (1998). Occupation in lifestyle redesign: The Well Elderly Study occupational therapy program. American Journal of Occupational Therapy, 52, 326-336. doi:10.5014/ajot.52.5.326. Link to full text Abstract →← Abstract 

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

Clark, F. A., Carlson, M. E., & Polkinghorne, D. E. (1997). The legitimacy of life history and narrative approaches in the study of occupation [The issue is]. American Journal of Occupational Therapy, 51, 313-317. doi:10.5014/ajot.51.4.313. Link to full text Abstract →← Abstract 

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

Clark, F. A., Azen, S. P., Zemke, R., Jackson, J. M., Carlson, M. E., Mandel, D., Hay, J., Josephson, K., Cherry, B., Hessel, C., Palmer, J., & Lipson, L. (1997). Occupational therapy for independent-living older adults: A randomized controlled trial. Journal of the American Medical Association, 278, 1321-1326. doi:10.1001/jama.1997.03550160041036. Link to full text Abstract →← Abstract 

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

Clark, F. A. (1997). Reflections on the human as an occupational being: Biological need, tempo, and temporality. Journal of Occupational Science: Australia, 4, 86-92. doi:10.1080/14427591.1997.9686424. Link to full text Abstract →← Abstract 

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

Spitzer, S. L., Smith Roley, S., Clark, F. A., & Parham, D. (1996). Sensory integration: Current trends in the United States. Scandinavian Journal of Occupational Therapy, 3, 123-138. doi:10.3109/11038129609106695. Link to full text Abstract →← Abstract 

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

Carlson, M. E., Fanchiang, S. P., Zemke, R., & Clark, F. A. (1996). A meta-analysis of the effectiveness of occupational therapy for older persons. American Journal of Occupational Therapy, 50, 89-98. doi:10.5014/ajot.50.2.89. Link to full text Abstract →← Abstract 

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

Clark, F. A., Carlson, M. E., Zemke, R., Frank, G., Patterson, K., Ennevor, B. L., Rankin-Martinez, A., Hobson, L. A., Crandall, J., Mandel, D., & Lipson, L. (1996). Life domains and adaptive strategies of a group of low-income, well older adults. American Journal of Occupational Therapy, 50, 99-108. doi:10.5014/ajot.50.2.99. Link to full text Abstract →← Abstract 

Older adults are at increased risk for a variety of physical and functional limitations that threaten their ability to lead independent and fulfilling lives. Consequently, they stand to benefit from personalized strategies of adaptation that enable them to achieve successful outcomes in their daily activities and desired goals. In the current investigation, a qualitative descriptive methodology was used to document the perceived life domain of importance and associated strategies of adaptation of 29 residents of Angelus Plaza, a federally subsidized apartment complex in downtown Los Angeles for low-income, well older adults. On the basis of interview data, 10 life domains were identified, and within each domain, a typology of adaptive strategies was derived. The domains were activities of daily living (ADL), adaptation to a multicultural environment, free time usage, grave illness and death–spirituality, health maintenance, mobility maintenance, personal finances, personal safety, psychological well-being and happiness, and relationships with others. Although the typology should not be generalized to a geriatric population, therapists may wish to refer to it to gain a sense of the extent to which certain adaptive strategies may be applicable to the lives of particular older adults to whom they deliver services. The teaching of these adaptive strategies could then be incorporated into an individualized treatment plan.
 
The typology also provides a broad picture of the kinds of adaptive strategies used by the older adults as a way of coping and adapting to their setting. Although some of the domains do not differ from those typically addressed in occupational therapy textbooks on geriatric care (e.g., ADL, health maintenance), others seem uniquely tailored to the specifics of the Angelus Plaza context (e.g., personal safety). Finally, certain domains emerged that may be highly relevant to older adults in most settings but are not typically the focus of occupational therapy programs (e.g., grave illness and death–spirituality, relationships with others). The emergence of these domains from our data suggests that therapists may wish to consider them more in treatment if they are convinced that they possess local relevance.

Christiansen, C., Clark, F. A., Kielhofner, G., & Rogers, J. (1995). Occupation [Position paper]. American Journal of Occupational Therapy, 49, 1015-1018. doi:10.5014/ajot.49.10.1015. Link to full text Abstract →← Abstract 

Concern with the occupational nature of human beings was fundamental to the establishment of occupational therapy. Since the time of occupational therapy's founding, the term occupation has been used to refer to an individual's active participation in self-maintenance, work, leisure, and play (American Occupational Therapy Association [AOTA], 1993; Bing, 1981; Levine, 1991; Meyer, 1922). Within the literature of the field, however, the meaning of occupation has been ambiguous because the term has been used interchangeably with other concepts. This paper's intent is to distinguish the term occupation from other terms, to summarize traditional beliefs about its nature and its therapeutic value, and to identify factors that have impeded the study and discussion of occupation.

Clark, F. A. (1993). Occupation embedded in a real life: Interweaving occupational science and occupational therapy [1993 Eleanor Clarke Slagle Lecture]. American Journal of Occupational Therapy, 47, 1067-1078. doi:10.5014/ajot.47.12.1067. Link to full text Abstract →← Abstract 

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

Clark, F. A., Zemke, R., Frank, G., Parham, D., Neville-Jan, A. M., Hedricks, C., Carlson, M. E., Fazio, L., & Abreu, B. (1993). Dangers inherent in the partition of occupational therapy and occupational science [The issue is]. American Journal of Occupational Therapy, 47, 184-186. doi:10.5014/ajot.47.2.184. Link to full text

Clark, F. A., Mailloux, Z., Parham, L. D., & Primeau, L. A. (1991). Statement: Occupational therapy provision for children with learning disabilities and/or mild to moderate perceptual and motor deficits. American Journal of Occupational Therapy, 45, 1069-1074. doi:10.5014/ajot.45.12.1069. Link to full text Abstract →← Abstract 

This paper discusses three major issues in the provision of occupational therapy services to persons with learning disabilities and/or mild to moderate perceptual and motor deficits. The issues are (a) the historical influence of federal legislation on the scope and content of occupational therapy services to persons with these disabilities; (b) the provision of occupational therapy services for this population from infancy to adulthood; and (c) the context of service provision and efficacy of occupational therapy models.

Carlson, M. E., & Clark, F. A. (1991). The search for useful methodologies in occupational science. American Journal of Occupational Therapy, 45, 235-242. doi:10.5014/ajot.45.3.235. Link to full text Abstract →← Abstract 

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

Clark, F. A., Parham, D., Carlson, M. E., Frank, G., Jackson, J. M., Pierce, D., Wolf, R. J., & Zemke, R. (1991). Occupational science: Academic innovation in the service of occupational therapy's future. American Journal of Occupational Therapy, 45, 300-310. doi:10.5014/ajot.45.4.300. Link to full text Abstract →← Abstract 

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

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

Wiss, T., & Clark, F. A. (1990). Validity of the Southern California Postrotary Nystagmus Test: Misconceptions lead to incorrect conclusions [The issue is]. American Journal of Occupational Therapy, 44, 658-659. doi:10.5014/ajot.44.7.658. Link to full text Abstract →← Abstract 

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

Yerxa, E., Clark, F. A., Frank, G., Jackson, J. M., Parham, D., Pierce, D., Stein, C., & Zemke, R. (1990). An introduction to occupational science: A foundation for occupational therapy in the 21st century. Occupational Therapy in Health Care, 6(4), 1-17. Link to full text Abstract →← Abstract 

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

Primeau, L., Clark, F. A., & Pierce, D. (1990). Occupational therapy alone has looked upon occupation: Future applications of occupational science to the health care needs of parents and children. Occupational Therapy in Health Care, 6(4), 19-32. Link to full text Abstract →← Abstract 

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

Clark, F. A., & Jackson, J. M. (1990). Contemplative occupational therapy: Thoughts on the application of the occupational therapy negative heuristic in the treatment of persons with human immunodeficiency infection. Occupational Therapy in Health Care, 6(4), 69-91. Link to full text

Hamilton-Dodd, C., Kawamoto, T., Clark, F. A., Burke, J. P., & Fanchiang, S. P. (1989). The effects of a maternal role preparation program on mother-infant pairs: A pilot study. American Journal of Occupational Therapy, 43, 513-521. doi:10.5014/ajot.43.8.513. Link to full text Abstract →← Abstract 

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

Jackson, J. M., Rankin, A., Siefken, S., & Clark, F. A. (1989). Options: An occupational therapy transition program for adolescents with developmental disabilities. Occupational Therapy in Health Care, 6(2/3), 197-214. doi:10.1080/J003v06n02_14. Link to full text Abstract →← Abstract 

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

Parush, S., & Clark, F. A. (1988). The reliability and validity of a sensory developmental expectation questionnaire for mothers of newborns. American Journal of Occupational Therapy, 42, 11-16. doi:10.5014/ajot.42.1.11. Link to full text Abstract →← Abstract 

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

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

Conducted a needs assessment of 45 high school students with severe disabilities to determine their perceived needs regarding independent living skills (ILS). Additionally, 38 of their parents and 7 of their teachers were surveyed to assess the students' ILS needs. Regardless of educational classifications, students and their parents tended to perceive that the greatest need was for development in social and vocational competence. Parents had needs for programming, especially in the areas of setting goals for their children and using community resources, and teachers indicated that a number of ILS areas were not sufficiently well covered in existing curricula.

Clark, F. A., & Primeau, L. (1988). Obfuscation of sensory integration: A matter of professional predation [Comment]. American Journal on Mental Deficiency, 92, 415-422. Link to full text Abstract →← Abstract 

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

Burke, J. P., Clark, F. A., Hamilton-Dodd, C., & Kawamoto, T. (1987). Maternal role preparation: A program using sensory integration, infant-mother attachment and occupational behavior perspectives. Occupational Therapy in Health Care, 4(2), 9-21. doi:10.1080/J003v04n02_03. Link to full text Abstract →← Abstract 

The Maternal Role Preparation (MRP) project demonstrates an innovative occupational therapy approach to increasing maternal competence in first time mothers. This four session program provided women with discussion, demonstration, practice and written materials covering topics concerning their infants (attachment, sensory systems, developmental abilities) and themselves (acquiring a new role as mother). Theoretical constructs from Behavioral Pediatrics, Sensory Integration and Occupational Behavior were evaluated for their compatibility and combined under the unifying framework of Occupational Behavior. The program represents an opportunity for occupational therapists to combine sensory integration theory and practice with other compatible treatment perspectives and approaches.

Clark, F. A. (1986). A new concept: Research apprenticeships for occupational therapy researchers [The foundation]. American Journal of Occupational Therapy, 40, 639-641. doi:10.5014/ajot.40.9.639. Link to full text Abstract →← Abstract 

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

Clark, F. A., Sharrot, G., Hill, D. J., & Campbell, S. (1985). A comparison of impact of undergraduate and graduate occupational therapy education on professional productivity. American Journal of Occupational Therapy, 39, 155-162. doi:10.5014/ajot.39.3.155. Link to full text Abstract →← Abstract 

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

Saeki, K., Clark, F. A., & Azen, S. P. (1985). Performance of Japanese and Japanese-American children on the Motor Accuracy-Revised and Design Copying Tests of the Southern California Sensory Integration Tests. American Journal of Occupational Therapy, 39, 103-109. doi:10.5014/ajot.39.2.103. Link to full text Abstract →← Abstract 

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

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

In this critique of Barris' article (CE 514 182) the authors find her conclusions undermined by Mannheim's Paradox--that a researcher's analysis is contaminated by his/her own ideological commitment. They suggest further clarification of the existence of ideological conflict in occupational therapy.

Bissell, J. C., & Clark, F. A. (1984). Dichotic listening performance in normal children and adults. American Journal of Occupational Therapy, 38, 176-186. doi:10.5014/ajot.38.3.176. Link to full text Abstract →← Abstract 

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

Clark, F. A. (1983). Research on the neuropathophysiology of autism and its implications for occupational therapy. Occupational Therapy Journal of Research, 3, 3-22. Link to full text Abstract →← Abstract 

Suggests that educational planning for autistic children has yet to undergo significant change as a consequence of findings that link autism to an underlying neuropathophysiological substrate. With occupational therapy's emphasis on the neurobiologic substrates of functional performance, it may be that researchers in this profession can, based on the current etiologic breakthroughs, develop new theories of practice, or refine existing ones, pertinent to autism. The author reviews recent research on the etiology of autism and discusses educational assessment and programming in light of the neuropathophysiology of autism. It is recommended that occupational-therapist involvement in autism be expanded through instrument development and refinement of theories used in clinical practice. Through this enterprise, occupational therapy may further establish its role in the educational management of autistic children, clarifying its relationship to special education.

Benson, J., & Clark, F. A. (1982). A guide for instrument development and validation. American Journal of Occupational Therapy, 36, 789-800. doi:10.5014/ajot.36.12.789. Link to full text Abstract →← Abstract 

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

Clark, F. A., & Steingold, L. R. (1982). A potential relationship between occupational therapy and language acquisition. American Journal of Occupational Therapy, 36, 42-44. doi:10.5014/ajot.36.1.42. Link to full text Abstract →← Abstract 

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

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

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

Shuer, J., Clark, F. A., & Azen, S. P. (1980). Vestibular function in mildly mentally retarded adults. American Journal of Occupational Therapy, 34, 664-670. doi:10.5014/ajot.34.10.664. Link to full text Abstract →← Abstract 

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

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

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

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

The expertise of speech pathologists and occupational therapists was combined to compare the relative effectiveness of an operant approach, a modified sensory integrative approach, and a combination of both methods in eliciting vocalization on other developmental skills on a sample of 27 profoundly retarded, minimally vocal, institutionalized adults. The combined results indicated that the therapy programs promoted significant gains in frequency of eye contact, frequency of vocalization, and quality of postural adaptation. There were no differences in the effects of the respective therapies. The fact that the more controversial sensory integrative procedures elicited comparable gains when compared with the more widely recognized operant method lends credence to the viability of sensory integrative methods.

Other Articles

Clark, F. A. (2011). White coat ceremonies [Perspectives]. OT Practice, 16(20), 22-23. Link to full text

Clark, F. A., Carlson, M. E., Jackson, J. M., & Mandel, D. (2003). Lifestyle Redesign: Improves health and is cost-effective. OT Practice, 8(2), 9-13. Link to full text

Conference Proceedings

Clark, F. A., Gordon, D. M., Mandel, D., McDannel, R., McDonald, A., Meltzer, P., Scroggins, B., Spitzer, S. L., & Young, B. (1996). Occupational science. In Infusing occupation into practice: Comparison of three clinical approaches in occupational therapy (P. A. H. Crist & C. B. Royeen, Eds.). Workshop proceedings of the AOTA Education Special Interest Section, Chicago, IL (pp. 13-17, 30-34, 40-43, 51-52, 57-59, 101-11). Bethesda, MD: American Occupational Therapy Association, Inc.

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

Clark, F. A. (1986). Leadership: Converting vision into positive action. In Proceedings of the conference: Occupational therapy for maternal and child health research and leadership development. Rockville, MD: American Occupational Therapy Association, Inc.

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

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

Clark, F. A. (1986). Faculty-student research collaboration. In Proceedings of Target 2000, occupational therapy education: Promoting excellence in education. Nashville, TN.

Manuals

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

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