CHAPTER 6 142 children. The instructions were further refined by the OT working in this center and experienced in adapting texts to all levels of education. Children without mitochondrial disorder, but with motor and cognitive disabilities and known to have fluctuations in functioning were recruited by the OT and the teacher. Five semi-structured interviews were conducted—four with parents and one with a teacher—with the topic list from cycle 2. All participants were successful in making and uploading the video material. Interviews were analyzed by content analysis (Hsieh & Shannon, 2005), resulting in three themes: the process of gaining video material, the content of video material, and the added value of video material (see Appendix 1 for in-depth results). We confirmed the instructions were clear and resulted in adequate video material. Remaining questions could not be covered in a general instruction and we proceeded to the second aim. Aim 2: Adequate Appliance of the PRPP-Assessment by OTs based on Video Material Cycle 4: Identify challenges when using the PRPP-Assessment based on parent- provided videos of children. As previous cycles did not incorporate the OT perspective, it was unknown if and what challenges OTs experienced when using PRPP-Assessment based on the parent-provided videos. Therefore, seven pediatric OTs certified in PRPP-Assessment scored six parent-provided videos of children performing an everyday activity. Next, a three-hour focus group was conducted by twomoderators (ML and LT) to discuss the scores and experiences of the PRPP-Assessment. Notes were taken and, after each discussed case, summarized and checked by participants. Four cases were discussed, which led to saturation of data. Although several challenges were uncovered (see Appendix 1), the major insight was that the OTs struggled with reasoning from a criterion-referenced perspective instead of their usual reasoning from a norm-referenced perspective. This reasoning based on developmental age led to inadequate results. Remarkably, the insights mostly focused on principles of the PRPP-Assessment applied to children in general. This conclusion gave input for the next cycle in which we aimed to implement training to overcome the identified challenges and then gather data on remaining challenges. Cycle 5: Identify and overcome remaining challenges after training based on cycle 4. Three experts designed refresher training for pediatric OTs, which was implemented within psychometric study of the PRPP-Assessment of children with mitochondrial disorder (Lindenschot et al., submitted). The course consisted of a four-hour session with homework (score video material of a child). During the training, video material was discussed, and theory was refreshed based on the
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