Received: 6 March 2018 Revised: 27 June 2018 Accepted: 21 July 2018

DOI: 10.1111/cch.12609

ORIGINAL ARTICLE

Quality of goal setting in pediatric rehabilitation—A SMART

approach
Annemarie Bexelius1 | Eva Brogren Carlberg2 | Kristina Löwing2

1
Habilitation & Health, Stockholm, Stockholm
2
Department of Women's and Children's
Health, Karolinska Institutet, Stockholm,
Sweden
Correspondence
Kristina Löwing, Neuropediatric Unit,
Department of Women's and Children's
Health, Astrid Lindgren Children's Hospital,
Karolinska Institutet, Q2:07, Karolinska
University Hospital, 17176 Stockholm,
Sweden.
Email: kristina.lowing@ki.se
Funding information
Norrbacka Eugenia Foundation; Habilitation &
Health
Abstract
Background: Setting goals for treatment is often the core of the rehabilitation pro-
cess. The quality of the set goals has however rarely been evaluated. The aims of this
study were therefore to assess the quality of goals set in clinical practice of pediatric
rehabilitation using SMART criteria (Specific, Measurable, Achievable, Relevant, and
Timed) and to assess if the goals were considered relevant from both a client perspec-
tive and expertise perspective.
Methods: In a retrospective multicase study, a total of 161 goals from 42 children
with disabilities (cerebral palsy, n = 22; Down syndrome, n = 16; and developmental
disability, n = 4) were assessed. The children were 1.5–5.5 years and had previously
participated in goal‐directed, activity‐focused therapy at four pediatric rehabilitation
centers. Collaborative goal setting had been used to define the desired treatment out-
come. The quality of the goals was assessed using defined SMART criteria.
Results: Specific: All goals could be reliably linked to International Classification of
Functioning, Disability and Health—Children and Youth version chapters within the
Activity/Participation domain. Measurable: A total of 75% of the goals were rated as
having a well‐defined scaling; in 20%, the scaling was less clear, and in 5%, a scaling could
not be determined. Achievable: A total of 80% of the goals were attained. Relevant: All
goals were set in collaboration with the family and could therefore be considered rele-
vant from a client perspective. Relevancy judged from a professional perspective was
strengthened by the fact that age, baseline status, and diagnosis had an influence on
the choice of goals. Timed: All goals were set within a specific time frame.
Conclusions: The goals set in clinical practice showed high quality with respect to
the SMART criteria. The most difficult part was the construction of the goal attain-
ment scale. The goals settled in clinical practice were considered relevant from both
a client perspective and expertise perspective.

KEY W ORDS

children, disability, family‐centered service, goal attainment scaling, SMART, therapy

1 | I N T RO D U CT I O N focusing primarily on reducing basic impairments (Brogren & Lowing,

2013; M. Law & Darrah, 2014; Novak et al., 2013). This approach
Over the past two decades, rehabilitation interventions for children involves both the family and child in order to identify which activities
with disabilities have gradually shifted focus and now emphasize the are meaningful in their current life situation, and it complies with a
children's possibilities to participate in everyday activities rather than family‐centered service (G. King, Williams, & Hahn Goldberg, 2017).

850 © 2018 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/cch Child Care Health Dev. 2018;44:850–856.
BEXELIUS ET AL.
This has resulted in a stronger focus on goals being linked to function-
ally based interventions in the context of the child's day‐to‐day
environment, and setting activity goals has become a core component
in the rehabilitation process (Bovend'Eerdt, Botell, & Wade, 2009;
Derick, 2015; Playford, Richard, William, & Jennifer, 2009). The chil-
dren are encouraged to practice and learn new skills in their everyday
environment and thereby step‐by‐step increase their proficiency and
their independence (Lowing, Bexelius, & Brogren Carlberg, 2009;
Myrhaug & Ostensjo, 2014; Vroland‐Nordstrand, Eliasson, Jacobsson,
Johansson, & Krumlinde‐Sundholm, 2016). The expertise of the
parents is imperative when determining the child's performance in
everyday activities, and a joint discussion with the family on the child's
abilities and shortcomings forms the basis for collaboration and
teamwork upon which decisions concerning goals for therapy can be
decided (G. King et al., 2017; Oien, Fallang, & Ostensjo, 2010; Playford
et al., 2009; Wiart, Ray, Darrah, & Magill‐Evans, 2010).
Apart from being a tool to decide the focus of treatment, to
actively engage families in decision making and therapy, and to
optimally coordinate services between family and professionals and
between professionals in a team, goals can, after scaling for
predetermined levels of outcome, allow evaluation of treatment
outcome. Goal attainment scaling (GAS; Kiresuk, Smith, & Cardillo,
1994) is considered to be sensitive to clinically meaningful change
and has demonstrated validity when used in pediatric populations
and has previously, under optimal conditions, demonstrated good reli-
ability (Jane, Ian, & Mark, 2006; Steenbeek, Gorter, Ketelaar, Galama, &
Lindeman, 2011; Steenbeek, Ketelaar, Galama, & Gorter, 2007;
Steenbeek, Ketelaar, Lindeman, Galama, & Gorter, 2010). Setting goals
for therapy is not considered an easy task when it comes to drafting a
full goal attainment scale, that is, to precisely describe each attainment
level (Bovend'Eerdt et al., 2009; Krasny‐Pacini, Hiebel, Pauly, Godon, &
Chevignard, 2013; Marsland & Bowman, 2010; Playford et al., 2009;
Siegert & Taylor, 2004). To facilitate the time‐consuming and often dif-
ficult process of expressing the child's and family's needs and priorities
in clear and measurable goals, it has been suggested that the SMART
goal framework can be used to encourage uniformity (Bovend'Eerdt
et al., 2009). According to the acronym, the goals should be Specific,
Measurable, Achievable, Relevant, and Timed. In the present study, these
words were defined and described below in Section 2.
Goal attainment scales have been used in several studies and have
worked as intended, but we know little about how the scales work in
clinical practice. In addition, more knowledge is required about the
quality of the scales. The overall aims of the present study were to
describe goals set in clinical practice of pediatric rehabilitation, to eval-
uate the quality of the goals using the defined criteria linked to the
SMART acronym, and to assess if the goals were considered relevant
from both a client perspective and expertise perspective.
2 | METHOD
2.1 | Material
In this retrospective multicase study, a total of 161 goals from 42 chil-
dren with disabilities (cerebral palsy, n = 22; Down syndrome, n = 16;
851
Key messages
• The quality of the settled goals in the clinical practice
was rather high.
• The most difficult part was the construction of the goal
attainment scale, and special attention should be
directed to the formulation and grading of clear and
one‐dimensional goals.
• The goals set in clinical practice were considered
relevant from both a client perspective and expertise
perspective.
and developmental disability, n = 4) were assessed. The age range of
the children was 1.5 to 5.5 years (Table 1). All children had previously
participated in goal‐directed, activity‐focused therapy for a preset time
period of 8 to 12 weeks depending on what was feasible in the clinical
practice at the four different rehabilitation centers where the therapy
was carried out. Data were retrieved from the children's medical
records by one of the researchers (A. B.). All parents had given informed
consent to the retrospective analysis of the data. The study was
approved by the Regional Ethics Committee (DNR 2011/2005‐31/5).
2.2 | The process of goal setting
All multidisciplinary teams had received a basic education in GAS
before the start of the therapy, and they had previous experiences of
setting goals and half of the teams also had experience in scaling goals
according to GAS. The process of goal setting took place as a collabo-
ration between each family and child and the professionals. Initially,
the Pediatric Evaluation of Disability Inventory (PEDI; Haley, Coster,
Ludlow, Haltiwanger, & Andrellos, 1992) was used as a tool to explore
the child's present capability and performance in everyday activities
and to capture possibilities and obstacles and thereby identify possible
goal areas. Then the family, on their own, discussed and prioritized the
goal areas over a few days. Subsequently, the professionals supported
the family and child in the final process of precisely constructing the
goal scales. For each goal identified by the family/child, a scale of five
levels of outcome descriptions was constructed in collaboration
between the family/child and the professionals (Table 2; G. A. King,
McDougall, Palisano, Gritzan, & Tucker, 1999; Kiresuk et al., 1994).
The parents decided on the number of goals appointed for each child,
which was between one and five goals (median: four).
2.3 | Intervention
The therapy was conducted by a multidisciplinary team consisting of a
physiotherapist, an occupational therapist, a special needs teacher,
and a speech and language therapist. The therapy was directed
towards learning specific activities, expressed as each child's individual
goals. The children predominantly practiced towards their specific
goals in their day‐to‐day environment (at home and preschool), sup-
ported by parents and preschool teachers, who in turn were coached
852 BEXELIUS ET AL.

TABLE 1 Descriptive statistics presented as mean, SD, median, min– TABLE 1 (Continued)
max, and number (n) for the total group and for participants with
Descriptive data
cerebral palsy (CP), Down syndrome, and developmental delay
Goals (n) 55
Descriptive data
Participants Development delay (n) 4
Participants total group (n) 42 Gender (n)
Gender (n) Male 3
Male 25 Female 1
Female 17 Age (months)
Age (months) Mean (SD) 44 (12)
Median 47 Median 47
Min–max 19–65 Min–max 27–55
Age groups (n) Age groups (n)
<3 years 11 <3 years 1
3–4 years 12 3–4 years 1
>4 years 19 >4 years 2
Goals (n) 161 Goals (n) 15
Participants CP (n) 22
Note. GMFCS: Gross Motor Function Classification System; MACS: Man-
Gender (n)
ual Ability Classification System.
Male 11
Female 11
Age (months)
TABLE 2 The five levels within the goal attainment scaling
Mean (SD) 41 (13)
Level Goal attainment scaling description
Median 40
Min–max 19–65 −2 The initial pre‐treatment (baseline)

Age group (n) −1 Progression towards the goal without goal attainment

<3 years 9 0 The expected level after treatment

3–4 years 5 +1 A better outcome than expected

>4 years 8 +2 A much better outcome than expected

GMFCS (n)
GMFCS I 16
by therapists on how to reach each specific goal. Once a week, the
GMFCS II 3
children participated in group activities for 2.5 hr at the rehabilitation
GMFCS III 0
center. The group (four to nine children, median: six) sessions
GMFCS IV 2
consisted of both play‐based therapy and individual goal practice.
GMFCS V 1
MACS (n)
MACS I 8 2.4 | Assessments of the goals
MACS II 8
In the present study, the content and the quality of the formulated
MACS III 5
goals (n = 161) were assessed using the SMART acronym defined
MACS IV 0
and described below.
MACS V 1
Goals (n) 91
Participants Down syndrome (n) 16
2.4.1 | Specific
Gender (n) A goal was considered specific if it could be reliably linked to one
Male 11 chapter within the Activity/Participation component of the Interna-
Female 5 tional Classification of Functioning, Disability and Health—Children
Age (months) and Youth version (ICF‐CY) using the linking rules from Cieza and
Mean (SD) 52 (10) colleagues (Cieza et al., 2005; World Health Organization, 2007).
Median 51 Two researchers (A. B. and K. L.) familiar with the linking process
Min–max 34–65 independently linked the concept of the content in the expected level
Age groups (n) (the zero level) of the goals to the first and second levels of ICF‐CY.
<3 years 1 The linking rules are constructed to link interventions and health
3–4 years 6 status measures but have earlier been used for linking goals (Jeglinsky,
>4 years 9 Brogren Carlberg, & Autti‐Rämö, 2014; Mittrach et al., 2008). The
ICF‐CY contains two parts. Part one covers functioning and disability
(Continues)
and includes Body functions (b), Structures (s), and Activities and
BEXELIUS ET AL. 853

Participation (d). Part two includes a list of Environmental factors and 3 | RESULTS
Personal factors (e).

2.4.2 | Measurable
To explore the measurability of the 161 goals, they were graded
according to the following criteria: Grade 2, the goal had well‐defined
steps expressing a single dimension of change; Grade 1, the goal had
less defined steps or expressing one or two dimensions of change;
and Grade 0, defined steps could not be distinguished. Two
researchers (E. B. C. and K. L.) with long and extensive experiences
of goal setting using GAS independently assessed the quality of the
formulated goals. Disagreements between the two researchers were
discussed and resolved in a consensus discussion.
2.4.3 | Achievable
The child's performance in the day‐to‐day environment for each goal
was described by the child's parents at the end of therapy, and the
professionals registered the level of goal attainment.
2.4.4 | Relevant
3.1 | Specific
The 161 goals were reliably linked to seven of the nine chapters within
the Activity and Participation domain of the ICF‐CY. The majority of
goals were linked to the Mobility chapter and the Self‐care chapter
(Table 3). The most commonly chosen goals were linked to d540 dress-
ing (n = 34), d455 moving around (n = 23), d137 acquiring concepts
(n = 16), and d335 using gestures, symbols, and drawings to communi-
cate (n = 15). The agreement between the two researchers was very
good (Cohen's kappa = 0.98, and the percentage agreement was 98%).
3.2 | Measurable
In 120 goals (75%), the scaling was rated as having well‐defined steps
for one single dimension, whereas in 33 goals (20%), the scales were
less defined and expressed one or two dimensions. In eight goals
(5%), an apparent scale could not be distinguished. The agreement
between the two researchers was very good (Cohen's kappa = 0.90,
and the percentage agreement was 96%).

All goals were selected by the parents and children with respect to
each family's priorities of meaningfulness in their specific life situation. 3.3 | Achievable
Furthermore, relevance was evaluated from a professional perspective
Goals were judged to be attained at the expected level or above in
by calculating the correlations between the number of goals linked to
128/161 of the goals (80%), and the median T score was 57
specific ICF‐CY chapters and the child's diagnosis, age, and baseline
(25th–75th percentiles: 50–62).
performance of everyday activities as captured by the PEDI.

2.4.5 | Timed 3.4 | Relevant

All goals were set for a specific time period, whereas this component
did not need to be specifically evaluated.
2.5 | Statistics
Statistical analyses were performed with Statistical Package for Social
Sciences version 24. Nonparametric statistics were used because the
data were not normally distributed and because ordinal scales were
used. Descriptive statistics are presented as the median and
25th–75th percentiles. Agreement of the assigned first‐level ICF‐CY
codes between two researchers (A. B. and K. L.) is presented as the
percentage agreement and with Cohen's kappa (Cohen, 1968).
Cohen's kappa provides the measure of agreement for nonparametric
ordinal or nominal data and takes into account the agreement
expected purely by chance. Fleiss has defined kappa values as follows:
Each family and child selected the goals they considered meaningful
and relevant. The age of the child was associated with the selected
goal area—young children's goals were predominantly linked to the
Mobility chapter (rs = 0.48, p = 0.001), whereas older children had
more goals related to Learning and applying knowledge chapter
(rs = 0.38, p = 0.013). The diagnosis influenced the choice of goal
area—children with cerebral palsy had more goals in the Mobility
chapter (p < 0.001), and children with Down syndrome had more goals
in the Communication chapter (p = 0.001). The children's capability
was also related to the choice of goals, and children with low scores
TABLE 3 The number of goals linked to the chapters within the
Activity and Participation domain in the ICF‐CY
ICF‐CY chapters within the Activity and Number of goals
Participation domain (%)

Less than 0.40 is considered low agreement, values between 0.40 and 1 Learning and applying knowledge 18 (11)
0.75 are considered fair to good, and kappa values over 0.75 indicate 2 General tasks and demands 6 (4)
strong agreement (Fleiss & Cohen, 1973). 3 Communication 25 (16)
Differences between diagnosis groups were calculated with the 4 Mobility 54 (34)
Mann–Whitney U test. Spearman's correlation coefficient (rs) was 5 Self‐care 48 (30)
calculated between the number of goals linked to chapters in the 6 Domestic life 0 (0)
ICF‐CY and the child's age, gender, and baseline scores on the PEDI. 7 Interpersonal interactions and relationships 1 (6)
Total goal attainment was calculated as the T score, where the average 8 Major life areas 9 (6)
is 50 with a standard deviation of 10 (Kiresuk et al., 1994). The 9 Community, social, and civic life 0 (0)
significance level was set at p < 0.05, and correlations were considered Note. The total number of goals was 161. ICF‐CY: International Classifica-
significant if they reached both a p < 0.05 and rs > 0.31. tion of Functioning, Disability and Health—Children and Youth version
854
in the mobility functional skill scale in the PEDI had a higher number of
goals linked to the Mobility chapter (rs = −0.38, p = 0.016).
Associations were also observed between the number of goals linked
to the Communication chapter and low scores on the PEDI social
function functional skill scale (rs = −0.48, p = 0.002, n = 40) and
caregiver assistance scale (rs = −0.49, p = 0.008, n = 29).
3.5 | Timed
All goals were set to be reached within a specific preset time frame of
8–12 weeks.
4 | DISCUSSION
In the present study, the overall quality of the examined goals set in
clinical practice could be considered good according to the defined
SMART criteria. All goals were reliably linked to ICF‐CY chapters
within the Activity and Participation domain. Because the goals were
defined as performance in the children's everyday context, the parents
described their child's current performance at the end of the decided
time period, and the extent of goal attainment was graded by the pro-
fessionals. The goals could be considered relevant in relation to factors
such as the child's age, diagnosis, and performance before the start of
therapy. However, the most difficult aspect of the collaborative goal
setting seemed to be the construction of the goal attainment scale.
Altogether, it was encouraging to see that the goals had such good
quality in the implementation of goal‐directed, activity‐focused
therapy in clinical practice. The importance of a high goal standard will
be discussed, including the relation to the three pillars of
evidence‐based practice (EBP)—Scientific studies, Clinical expertise,
and Patient values (Sackett, 1997).
Today, it is assumed that professionals must be well informed and
up‐to‐date with the latest knowledge in order to best serve their cli-
ents and to remain professionally relevant (Imms et al., 2015). To
implement new interventions that have demonstrated positive evi-
dence is crucial, and it is necessary to systematically evaluate the
implementation to ensure that the regular clinical practice maintains
an equivalent standard compared with the original scientific studies.
The combination of using goals together with other standardized
outcome measures has been recommended with the aim to compare
results with other studies (Heinen et al., 2010). In the present study,
the goal‐directed, activity‐focused therapy was completed in the clin-
ical practice, and the PEDI was used before each family selected the
goals for their child, to explore the child's everyday activities and need
of caregiver assistance. The family achieved a solid foundation for
discussing and prioritizing meaningful goals before the intervention,
but to strengthen the link to the scientific studies forming the
evidence base of goal‐directed, activity‐focused therapy, it would
have been better to also have utilized PEDI as a standardized outcome
measures for the final evaluation in combination with GAS (Darrah,
Wiart, Magill‐Evans, Ray, & Andersen, 2012; Lowing, Hamer, Bexelius,
& Carlberg, 2011; Steenbeek et al., 2007).
“Scientific studies” presenting the best available evidence form one
of the three pillars in EBP (Sackett, 1997), and because goal‐directed
BEXELIUS ET AL.
activity‐focused therapy has demonstrated clear evidence (Novak
et al., 2013), the implementation of such therapy in clinical practice is
considered positive. The second pillar contains the clinical judgment
and personal knowledge of the practitioner, in the EBP context often
called “Clinical expertise.” This concern deciding whether the content
of the goals reflects what a clinician would consider important for a
child with a specific disability to learn at a specific age (Darrah et al.,
2012; Lowing et al., 2011; Steenbeek et al., 2011). The relevance of
goals from the parents' perspective was encompassed in letting the par-
ents and children decide the specific goals. To systematically investi-
gate the relevance of the selected goals from a clinician's perspective
(Clinical expertise), the selected goal areas were correlated to the age,
diagnosis, and everyday performance of the children before start of
the intervention. The results confirmed the relevance of the selected
goals also from a clinician's perspective and in addition demonstrated
that there was a joint perception of the importance of the chosen goals
between families and professionals (G. King et al., 2017). This was a fact
that further could have supported the goal attainment, because
experienced clinicians could support the family in grading the goals by
creating individually tailored step‐by‐step scales for each goal. The
scales served not only as an obvious way to observe each small step
towards the goal but also as a plan for how to practice to reach the goal.
Experienced clinicians could identify the possibilities to reach the goal
and could eliminate obstacles and motivate people in the child's envi-
ronment (G. King et al., 2017; M. C. Law et al., 2011; Lowing et al.,
2009). Hypothetically, these factors could have supported the rather
high total goal attainment, which was above the expected level, a result
that complies with other studies (Lowing et al., 2009; Ostensjo, Oien, &
Fallang, 2008; Vroland‐Nordstrand et al., 2016).
The third pillar concerns “Patient values,” and in the present study,
these were represented by the child and their family. The family was
important not only in the selection of meaningful goals but also in
the child's everyday practice and motor learning towards the specific
goals (Oien et al., 2010; Playford et al., 2009; Wiart et al., 2010).
Parents have earlier reported that goals needed to be concrete, observ-
able, contextualized, written, and visible for everyone involved with
the child (Oien et al., 2010). Therefore, ensuring good quality of goals
is essential in many aspects. From the parents' point of view, the goals
provide a focus on meaningful activities and thereby the possibilities
for repetition and integration into the child's everyday context.
In the present study, the Measurability aspect was the most
difficult part aimed at reaching high quality. To make a scale of high
quality requires knowledge of factors in the actual environment where
the child is going to practice and an idea of the expected learning
curve of the child (Hanna, Bartlett, Rivard, & Russell, 2008;
Rosenbaum et al., 2002). From the point of view of being an
evaluation instrument after treatment, high quality requires clear steps
and specifying one single activity because evaluation becomes difficult
if several activities are included but only one is attained.
5 | CO NC LUSIO NS
The goals set in clinical practice showed high quality with respect to
the SMART criteria. The most difficult part was the construction of
BEXELIUS ET AL.
the goal attainment scale. The goals set in clinical practice were con-
sidered relevant from both a client perspective and expertise perspec-
tive. Setting SMART goals can support aspects of EBP.
ACKNOWLEDGMENTS
We gratefully acknowledge all of the children and their families for
participating. We also thank our colleagues at Habilitation & Health
for their contribution.
CONF LICT OF INT E RE ST
The authors report no conflicts of interest. The authors alone are
responsible for the content and for writing this paper.
FUND ING SU PPORT
The study was supported by contributions from the Norrbacka
Eugenia Foundation and Habilitation & Health.
ORCID
Kristina Löwing http://orcid.org/0000-0001-8540-4896
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How to cite this article: Bexelius A, Carlberg EB, Löwing K.
Quality of goal setting in pediatric rehabilitation—A SMART
approach. Child Care Health Dev. 2018;44:850–856. https://
doi.org/10.1111/cch.12609