Developing a Bimanual Task-Oriented Training Program for Young Children With Unilateral Cerebral Palsy: A Delphi Consensus Study Open Access

Children with unilateral cerebral palsy (UCP) often exhibit motor impairments in the predominantly affected upper extremities along with challenges in bimanual coordination (Hung et al., 2004). These functional limitations affect daily activities and independence levels (Shaughnessy et al., 2006; Wagner et al., 2007). Thus, addressing upper limb dysfunction through specialized therapy is crucial for enabling children to effectively use their affected arms and hands to perform daily bimanual tasks (Klingels et al., 2013).

Recently, support for the effectiveness of intensive motor-learning–based therapies—notably, constraint-induced movement therapy (CIMT; Hoare et al., 2019) and hand–arm bimanual intensive therapy (HABIT; Ouyang et al., 2020)—has increased. Both CIMT and HABIT focus on integrating the comprehensive and targeted practice of motor skills, adapting tasks to prompt desired movements, and ensuring the progressive achievement of more complex tasks (Brandão et al., 2014; Charles & Gordon, 2006). However, the translation of these motor improvements into enhanced functionality during daily activities remains unclear (Corbetta et al., 2015). Families and clinicians, and occupational therapists in particular, often note a discrepancy between a child’s actual use of the affected limb in daily routines and the level of upper limb function observed in controlled clinical settings (Sutcliffe et al., 2009; Zielinski et al., 2014). This underscores the disconnection between motor skill acquisition in clinical settings and functional applications in real-world contexts, highlighting the need for interventions that specifically target functional performance and skill integration into daily activities.

Translating capacities into actual performance is complex and requires more than just repetitive training; it may necessitate a focus on task-specific training that is aligned with a child’s daily routine (Novak et al., 2009). The significance of task-oriented training (TOT), which allows children to practice their skills in familiar contexts, has become evident, especially in home-based settings (Sakzewski et al., 2014). For example, Ferre et al. (2015) demonstrated that a caregiver-directed, home-based HABIT program was feasible and associated with improved bimanual hand function, without increasing caregiver stress. This parent-involved approach aligns well with family-centered care models and may offer a more sustainable and integrated method of therapy (Schnackers et al., 2018). The home setting naturally allows children to learn and apply new skills, potentially leading to better generalization of therapeutic effects (Novak et al., 2009). Despite these promising findings, well-established, evidence-based practices are lacking.

In this study, we aimed to identify and prioritize challenging daily tasks that are essential for children with UCP and develop a home-based TOT program that addresses these tasks. We hypothesized that a systematic approach involving expert insights would effectively highlight and validate these tasks and activities.

The Delphi method was used to achieve an expert consensus on a home-based bimanual training program for children with UCP. The Delphi survey method is a well-established tool for structuring group communication among experts, allowing participants to provide anonymous feedback over several iterative rounds. This approach minimizes the bias and potential conflicts often encountered in committees or panels and enables participants to revise their responses on the basis of emerging group trends, leading to a more refined and collective consensus (McIntyre et al., 2010). Given the limited empirical evidence in this area, the Delphi technique is particularly suitable for identifying the key activities that are feasible, relevant, and applicable in real-world settings.

This study builds upon a previous randomized controlled trial (RCT) conducted by our research team that used the Canadian Occupational Performance Measure (COPM; Law et al., 2019) to identify the priorities of daily activities for children with UCP. Insights from the COPM data helped categorize these priorities into self-care, productivity, and leisure following the Canadian Model of Occupational Performance and Engagement (CMOP-E; Townsend & Polatajko, 2007). These categories guided the development of task-specific bimanual training activities. A two-round Delphi technique, preceded by an initial pilot survey, was used to gather an expert consensus (Figure 1). The primary goal was to achieve a consensus among the experts, defined as ≥70% agreement, with a mean agreement score of ≥7 for inclusion in further analysis. A questionnaire was created and sent via email, and respondents provided their ratings using a Likert scale (Likert, 1932).

We analyzed data from two groups: (1) children with UCP who had participated in a prior RCT and (2) an expert panel of clinicians involved in the Delphi process.

The children, who were ages 4.00 to 10.58 yr (M = 5.48 yr, SD = 1.34 yr) and classified as being at Levels I–III on the Manual Ability Classification System (MACS; Eliasson et al., 2006), had their activity priorities assessed using the COPM. The age distribution was as follows: Nineteen children were ages 4 to 6 yr, and 3 children were ages 9 to 10 yr. The distribution of MACS levels among the 22 children was as follows: Seven (31.8%) were at Level 1, 10 (45.5%) were at Level 2, and 5 (22.7%) were at Level 3. These assessments were performed in a previous study conducted by our research team.

The expert panel consisted of occupational therapists, physical therapists, and pediatric physiatrists with expertise in managing children with UCP. The two inclusion criteria for the experts were as follows: (1) a minimum of 3 yr clinical experience in pediatric rehabilitation and (2) hands-on experience with the treatment or management of UCP. The experts were selected through purposive sampling from tertiary care hospitals, rehabilitation centers, and academic institutions across the Republic of Korea to ensure diverse professional experiences. All the participants endorsed these qualifications during the brief screening process.

Phase 1 involved analyzing the activity priorities of 22 children with UCP using the COPM. To ensure consistent data collections, all COPM assessments, including those for children ages 9–10 yr, were conducted by caregivers. The assessments highlighted problematic daily activities due to upper extremity paralysis, which were categorized under the three domains of the CMOP-E: (1) self-care, (2) productivity, and (3) leisure.

• ▪ Self-care includes tasks related to dressing (e.g., buttoning clothes), feeding (e.g., using utensils), hygiene (e.g., brushing teeth), bathing (e.g., washing hair), transfers (e.g., going down stairs), and toileting (e.g., folding toilet paper).

• ▪ Productivity focuses on school-related tasks (e.g., using scissors) and household tasks (e.g., washing dishes).

• ▪ Leisure covers quiet activities (e.g., playing piano) and active activities (e.g., jumping rope).

The experts were instructed to consider children’s ages and capabilities to ensure the developmental appropriateness of their feedback. They reviewed the identified tasks and rated their importance in promoting functional independence in daily activities. In addition, the experts provided suggestions for modifications or additional tasks through open-ended responses, and these insights were integrated into Phase 2.

Building on Phase 1 outcomes, a core research team comprising four members—two occupational therapists, one physical therapist, and one pediatric physiatrist, who were entirely distinct from the Phase 1 experts—developed preliminary therapeutic activities. These activities specifically targeted tasks identified in Phase 1, such as buttoning clothes, and were further refined into specific activities, such as making a button snake and dressing a doll. The activities were diverse, catering to various skill levels, and designed to be theoretically sound and feasible within a home setting.

The developed activities underwent pilot testing with a subgroup of pediatric therapy experts who had participated in Phase 1. In the first part of the pilot study, the experts provided detailed feedback through open-ended questions, specifically addressing the clarity of instruction, practicality, and potential for sustained interest among children. The second pilot study assessed the validity of each activity.

An expert panel comprising the remaining participants from Phase 1 who were not involved in Phase 2 evaluated the therapeutic activities. They used a Likert scale to indicate their level of agreement with the inclusion of each activity in the program. Open-ended questions provided qualitative insights into possible modifications, concerns, and suggestions for additional activities that were not previously listed. Feedback from the first round was summarized and informed the second round, in which panel members reevaluated the activities to achieve a final consensus. To ensure timely responses, reminders were sent after 1 wk and 2 wk (Figure 1).

The hospital review board approved the study (Approval No. SMC 2024-02-060). Informed consent was obtained from all participants before enrollment. This study is registered in the Clinical Trials Database (Clinical Trial Registration No. NCT06272760).

Descriptive statistics were performed using IBM SPSS Statistics (Version 21) to analyze the participants’ agreement with the identified tasks and the overall consensus levels.

• ▪ Phase 1: Experts rated tasks on a scale that ranged from 1 (not important) to 10 (extremely important). Mean importance scores were calculated, and tasks with a mean score ≥7 were considered of high priority for further development.

• ▪ Phase 2: The item content validity index (I-CVI) was calculated on the basis of the proportion of experts who rated each activity as 3 or 4 on a 4-point relevance scale (1 = not relevant, 4 = highly relevant). An I-CVI score ≥.78 was considered acceptable (Cabatan et al., 2020).

• ▪ Phase 3: Participants expressed their agreement on a Likert scale that ranged from 1 (strongly disagree) to 10 (strongly agree). A consensus was defined as ≥70% agreement among panelists, with agreement being a score ≥6 (Graham et al., 2003; Naidoo & Joubert, 2013; Rencken et al., 2021). Activities that achieved this consensus and had a mean agreement score ≥7 were retained for further analysis. Qualitative responses were subjected to thematic content analysis by two research team members, who independently reviewed the feedback, coded key ideas, and grouped similar responses into themes. Discrepancies were resolved through discussions until a consensus was reached.

Sixty-five experts, including 30 occupational therapists, 30 physical therapists, and 5 doctors, participated in Phase 1 of the study. From this group, 10 experts (7 occupational therapists, 2 physical therapists, and 1 pediatric physiatrist) participated in the Phase 2 pilot, and 55 experts (23 occupational therapists, 28 physical therapists, and 4 pediatric physiatrists) participated in the Delphi rounds of Phase 3. The experts had varying degrees of professional experience and educational qualifications (Table 1). They were affiliated with 20 institutions across the Republic of Korea, including tertiary general hospitals, rehabilitation centers, and other health care facilities.

Self-care was the predominant category, encompassing 72.7% of all priorities, with an average importance rating of 8.2 (1.3%). Key activities included dressing (8.8; 21.8%), eating (8.5; 16.4%), hygiene (8.3; 18.2%), bathing (6.6; 11.8%), toileting (8.5; 3.6%), and transfers (9.0; 0.9%; Table 2).

Further analysis by age group revealed that among 4- to 6-yr-olds, self-care priorities comprised 72.6% of the sample, productivity comprised 1.1%, and leisure comprised 26.3%, whereas in 9- to 10-year-olds self-care accounted for 73.3% of the sample, productivity comprised 20.0%, and leisure comprised 6.7%. For detailed age-specific priorities and proportions, see Table A-1 in the Supplemental Material, available online with this article at https://research.aota.org/ajot.

Activities with an average importance score <7, such as wearing gloves, tying hair, wrapping and eating food, and playing the piano, were excluded on the basis of expert feedback. Conversely, items with an average score ≥7 were retained, except for two items (opening a book or binder and origami and gluing) that were removed on the basis of expert comments. Several experts felt that opening a book or binder and origami and gluing were rarely performed in everyday routines and thus less impactful for functional independence, leading to their removal.

On the basis of expert feedback and analysis, household management activities, such as folding clothes and washing dishes, were added to the productivity category. Experts specifically noted that these tasks demand sustained bimanual coordination, reflection on common family routines, and encouragement of children’s active participation at home. The additional items are listed in Table 2.

Feedback from the first pilot study led to simplified instructions, substitution of materials with household items, and addition of playful elements to improve engagement. In the second pilot study, all 110 refined activities achieved I-CVI scores >.78, demonstrating high content validity (Table 3).

The Delphi Round 1 survey included 110 activity items. On the basis of feedback from experts in Round 1, 12 additional items were included in the questionnaire for Round 2. Of the 122 items in Round 2, a consensus was reached on 106. The number of activities that reached a consensus within each task category included 20 dressing, 14 feeding, 12 hygiene, 9 bathing, 9 toileting, 5 transfer, 15 school, 10 household management, 6 quiet leisure, and 6 active leisure tasks (see Tables A-2.1–A-2.10 in the Supplemental Material).

The significance of home-based occupational therapy has been increasingly recognized in recent years (Beckers et al., 2020), highlighting its potential to provide continuous and contextually relevant therapeutic interventions for children with UCP. Despite a consensus on the importance of home-based upper limb training programs for children with cerebral palsy (CP), there is a lack of detailed information regarding the specific characteristics of these programs that influence family participation (Novak & Cusick, 2006). Although caregivers recognize the value of home-based occupational therapy and can implement interventions under remote observation and therapist guidance (Unholz-Bowden et al., 2020), the presence of a structured program framework can help with the delivery of interventions more consistently across sessions and among different caregivers while facilitating progress monitoring. Such a framework will help clarify objectives and ensure that interventions align with therapeutic goals, which can sustain engagement and promote better outcomes. In pursuit of these aims, we developed and validated a standardized protocol consisting of 106 therapeutic activities designed for children with UCP. Using a rigorous Delphi method, we achieved an expert consensus on the therapeutic activities that demonstrated high content validity (I-CVI scores >.78), reflecting strong agreement and relevance. By specifying activities on which to focus, such as self-care tasks, our study offers a practical framework that can be readily adopted in home settings. This structured approach is ultimately intended to foster ongoing motivation and promote better daily functioning and quality of life in children with UCP by providing a practical and clinically relevant framework for implementation in home settings.

The key strength of our program is its alignment with caregiver-identified priorities through the COPM. Age-specific findings indicated that parents of younger children (4–6 yr) frequently emphasized self-care tasks as priorities, whereas parents of older children (9–10 yr) highlighted a growing focus on productivity tasks, such as school-based activities. This developmental transition is consistent with findings reported by Kerem-Günel et al. (2023), who applied the “6 F-words” framework (function, fitness, family, friends, fun, and future) to highlight how mobility and social engagement become more significant as children mature. Mei et al. (2015) indicated that communication barriers and mobility limitations become more pronounced when children play more complex, socially demanding roles. Our observation that productivity priorities gain prominence for older children underscores the importance of addressing not only motor skill development but also communication and environmental supports. Frameworks such as the one provided by the International Classification of Functioning, Disability and Health: Children and Youth Version (World Health Organization, 2007) and the 6 F-words emphasize how personal and contextual factors (e.g., caregiver involvement, family routines, cultural expectations, and environmental accessibility) critically shape participation outcomes. Therapists thus should consider both children’s changing priorities with age and the broader developmental, social, and environmental challenges encountered by children with UCP. If they adopt this holistic perspective, they can adapt interventions more flexibly for individual families, supporting smoother developmental transitions and fostering more meaningful real-world gains across the life course.

Building on the priorities and needs identified through the COPM, we developed task-specific activities to improve functional independence and bimanual coordination in children with UCP. The cultural context of our study influenced our findings given that the intervention program was based on priorities identified by caregivers in the Republic of Korea. Although self-care tasks are commonly prioritized by younger children with UCP (Branjerdporn et al., 2018; Metzler et al., 2021), specific tasks differ according to cultural practices. Our study prioritized tasks such as using chopsticks and holding a rice bowl, reflecting local dining customs. Cultural values can influence rehabilitation goals. For instance, in the East Asian context there may be a stronger emphasis on social harmony and community interdependence (Rothbaum & Wang, 2010), which may lead to the prioritization of tasks that facilitate social integration and family participation. In contrast, some Western cultural contexts may place more emphasis on individualism and personal independence (Humphrey & Bliuc, 2021), which can affect the selection of rehabilitation goals. We recognize that our position as clinicians in a particular cultural context may have influenced the selection and framing of these activities and potentially introduced biases that could affect the generalizability of the program. Therefore, future research should consider cultural adaptations of this intervention program. Collaborations between clinicians and researchers from diverse cultural backgrounds can help modify and validate programs with broader applicability and effectiveness.

However, this program is intended to serve as a flexible resource that therapists can adapt to meet client-centered goals. Although it provides a comprehensive list of therapeutic activities as a valuable starting point for intervention planning, it does not replace therapists’ clinical judgment or their need to identify and address individual goals. By first identifying each child’s specific priorities and matching them to relevant activities from our curated list, therapists can collaborate with caregivers to establish a structured home program: demonstrating each task, developing practice schedules, and providing ongoing feedback. This approach may help therapists create more tailored interventions grounded in evidence-based practices while potentially enhancing the consistency and overall quality of therapeutic services for children with UCP. Nevertheless, despite its flexibility, the program may not address all cultural and individual differences inherent in diverse populations. Future research involving diverse stakeholders, including caregivers and children from various backgrounds, is recommended to enhance the relevance and effectiveness of the program across diverse populations. Engaging with a broader range of perspectives can help validate the program and broaden its applicability, ensuring that it meets the needs of a wider population.

Social participation is a critical aspect of the development of children with CP and affects their well-being and social integration (Sahoo et al., 2017). Our program aims to integrate bimanual activities into family and social play settings where possible. For example, incorporating bimanual skills practice within imaginative play (e.g., collaboratively dressing dolls in role play scenarios) provides children with meaningful and interactive opportunities to practice motor skills (Jankowska & Omelańczuk, 2019). Shared activities with peers or family members may foster social engagement, offering a supportive environment in which to apply bimanual skills. By incorporating enjoyable, socially meaningful activities, the program encourages children to practice these skills in a social context, promoting social inclusion, peer relationships, and family bonding. Future program iterations could involve families in codesigning activities that cater to their individual preferences, which may enhance motivation and adherence.

This study has some limitations. First, it primarily focused on developing and theoretically validating TOT activities rather than empirically validating them. Although an expert consensus provides a strong foundation, the efficacy and practicality of these TOT activities require testing in real-world settings through longitudinal studies and RCTs to establish robust evidence of their effectiveness and feasibility.

Second, although caregivers completed the COPM assessments to represent their children’s daily priorities—a standard practice for young children under ages 7–8 yr (Cusick et al., 2007)—this approach may introduce discrepancies between parents’ perceptions and children’s actual priorities. Future studies could explore ways to integrate direct child input, where feasible, to enhance goal alignment and relevance in TOT programs.

Finally, although caregivers participated in identifying daily tasks that were challenging for their children, we did not involve caregivers and children directly in the development of therapeutic activities in the TOT program. This may affect the acceptability, accessibility, and accommodability of the interventions from families’ perspectives. Interventions developed without direct family input may not fully address the practical considerations and preferences of individual families, potentially affecting successful implementation of the program at home. This lack of tailored involvement could place additional responsibility on families to adapt to these activities, potentially increasing stress or feelings of guilt about their child’s progress. Therefore, involving families in codesigning interventions and providing training, resources, and ongoing support are essential for mitigating these challenges.

This study provides insights into the development and validation of therapeutic activities for children with UCP, thereby enhancing their clinical practice. It has the following implications for occupational therapy practice.

• ▪ Tailored therapeutic activities address the unique challenges children with UCP face and foster meaningful improvements in their daily functioning. Occupational therapists can use these evidence-based, expert-validated activities as supportive resources in clinical practice, although further research is needed to confirm their ease of implementation and relevance to parents and children.

• ▪ These activities, which were designed to be feasible within home settings, extend the therapeutic benefits beyond clinical environments, support continuity of care, and facilitate real-world skill applications. By covering a comprehensive range of functional areas, this program has the potential to support holistic development and may contribute to improved outcomes in children with UCP. Practitioners should document the treatment content, client responses, and functional changes so they can monitor progress and adjust interventions as needed.

This study advances the development of TOT programs tailored to children with UCP. Using the Delphi method, we engaged a multidisciplinary panel of experts to identify and prioritize critical daily tasks. The resulting consensus-driven, home-based therapeutic activities offer expert-informed guidance that may support the implementation of these interventions in real-world settings. Future research should focus on empirical validation across diverse populations to evaluate the effectiveness and feasibility of such programs.

We extend our sincere gratitude to the expert panelists, including occupational therapists, physical therapists, and pediatricians, for their invaluable contributions to this study. Their insights and expertise were essential in achieving consensus. We also thank the National Research Foundation and the Korean government for their support (Grant No. RS-2023-00278700). The data supporting this study’s findings, along with information about the ethics approval, are available from the corresponding author upon reasonable request.