Can the Performance of Activities of Daily Living Questionnaire

Identify Children with Developmental Coordination Disorder?

Catherine Lindsay Hill

BSc (Hons) Natural Sciences

This thesis is presented for the degree of Master of Science of the

University of Western Australia

School of Human Movement and Exercise Science

2007

ii

I dedicate this thesis to the memory of Mrs Anne Turner (1912-2004)

iii

A b s t r a c t

Currently a lack of guidelines for Criterion B of the DSM-IV-TR (American Psychiatric

Association, 2000) hampers diagnosis of children with developmental coordination

disorder (DCD). The Performance of Activities of Daily Living Questionnaire (PADL-Q;

Dewey, Larkin & Summers, 2004) is a new parent-reported instrument developed to

quantify the level of interference in activities of daily living (ADL) experienced by

children with DCD and was tested for its efficacy in addressing Criterion B. Thirty-two

children aged between 5 and 10 years comprising two matched groups, 16 with DCD

(8 boys and 8 girls) and 16 without DCD (8 boys and 8 girls) participated in the study.

The aim of the research was to investigate the ability of the PADL-Q to identify

differences between children with and without DCD. A further 5 children, in the same

age range, who did not have DCD added data that was used to ascertain relationships

between the constituent assessments. All children were tested using the MAND

(McCarron, 1982) whilst their parents completed the PADL-Q. A set of Tests of

Activities of Daily Living (TADL) tasks were devised for the children to perform that

further validated parents ratings of children’s ADL performance. A Group x Gender

MANCOVA, controlled for age, of the PADL-Q total scores demonstrated that there

was a significant difference between the children with and without DCD (F(3,25) = 9.44, p

< .001; Wilks’ lambda = 0.47). Follow-up univariate tests showed a Group x Gender

interaction and simple main effects of this interaction indicated that the PADL-Q did not

discriminate between the DCD and non-DCD boys. The ability of the PADL-Q to

identify DCD was explored in the concurrent validity against the MAND when using a

diagnostic cut-off point. The PADL-Q demonstrated 100% specificity and positive

predictive values but only 19% sensitivity and 62% negative predictive values. There

was a moderately strong relationship (r = .71), between the PADL-Q total score,

considered a measure of Criterion B, and the MAND, a measure of Criterion A (DSM-

IV-TR, 2000). A two factor (Group x Gender) ANCOVA, controlled for age, of the TADL

items revealed a statistically significant effect for DCD only (F(1,19) = 34.65, p < .001).

There was a moderate correlation (r = -.64) between the PADL-Q total score and the

TADL tasks, indicating that parent-reports are supported by their child’s performance.

The PADL-Q appears to have potential as part of the DCD diagnostic process;

however, further refinement on a larger sample is necessary before it can be used as

an easily-administered guide to ADL performance levels in children.

iv

A c k n o w l e d g m e n t s

I thank Dr David Lloyd, for initiating this Masters research, and Prof. Brian Blanksby for

financial assistance.

Thanks to my supervisors, Dr Dawne Larkin and Dr Jacque Alderson, for their scholarly

guidance in all aspects of this lengthy learning exercise. I have also appreciated the

contributions of: Kerry Smith for helpful UniGym advice; Mel Licari for testing

assistance and proof-reading; A/Prof. Deb Dewey, Dr Krystyna Haq, and Anna Wilson

for proof-reading; and, of course, the children and parents who participated.

There are many people who have helped in other ways and made the journey a

pleasure: the staff and students in Human Movement, especially Margaret Durling,

Barbara Smith, Annette Macrides, Brenda Churchill, and the biomechanics crew in

1.57; The Defeating Self Sabotage/Thesis Completers Group; and Chris & Daisy

Wood. I am very grateful for my friends in both hemispheres: Dr Jodie Cochrane,

Donna-Lee Ferguson, Sarah Mills, Dr Emily Payne, Tricia Willis, and, in particular,

Kristin Lage, Dr Helen Milne, and Dr Siobhán Reid.

I give thanks for, and to, my ever-supportive family: Sue & Roger and Alister Hill.

Finally, by special request of Lisa Stevenson, a mention to Daniel & Nathan in Dunt.

v

T a b l e o f C o n t e n t s

Dedication ii

Abstract iii

Acknowledgments iv

Table of Contents v

List of Tables vii

List of Figures viii

List of Abbreviations ix

Chapter 1: Introduction 1

The Problem 1

Aims and Hypotheses 3

Significance of the Study 3

Delimitations 4

Limitations 4

Chapter 2: Review of literature 5

Introduction 5

Meeting the DSM-IV-TR (2000) Criteria 5

Current Measures of Criterion B 8

Issues When Measuring Criterion B 11

Summary 17

Chapter 3: Method 18

Introduction 18

Participants 18

Instruments 21

Statistical Analyses 24

Chapter 4: Results 26

Introduction 26

Group Differences on the PADL-Q 26

Concurrent Validity of the PADL-Q with the MAND 28

Relationship Between the PADL-Q and the MAND 29

Performance Times of Children on TADL Tasks 30

vi

Relationship Between the TADL and PADL-Q 31

Summary 32

Chapter 5: Discussion 33

Introduction 33

Using the PADL-Q to Identify Children with DCD 33

Relationship Between the MAND and the PADL-Q 36

Validation of the PADL-Q using the TADL Tasks 38

Suggestions for the Next Version of the PADL-Q 41

General Implications 44

Summary 44

Chapter 6: Conclusions 46

Problem Summary 46

Major Findings Support All Hypotheses 46

Significance of Findings 47

Future Research 47

References 48

Appendices 58

Appendix A: Ethics clearance letter 58

Appendix B: Sample invitation letter to parents 60

Appendix C: Information sheet for parents 62

Appendix D: Consent form 65

Appendix E: PADL-Q 67

Appendix F: TADL tasks instructions 73

Appendix G: MAND sample score sheet 77

Appendix H: Formulae used for calculations 80

Appendix I: Raw data tables 81

Appendix J: Test Statistics 85

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L i s t o f T a b l e s

Table 3.1 Age & NDI statistics of matched boys 20

Table 3.2 Age & NDI statistics of matched girls 20

Table 3.3 Age & NDI statistics of MAND Exclusion group 20

Table 3.4 Age & NDI statistics of Unmatched non-DCD group 20

Table 4.1 PADL-Q mean and standard deviation values for boys and girls

with and without DCD 27

Table 4.2 Follow-up ANOVA tests for PADL-Q section total scores and DCD

Group, Gender and DCD*Gender interaction 28

Table 4.3 Simple main effect of presence of DCD on gender 28

Table 4.4 Concurrent validity values for PADL-Q subsection and total scores

at diagnostic cut-off 29

Table 4.5 Correlations between MAND and PADL-Q sections 30

Table 4.6 Correlation between the PADL-Q sections 30

Table 4.7 Correlations and corresponding significance for TADL total z score

and PADL-Q sections 32

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L i s t o f F i g u r e s

Figure 4.1 Group mean PADL-Q total scores 26

Figure 4.2 Interaction graphs for DCD*Gender for (a) ADL score, (b) Play

preferences score, and (c) Movement descriptions score

28

Figure 4.3 Correlation between PADL-Q total score and MAND score 30

Figure 4.4 Group mean TADL total z scores 31

Figure 4.5 Correlation between PADL-Q total score and TADL total z score 31

Figure H1 Questionnaire validation calculations (Portney & Watkins, 1993,

p. 80)

80

ix

L i s t o f A b b r e v i a t i o n s

ADL Activities of daily living

ChAS-P Children’s Activity Scales – Parent (Rosenblum, 2006)

DCD Developmental Coordination Disorder

DCDQ Developmental Coordination Disorder Questionnaire

(Wilson et al., 2000)

DSM-IV-TR Diagnostic and Statistical Manual (Fourth Edition, Text

Revision) of the American Psychiatric Association (2000)

MABC Movement Assessment Battery for Children (Henderson

& Sugden, 1992)

MAND McCarron Assessment of Neuromuscular Development

(McCarron, 1982)

nDCD/non-DCD Child/children without DCD. “nDCD” used in tables and

graphs; “non-DCD” used in text

NDI Neuromuscular Development Index (McCarron, 1982)

PADL-Q Performance of Activities of Daily Living Questionnaire

TADL Tests of Activities of Daily Living

1

C h a p t e r 1 : I n t r o d u c t i o n

The Problem

The Diagnostic and Statistical Manual (DSM-IV-TR, American Psychiatric

Association, 2000) lists Developmental Coordination Disorder (DCD) as a “motor skills

disorder” (p. 56, DSM-IV-TR, 2000) affecting children. DCD manifests as a physical

syndrome and is indicated by delays in reaching motor skill milestones, such as

walking and handwriting (DSM-IV-TR, 2000). The DCD group is heterogeneous in

nature; that is, children with DCD have individual strengths and weaknesses in fine

and/or gross motor skills (Davis, 1984; Dawdy, 1981; Gibson, 1996; Maeland, 1992).

In addition, these children often experience problems mastering activities of daily living

(ADL) in comparison to their peers (Mandich, Polatajko & Rodger, 2003). This study

investigates the relationship between movement ability and ADL performance and the

use of such tasks to identify DCD, in line with the DSM-IV-TR criteria (2000).

In 1994, the DCD research community adopted the DSM-IV criteria (1994) as

the judgement basis for diagnosing children with DCD (Polatajko, Fox & Missiuna,

1995) and in 2006 this was updated in light of publication of the DSM-IV-TR (2000;

Sugden, 2006). The DSM-IV-TR (2000) outlines the following four criteria that should

be met for a DCD diagnosis:

A. Performance in daily activities that require motor coordination is

substantially below that expected given the person’s chronological age

and measured intelligence. This may be manifested by marked delays

in achieving motor milestones (e.g., walking, crawling, sitting), dropping

things, “clumsiness”, poor performance in sports, or poor handwriting.

B. The disturbance in Criterion A significantly interferes with academic

achievement or activities of daily living.

C. The disturbance is not due to a general medical condition (e.g., cerebral

palsy, hemiplegia, or muscular dystrophy) and does not meet criteria for

a Pervasive Developmental Disorder.

D. If Mental Retardation is present, the motor difficulties are in excess of

those usually associated with it.

(DSM-IV-TR, 2000, p. 58)

A full diagnosis requires all four criteria to be satisfied. Nevertheless,

practitioners do not always specifically test for each criterion when a child is assessed

2

for a diagnosis of DCD (Geuze, Jongmans, Schoemaker & Smits-Engelsman, 2001). If

Criteria C and D are met, Criterion A is fulfilled by the child undertaking a motor ability

test to assess fine and gross motor skills. There are a variety of such tests available,

including the Test of Motor Impairment (TOMI, Stott, Moyes & Henderson, 1984), the

Movement Assessment Battery for Children (MABC, Henderson & Sugden, 1992), the

Bruininks-Oseretsky Test of Motor Proficiency (BOTMP, Bruininks, 1978), and the

McCarron Assessment of Neuromuscular Development (MAND, McCarron, 1982)

amongst others. As these instruments measure quantifiable constructs, such as

bimanual coordination and balance, it is possible to categorise children into groups

depending upon the severity of their movement problems. Three groups are usually

identified: severe DCD, suspect DCD, and non-DCD (Dewey, Kaplan, Crawford and

Wilson, 2002; Henderson & Sugden, 1992). However, for a complete diagnosis of

DCD it must also be shown that the identified low motor ability pervades other areas of

the child’s life; yet this section of the DSM-IV-TR (Criterion B, 2000) is often only

assumed (Dewey & Wilson, 2001; Geuze et al., 2001; Kaplan, Wilson, Dewey &

Crawford, 1998; Watkinson, Causgrove Dunn, Cavaliere, Calzonetti, Wilhelm & Dwyer,

2001; Wilson, 2005).

The main difficulty in assessing the impact of poor motor skills identified in

Criterion A lies inherently in the definition of Criterion B. It states that “the disturbance

in Criterion A significantly interferes with academic achievement or activities of daily

living” (DSM-IV-TR, 2000, p. 58) without providing guidelines as to how school

achievement or ADL would be affected, less what to include in such an assessment.

Previous research has shown that children with DCD are at risk of poor school

achievement outcomes (Dewey et al., 2002). With respect to ADL however, there is a

paucity of research investigating the effect of DCD on everyday life and a concurrent

lack of explicit definitions of ADL undertaken by children, both with and without DCD.

Adequately fulfilling Criterion B is a major obstacle in using the DSM (1994, 2000) as

diagnostic criteria (Geuze et al., 2001; Henderson & Barnett, 1998).

Summers, Larkin and Dewey (2007a) identified those ADL most commonly

undertaken by children in two age groups: younger, aged 5 to 7 years; and older, aged

8 to 9 years. This data had been used to develop a parental questionnaire titled the

Performance of Activities of Daily Living (PADL-Q; Dewey, Larkin & Summers, 2004).

Recent studies have shown that it is possible to use parent reports to measure ADL

performance and, in turn, determine the presence of DCD (Rosenblum, 2006). This

thesis continues Dewey and colleagues’ (2004) work by focusing on the validity of the

PADL-Q as a means of identifying children with DCD and addresses the lack of

guidelines in Criterion B of the DSM-IV-TR (2000) in using ADL performance to indicate

DCD.

3

Various definitions of ADL performance exist in the occupational/ physical

therapy literature (e.g., Vreede, 1988; Chapparo & Ranka, 1997), however, in this

study DCD will be measured using the definition of ADL described by Wall, Reid and

Paton (1990, p. 287) who stated that “culturally-normative skills are those that are

commonly used by a majority of the children at certain ages within a given socio-

cultural setting”. Watkinson and colleagues (2001) used this definition of ADL when

investigating the level of engagement by children with and without DCD in playground

activities.

Further validation of the PADL-Q in identifying DCD in this sample of children is

undertaken by examining a set of performance based tests. These Tests of Activities

of Daily Living (TADL) are based on selected PADL-Q items. In clarifying and

measuring the performance of ADL in children with and without DCD, it will be possible

to quantify the level of disturbance that signifies the condition.

Aim and Hypotheses

This study aimed to quantify the interference in ADL experienced by children in

everyday life using the parent reported PADL-Q. In doing so, the PADL-Q score may

be used to satisfy Criterion B of the DSM-IV-TR (2000) as part of the DCD diagnosis.

The specific hypotheses are:

1. Children with DCD will have lower scores on the PADL-Q than children

without DCD, p < .05.

2. Using a diagnostic cut-off point, the PADL-Q will display ≥80%

concurrent validity with the MAND for sensitivity, specificity, positive and

negative predictive values (Riggen, Ulrich & Ozmun, 1990).

3. The PADL-Q scores will be positively correlated with a standardised and

internationally accepted measure of motor skill performance (MAND,

McCarron, 1982), p < .05.

4. The TADL task data will support parent ratings of ADL performance by

(a) the children with DCD taking longer to perform the TADL tasks, p <

.05; and (b) the TADL tasks total z score demonstrating an inverse

relationship to the PADL-Q total score, p < .05.

Significance of the Study

Knowledge and data regarding childhood ADL is scant (Dewey & Wilson, 2001;

Geuze, 2005; Geuze et al., 2001; Henderson & Barnett, 1998; Kaplan et al., 1998;

Watkinson et al., 2001; Wilson, 2005). This study explicitly addresses the lack of

guidelines provided in the DSM-IV-TR (2000) for Criterion B, relating to DCD impeding

a child’s ADL performance. The PADL-Q offers to be an instrument that can be used

4

by DCD researchers to measure interference in everyday tasks and determine if

Criterion B of the DSM-IV-TR (2000) is satisfied.

Delimitations

The DCD group participants are children who have a Neuromuscular

Development Index (NDI) score of less than 85 as measured in a MAND (McCarron,

1982) assessment, thus fulfilling Criterion A of the DSM-IV-TR (2000). The age range

is from 5 to 10 years. These children will have a minimum of coexisting problems;

however, DCD is rarely experienced in isolation (Kaplan et al., 1998). The PADL-Q is

administered to the parents of these children. Children who do not satisfy criteria C

and D of the DSM-IV-TR (2000) will be excluded.

The non-DCD group participants are children who score above 90 on the

MAND assessment. These children will be matched to a child with DCD based on their

gender and age at testing, according to the MAND assessment. The PADL-Q is

administered to the parents of these children.

Limitations

The availability of children with DCD in the Perth metropolitan area precludes a

large sample. The non-DCD group was a convenience sample of children and

recruitment reliant on parents volunteering their time to attend the testing session with

their child.

Parents are assumed to be knowledgeable enough of their child’s performance

of ADL to accurately answer the PADL-Q, an assumption supported by previous

literature (Pless, Persson, Sundelin & Carlsson, 2001; Polatajko et al., 1995). Some

research has shown that parents are liable to over-endorsement (Wilson, Kaplan,

Crawford, Campbell & Dewey, 2000) or may report the level of assistance they offer

rather than the actual amount of help their child needs (Burgman, 1998). However, the

majority of studies involving parent reporting have shown them to be adequate

observers of their child’s behaviour, irrespective of the level of parent education and/or

parenting experience (Glascoe, 1997b, 2000; Green, Bishop, Wilson, Crawford,

Hooper, Kaplan & Baird, 2005; Missiuna & Pollock, 1995; Pless et al., 2001; Wilson et

al., 2000).

5

C h a p t e r 2 : R e v i e w o f t h e L i t e r a t u r e

Introduction

The identification of DCD at a young age is regularly cited as important by DCD

researchers in order for intervention strategies to be employed at an early stage

(Cantell, Smyth & Ahonen, 2003; Crawford, Wilson & Dewey, 2001; Geuze et al., 2001;

Gubbay, 1978; Polatajko et al., 1995; Schoemaker & Kalverboer, 1994; Skinner & Piek,

2001; Wilson, 2005). The primary rationale for this position is to reduce the negative

outcomes of DCD that are well documented in longitudinal studies; including poor

academic performance at school, reduced participation in sports and social groups,

and low self-esteem (Cantell, Smyth & Ahonen, 1994, 2003; Hellgren, Gillberg, Gillberg

& Enerskog, 1993; Losse, Henderson, Elliman, Hall, Knight & Jongmans, 1991;

Sugden & Sugden, 1991). Severely affected children seem to endure negative

consequences to a greater extent when compared to those who have moderate DCD,

the latter of whom can be performing at a similar level to the unaffected children by the

end of the teenage years (Cantell et al., 2003; Cousins & Smyth, 2003; Losse et al.,

1991; Rasmussen & Gillberg, 2000). However, regardless of the severity of DCD it is

suggested that the adverse emotional effects of having DCD threaten to be more

debilitating than the condition itself (Cantell et al., 1994; Dewey et al., 2002; Hellgren et

al., 1993; Losse et al., 1991; Schoemaker & Kalverboer, 1994). Parents have reported

the associated adverse emotional effects of DCD when describing the difficulties

experienced by their children in performing ADL (Mandich et al., 2003). While

difficulties in performing ADL are a defining feature of DCD these are rarely tested

explicitly during assessment for the condition (Geuze et al., 2001).

Meeting the DSM-IV-TR (2000) Criteria

DCD has been documented in both the DSM-III-R (American Psychiatric

Association, 1987) and the DSM-IV (American Psychiatric Association, 1994) as a

motor skills disorder. For over ten years, DCD researchers have used criteria set out in

the DSM-IV (1994) as the standard for diagnosing the condition (Polatajko et al., 1995).

More recently, the Leeds Consensus Statement (Sugden, 2006) agreed that the DSM-

IV-TR (American Psychiatric Association, 2000) be the basis upon which to make a

diagnosis of DCD, although the specific criteria remained as that described in the

previous edition. The four criteria state that (a) motor coordination is considerably

below the average expected for a child of that age; (b) the motor incoordination affects

the child‟s school achievement or their ADL; (c) the motor incoordination is not due to a

6

medical condition; and (d) if the child is intellectually impaired, the motor problems are

greater than would have been expected for their IQ level (DSM-IV-TR, 2000).

Having identified that there are problems with a child‟s movements, and that the

child satisfies criteria C and D, the child undertakes a motor performance assessment

to determine if Criterion A is met. Various measurement instruments for Criterion A are

used and in Western Australia the most common is the McCarron Assessment of

Neuromuscular Development (MAND, McCarron, 1982; Larkin, Hands, Parker, Sloan &

Kendall, 2005; Licari, Larkin & Miyahara, 2006; Rose, Larkin & Berger, 1997). The

MAND was developed “as a standardised and quantitative procedure for assessing fine

and gross motor abilities” (McCarron, 1997, p. 2). The fine motor skills involve finger,

hand, and arm dexterity for both unilateral and bilateral tasks. The gross motor skills

include strength, coordinated movement of all limbs, and balance tasks. A score for

each fine/gross component is summed for an overall score that is translated into the

Neuromuscular Development Index (NDI) according to the child‟s age. Although the

norms for the MAND are based on a sample from the USA, Tan, Parker and Larkin

(2001) validated its use with children from Western Australia.

A complete diagnosis of DCD as per the DSM-IV-TR (2000) guidelines requires

that the child‟s poor motor ability affects their performance at school or around the

home, but fulfilling Criterion B is often only implied when Criterion A is satisfied (Geuze

et al., 2001). For many years, only tests for Criterion A have been used to identify

children with DCD (O‟Dwyer, 1987; Schoemaker, van der Wees, Flapper, Verheij-

Jansen, Scholten-Jaegers & Geuze, 2001); yet research evaluating existing DCD

diagnosing instruments suggest that there are a number of problems relying on these

measures.

First, a traditional testing session to assess Criterion A is performed to provide

an overall snapshot of a child‟s particular motor skill ability at that point in time. Dewey,

Crawford and Kaplan (2003) suggests that this provides the ideal situation to assess

the child‟s motor skills as the tasks are organised in a manner that enables a child to

do their best in a quiet environment free from distractions. The disadvantage of this

approach is that children are aware of being assessed and may experience test

anxiety, as described by Goshi, Demura, Kasuga, Sato & Minami (2000).

A further limitation of relying solely on traditional motor skill assessments is that

tasks are often isolated to a specific domain and out of context of the child‟s normal

movement experience (Burgman, 1998; Wall, McClements, Bouffard, Findlay & Taylor,

1985). Motor tasks in isolation may be easier to complete because there are less

extraneous demands on the child, such as the need to process environmental cues

related to the task (Burgman, 1998). This means that using only a test for Criterion A

for the diagnosis of DCD may result in a child with DCD being overlooked due to the

7

tasks in a standardised Criterion A assessment being simple and abstract. For simple

tasks, children with DCD have demonstrated similar skill acquisition profiles as age-

matched controls (Missiuna, 1994). However, when task complexity increases children

with DCD take longer to learn correct motor patterns (Marchiori, Wall & Bedingfield,

1987). Only when task complexity increases, such as in ADL, does the likelihood of

identifying DCD become greater (Wilson, Maruff & Lum, 2003).

A third issue with relying on a Criterion A assessment for the diagnosis of DCD

is that there is no standardised cut-off measurement for DCD diagnosis, with each

motor ability test identifying its own cut-off point (Dunford, Street, O‟Connell, Kelly &

Sibert, 2004; Schoemaker, Flapper, Verheij, Wilson, Reinders-Messelink & de Kloet,

2006). Further, individual studies have used different cut-offs depending upon the

hypotheses examined and the research methods employed (Sugden & Sugden, 1991).

In many studies, children scoring below the 15th percentile have been diagnosed as

having DCD (as recommended by Geuze et al., 2001) and those scoring between the

16th and 25th referred to as „suspect DCD‟ (Dewey et al., 2002; Wilson et al., 2000). A

more lenient cut-off point has been employed for screening instruments, which are

intended to highlight children who may be at risk of DCD, and are then referred for

further motor skill testing. Screening instruments capture more children than would

typically be diagnosed with the disorder and this is felt to be preferable to a child‟s

motor problems being overlooked (Schoemaker, Smits-Engelsman & Jongmans, 2003;

Watkinson et al., 2001).

The problem in assigning a cut-off point for children‟s movement proficiency is

that it separates a line of continuum into two discrete parts, but those falling on either

side of a cut-off border are not so different in their abilities as the classification

suggests (Smoll, 1974; Dwyer, 1996; Sonnander, 2000). Due to the heterogeneous

nature of DCD, it means that children who have specific motor ability problems may still

score on the unaffected side of an assessment cut-off point and, hence, be incorrectly

classified as not having DCD (Dawdy, 1981; Hoare, 1994; Wright & Sugden, 1996a).

Another concern is that there is often little consistency between tests of motor

skill given that each has been developed to reflect a different mechanism or feature of

DCD (Crawford et al., 2001; Missiuna, 1994; Missiuna & Polatajko, 1995; Sugden &

Sugden, 1991). This problem seems unavoidable as there is currently no test that

examines all of the aspects of motor skill a child might be expected to have acquired at

a given age (Davis, 1984; Geuze et al., 2001; Henderson & Barnett, 1998; Maeland,

1992).

Criterion B of the DSM-IV-TR (2000) concedes this last point and demands that

the motor skill deficiency must affect the child‟s quality of life, with specific mention of

ADL. During the formulation of the Leeds Consensus Statement (Sugden, 2006) there

8

was discussion that Criterion B provide functional examples of the motor deficiency in

Criterion A. The same consensus statement also opined that such assessments

should be relevant to the environment in which the child is developing; for example,

different geographical areas of the world have particular climate considerations (cf.

Australian to Canadian winters), social etiquette (cf. European and Asian eating

utensils), and lifestyle experiences (e.g., availability of parkland or swimming pools).

This means that measures of childhood ADL performance will need to be validated in

all cultures in which it is planned for use.

Gaining data of the skills demonstrated by children within a particular culture

requires a profile of the child‟s motor ability to be constructed using information from

multiple sources, such as reports from professionals, teachers, parents, and children

(Dunford & Kelly, 2001; Rodger, Ziviani, Watter, Ozanne, Woodyatt & Springfield,

2003). Profiling offers a more varied and realistic description of a child‟s movement

potential than a single standardised test in isolation (Davis, 1984; Gubbay, 1978;

Missiuna & Pollock, 1995; Rodger et al., 2003; Wilson, 2005; Zittel, 1994). Despite the

well-recognised advantages in using a profile of a child‟s motor ability, there are

difficulties in using such assessments for Criterion B as the specifics of what and how

to measure ADL performance are yet to be determined (Henderson & Barnett, 1998).

Current Measures of Criterion B

Criterion B of the DSM-IV-TR (2000) makes specific mention of academic

achievement and the performance of ADL. Children with DCD often have learning

difficulties in addition to motor incoordination, such as language and reading problems

(Cantell et al., 1994; Dewey et al., 2002; Rasmussen & Gillberg, 2000). For the child

who experiences DCD in isolation, a more appropriate measure of the impact of DCD

on their quality of life is a report of their actual ADL performance. Such reports are

often referred to as an assessment of function because they evaluate the child‟s ability

to function in a natural setting (Case-Smith, 1995; Fisher, 1997; Msall, Tremont &

Ottenbacher, 2001).

Teacher Reports

One such ADL function report is teacher feedback of a child‟s motor abilities in

the classroom and two examples are the MABC Checklist (Sugden & Sugden, 1991)

and the Early Years Movement Skills checklist (Chambers & Sugden, 2002). The

MABC Checklist is validated for use with children aged 7-9 years old and comprises a

55-item instrument with ratings by teachers of a child‟s performance across different

movement situations (e.g., “Child Moving-Environment Stable”, in reference to the child

manoeuvring around furniture in the classroom). However, this instrument has been

9

reported to be inaccurate when applied across all age groups (Schoemaker et al.,

2003).

The Early Years Movement Skills checklist was designed for children aged from

3 to 5 years old and comprises 23 questions in four sections. These sections represent

areas of self-care, hand manipulation tasks, classroom skills, and play activities;

performance in general is rated for each question on a 4-point scale (Chambers &

Sugden, 2002). The authors found that it differentiated between children with and

without movement problems, but it has been noted that before the age of five the

successful accomplishment of skills varies widely between children and can depend

upon their exposure to the task being measured (Case-Smith, 1995, 1996; Chambers

& Sugden, 2002; Gibson, 1996).

In addition to the specific difficulties of each of the aforementioned teacher

reports, the reliability of such measures has been reported to be influenced by the

amount of physical education training the evaluating teacher has completed (Maeland,

1992; Piek & Edwards, 1997). Consequently, there are mixed results describing the

accuracy of teacher reports with some studies reporting that they correctly identify

childhood DCD (Dunford, Missiuna, Street & Sibert, 2005; Henderson & Hall, 1982;

Losse et al., 1991; Rosenblum, 2006) and others finding that teachers are unsuitable

assessors of movement problems in children (Dunford et al., 2004; Revie & Larkin,

1993a; Schoemaker et al., 2003). Moreover, using teacher reports is dependent upon

permission from education authorities and reliant on teachers responding within the

time period for that aspect of child development under investigation (Dunford et al.,

2005; Losse et al., 1991; Revie & Larkin, 1993a; Rosenblum, 2006). Overall, research

suggests that teacher ratings of childhood ADL function are difficult to administer,

problematic to organise, and their reliability variable.

Existing Function Reports

Other measures of ADL function currently available are for children who have a

diagnosed medical condition such as cerebral palsy, developmental delays, and

neurological disorders. Two such examples are the Pediatric Evaluation of Disability

Inventory (PEDI; Haley, Coster, Ludlow, Haltiwanger & Andrellos, 1992) and the

Pediatric Functional Independence Measure (WeeFIM; Msall, DiGaudio, Duffy,

LaForest, Braun & Granger, 1994). However, even these do not provide the full range

of contextually based information about a child‟s ability in the performance of daily

activities (Burgman, 1998; Dunford & Kelly, 2001; Hayase, Mosenteen, Thimmaiah,

Zemka, Atler & Fisher, 2004; Msall et al., 2001). Children with DCD do not, by

definition, suffer from a general medical condition (DSM-IV-TR, 2000) and despite ADL

impairment being a significant feature of DCD, there are few measures of ADL function

10

sensitive enough for this group of children (Rodger et al., 2003; Watkinson et al., 2001;

Wilson, 2005).

Until recently, the nearest tool to appraise ADL in children with DCD was the

Developmental Coordination Disorder Questionnaire (DCDQ; Wilson et al., 2000)

which is a parent rated review of children‟s abilities in sports, school and some self-

care tasks. The DCDQ has been validated for use on groups of children in Australia,

the Netherlands, and the UK (Boyle, 2003; Green et al., 2005; Schoemaker et al.,

2006). The main limitation is its brevity with only 17 questions providing insufficient

detail to gain an accurate view of the child‟s performance in the mandatory aspects of

daily life, such as brushing teeth, using eating utensils, and dressing.

The latest work, by Rosenblum (2006), detailed the development of a 27-item

questionnaire that required parents to answer questions regarding their child‟s abilities

in ADL (called the Children Activity Scales, ChAS-P). Although in the early stages of

testing, and only with children aged between 5 and 6½ years old, Rosenblum (2006)

found it distinguished between those with and without DCD.

Both the DCDQ (Wilson et al., 2001 in Crawford et al., 2001) and the ChAS-P

(Rosenblum, 2006) underwent concurrent validity testing against an existing measure

of motor ability, the MABC (Henderson & Sugden, 1992). Using a Criterion A

assessment to appraise the efficacy of a new test is not flawless because, at present,

there is no gold standard test for Criterion A (Henderson & Barnett, 1998).

Concurrent validity is comprised of scores assessing four aspects of validity: (a)

sensitivity, the ability of the new test to accurately identify the same cases of DCD as

the Criterion A test; (b) specificity, the ability of the new test to accurately identify the

same cases of typically developing children as the Criterion A test; (c) negative

predictive value, the proportion of children that the new test identified as typically

developing who were typically developing; and (d) positive predictive value, the

proportion of children identified as DCD on the new test who were DCD as measured

by the Criterion A test.

The threshold for acceptable concurrent validity is generally 80%, as used by

Riggen and colleagues (1990). The DCDQ (Wilson et al., 2000) and ChAS-P

(Rosenblum, 2006) both exceeded this threshold for specificity but did not reach it for

sensitivity. This indicates these tests are more suitable for identifying children who do

not have DCD (Crawford et al., 2001; Rosenblum, 2006). Variations in identification

between the new and existing test are to be expected when the constructs are slightly

different and, in particular, when dealing with children with DCD who often present with

a heterogeneous movement profile (Gibson, 1996; Kaplan et al., 1998; Maeland, 1992;

Sugden & Sugden, 1991).

11

Issues When Measuring Criterion B

The Problem

The heterogeneous nature of the DCD group exacerbates the difficulty with

using function reports to identify children with DCD as measuring and interpreting

competence in ADL tasks is part quantitative and part qualitative. Case-Smith (1995,

1996) described such a difference between quantitative and qualitative measures when

investigating motor skill and motor function in children aged 4-6 years before and after

an occupational therapy intervention programme to improve their fine motor skills.

Motor skill was tested quantitatively using the Peabody Developmental Motor Scale –

Fine Motor (Folio & Fewell, 1983) and motor function tested qualitatively with the PEDI

(Haley et al., 1992). Case-Smith (1995, 1996) found that fine motor skills are an

indicator of self-care function but do not fully account for proficiency in self-care tasks.

This may be because there are multiple ways of accomplishing a task, with the end

result dependant upon the performer, the environment, and the goal of the task (Burton

& Davis, 1996; Case-Smith, 1995; Haley, Coster & Binda-Sundberg, 1994; Newell,

1986; Smoll, 1974; Sonnander, 2000; Thelan, 1995).

Using both quantitative and qualitative measures to take a holistic approach to

the reporting of a child‟s abilities has historic merit. White (1959) theorised that

children become competent at dealing with their surroundings by playing and they

acquire motor skills from being stimulated by the environment and learning how to

manipulate themselves in relation to it. He noted that “the transactions as a whole”

(White, 1959, p. 320), rather than individual components of the situation, develop motor

skills. This point has been echoed by several researchers who have stated that the

performer of an action does so in relation to the environment and the three aspects are

inseparable (Davis & Burton, 1991; Fisher, 1997; Newell, 1986; Polatajko, Mandich &

Martini, 2000; Smith & Thelan, 2003).

As the interaction between the performer, task, and environment becomes more

complex, a construct called General Motor Ability (GMA; Burton & Rodgerson, 2001)

correspondingly exerts its influence. The theory of GMA describes how it pervades all

movement skills without being a tangible competency that is easily measured. Instead,

it can be judged by observing such performer-task-environment interactions and rating

how well these are performed (Burton & Rodgerson, 2001).

With regard to testing ADL two opposing situations can arise from this

approach. On the plus side, functional tests are more likely to highlight stages where

the child has difficulty that may be overlooked in a traditional test due to the skills being

abstract in relation to the child‟s everyday life (Burgman, 1998; Larkin & Cermak, 2002;

Rodger et al., 2003; Wall et al., 1985). The negative side concerns the difficulty in

interpreting Newell‟s (1986) observation that the goal of a task may not require a

12

specific procedure to be followed and the variety of personal interpretations of the

functional situation may result in the same outcome, despite differing methods being

employed to achieve such an outcome.

The difficulty judging childhood ADL performance with respect to the performer-

task-environment interaction is in addition to other, more general issues in using ADL

to assess Criterion B (Dewey & Wilson, 2001; Geuze et al, 2001; Henderson & Barnett,

1998; Missiuna & Polatajko, 1995). The main concerns revolve around absolute

measurement issues, in that there are no clear guidelines on what should be included

in an assessment for Criterion B; no standardised measures to identify abnormality;

and no norms to which resulting scores can be compared (Geuze et al, 2001;

Henderson & Barnett, 1998; May-Benson, Ingolia & Koomar, 2002). It appears,

therefore, that evaluating ADL performance is far more involved than rating success or

failure using a traditional motor test.

The Solution

In response to the indeterminacy of Criterion B, expository work by Summers,

Larkin and Dewey (2007a) has addressed the first of these measurement difficulties,

that of no guidelines on what to include in an ADL assessment. Summers and

colleagues (2007a) interviewed Australian and Canadian parents of children with and

without DCD, in two age groups: 5- to 7-year-olds and 8- to 9-year–olds, to qualify

their child‟s engagement in, and performance of, ADL with regard to those defined by

Chapparo and Ranka (1997).

A difference in the capabilities of the younger children to dress themselves was

already evident, with the DCD group reported to be slower and to have more difficulties

managing fastenings (buttons/zips) when compared with the typically developing

group. The same pattern was seen in the older group of children with DCD, who were

underperforming relative to their peers and still experiencing problems with the spatial

orientation of clothing and speed of dressing. In personal tasks, such as effective oral

care, both DCD age groups were, on the whole, performing at a lower level than that of

the non-DCD group (Summers et al., 2007a). This data affirmed observations made by

Missiuna (1994) that those with DCD experienced an inadequacy in their performance

of age-appropriate motor skills.

The data from the Summers and colleagues‟ (2007a) parent interviews has

been used to develop the parent-reported Performance of Activities of Daily Living

questionnaire (PADL-Q; Dewey et al., 2004), based on those aspects of a child‟s

routine identified as being common across participants. This is in line with the

definition of ADL described by Wall and colleagues (1990, p. 287) who stated that

“culturally-normative skills … are [those] commonly used by a majority of the children at

13

certain ages within a given socio-cultural setting”. The original 136-item PADL-Q

questionnaire was tested on 448 typically developing Canadian children, aged from 5

to12 years old. Items were removed if they displayed gender bias and those that did

not show a developmental trend were also removed.

The current version of the PADL-Q has 61-items that cover mealtimes,

dressing, washing, play preferences, organised activities, and fine and gross motor skill

estimations (Appendix E). In comparison to existing parent-report questionnaires, the

PADL-Q data provides a panoptic opportunity to analyse a child‟s ADL function.

Summers, Dewey and Larkin (2005) found that the Cronbach‟s alpha (internal

consistency) of the 61-item PADL-Q was .93; indicating a very high correlation between

the items in the questionnaire. However, high values for Cronbach‟s alpha may also be

a symptom of redundancy. The PADL-Q is still evolving as a measure of childhood

ADL performance and is yet to be validated with Australian children.

The PADL-Q addresses many aspects of childhood ADL that are not specific to

Canadian or Australian children, and designed for boys and girls aged between 5 and

11 years of age. The performance of ADL by children significantly improves between

the ages of 3 and 6 years and by the latter age the ability in these skills is stabilising

(Chambers & Sugden, 2002; Gesell, Ilg & Bates Ames, 1977; Hayase et al., 2004;

Sugden & Sugden, 1991). By 6 years of age, children have commenced school,

resulting in an increase in the demands on a child in almost every facet of their life:

academic, self-care, and social (Schoemaker & Kalverboer, 1994). Regarding self-

care, Lasky and Eichelberger (1985) found that in preschoolers aged between 4 and 6

years old, the level of self care was similarly related to their level of independence.

This is supported by Chapparo and Hooper (2002, 2005) who reported that at age 6

years, children are aware of their responsibilities to look after themselves and already

categorise such actions as „work‟ or „play‟ depending upon their abilities in a given task.

For example, children who found tying shoelaces hard designated this as work,

whereas children who found it manageable labelled it as play. This recognition in self-

care tasks contributed to a child‟s perception of their performance at school, with those

who were classified as independent feeling more successful (Chapparo & Hooper,

2005).

Feelings of success surrounding motor proficiency assist the child in coping

with their environment and are a precursor to feelings of improved self-esteem. This in

turn, provides motivation to continue seeking engagement with the environment

(Mandich et al., 2003; Shaw, Levine & Belfer, 1982; Skinner & Piek, 2001; Wall et al.,

1985; White, 1959; Zittel, 1994). Play is one area that involves a child engaging with

the environment and is an important aspect of child development (White, 1959).

Recognised as an ADL by the occupational therapy literature, play is included in the

14

PADL-Q (Chapparo & Ranka, 1997) and with respect to children with DCD, play is

often another ADL area in which they experience movement difficulties.

Mandich and colleagues (2003) described how children who were less

proficient in ADL experienced activity restrictions in normal childhood activities such as

riding a bike and using climbing equipment. Other researchers have found that

children with DCD have lower levels of activity participation than their peers during

periods of both free play and structured physical activities (Bouffard, Watkinson,

Thompson, Causgrove Dunn & Romanow, 1996; Cairney, Hay, Faught, Mandigo &

Flouris, 2005; Thompson, Bouffard, Watkinson & Causgrove Dunn, 1994; Watkinson et

al., 2001).

Lower levels of activity participation have adverse social and emotional effects

for children due to the influence of activity participation on their position in a peer

group. This is a common issue for children with movement problems because child

social status is largely based on motor proficiency (Chia, 1997; Evans & Roberts, 1987;

Schoemaker & Kalverboer, 1994; Smoll, 1974; Weiss & Duncan, 1992). The

consequence of having low peer status is not being asked to participate in play and

games, further confounding the movement and confidence problems these children

endure (Evans & Roberts, 1987).

The distinction between children with and without DCD is less well defined with

reference to informal play opportunities. When involved in free play, Summers (2002)

reported that parents of children with DCD observed their child to be more hesitant to

participate and below the level of motor ability for their peer group. That said, the

heterogeneous nature of the DCD group was highlighted by the diverse choice of

activities in which the children participated, which was was not necessarily dependent

upon skill level. For example, some parents of children with DCD expressed surprise

their child was riding a bike without training wheels, although they may still not be as

well balanced as their friends (Summers, 2002). Parents of children with gross motor

problems stated their child favoured fine motor activities. Other children with DCD who

spent time on construction/craft activities experienced problems in similar fine motor

skills, such as writing. In some cases, parents reported their child with DCD as well

practised in fine motor activities and had achieved success (Summers, 2002). The

combination of personal choice and heterogeneity of movement ability make it difficult

to rate children‟s performance in informal play activities.

Children‟s Own Views

Although a child with DCD may have become accomplished in certain tasks,

this is likely to have taken more time than it would for a child without DCD (Missiuna,

1994; Summers, Larkin & Dewey, 2007b). This can lead to a child with DCD confusing

15

their level of ability with their level of effort (Rodger et al., 2003). This mistaken illusion

of being well skilled in motor activities may explain the difficulties in gaining reliable

child self-reported data regarding movement abilities. In the DCD literature, studies

that have shown a clear link between the low self-perception of the movement abilities

of children with DCD and their low scores on accepted motor ability tests were

generally children aged 8 years and older (Cantell et al., 1994; Hay, Hawes & Faught,

2004; Rose et al., 1997). For younger children, the results are mixed: Schoemaker and

Kalverboer (1994) found children with DCD aged between 6 and 9 years to feel less

competent then their non-DCD peers whereas Rodger and colleagues (2003) and

Boyle (2003) reported this same age group of DCD children to rate themselves equally

as proficient as their non-DCD classmates. Dunford and colleagues (2005) reported

that two of the 35 children in their study, aged 6 and 10 years old, rated themselves at

the competent end of the scale on almost all items - despite having severe DCD. The

reliability of child self-reporting in the age range of 5 to11 years old is, at best, difficult

and, at worst, contentious.

Parent Perceptions

In light of the conflicting results of both child self-perception and teachers

reports in measuring ADL in children, the PADL-Q has been designed for parents to

appraise their own child relative to other children of the same age in a natural

environment, in accordance with recommendations in the literature (Burgman, 1998;

Chambers & Sugden, 2002; Davis, 1984; Dunford et al., 2004; Green et al., 2005;

Missiuna & Pollock, 1995; Pless et al., 2001; Polatajko et al., 1995; Sugden, 2006;

Sugden & Sugden, 1991; Wilson et al., 2000; Zittel, 1994).

Moreover, parent reports have been reported to be an accurate and useful

addition to clinical diagnostic tools (Dewey et al., 2003; Glascoe, Altemeier & MacLean,

1989; Glascoe & Dworkin, 1995). Parents can provide commentary for areas of

performance difficult for researchers to gain access to and can rate their child‟s

performance in the context of the situation (time limited), environment

(school/home/club) and mood (Case-Smith, 1996; Fox & Lent, 1996; Glascoe, 1997b,

2000; Msall et al., 2001; Wilson et al., 2000).

For the child, parent reports are advantageous for three reasons. First, the

home is where most parents believe their child performs best (Chesson, McKay &

Stephenson, 1990). Second, the child is unaware of being tested thus removing the

need for their cooperation and other factors out of the examiner‟s control, such as

tiredness, irritability, and test anxiety (Glascoe & Dworkin, 1995; Goshi et al., 2000).

Third, using parental reports is congruent with the ideal method of gaining reliable

information about a child‟s capabilities; that is, making observations over a number of

16

tasks (Larkin & Cermak, 2002).

The concern that parents may over-represent their child‟s abilities or mistake

the level of care given for the level of independence has been reported (Burgman,

1998; Case-Smith, 1995; Glascoe, 2000). In light of the relationship between self-care

and independence (Chapparo & Hooper, 2002, 2005; Lasky & Eichelberger, 1985),

parents reporting the level of care they provide for their child may indicate DCD if the

parent(s) do not feel their child adequately performs the task.

Glascoe and colleagues (1989) found that the ability of parents to report

developmental problems in their child was unrelated to any of the following factors:

parenting experience, birth order of child, levels of education, standard of living, and

time spent with the child. The knowledge of parents regarding their child‟s movement

problems was highlighted by Chesson and colleagues (1990) who reported that 77% of

the parents were aware of their child‟s movement difficulties before official diagnosis.

Parent reports then, appear to be a suitable method of gathering data on child motor

skill performance for both the researcher and the child.

Validating the PADL-Q with Tests of Activities of Daily Living

Parent perceptions of their child‟s movement abilities in the home are supported

by researchers investigating speed of movement. It is known that children with DCD

perform tasks more slowly than children without DCD; however, these studies have

concentrated on motor-perception skills such as maze-tracing and target aiming tasks

(Hellgren et al., 1993; Henderson, Rose and Henderson, 1992; Missiuna, 1994;

Rösblad & von Hofsten, 1994; Schellekens, Scholten & Kalverboer, 1983; Schoemaker

et al., 2001).

The PADL-Q specifically asks if fine and gross movements are performed

slowly because this indication of DCD can adversely affect family life. Parents have

reported higher levels of tension within the family during the busy morning routine,

altered expectations for siblings depending on whether or not they have DCD, and the

reduced capacity of their child with DCD to maintain pace in school (Chesson et al.,

1990; Chia, 1997; Fox & Lent, 1996; Gibson, 1996; Missiuna & Pollock, 1995;

Summers et al., 2007b).

To date, there is a paucity of quantitative analyses assessing specific ADL task

performance in children (Wagoner & Armstrong, 1928; Inomata & Simizu, 1991).

Furthermore, current researchers in the discipline acknowledge that the collection of

reliable childhood ADL data is problematic (Henderson & Barnett, 1998).

Using measurable items from the PADL-Q, the development of a set of Tests of

Activities of Daily Living (TADL) for this research project complements the

questionnaire and provides a means of quantifying ADL performance. As ADL skills

17

are culture-specific (Sugden, 2006), and the items in the PADL-Q have been identified

as being common ADL for Australian children, testing the validity of parents‟ reports

with identical items presented to the children as practical tasks will allow for a

comparison to be made between the parents‟ perceptions and the children‟s actual

abilities.

Extrapolating from the research showing children with DCD to be slower than

their typically developing peers when performing motor-tasks (e.g., Missiuna, 1994), it

is likely that the children with DCD will take longer than children without DCD to

complete the TADL tasks. This should result in an inverse relationship between the

TADL and PADL-Q as those children with low motor ability score lowly on the PADL-Q

and highly on the TADL tasks.

This proposed relationship may serve to be a novel method of validating the

PADL-Q and to ascertain if parental reports of children‟s ADL ability are a suitable

means to satisfy Criterion B of the DSM-IV-TR (2000). This in turn will allow for all

facets of the DSM-IV-TR criteria to be examined and provide a mechanism for the

complete diagnosis of DCD with respect to these criteria.

Summary

The aim of this study is to investigate the efficacy of the PADL-Q in quantifying

the level of interference in ADL performance used in the diagnosis of DCD, as per

Criterion B of the DSM-IV-TR (2000). The TADL tasks have been designed to validate

the parent reports and provide an indication of the ADL performance of children with

and without DCD. Together these two experiments attempt to bridge the gap between

the observations of parents and the actual ADL abilities of their children.

18

C h a p t e r 3 : M e t h o d

Introduction

To measure the PADL-Q for its ability to discern between children with and

without DCD, two groups of children were recruited and tested on a standardised motor

skill test (MAND, McCarron, 1982). Concurrently, each child’s parent filled in the

PADL-Q. To validate the parent-ratings of their child’s ADL performance, children

completed 7 Tests of Activities of Daily Living (TADL) tasks following the MAND.

This study was granted ethics approval (Appendix A) by the Human Research

Ethics Committee at the University of Western Australia (UWA), in accordance with the

guidelines of the [Australian] National Health and Medical Research Council.

Participants

Matched Children

DCD group. Recruitment for the DCD group was initiated through a university

based movement enrichment programme designed for children aged 5 to 10 years of

age who experience motor control problems. These children were originally referred to

the programme either by educational and health professionals or through word of

mouth. Participants in the DCD group were children and their parents who attended an

assessment appointment lasting 45 minutes. During the appointment each child

underwent a MAND assessment and performed the TADL tasks, detailed below. At, or

around the same time, each child’s parent filled in the PADL-Q.

The inclusion criteria for the DCD group required the child to be aged between

5 and 10 years and present with a Neuromuscular Developmental Index (NDI) score of

85 on the MAND. As the resulting MAND (NDI) score was calculated by the first

examiner a second examiner assessed the child performing the TADL tasks. Each

examiner was blind to the child’s performance and scores from the other assessment.

Tables 3.1 and 3.2 detail the mean age and NDI scores for the DCD boys and girls,

respectively.

Non-DCD group. The non-DCD (nDCD) children were recruited in two ways.

First, those children, and their parents, who had attended an assessment appointment

for the movement enrichment programme and had scored 91 on the MAND.

Second, children, and their parents, who were recruited by word of mouth who scored

91 on the MAND. The inclusion criteria for the non-DCD group were that the child

matched the gender of a child with DCD and was within the same MAND specified age

band on the day of testing. The MAND provides an age-adjusted motor skill

19

performance score according to one of two age bands in each year group from 3 to 18

years: between 0 and 5 months 30 days, or between 6 months and 11 months 30 days

of their last birthday. The testing procedure, for both the parents filling in the PADL-Q

and the non-DCD children performing the MAND and TADL tasks, was identical to the

DCD group. Tables 3.1 and 3.2 describe the age and NDI statistics of the non-DCD

boys and girls, respectively.

Unmatched Children

MAND Exclusion group. Children with an NDI score between 86 and 90 on the

MAND were excluded from the matched control group and labelled as ‘MAND

Exclusions’. This is similar to the ‘suspect DCD’ group categorised by Wilson and

colleagues (2000) when investigating the psychometric properties of the DCDQ. Data

from the MAND Exclusion group, for both the PADL-Q and TADL tasks, was used in

both the correlation and concurrent validity analyses (detailed below) to ascertain how

the PADL-Q performs with children who are borderline DCD. Table 3.3 shows the

mean age and NDI scores for children in this MAND Exclusion group.

Unmatched non-DCD group. Two non-DCD boys who could not be matched

with a DCD child (due to lack of available children) were labelled as ‘Unmatched non-

DCD’ (U-nDCD). Both boys had a motor ability score that was on the low side of

average and their PADL-Q and TADL task data were used in both the correlation and

concurrent validity analyses (detailed below) to investigate if the PADL-Q was

sufficiently sensitive to their ADL performance. Table 3.4 details the mean age and

NDI scores for the children in the Unmatched non-DCD group.

Exclusions

If a child had any other medical conditions, such as developmental delays,

autism or cerebral palsy, they were excluded in line with the definition of DCD in the

DSM-IV-TR (2000). The prevalence of a co-existing disorder, such as attention deficit

hyperactivity disorder, although undesirable, was not a basis for exclusion as DCD

rarely occurs in isolation (Dunford et al., 2004; Kaplan et al., 1998).

Final Sample

The final sample of participants comprised of 37 children: 8 DCD boys, and 8

age-matched nDCD (control) boys; 8 DCD girls, and 8 age-matched nDCD (control)

girls; 3 children who were borderline DCD (2 boys and 1 girl), and 2 unmatched non-

DCD boys.

20

Table 3.1: Age & NDI statistics of matched boys

DCD Boys nDCD Boys

n 8 8

Age

range 5yrs 7mths - 9yrs 9mths 5yrs 11mths - 9yrs 10mths

m 7yrs 8mths 7yrs 9mths

sd 15.27mths 15.41mths

ND

I

range 54 - 84 93 - 137

m 73.50 107.88

sd 12.06 15.75

Table 3.2: Age & NDI statistics of matched girls

DCD Girls nDCD Girls

n 8 8

Age

range 5yrs 6mths - 10yrs 9mths 5yrs 8mths - 10yrs 9mths

m 8yrs 9mths 8yrs 10mths

sd 22.26mths 22.41mths

ND

I

range 49 - 85 101 - 146

m 67.00 125.88

sd 13.01 14.48

Table 3.3: Age & NDI statistics of MAND Exclusion group

MAND Exclusion Boys MAND Exclusion Girl

n 2 1

Age

range 6yrs 2mths – 6yrs 3mths 7ys 7mths

m 6yrs 2mths n/a

sd 0.71mths n/a

ND

I

range 87 - 88 86

m 87.50 n/a

sd 0.71 n/a

Table 3.4: Age & NDI statistics of Unmatched non-DCD group

U-nDCD Boys U-nDCD Girls

n 2 -

Age

range 7yrs 3mths - 9yrs 4mths -

m 8yrs 4mths -

sd 17.68mths -

ND

I

range 97 - 98 -

m 97.50 -

sd 0.71 -

21

Instruments

McCarron Assessment of Neuromuscular Development

The MAND (McCarron, 1982) is a 10-item assessment of a child’s movement

skills; there are five tasks relating to fine motor skill and five tasks concerned with gross

motor skills. The items are presented as follows:-

- beads in a box, in the order of preferred then non-preferred hand;

- beads on a rod, eyes open and eyes closed trials;

- finger tapping, both preferred and non-preferred hand;

- nut and bolt, using a large and then a small size;

- rod slide, preferred and non-preferred hand;

- hand strength, preferred and non-preferred hand;

- finger-nose-finger, eyes open and eyes closed trials;

- jumping, standing broad jump landing on both feet;

- heel-toe walk, forwards and backwards along a line;

- standing on one foot, preferred and non-preferred foot with eyes open

and then repeated with eyes closed.

This procedure takes between 15 and 30 minutes. Higher scores indicate superior

motor control and a score ranging from 85 down to 40 signifies mild to severe DCD.

McCarron (1997) measured reliability using a test-retest correlation procedure and

found it to be very high. Moreover, the MAND has been validated for use with children

with and without DCD in Western Australia (Tan et al., 2001).

All children were assessed using the MAND (sample score sheet presented in

Appendix G) and this was administered by an experienced examiner, who was not

otherwise involved with this study. The study author was present during every child’s

MAND assessment and in the later stages of data collection administered the tasks,

but did not score any of the subjective items. Calculating the NDI score took several

minutes and was performed by the experienced examiner whilst the study author and

the child were completing the TADL tasks. Both the experienced examiner and the

study author were blinded to each other’s scores until all tests had been completed.

PADL-Q

Questions and sections. The PADL-Q (Dewey et al., 2004; Summers et al.,

2005) consists of 61 questions in three main sections, presented in Appendix E. The

first section, referred to as Activities of Daily Living (ADL), contains 45 statements

regarding a child’s performance in everyday tasks. The second section, Play

Preferences, requires parents to respond to 8 items related to how much their child

enjoys playing particular games or being engaged in certain leisure activities. The third

22

section, Movement Descriptions, comprises two parts of the same 4 items. Both parts,

one each for fine and gross motor skills, contain 4 words (‘coordinated’, ‘agile’

[gross]/’accurate’ [fine], ‘fluent’, and ‘slow’) and requires parents to rate their child’s

movements accordingly. There are additional open-ended questions between the Play

Preferences and Movement Descriptions sections regarding social groups/activities

and at the end of the questionnaire, 6 reference questions about the child such as

school year and hand preference. Only the items in the ADL, Play Preferences, and

Movement Descriptions sections of the questionnaire were used in the statistical

analyses.

Pilot testing. As this study was the first to trial the PADL-Q with Australian

parents, a pilot run was conducted on selected parents of children enrolled in the

movement enrichment programme. The purpose of the pilot testing was to ensure all

questions were clear and unambiguous. An interview was conducted on three

separate occasions with five mothers. In each case the mothers read the PADL-Q

aloud and answered verbally to questions relating to their child’s abilities. They were

encouraged to elaborate or seek clarification on any questions or language

ambiguities. It was demonstrated that the mothers understood each question as was

the intention of the PADL-Q designers and only minor revisions were made to the

formatting and layout of the questionnaire. This data was not used in the final analysis.

Administration. The PADL-Q pack contained an information sheet (Appendix

C), a consent form (Appendix D), the PADL-Q (Appendix E), and a reply-paid envelope

in which to return the consent form and PADL-Q. Parents either received the PADL-Q

pack in person or by mail with a cover letter (Appendix B) explaining why they had

been invited to participate. Parents signed the consent form and returned this with the

completed PADL-Q, either in person or by return-post. The study author verbally

checked with each parent completing the PADL-Q that they could respond to the items

without difficulty and all parents were offered the opportunity to email the study author if

they had any questions.

Scoring. Parents were asked to circle a number from 1 to 5 on an ascending

Likert scale that best described their child’s performance in each item. The ratings

ranged from 1 (not at all like my child) to 5 (a lot like my child) which were converted

into point scores. There was a further option of ‘not applicable’ (N/A), scored as zero, if

a parent felt the question was unsuitable for their child’s age. For example, bathing

unsupervised and attitudes to homework may not be appropriate for the youngest

children in the study. All except 6 items were worded in the positive sense; questions

3, 5, 30, 31, 57,and 61 were worded negatively. For these items, parents scored

conversely, that is where 1 indicated the child was independent in the task and 5

indicated the child could not complete this task; however this scoring was itself

23

reversed in order that a high score indicated competency.

Tests of Activities of Daily Living

TADL tasks. Seven measurable tasks were chosen from the ADL section of the

PADL-Q that represented typical ADL in the areas of dressing, mealtimes, and play.

These were: time to put on and take off a sock; time to do up 6 buttons on a shirt front;

time to button a shirt collar; time to tie a knot; time to tie a bow; time to pour water into

a cup up to a specified line; and distance walked in 30 seconds. The last task is a

modified version of the 30s walk test previously validated by Knutson, Schimmel and

Ruff (1999).

Pilot testing. The TADL tasks were piloted on six children. During this pilot

session the instructions for each task were formalised and a 30 second cut-off time

was adopted for all tasks except the sock task, to ensure children did not attempt tasks

indefinitely. This is in agreement with Gubbay (1975) who noted that children with

DCD who were unable to tie shoelaces the most difficult of the TADL tasks within

23 seconds could not complete the task within 60 seconds. Pilot testing data was not

used in the final analysis.

Administration. The 7 TADL tasks were performed following the MAND

assessment. A short break between the two assessments was implemented to

minimise fatigue effects. The TADL tasks were presented as follows (for detailed

instructions, please refer to Appendix F):-

- socks, putting on and taking off a sock in the fastest time

- shirt buttons, time to button up 6 shirt front buttons

- collar button, time to button up shirt collar button

- knot tying, time to tie two short-length ribbons into a knot

- knot/bow tying, time to tie two long-length ribbons in to a knot (for

children below 7 years of age) or bow (for children 7 years or older, as

recommended by Dunford et al., 2005)

- pouring, time to pour liquid from a 1 litre container into a beaker

- 30s walk test, based on Knutson et al. (1999).

The TADL tasks were usually completed within 10 minutes and concluded the child’s

testing session.

Scoring. The sock task score did not have a maximum time limit and scoring

was based on the total time taken. For all other tasks there was a maximum time limit

of 30 seconds. Each child received a time score and an indication of task completion,

however, only the time score was used in this analysis. All but one child managed to

do up at least one shirt button within the 30 seconds allocated for this task and to

differentiate this score from the others, an extra second was added to that child’s

24

score. No child who recorded a score of 30s for either the collar, knot, and/or bow

tasks managed to complete that task in the allotted time.

Data preparation. Each TADL item score was first converted to seconds per

task. For the collar task, the two tying tasks, and the pouring task this was simply the

length of time taken to complete the task up to a maximum of 30 seconds. For the

sock task, there was no time limit and the value was the length of time in which the

child completed the task. For the shirt buttons task and the 30s walk test (Knutson et

al., 1999) the number of buttons and distance walked in metres were divided into 30s

to obtain a unit measure of seconds per button and seconds per metre, respectively.

From this seconds per task format, z scores were calculated using Microsoft Excel,

please refer to Appendix H(a) for the procedure. The seven z scores were then

summed to create a total z score for each child (raw total z score data in Appendix I)

and this was used in the ANCOVA and correlation procedures, determined in SPSS.

Statistical Analyses

Data

Children had three types of scores: a MAND (NDI) score; a PADL-Q total score,

in addition to the individual section scores for ADL, Play Preferences, and Movement

Descriptions; and a TADL total z score. There were 4 DCD children, 2 boys and 2

girls, who did not complete the TADL tasks and so the data from their respective

matched control was not used when calculating group differences involving the TADL

task scores.

Each set of scores (MAND, PADL-Q total and subsection scores, and TADL)

was tested for normality using the one sample Kolmogorov-Smirnov test in SPSS. All

three were shown to be normally distributed (Appendix J) and justified the use of

parametric tests.

Analyses

Ascertaining Group Differences. It was predicted that children with DCD, as

identified by the MAND, would score lower on the PADL-Q questionnaire than children

without DCD, p < .05. To discover any group differences, an independent measures

multivariate analysis of covariance (MANCOVA) was performed using the presence of

DCD, as dictated by the MAND, and gender as the independent variables; the 3

individual PADL-Q section scores as the dependent variables; whilst controlling for

age. Each effect was followed up with a univariate analysis of variance (ANOVA),

using a Bonferroni correction (p < .05), and interaction effects graphed. Further, simple

main effects of the interaction were calculated to discover the exact nature of the

interaction. The sample was comprised of 32 children: 8 DCD boys and their matched

25

control and 8 DCD girls and their matched control.

It was hypothesised that children with DCD, as identified by the MAND, would

have a higher TADL total z score than children without DCD, p < .05. To search for

group differences, a two factor (Group x Gender) independent analysis of covariance

(ANCOVA) was performed using presence of DCD and gender, controlling for age (in

years). The sample was comprised of 24 children: 6 DCD boys and their matched

control, 6 DCD girls and their matched control.

Relationships between variables. It was predicted that there would be a strong

positive correlation between the MAND score and the PADL-Q total score in both

groups and to this end a Pearson r correlation was performed using all 37 participants:

16 DCD children and 21 non-DCD children.

To ascertain the shared variance between the PADL-Q and the TADL tasks a

Pearson r correlation was undertaken using the PADL-Q total score and the TADL total

z score. This included data from 33 children: 12 DCD and 21 non-DCD children.

Concurrent validity. An evaluation of the accuracy of the PADL-Q questionnaire

was performed, using Microsoft Excel. For the PADL-Q, DCD was indicated using a

cut-off point of a total or section average score of <2.5 (refer to Appendix I for the raw

PADL-Q scores). Using the formula shown in Appendix H(b), values of sensitivity,

specificity, and positive and negative predictive values were calculated using data from

all 37 participants. A variety of thresholds to indicate sufficient concurrent validity have

been used in previous studies comparing a new test for DCD with a standardised

measure. Riggen and colleagues (1990) selected an arbitrary 80% agreement

between the two tests and this was also used by Crawford and colleagues (2001).

Schoemaker and colleagues (2006) tested sensitivity, specificity, and positive

predictive values using 80%, 90%, and 70% agreement, respectively. In this study, the

Riggen et al. (1990) 80% agreement between the PADL-Q and MAND for all aspects of

concurrent validity is the standard by which the efficacy of the PADL-Q in identifying

children with DCD was measured. Moreover, the same calculations with the same

agreement level thresholds for concurrent validity were performed for the individual

PADL-Q sections to ascertain if sections in isolation were accurate in identifying DCD

in children (refer to Appendix I for the raw data).

26

C h a p t e r 4 : R e s u l t s

Introduction

The aim of this study was to ascertain if a parent-reported questionnaire (PADL-

Q) can quantify the level of interference in ADL performance in children and, in turn,

accurately categorise children as with or without DCD. The PADL-Q consisted of three

sub sections; ADL, Play Preferences, and Movement Descriptions, that differed in their

focus of questioning. The validity of the PADL-Q was addressed by measurement of

children’s ADL performance in the TADL tasks, which were a set of seven performance

tasks adopted from the ADL section of the PADL-Q. Four hypotheses addressed the

following themes: group differences on the PADL-Q; validity of the PADL-Q with the

MAND; validity of the PADL-Q with the TADL tasks. The result of each hypothesis test

is presented below with relevant data.

Group Differences on the PADL-Q

As predicted, the DCD group scored lower (187; average score = 3.1) on the

PADL-Q than the non-DCD group (244; average score = 4.0), as illustrated in Figure

4.1 (error bars represent 1sd). Table 4.1 displays the means and standard deviations

for the DCD and non-DCD groups, further classified by gender, for all three sections of

the PADL-Q. There was a significant difference (p < .001) between the DCD and non-

DCD groups for the total PADL-Q score and the ADL and Movement Description

subsections.

Figure 4.1: Group mean PADL-Q total scores

* significantly different from nDCD, p < .001

nDCDDCD

Presence of DCD

300

250

200

150

100

50

0

Mean

PA

DL

To

tal

27

Table 4.1: PADL-Q mean and standard deviation values for boys and girls with and without

DCD

PADL-Q Section

DCD nDCD

Boys Girls Total Boys Girls Total

ADL m 147.63 125.25 136.44 * 161.5 198 179.75

sd 15.08 25.16 23.13 33.45 31.27 36.52

Play preferences m 31.25 28.13 26.69 28.75 36.13 32.44

sd 6.18 5.72 5.98 6.92 2.95 6.40

Movement descriptions m 24.00 18.50 21.25 * 27.75 36.13 31.94

sd 6.85 6.02 6.85 6.56 4.49 6.94

Total score m 202.88 171.88 187.38 * 218.00 270.25 244.13

sd 24.82 31.65 31.80 41.13 34.25 47.18

* Significantly different from the nDCD group (p < .001)

A group by gender MANCOVA of the PADL-Q sections, which controlled for

age, found a statistically significant main effect for DCD: F(3,25) = 9.44, p < .001; Wilks’

lambda = 0.47; indicating a significant difference between the DCD and non-DCD

children. However, there was no statistically significant main effect for gender (F(3,25) =

0.50, p = .684; Wilks’ lambda = 0.94), but a statistically significant interaction between

DCD and gender: F(3,25) = 4.20, p = .015; Wilks’ lambda = 0.67 was found. This means

that the effect of DCD, as measured by the PADL-Q, was different for the boys than for

the girls.

To determine if the interaction was present for all PADL-Q subsections, the

MANCOVA was followed-up with univariate tests on the 3 subsections of the PADL-Q,

as shown in Table 4.2. The results indicated that the ADL and Movement Descriptions

sections distinguished between children to a greater extent than the Play Preferences

section, for both presence of DCD and the interaction between DCD and gender. The

interaction graphs, Figures 4.2 (a), (b), and (c) highlight the similarity in results of the

ADL and Movement Descriptions sections.

Further analyses investigating the simple main effects of the DCD and gender

interaction revealed an important finding regarding the sample: the PADL-Q did not

distinguish a significant difference between the DCD and non-DCD boys on any of the

subsections, as shown in Table 4.3.

28

Table 4.2: Follow-up ANOVA tests for PADL-Q section scores and DCD Group, Gender and

DCD*Gender interaction

PADL-Q Section Presence of DCD Gender DCD*Gender

F(1,27) p F(1,27) p F(1,27) p

ADL 22.57 < .001 .001 .980 10.43 .003

Play Preferences 1.85 .186 0.68 .418 6.72 .015

Movement Descriptions 24.13 < .001 0.30 .591 10.17 .004

Figure 4.2: Interaction graphs for DCD*Gender for (a) ADL score, (b) Play Preferences score,

and (c) Movement Descriptions score

Table 4.3: Simple main effect of presence of DCD on gender

PADL-Q Section Boys Girls

F(1,27) p F(1,27) p

ADL 1.16 .291 31.84 < .001

Play Preferences 0.76 .390 7.81 .009

Movement Descriptions 1.49 .233 32.81 < .001

Concurrent Validity of the PADL-Q with the MAND

Evaluation of the PADL-Q with regard to its ability to accurately identify children

100

120

140

160

180

200

Boys Girls

AD

L S

co

re

DCD

nDCD

15

20

25

30

35

40

Boys Girls

Mo

ve

me

nt

De

sc

rip

tio

ns

Sc

ore

DCD

nDCD

25

30

35

40

Boys Girls

Pla

y P

refe

ren

ce

s S

co

re

DCD

nDCD

29

with DCD was carried out by calculating the sensitivity (the number of the DCD group

correctly identified), specificity (the number of the non-DCD correctly identified) and

positive/negative predictive values. These calculations are described in Appendix H(b).

Table 4.4 shows that the specificity and positive predictive values were both

excellent; however, for this sample, the sensitivity and negative predictive values were

poor and moderate, respectively. The Play Preferences section failed to identify any of

the DCD group.

Table 4.4: Concurrent validity values for PADL-Q subsection and total scores at diagnostic cut-

off

PADL-Q section Sensitivity,

%

Specificity,

%

+ve predictive

value, %

-ve predictive

value, %

ADL 18 91 60 59

Play Preferences 0 95 0 56

Movement Descriptions 31 86 63 62

Total 19 100 100 62

Relationship Between the PADL-Q and the MAND

The PADL-Q total score and the MAND (NDI) score were found to be positively

correlated, r = .71, (Figure 4.3) and this relationship was statistically significant, p <

.001. The positive correlations between PADL-Q sections and the MAND (NDI) score

were also statistically significant: p < .001 for both the ADL and Movement Description

sections, and p = .028 for the Play Preferences section (Table 4.5).

A more informative measure for assessing a relationship between variables is

the coefficient of determination, r2, which provides an indication of the percentage of

shared variance between the scores of the PADL-Q and MAND (NDI). In Table 4.5 it

can be seen that the ADL and Movement Descriptions sections in isolation have the

same shared variance (50% and 49%, respectively) as the PADL-Q total score (50%).

Further support for the efficacy of the ADL and Movement Description sections is seen

in the correlation between these two sections as highlighted in Table 4.6.

30

Figure 4.3: Correlation between PADL-Q total score and MAND score

Table 4.5: Correlations between MAND and PADL-Q sections

PADL-Q Section Pearson r Significance, p % Shared variance (r2)

ADL .71 < .001 50

Play Preferences .32 .028 10

Movement Descriptions .70 < .001 49

Total .71 < .001 50

Table 4.6: Correlation between the PADL-Q sections

PADL-Q Sections Pearson r Significance, p % Shared variance (r2)

ADL & Play Preferences .59 < .001 35

ADL & Movement Descriptions .83 < .001 69

Play Preferences & Movement Descriptions .45 .005 20

Performance Times of Children on TADL Tasks

It was anticipated that children with DCD would perform the TADL tasks more

slowly and, thus, score higher on the TADL total z score (Figure 4.4; error bars

represent 1sd). For this sample, this hypothesis was confirmed: a two factor (Group x

Gender) ANCOVA, which controlled for the age difference between the boys and girls,

in the TADL items revealed a statistically significant effect for DCD (F(1,19) = 34.65, p <

.001). There was no significant effect for either gender (F(1,19) = 1.59, p = .223) or for

the interaction of DCD and gender (F(1,19) = 0.57, p = .462).

100

125

150

175

200

225

250

275

300

25 50 75 100 125 150

MAND NDI Score

PA

DL

-Q T

ota

l S

co

re

DCD

nDCD

MAND Exclusions

Unmatched nDCD

31

Figure 4.4: Group mean TADL total z scores

* significantly different to nDCD group, p < .001

Relationship Between the TADL and PADL-Q

For this sample, Figure 4.5 illustrates support for the hypothesis that children

with high PADL-Q scores will generally score lower on the TADL tasks (r = -0.64, p <

.001). Table 4.7 shows that all sections of the PADL-Q demonstrated statistically

significant inverse correlations with the TADL total z score and that both the ADL

section in isolation and the total PADL-Q score share the same variance (41%) with the

TADL total z score.

-10

-8

-6

-4

-2

0

2

4

6

8

10

125 150 175 200 225 250 275 300

PADL-Q Total Score

TA

DL

To

tal z

Sc

ore

DCD

nDCD

MAND Exclusions

Unmatched nDCD

Figure 4.5: Correlation between PADL-Q total score and TADL total z score

nDCDDCD

Presence of DCD

8.0

6.0

4.0

2.0

0.0

-2.0

-4.0

-6.0

-8.0

Mean

TA

DL

to

tal z s

co

re

32

Table 4.7: Correlations and corresponding significance for TADL total z score and PADL-Q

sections

PADL-Q Section Pearson r Significance, p % Shared variance (r2)

ADL -.64 < .001 41

Play Preferences -.31 .04 10

Movement Descriptions -.57 < .001 32

Total -.64 < .001 41

Summary

Overall, the children with DCD performed more poorly on the PADL-Q than the children

without DCD; however, the DCD and gender interaction was largely due to the superior

MAND scores of the non-DCD girls. Concurrent validity of the PADL-Q total score with

the MAND showed excellent specificity and positive predictive value; however, the

sensitivity and negative predictive values were not as high. The positive correlation

between the PADL-Q and the MAND indicated association between the standardised

motor skill construct and ADL performance. The significant difference in the TADL task

performances between the DCD and non-DCD groups, together with the significant

inverse relationship between the PADL-Q and TADL tasks, support parent ratings of

childhood ADL performance.

33

C h a p t e r 5 : T h e D i s c u s s i o n

Introduction

In response to the lack of guidelines for measuring Criterion B of the DSM-IV-

TR (2000), the recently developed Performance of Activities of Daily Living

questionnaire (PADL-Q) was tested for its ability to identify childhood DCD. It was

found to distinguish between the DCD and non-DCD groups. Further investigation of

the PADL-Q explored its efficacy as a diagnostic tool for DCD; with it reaching 100%

for both specificity and positive predictive values, but not exceeding the 80% threshold

for sensitivity or negative predictive values. There was a moderate relationship

between the MAND and the PADL-Q, indicating a shared motor ability construct

between measures of Criterion A and Criterion B of the DSM-IV-TR (2000).

Seven Tests of Activities of Daily Living (TADL) tasks were also administered to

the children to validate the parent-reported PADL-Q. There was a significant difference

between the performances of the DCD and non-DCD groups and a moderate inverse

correlation between the TADL tasks and the PADL-Q that indicated children with DCD

performed the TADL tasks more slowly than the children without DCD.

Major findings are now discussed individually with each section incorporating

relevant literature, implications for the present DCD diagnostic process, and

suggestions for future research. The PADL-Q subsections are also reviewed for their

efficacy in isolation and their contribution to the PADL-Q as a whole, with suggestions

for revision. Finally, the general implications of using the PADL-Q to assess ADL skill

in children are offered.

Using the PADL-Q to Identify Children with DCD

The hypothesis that the PADL-Q would identify between the DCD and non-DCD

children was partially supported. The PADL-Q total score did distinguish the two

groups of children, in agreement with previous work using ADL performance to identify

DCD (Rosenblum, 2006; Wilson et al., 2000). This demonstrates that the ADL items

identified by parents as important aspects for their child have potential for identifying

ADL performance (Summers et al., 2007a).

Closer examination of the PADL-Q sub-sections, however, revealed that all

three failed to distinguish the DCD and non-DCD boys as significantly different from

each other. This was a consequence of the convenience sample: half of the

participants in the non-DCD boys group (4/8) had been referred for motor skill testing

and scored at the lower end of the MAND average range. Furthermore, by chance, the

34

sample of participants in the non-DCD girls group was comprised mostly (7/8) of girls

who recorded high (>1sd above average) or very high (>2sd above average) MAND

scores. Nevertheless, the unrepresentative samples for both boy and girl control

groups and the lack of significance between the DCD and non-DCD boys has drawn

attention to the language used for the ratings.

The PADL-Q ratings were intended to be a reflection of ADL competence over

time, using a 5-point Likert scale: not at all like my child; a bit like my child; sometimes

like my child; mostly like my child; and a lot like my child. These ratings, however,

appear to have influenced parents into measuring ADL behaviour over time rather than

the intended measurement of ADL competence over time. For example, the rating of

sometimes like my child may have been chosen by some parents to indicate that their

child can complete the task but does not do it often (Summers, 2002); whilst other

parents may have used this rating to indicate that their child is experiencing the

variability in task success that accompanies the learning of a new skill (Case-Smith,

1995; Thelan, 1995).

The ambiguity in the language is reflected in the lack of significance between

the scores for the two groups of boys: the PADL-Q average item score was 3.3 for the

DCD boys and 3.6 for the non-DCD boys. Ill-defined rating responses may have

caused an additional difficulty for parents of children with DCD as they tried to rate the

heterogeneity of movement ability that often accompanies the condition (Gibson, 1996;

Kaplan et al., 1998; Maeland, 1992; Sugden & Sugden, 1991). The data suggest that

parents over-reported their child’s ADL performance when rating how often their child

behaves in response to the questions.

Over-reporting on the PADL-Q refers to parents who rated their child as more

competent than their measured skills actually suggested and is demonstrated by a low

sensitivity value. Sensitivity refers to the ability of the PADL-Q to identify as DCD those

children who were measured as DCD by the MAND. The sensitivity value for the

PADL-Q was 19%, meaning that it failed to identify 81% (13/16) of the children who

had been assessed as having DCD by the MAND.

In such cases, parents may have erroneously reported the level of effort

required by their child to complete ADL tasks or parents may have allowed extended

amounts of time in which the task was completed. The low sensitivity sustains the

argument that the PADL-Q measured ADL behaviour, not ADL competence. If it had

measured ADL competence it would be expected that a higher number of the children

with poor motor skill would have been identified by the parent reports because

functional tests highlight movement difficulties to a greater extent than tests of simple

motor skill (Rodger et al., 2003; Wilson et al., 2003). Instead, as the PADL-Q

measured ADL behaviour in this sample, the opposite occurred: children with DCD

35

were more likely to be misclassified as non-DCD.

The low sensitivity was not solely attributed to the inability of the PADL-Q to

distinguish between the boys; it still only identified 2 of the 8 DCD girls. It appears that

the ADL behaviour ratings were unsuitable even between the DCD and non-DCD girls

who were polar opposites in their performance on the MAND.

Previous researchers have reported difficulties using perceived performance of

aspects of ADL to correctly identify children with DCD. Schoemaker and colleagues

(2006) investigated the sensitivity of the DCDQ with the MABC and found 82%

sensitivity in the combined clinic/control sample; yet in the same study using a

population based sample, the sensitivity was only 29%. These authors surmised that

mild cases of childhood DCD were more likely to be missed by parents in the general

population.

The inability of the PADL-Q to identify differences between the boys with and

without DCD, as a result of the semantics of the rating responses, was an unavoidable

issue as the PADL-Q used in this study deliberately remained identical to one currently

being used for a similar cohort in Canada. A more appropriate measure of the level of

interference in ADL necessary to satisfy Criterion B of the DSM-IV-TR (2000) would be

a rating scale that indicated a child’s progress in learning ADL skills. Suggestions for a

similar ascending Likert scale would be: (a) 0 = not applicable for child’s age; (b) 1 =

early stages of learning task; (c) 2 = becoming competent; (d) 3 = generally competent;

and (e) 4 = proficient. This scale may be easier for parents to respond to as they

would rate their child’s progress in skill competence in absolute terms, not relative to

the child’s peers.

Future research investigating the efficacy of the PADL-Q, with the suggested

ratings of a child’s progress in learning ADL skills, will need a cross-sectional

experimental design at 6-month intervals (as per the MAND, McCarron, 1982) to

capture the ages at which typically developing children become competent in ADL.

This data can then be compared to that from children with DCD, using the same

hypothesis that children with DCD would not be as proficient as their peers.

Conversely, under-reporting on the PADL-Q refers to parents who rated their

child as less competent than their measured skills actually suggested. When using the

PADL-Q to identify DCD, under-reporting would be indicated by low specificity between

the MAND and the PADL-Q. Low specificity occurs when children who do not have

DCD are misclassified as having DCD. This may be the result of parents completing

ADL tasks on their child’s behalf, such as tying shoelaces to ensure they are tight

enough (Burgman, 1998; Case-Smith, 1995). Low specificity was not observed in this

sample. To the contrary, the 100% specificity demonstrated that all of the non-DCD

children were correctly identified by the PADL-Q as being non-DCD.

36

High specificity values have been observed in similar studies and in those, the

researchers used this value to screen out those children who were not experiencing

ADL performance problems (Crawford et al., 2001; Rosenblum, 2006; Schoemaker et

al., 2006; Wilson et al., 2000). Both the DCDQ (Wilson et al., 2000) and the ChAS-P

(Rosenblum, 2006) used rating scales that encouraged detection of non-DCD children,

rather than identification of those children who do have DCD. The DCDQ asks parents

to rate from the same options as the PADL-Q: not at all like your child, a bit like your

child, moderately like your child, quite a bit like your child, and extremely like your child

(Wilson et al., 2000). The ChAS-P (Rosenblum, 2006) uses a different ascending 5

point Likert scale: less adequately, adequately, almost well, well, very well; however,

although these are competence based ratings there is only one item that captures poor

movement ability. This may bias the results against measuring poor ADL performance

and, as such, the ChAS-P appears more likely to identify children as being well

coordinated because there are more options to describe ability than there are to

describe inability.

The similar levels of specificity, indicating those children who do not have DCD,

between this and previous studies of childhood ADL performance suggests that such

measures are unable to accurately identify the children who do have DCD. Research

assessing ADL motor skill is still in its infancy and appears more difficult to measure

than the literature suggests (e.g., Rodger et al., 2003; Wilson et al., 2003). Further

studies investigating the strategy and movement quality of common ADL tasks in

typically developing children would provide a benchmark against which developmental

motor problems can be compared.

Relationship Between the MAND (Criterion A test) and the PADL-Q (Criterion B

test)

Although the concurrent validity between the MAND and the PADL-Q was

mixed, there was a significant relationship between the respective measures of

Criterion A and Criterion B of the DSM-IV-TR (2000). The 50% shared variance

provides evidence that poor motor ability, as measured on a standardised test,

pervades into the ADL performance of children with DCD and vice versa. It may be

that ADL skills are a subset of a larger motor ability construct, similar to Burton &

Rogerson’s (2001) General Motor Ability (GMA) theory, and deficiencies at the GMA

level are similarly present at the functional level.

Previous studies investigating ADL skill have each used a different

standardised test with which to compare the parent-reported assessment and

consequently there have been varying levels of association between the motor skill and

ADL skill assessment. The ChAS-P (Rosenblum, 2006) was found to share 26%

37

variance with the MABC. The DCDQ (Wilson et al., 2000) has been found to share

35% and 22% variance with the MABC (Schoemaker et al., 2006; Wilson et al, 2000);

an average of 38% across the four factors of the BOTMP (Wilson et al., 2000); and

62% variance with the MAND (Boyle, 2003). In comparison, these results show the

PADL-Q and MAND to share a more similar underlying motor ability construct than that

observed in previous research; however, this is likely because the PADL-Q is the most

comprehensive of all the ADL assessments. The ChAS-P (Rosenblum, 2006) and the

DCDQ (Wilson et al., 2000) contain 27 and 17 items, respectively, whereas this version

of the PADL-Q is comprised of 61 items. The range of levels of association (22-62%)

highlights the difficulty in adequately measuring ADL performance in children.

As yet unknown, the nature of the relationship between parent-reported ADL

performance and standardised motor tests needs to be elucidated in future childhood

motor skill research. Such work could include a complete task analysis of the items

within the PADL-Q and, using scores from children with DCD, a comparison between

specific PADL-Q items and corresponding items on a standardised test.

There was 50% unexplained variance between the MAND and PADL-Q; this is

demonstrative of how multiple sources of information can be divergent in their

assessment of a child’s skill (Dewey et al., 2003; Glascoe, 2000; Glascoe & Dworkin,

1995). There are 3 factors that explain the disparity between the MAND and the

PADL-Q:

First, although it would be expected that interference in ADL skills will naturally

correspond to skills measured as poor on the MAND, it is possible that ADL

interference may not be in accordance with the specific low motor ability assessed by

the MAND. The relationship between the MAND and the PADL-Q may be confounded

by the well-known heterogeneous movement profile that often accompanies DCD

(Davis, 1984; Dawdy, 1981; Gibson, 1996; Kaplan et al., 1998; Maeland, 1992).

Second, parent-reported perceptions of function and standardised tests differ in

their administration, environment in which the assessment is performed, and methods

of judging motor ability (Case-Smith, 1995). For example, the MAND is testing the

child, who is given item instructions and an allocated length of time for each task. The

instructions must be followed correctly and completed in a once-only test, which is a

common feature of measures of Criterion A (Crawford et al., 2001). The PADL-Q, in

contrast, is based on parent observations over time, which is the preferred method of

assessing motor ability (Larkin & Cermak, 2002). Observations made over time allow

for more understanding that tasks may be performed in a number of different ways yet

result in the same outcome, as described by Newell (1986).

Finally, a proportion of the unexplained variance may be due to the measuring

instruments for Criterion A and Criterion B assessing at different levels of analysis: the

38

MAND is testing for simple skills, whilst the PADL-Q is evaluating complex skills.

Wilson and colleagues (2003) stated that identifying DCD is more likely when task

complexity increases; it is inevitable that the MAND and PADL-Q offer two opinions of

the child’s motor skills as they observe movement ability at two different levels of

complexity. Schoemaker and colleagues (2006) made a similar conclusion that, when

compared to each other, the MABC (standardised test) and the DCDQ (parent report)

were not assessing the same motor ability construct.

It appears that the ADL motor ability construct is more abstruse than existing

standardised tests are currently able to measure (Wilson et al., 2000). This does not

dispute the validity of standardised tests, rather, it highlights that there is no one test of

motor skill that can adequately cover the full range of human motor ability (Davis, 1984;

Dawdy, 1981; Geuze et al., 2001; Henderson & Barnett, 1998). The implications for

the identification of DCD in children with regard to the DSM-IV-TR (2000) suggest that

the guidelines be re-interpreted to formally incorporate multiple sources of information.

The DSM-IV-TR (2000) states that a complete diagnosis of DCD is given only

when all four criteria are satisfied. At present, however, there is an over-reliance on

addressing Criterion A for a diagnosis of DCD with little attention given to addressing

Criterion B (Geuze et al., 2001). Although tests for Criterion A are a suitably rigorous

method of DCD diagnosis, it is not in keeping with the DSM-IV-TR (2000) guidelines.

Low motor ability fulfils the criteria for part of the diagnosis and the remaining criteria

each add to the child’s profile, until it can be determined if the complete diagnosis is

warranted. For equal weight to be attributed to each of the DSM-IV-TR (2000) criteria,

it would be necessary to reduce the dependency on the measurement for Criterion A.

Consequently, cut-off points indicating DCD for Criterion A tests would be less stringent

as stand-alone measurements; however, the requirements of the DSM-IV-TR (2000)

indicate that a similar level of inability is recorded for the other 3 criteria. Therefore,

although each criterion is easier to satisfy in isolation, all four criteria scores must be in

the DCD range for the complete diagnosis. Wilson and colleagues (2000) justified a

similar approach when identifying DCD in children on the basis that it aided in

addressing the heterogeneity of movement ability displayed by such children.

Validation of the PADL-Q using the TADL Tasks

Changing the way the DSM-IV-TR (2000) criteria is interpreted to formally

include a measure of Criterion B will not be possible until childhood ADL skills have

been investigated in a large sample of typically developing children. The TADL tasks

were designed as a validation tool for the PADL-Q and supported the hypothesis that

children with DCD would score higher (be slower) performing the tasks than children

without DCD. There was no gender difference in the TADL total z score after the effect

39

of age had been removed. This was necessary because there was an age difference

of 18 months between the mean age of the boys and girls in the subset of children that

completed the TADL tasks. The TADL task data supports the earlier observation that

the PADL-Q measured parent perceptions of their child’s ADL behaviour and suggest

that parents reported their child’s ADL performance according to expectations of skill

level.

It appears that parents of girls assumed that their daughter should have better

fine motor control than boys of the same age. The effect size calculations of the

differences between the DCD and non-DCD girls show two curious findings. First,

parents of daughters with DCD rated their child more critically (under-reported) on the

ADL section of the PADL-Q (on which the TADL tasks were based) than the TADL

performance indicated. Second, the effect size difference between the DCD and non-

DCD girls on the MAND was double that for the effect size in the TADL task

performance. This means that the ADL performance difference between the DCD and

non-DCD girls is not as obvious during complex motor tasks (TADL) as during simple

motor tasks (MAND).

This finding is counter-intuitive to the fact that complex tasks are more likely to

expose movement difficulties (Roger et al., 2003; Wilson et al., 2003). Although it is

not known why this occurred, it concurs with the low sensitivity of the PADL-Q data. It

suggests that childhood ADL performance is complex and influenced by factors beyond

poor motor ability such as task experience, parental attitudes, family routines, and

personal characteristics of the child (Burgman, 1998; Case-Smith, 1995, 1996;

Chapparo & Hooper, 2002; Geuze, 2005). Further research into childhood ADL skill

that includes detailed family routines is necessary in order that the determinants of

adequate ADL performance can be identified. This may also aid intervention strategies

as correct models of ADL competence can be adopted by families to encourage

improved ADL performance in a child with DCD.

In contrast, the effect size differences between the DCD and non-DCD boys

alludes to the fact that parents of boys with DCD may have subscribed to the myth of

boys typically being more gross-motor inclined. In comparison to the TADL task

performance data, parents of the boys with DCD were more lenient when rating their

sons’ ADL performance. Confirmation that ADL performance of the DCD boys was

lower than parents reported is evidenced by the effect size difference between the

DCD and non-DCD boys, for which the MAND fine motor component was 1.5 times

greater than that on the TADL tasks.

Similar to the girls’ data, it is unknown why there is less performance difference

exhibited in the complex skills (TADL tasks) than in the simple skills (MAND). It is also

unknown why parents rated their child’s performance on the PADL-Q differently to that

40

measured on the TADL. To counteract this effect, a subset of parents should be

interviewed in an effort to assess if parents do report in relation to gender stereotypes.

As predicted, there was an inverse relationship between the PADL-Q and

TADL tasks. The 41% shared variance reflects that the TADL tasks were quantifiable

items from the ADL section of the PADL-Q. It provides support for directly measuring

ADL performance in children with well-chosen tasks that are easily administered. The

lack of previous research investigating childhood ADL skill is an impediment to full

analysis of the TADL task results because, as yet, no reliable normative data exists to

which they can be compared (Henderson & Barnett, 1998).

Another difficulty in using the TADL task results with which to compare the

parent responses is that the TADL tasks contained only a small subset of the items

addressed in the PADL-Q. This contributed to the 59% of unexplained variance

between the PADL-Q and the TADL tasks and suggests two points regarding testing

for ADL.

First, the TADL tasks comprised six fine motor tasks and one gross motor task

and, hence, the TADL total z score is biased to represent a measure of fine motor

ability. Those children with DCD who experienced problems with fine motor skill would

have been disadvantaged in comparison to children with DCD with gross motor

difficulties. The PADL-Q contains a more equal ratio of fine and gross motor skills and

also rates children using personal and household items that are familiar. This is in

agreement with Chesson and colleagues (1990), who stated that parents felt their

children performed best in the home environment.

The second reason for the unexplained variance is the difference in

assessment. The PADL-Q is a subjective measure based on observations over time,

whereas the TADL tasks are performed in a once-only assessment environment.

Whilst the latter was a situation in which children performed free of distractions (Dewey

et al., 2003), they may still have experienced test anxiety (Goshi et al., 2000). The

children were told that they were being timed for each task and may have attempted to

complete a task faster than they would do so normally. For example, during the bow

tying task it was observed that some children appeared to rush this task and in doing

so did not complete the bow on the first attempt. This test anxiety may have adversely

affected the performance times of all children during the TADL tasks.

The difficulty in selecting tasks that represent a child’s typical ADL is similar to

the problem of there being no one test of motor skill that can adequately cover the full

range of human motor ability (Davis, 1984; Dawdy, 1981; Geuze et al., 2001;

Henderson & Barnett, 1998). It adds further support to the use of multiple sources of

information during the DCD diagnosis process (Dunford et al., 2004; Pless et al., 2001;

Rodger et al., 2003; Zittel, 1994). It is recommended that the DSM-IV-TR (2000)

41

criteria are satisfied by using a comprehensive profile of the child’s motor skill

performance, with each criterion sharing equal importance. Improving these guidelines

will assist researchers and clinicians when diagnosing children with DCD. It was

suggested in the Leeds Consensus Statement (Sugden, 2006, p. 26) that “Criterion A

should be about motor impairment in a general sense, with Criterion B providing a

functional elaboration”. Using such an approach may also identify specific strengths

and weaknesses of a child’s motor skill ability and help to individualise treatment

programmes.

Suggestions for the Next Version of the PADL-Q

The TADL tasks were intended to validate parental measures of ADL

performance; however, this data drew attention to the paucity of research examining

childhood ADL skill. This point has been repeated over the years as the lack of specific

guidelines for Criterion B hampers the standardisation of the DCD diagnostic process

(Dunford et al., 2004; Geuze et al., 2001; Henderson & Barnett, 1998; Sugden, 2006;

Watkinson et al., 2001). The PADL-Q has been developed in response to the lack of

guidelines to satisfy Criterion B and, therefore, is recommended to be used alongside

standardised tests, to assist clinicians and researchers when assessing a child’s

movement profile. However, it does require revision for the next version. Each

subsection is now reviewed for its ability in isolation and its role in relation to the other

subsections that form the whole PADL-Q.

The items in the ADL section were those previously identified by parents as

difficult to perform by children with DCD (Summers et al., 2007a). The ADL subsection

shared the greatest variance (50%) with the MAND (McCarron, 1982) when compared

to the other sections. This is because of all the PADL-Q items, those in the ADL

section were most similar to the MAND items. For example, the items referring to how

well a child can manipulate buttons/fasteners, shoelaces, eating utensils, and scissors

(PADL-Q questions 3, 5, 16-20 & 26, and 34, respectively, refer to Appendix E) are

akin to the beads on a rod, and nut & bolt items in the MAND; all require bilateral fine

motor control. The relationship between the ADL section and the MAND is as strong

as that between the PADL-Q total score and the MAND, confirming that the ADL items

form an integral part of the whole questionnaire.

The ADL section alone does omit one important item regarding motor skill

performance of children with DCD: speed of movement. An item referring to a child’s

movement skill speed is included in the Movement Descriptions section of the PADL-Q

because of the anecdotal evidence from parents that their child with DCD was slow

during ADL performance (Chia, 1997; Chesson et al., 1990; Gibson, 1996; Summers,

2002). This is in addition to previous research that has reported speed differences

42

between children with and without DCD when undertaking motor-perception tasks

(Hellgren et al., 1993; Henderson et al., 1992; Missiuna, 1994; Rösblad & von Hofsten,

1994; Schellekens et al., 1983; Schoemaker et al., 2001).

In the Movement Descriptions section, parents rated their child’s fine and gross

motor skills with reference to four descriptive words: coordinated, agile [fine] or

accurate [gross], fluent and slow. Although parents often sought clarification from the

researcher for the meaning of these words, it was evident their understanding was

adequate: as the Movement Descriptions section identified 2 extra children with DCD

than the PADL-Q total score. This demonstrates that the Movement Descriptions

section in isolation was more sensitive than the entire questionnaire.

Movement Descriptions shared 49% variance with the MAND, which is similar

to the PADL-Q total score shared variance and indicates a congruence between

general parent observations of their child’s movement and the standardised motor

ability test score. This shared variance may be due to two reasons. First, the

descriptive words are broad in their meaning and each encompass many items tested

in the MAND. For example, the word coordinated refers to the child’s ability to achieve

a task goal through the successful use of their body (Magill, 2004) and is the basis of

every item in the MAND. Second, the order of the PADL-Q items; the first two sections

may have cultivated an ability to think about movements in an analytical manner.

Before answering the final section, parents had rated their child 45 times in the ADL

section and a further 8 times regarding enjoyment of play activities. Having responded

to specific instances of movement ability, it is speculated that it may have been easier

for parents to then think about their child in a more general manner. The relationship

between the Movement Descriptions ratings and children’s motor ability suggests that

parents can be as accurate as trained movement observers when rating their child’s

ADL performance. Using parents to rate their child’s movement ability would negate

the costly practise of using only qualified assessors to measure childhood ADL ability,

as was done by Watkinson and colleagues (2001).

The 51% unexplained variance between the Movement Descriptions section

and the MAND may be due to the subjective nature of the questions and the difficulty of

choosing one response to represent a variety of activities. For example, some parents

noted that their child was good at one type of fine/gross motor activity but not in

another. This is a reflection of the heterogeneity in movement ability that indicates

DCD in children (Kaplan et al., 1998).

It is important to capture the heterogeneous nature of movement ability

exhibited by children with DCD and it appears that, individually, the Movement

Descriptions and ADL sections offer parents the variety of items necessary to do so.

Considering the PADL-Q in its entirety, both these sections are relevant to measure the

43

ADL interference necessary to satisfy Criterion B of the DSM-IV-TR (2000).

The relevance of the Play Preferences section to the PADL-Q, however, is

debatable because not only did it did fail to detect differences between the DCD boys

and non-DCD boys, it also failed to identify any of the DCD children when tested for

sensitivity. It was included in this version of the PADL-Q because, according to the

underlying occupational therapy theory used to develop the PADL-Q, play is defined as

an ADL for children (Chapparo & Ranka, 1997). This section contained a set of

questions that were worded differently to the ADL and Movement Descriptions

sections. Rather than asking parents to rate the performance ability of their child, it

required only an indication of the child’s enjoyment levels when participating in certain

activities, such as role playing games or on playground equipment. Scores for Play

Preferences, then, were parent perceptions of a child’s apparent enjoyment of

activities.

Enjoyment of activities is not comparable to any of the items in the MAND and

this was reflected in the lack of shared variance, only 10%, between the Play

Preferences section and the MAND. The low shared variance reveals two points

observed by Summers (2002). First, parents may be reporting the activities their child

does enjoy whilst engaged in the task, but that the task itself may not be undertaken on

a regular basis. Second, it may reflect pursuits that parents encourage their child with

DCD to follow regardless of their skill level, in the knowledge that it is ultimately

beneficial for improving motor ability.

Both of these points are supported by two mothers who participated in the pilot

study. The mothers commented that this section did not allow them to rate their child’s

ability in the activity and whilst their respective sons did enjoy these sorts of games,

they were not necessarily competent in them. The equivocal results for the children

with DCD make it difficult to compare results with previous studies that have shown

children with DCD to shy away from activity, in particular playground equipment and

organised sport (Bouffard et al., 1996; Cairney et al., 2005; Watkinson et al., 2001).

The Play Preferences section reported only 35% and 20% explained variance

with the ADL and Movement Descriptions sections, respectively. The shared variance

with the ADL section is likely because all of the items in the Play Preferences section

are repetitions of items already rated in the first section, with four of the questions

similarly worded. The fact that the ADL and Movement Descriptions sections shared

69% variance suggests that the Play Preferences is measuring something other than

motor skills; for example, social behaviour or peer group interests. These findings

suggest that the Play Preferences may not be a suitable method in the PADL-Q of

identifying ADL interference as required by the DSM-IV-TR (2000) guidelines.

Removal of the Play Preferences section, for being incongruent with the other

44

sections, may seem premature prior to a full content validity test being undertaken on a

large sample. Such an analysis would include an internal reliability test (e.g.,

Cronbach’s alpha that measures internal consistency) and items can be removed with

the statistical knowledge that they are either redundant or irrelevant. A Cronbach’s

alpha was not calculated for the PADL-Q in this study because the sample was

considered too small for a robust analysis.

General Implications

The implications of this study are based on the projected use of the PADL-Q

after further research has been carried out to refine its content and assess its efficacy

in a larger sample. The PADL-Q has shown promise as a measure of Criterion B of the

DSM-IV-TR (2000) and if it can accurately rate ADL performance it could be

administered to all parents during their child’s first year at school. In this way it acts as

a screening tool to assess if a child requires further testing for Criterion A and, if

necessary, form part of the full diagnosis for DCD that was described earlier. The ease

of administering and calculating the section and total scores of the PADL-Q negates

the use of trained movement observers that have previously been necessary to identify

children with DCD (Bouffard et al., 1996; Thompson et al., 1994; Watkinson et al.,

2001). This is advantageous if the PADL-Q is used for a larger population because

children can be evaluated for their ADL ability with minimum time and resources costs.

Early diagnosis and, hence, an early start to treatment, has been shown to give the

most favourable outcome for children with DCD (Schoemaker & Kalverboer, 1994;

Skinner & Piek, 2001).

Summary

The PADL-Q did identify differences between the groups of children with and

without DCD, although its efficacy may have been diminished by the semantics of the

rating scale. Despite limitations with the sample of control boys and girls, the PADL-Q

correlated well with the MAND. This relationship between a parent-reported

questionnaire of ADL and a standardised test of motor skill supports previous research

in this area (Rosenblum, 2006; Wilson et al., 2000). Parent ratings were generally

supported by the TADL task results; however the lack of age-appropriate ADL

movement performance data for typically developing children precluded meaningful

interpretation for the children with DCD.

It is suggested that the PADL-Q be re-structured before further testing on a

larger sample, at which point it may offer a possible solution to the problem of there

being no formal measure of Criterion B of the DSM-IV-TR (2000). Research into

childhood ADL is evolving and should now address the concern of established

45

researchers who have bemoaned the lack of data for typically developing children to

which data from children with DCD can be compared (Geuze et al, 2001; Henderson &

Barnett, 1998).

46

C h a p t e r 6 : C o n c l u s i o n s

Problem Summary

The DSM-IV-TR (2000) guidelines referring to the level of interference in

childhood ADL necessary for a diagnosis of DCD are vague and unsubstantiated with

normative data (Henderson & Barnett, 1998). This study continued research by Dewey

and colleagues (2004) investigating the development of the PADL-Q with parents

responding to items regarding their child’s abilities in everyday tasks.

Major Findings Support All Hypotheses

The four hypotheses intended to determine the efficacy of the PADL-Q in

identifying children with DCD and quantify their performance in ADL.

1. Children with DCD will score lower on the PADL-Q, p < .05

The PADL-Q total scores for the DCD and non-DCD groups were significantly

different and children with DCD scored lower than those without DCD. The ADL and

Movement Descriptions sections in isolation were as discriminative as the PADL-Q

total score. However, it was also found that neither the PADL-Q total score nor the

individual sub-sections distinguished between the DCD and non-DCD boys in this

sample. There are a number of possible reasons for this including the type of language

used to rate the PADL-Q items and suggestions for a new scale were provided.

Further investigation with a large sample of children with and without DCD is necessary

because the difficulties experienced with the small convenience sample in this study

precluded full interpretation of all the factors that may be involved with parents rating

their child’s ADL proficiency.

2. The PADL-Q will display sufficient concurrent validity with the MAND

Using a diagnostic cut-off point, the PADL-Q exceeded the 80% threshold for

specificity and positive predictive values, showing that it identified those children who

did not have DCD. This was not matched by the sensitivity and negative predictive

values, which were poor. These results are similar to previous literature in this area

and comment was made regarding the difficulties of assessing childhood ADL

performance in the absence of normative data.

3. The PADL-Q scores will be positively correlated with the MAND scores, p < .05

The PADL-Q total and section scores were positively correlated with the MAND.

47

This indicates that the PADL-Q shares a similar motor control construct as the MAND.

There was a similar relationship between the MAND and both the ADL and Movement

Descriptions sub-sections, highlighting that parent reports of their child’s development

have merit in the DCD diagnostic process. In light of the differences between

assessing simple and complex motor skills as per the DSM-IV-TR (2000) guidelines, it

was advocated that the criteria be re-interpreted to give equal weight to each criterion.

4. The TADL task data will support parent ratings of ADL performance

The children with DCD performed significantly slower on the TADL tasks than

their non-DCD peers; however, not to the same extent as measured by the PADL-Q. It

appears that parents may be reporting to gender expectations of ADL skill level. The

inverse correlation between the TADL total z score and the PADL-Q score generally

supported the parental reports of the children’s ADL performance in the home;

however, further research examining childhood ADL performance is required.

Significance of Findings

This research supports previous literature in using parent reporting ADL

performance as a measure of DCD in children (Boyle, 2003; Rosenblum, 2006; Wilson

et al., 2000). Previously lacking from Criterion B of the DSM-IV-TR (2000), the PADL-

Q has offered a set of detailed guidelines that can be further refined in order to quantify

ADL skill in children aged 5-10 years.

Future Research

These findings provoke progression in this area of DCD research. One

direction is to trial a re-structured PADL-Q in primary schools, or as part of the existing

Raine Study in the Perth metropolitan area, using a cross-sectional design to answer

two important questions arising from this study. First, what is the average ADL ability

of the different age groups? Second, are there significant differences in the ADL

performance between genders in both the DCD and non-DCD groups? From such a

study the PADL-Q could be further refined and eventually used to gather ADL

performance data for boys and girls in all age groups from 5-10 years.

48

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58

Appendix A: Ethics Clearance Letter

60

Appendix B: Sample Invitation Letter to Parents

School of Human Movement and Exercise Science

The University of Western Australia

35 Stirling Highway, Crawley, WA 6009

Phone 08 6488 2361

Fax 08 6488 1039

Kerry Smith

Phone: +618 6488 2474

Email ksmith@cyllene.uwa.edu.au

9 June 2008

Dear Mr and Mrs «SURNAME»,

I would like to invite you to participate in a research study looking at performance of activities of daily living in

children. Please find enclosed an information sheet, a consent form, the Performance of Activities of Daily

Living questionnaire (PADL) and a reply-paid envelope.

You have been selected because you and «FIRST_NAME» recently attended an appointment in regards to

enrolling in the UniGym programme here at the School of Human Movement. As researchers, we are interested

in children of all motor abilities and your involvement in UniGym is not relevant to this study. This means that if

«FIRST_NAME» is enrolled in the Unigym program your access to, and tuition received in, Unigym will be

unaffected regardless of your contribution to this study. If you choose to take part and then later withdraw, the

same applies, your participation in UniGym will not be affected.

Once you have read the information sheet and had any questions answered, our details are on all the enclosed

documents, you may choose whether or not to participate. If you do choose to participate, all that we require is

that you sign the consent form and fill in the PADL questionnaire. The PADL questionnaire contains a series of

statements that you are asked to think about and rate your child according to the scale indicated in the

instructions. From past experience, this usually takes about 15 minutes and you can post the PADL and

consent form back to us in the pre-paid envelope provided. The consent form allows us to use the information

you provided at the UniGym interview and also the scores «FIRST_NAME» received in his motor ability

assessment. At all times you and your child remain anonymous and only identified by a number.

If you have any questions, do not hesitate to call and please accept our thanks in advance for your help.

Yours faithfully,

Kerry Smith (Mrs)

UniGym Coordinator

62

Appendix C: Information Sheet for Parents

School of Human Movement and Exercise Science

The University of Western Australia

35 Stirling Highway, Crawley, WA 6009

Phone 08 6488 2361

Fax 08 6488 1039

Dr Dawne Larkin

Phone: 08 6488 3842

Email dlarkin@cyllene.uwa.edu.au

INFORMATION SHEET:

Investigation of a New Screening Questionnaire for Children with Developmental Coordination Disorder

The purpose of this study is to validate a new questionnaire, called the Performance of Activities of Daily Living

(PADL), which has been developed for use with children aged between 5 and 10 years of age. The PADL

questionnaire was designed through interviews with parents and we are looking to test whether it can correctly

identify children with movement difficulties such as developmental coordination disorder (DCD). To do this we

need the participation of children, 5 to 10 years of age with a wide range of motor ability, as well as one of their

parents.

There are three parts to this investigation. The first involves you, the parent, filling in the PADL questionnaire by

answering statements regarding your child’s abilities to perform everyday tasks; this will take about 15 minutes.

In addition, your child will do a motor performance test involving 10 items, as well as 5 tasks that represent

activities of daily living. These motor tasks are presented as a series of fun activities for your child to complete.

Overall your child’s motor assessment session is not expected to exceed 40 minutes and the demands on your

child is considered to be equal to 40 minutes of light physical play. Experienced assessors at the University of

Western Australia will conduct the motor assessments.

There are deemed to be no risks for you or your child during any part of your and your child’s involvement. The

motor performance test has been used with children in Western Australia for over 15 years without any adverse

consequences. The tasks of daily living, such as pouring a drink and buttoning a shirt, are encountered during

the course of a normal day. The only inconvenience is that you are required to attend an appointment at the

University of Western Australia, but this will be arranged at a mutually convenient time.

You have been invited to participate because your child is in the required age range and is representative of the

wide range of motor abilities in children. Data from you and your child remain anonymous at all stages of the

investigation and are only identified by a number. The data is kept securely in the School of Human Movement

and Exercise Science and only accessed by the researchers concerned with the study. In the event that your

child is participating in the Unigym program, her/his movement assessment will be kept securely in a Unigym file

and used to assist his/her teacher in the development of an individual movement program. Furthermore, your

choice of whether or not to participate in this investigation will in no way affect your access to, or the quality of,

the Unigym program offered to your child.

This study of the PADL will be compared to a database already collected in Canada and the results will be used

to improve the questionnaire. The only direct benefit from the movement assessment of your child, is that we

will be able to give you an indication of the motor ability of your child. There is no direct benefit to you from filling

in the PADL Questionnaire. However, your help in developing the PADL is invaluable in the search to find more

efficient ways of identifying children with DCD. If the PADL accurately identifies DCD, then its use at school

entry would provide an effective method of screening for the condition, prompting further in-depth testing if

necessary and leading to appropriate support.

Completion of the PADL questionnaire is considered evidence of your consent to participate in the study. In

addition, you will need to sign a consent form on behalf of your child. You and/or your child are free to withdraw

consent to further participation without prejudice in any way. You need give no reason or justification for such a

decision and any data relating to you will be destroyed, unless otherwise agreed by you. If your child is

participating in the Unigym program their treatment remains unaffected at all times, regardless of your

participation in, or subsequent withdrawal, from this study. Your participation in this study does not prejudice

any right to compensation, which you may have under statute or common law.

If you have any questions, at any time, please ask! We endeavour to provide you with as much help and

assistance as you are giving to us during this study.

65

Appendix D: Consent Form

C/JobShare/Manderson/Reference

School of Human Movement and Exercise Science

The University of Western Australia

35 Stirling Highway, Crawley, WA 6009

Phone 08 6488 2361

Fax 08 6488 1039

Dr Dawne Larkin

Phone: 08 6488 3842

Email dlarkin@cyllene.uwa.edu.au

CONSENT FORM:

Investigation of a New Screening Questionnaire for Children with Developmental Coordination Disorder

I have read the information provided and any questions I have asked have been answered to my satisfaction. I

agree to allow my child to participate in this activity, realising that I, or my child, may withdraw at any time

without reason and without prejudice.

I understand that all information provided is treated as strictly confidential and will not be released by the

investigator unless required to by law. I have been advised as to what data is being collected, what the

purpose is, and what will be done with the data upon completion of the research.

I agree that research data gathered for the study may be published provided my name or my child’s name or

other identifying information is not used.

_______________________ ______________

Parent/Guardian Signature Date

_______________________

Parent/Guardian Name (printed)

The Human Research Ethics Committee at the University of Western Australia requires that all participants are informed that, if they have

any complaint regarding the manner, in which a research project is conducted, it may be given to the researcher or, alternatively to the

Secretary, Human Research Ethics Committee, Registrar’s Office, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009

(telephone number 6488-3703). All study participants will be provided with a copy of the Information Sheet and Consent Form for their

personal records.

67

Appendix E: PADL-Q

A Parent Completed Questionnaire:

Performance of Activities of Daily Living for Children Aged 5-10 years

Thank you for participating in this research study; the information you provide is helping to

test a new screening method to identify children with developmental coordination disorder.

You and your child remain anonymous throughout this study and your contribution to this

questionnaire will be kept confidential at all times

I.D. Number:

Performance of Activities of Daily Living Questionnaire: For Children Aged 5-10 years

Please read the following statements and indicate by circling the number on the scale below how well it

represents your child’s ability or behaviour: - 1 = Not at all like my child

- 2 = A bit like my child

- 3 = Sometimes this is like my child

- 4 = Mostly like my child

- 5 = A lot like my child

- N/A = not applicable for my child’s age

My Child:

1 Gets ready for school without prompts or reminders 1 2 3 4 5 N/A

2 Is energetic at the end of the school day 1 2 3 4 5 N/A

3 Requires physical assistance with clothing and fastenings 1 2 3 4 5 N/A

4 Has good standing balance when placing feet through underwear, pants or skirt

1 2 3 4 5 N/A

5 Has difficulty with tying shoelaces 1 2 3 4 5 N/A

6 Cleans his/her teeth with minimal supervision 1 2 3 4 5 N/A

7 Is proficient at cutting his/her finger and toe nails 1 2 3 4 5 N/A

8 Is independent in personal care (e.g., toileting, grooming) 1 2 3 4 5 N/A

9 Bathes without supervision 1 2 3 4 5 N/A

10 Washes all body parts without assistance 1 2 3 4 5 N/A

11 Washes and rinses his/her hair effectively 1 2 3 4 5 N/A

12 Dries his/her body without assistance 1 2 3 4 5 N/A

13 Towel dries hair without assistance 1 2 3 4 5 N/A

14 Is always dry at night 1 2 3 4 5 N/A

15 Can pour a drink from a 1 litre container without spilling 1 2 3 4 5 N/A

16 Holds required eating utensils in an appropriate grasp 1 2 3 4 5 N/A

17 Uses a spoon and fork together efficiently 1 2 3 4 5 N/A

18 Uses a spoon or fork without spilling food 1 2 3 4 5 N/A

19 Successfully cuts soft foods using a knife and fork 1 2 3 4 5 N/A

20 Successfully cuts tough foods (cooked meat) using a knife and fork 1 2 3 4 5 N/A

Not

at

all

like

A b

it lik

e

Som

etim

es lik

e

Mo

stly lik

e

A lot

like

Not

applic

able

21 Spreads food onto bread or a cracker efficiently 1 2 3 4 5 N/A

22 Maintains an acceptable sitting posture 1 2 3 4 5 N/A

23 Correctly aligns him/herself in front of the plate 1 2 3 4 5 N/A

24 Does not spill or knock things over 1 2 3 4 5 N/A

25 Tidies his/her room and puts away toys 1 2 3 4 5 N/A

26 Is able to cut up and peel some fruit/vegetables safely 1 2 3 4 5 N/A

27 Does his/her homework on time with very little prompting 1 2 3 4 5 N/A

28 Requires minimal assistance to complete homework 1 2 3 4 5 N/A

29 Enjoys active play (indoor or outdoor) 1 2 3 4 5 N/A

30 Prefers sedentary indoor play (seated/stationary activities) 1 2 3 4 5 N/A

31 Prefers to play alone 1 2 3 4 5 N/A

32 Plays mainly with friends of similar age 1 2 3 4 5 N/A

33 Is able to maintain friendships 1 2 3 4 5 N/A

34 Is proficient at using scissors to cut out shapes and pictures 1 2 3 4 5 N/A

35 Can colour pictures neatly and stays within the lines of the drawing 1 2 3 4 5 N/A

36 Can write neatly for his/her age 1 2 3 4 5 N/A

37 Is competent at using all playground equipment 1 2 3 4 5 N/A

38 Is competent riding a bicycle (without training wheels) 1 2 3 4 5 N/A

39 Has the speed, agility and/or endurance of his/her age-mates 1 2 3 4 5 N/A

40 Has ball skills similar to age-mates 1 2 3 4 5 N/A

41 Can kick a ball with accurate force and direction 1 2 3 4 5 N/A

42 Can catch a tennis ball with both hands away from the body 1 2 3 4 5 N/A

43 Can throw a basketball with accurate force and direction 1 2 3 4 5 N/A

44 Can hit a ball moving through the air or along the ground with similar accuracy as age-mates

1 2 3 4 5 N/A

45 Is a competent swimmer for his/her age 1 2 3 4 5 N/A

Not

at

all

like

A b

it lik

e

Som

etim

es lik

e

Mo

stly lik

e

A lot

like

Not

applic

able

My Child enjoys playing:

46 With groups of children (T-Ball, soccer, hockey) 1 2 3 4 5 N/A

47 Running, chasing, climbing games 1 2 3 4 5 N/A

48 Imaginary games and characters - martial arts/fairy princesses, outdoor explorer

1 2 3 4 5 N/A

49 On playground equipment: swings, monkey bars, flying fox 1 2 3 4 5 N/A

50 On wheels: bicycle, scooter, skate board, roller blades or skates 1 2 3 4 5 N/A

51 Computer type games 1 2 3 4 5 N/A

52 Creative construction using material and tools such as cardboard boxes, sticky tape, scissors, Lego, Meccano

1 2 3 4 5 N/A

53 Drawing, colouring 1 2 3 4 5 N/A

Other outdoor or indoor activities your child enjoys, please elaborate:

Are there any reasons that affect your child’s ability to participate in physical activity play or sport?

What organised activities does your child attend after school and weekends? (For example, sport, club,

education, music and creative pursuits)

Not

at all

like

A b

it lik

e

Som

etim

es lik

e

Mo

stly lik

e

A lot

like

Not

applic

able

Thank you for completing this questionnaire!

When using whole body movement such as running, jumping, climbing, swimming, I would describe my

child’s movement as:

54 Coordinated 1 2 3 4 5 N/A

55 Agile 1 2 3 4 5 N/A

56 Fluent 1 2 3 4 5 N/A

57 Slow 1 2 3 4 5 N/A

When using movement that requires fine control with the eyes and hands such as sewing, drawing,

manipulating, I would describe my child’s movement as:

58 Coordinated 1 2 3 4 5 N/A

59 Accurate 1 2 3 4 5 N/A

60 Fluent 1 2 3 4 5 N/A

61 Slow 1 2 3 4 5 N/A

Please provide the following information about your child:

Age: ___ years Date of Birth: ____/_____/_____ Gender: male female

(day/month/year)

School Grade/Year: ______

Handedness: right left mixed

Was your child born prematurely? no yes - number of weeks _____

Has your child a diagnosed medical condition that affects his/her performance of daily activities?

no yes - what is the name of the condition? ___________________________________

Is your child taking any medication?

no yes – what is the name of the medication? __________________________________

73

Appendix F: TADL Task Instructions

Task 1: Socks

The child was asked to sit on a bench and remove one of their shoes and

socks. A clean sock, of either a small or large size appropriate for the child, was given

with the instruction

I‟d like you to start with your hands on your knees and when I say “go” I‟d like

you to reach down and put on the sock just like you normally would. Make sure

the toes and heel are in the right place and then take it off again. I‟m going to

see how long it takes you. Do you know what you have to do?

If necessary the instruction was repeated; the task did not begin until positive

affirmation was given by the child to the last question. Encouragement was given

throughout the task and all children were prompted to pull the sock from the toes

because both sizes were a tight fit. Scoring for this task was the time taken in seconds.

Task 2: Shirt Buttons

Before starting this task, the study author helped each child into a large size

school shirt (for age 16 boys) and commented that the shirt was meant to be too big in

order to fit over their clothes. This was done to allay any fears of the task seeming

more difficult because the shirt was not the same size as the child. The instructions

given were

This is the button I‟d like you to start on, please [pointing to the second button

from the top]. Have a feel of it so you know where it is. OK, now I‟d like you to

start with your hands by your side and then when I say “go” I‟d like you to start

at this button [pointing to second button] and do up as many buttons as you can

in 30 seconds [simultaneously pointing to the remaining buttons down the shirt].

I‟m going to see how many buttons you can do up in 30 seconds. Do you know

what you have to do?

The task started when the child was clear on what they had to do. Encouragement

was given throughout the task, either until the child had completed all six buttons or the

30s cut-off time was reached. The number of buttons completed within the time limit

was recorded.

74

Task 3: Collar Button

The child remained standing in the shirt and was given another 30s in which to

do up the collar button. As before, there was a familiarity instruction with this task

Now I‟d like you to have a go at the collar button, please [pointing to the collar

button]. Have a feel of it so you know where it is. It‟s a tricky one so see how

you go. OK, now I‟d like you to start with your hands by your side and then

when I say “go” I‟d like you to try to button up this collar button and I‟m going to

see how long it takes you. It is the most difficult button, so just try your best.

Do you know what you have to do/OK?

Encouragement was given throughout the task and if the child nearly had the

button through the hole but subsequently lost it, they were instructed to have another

go. This procedure repeated until the button was successfully done up or time ran out.

The score was the length of time to complete the collar task, up to a maximum of 30s,

and a yes/no indication of task success.

Task 4: Knot Tying

The child was presented with a gift-wrapped shoe box placed at an appropriate

table height. The box was decorated with two ribbons, arranged perpendicularly to

each other, each securely fastened around three sides of the box but loose on the top.

The first was a shorter length to be tied into a knot and the other was longer, to be tied

into either a knot or a bow, depending on the child‟s age. During conversation, before

this task, it was known whether the child was able to tie their own laces.

For the knot task a demonstration was provided whilst the following instructions

were given “I‟d like you to tie a knot, just like I‟m doing here. Can you see what I‟m

doing?”. It was ensured that the child was clear that the task only required a knot to be

tied. Then the instructions “OK, I‟d like you to start with your hands by your side please

and when I say „go‟, I‟m going to see how long it takes you to tie a knot”. For all

children the middle of the first movement of the knot was held by the examiner because

the ribbon used did not have the same friction coefficient as normal shoelaces.

Encouragement was given throughout the task and timing stopped when the child had

successfully tied a knot or when the 30s mark had passed.

Task 5: Knot/Bow Tying

If the child was aged 5 or 6 years they were asked to repeat the knot tying task

with the longer ribbons. The same instructions as before were given whilst I

75

demonstrated tying a knot with the long ribbons. Timing stopped when the child had

successfully tied the knot or the 30s time limit was reached.

Children aged 7 years and over were expected to tie a bow (Dunford et al.,

2005) but if they were unable to do so were asked to try their best. The instructions

given during the demonstration of how to tie the bow were

I‟d like you tie a bow, just like I‟m doing here. Can you see what I‟m doing?

[check child‟s comprehension of the task requirements] OK, I‟d like you to start

with your hands by your side please and when I say “go”, I‟d like you to tie a

bow and I‟m going to see how long it takes you.

It had been noted that most of the children in the pilot study had been taught to tie

shoelaces using the „two bunny ears‟ method. This was different to the (single loop)

method favoured by the study author. As this task was being demonstrated, it was

made clear to each child undertaking the bow task that either method was acceptable

and, in some cases, the investigator showed the child that she was not very good at

the bunny ear method in order to alleviate any fears of being unable to complete the

task. Timing stopped when the child had successfully tied a bow or 30s had passed.

Task 6: Pouring

The child was asked to pour liquid from an open 1 litre container up to a line in

a beaker as quickly as possible. The container and beaker were in designated

positions on a placemat on a table in front of the child at an appropriate height,

adjusted for right or left handed children. All children received the instructions

OK, I‟m just going to take the top off for you because it‟s a tricky tight fit. Then

I‟d like you to start with your hands by your side and when I say “go”, I‟d like you

to pick up the bottle, you can use both hands if you like, and pour the liquid into

the cup up to the line [pointing to the line] then replace the bottle back on its

spot. I‟m going to see how long that takes. OK/Do you know what you‟ve got to

do?

Encouragement was given throughout the task and the number of seconds to complete

this task was recorded.

Task 7: Walk

This test measures the distance a child can walk in 30s, adapted from Knutson

and colleagues (1999). The child started at a designated corner point on a green line

along the gym floor, measuring 22m in length and 18m in width. All children were

76

given the instructions

Come and stand on this corner, please [pointing to the spot at which two green

lines met at 90º]. Can you see the green line? It runs all the way down this

side [pointing along the green line to the end of the gym] even though it breaks

in the middle, it continues to the end of the gym and then it goes all the way

along that side [pointing along the green line to the opposite corner] and back

up that side [still following the line with pointed finger] and back along to here.

I‟m going to see how far along this green line you can walk in 30s. So I‟d like

you to walk as fast as possible please, but no running. If you start running I‟ll

make you start again! OK? So fast walking only. Are you ready?

The examiner walked beside the child and encouraged each child to walk as

fast as they could without running. All children were prompted to make left hand turns

at the far end of the line. The task ended at 30s and the distance the child walked in

this time was measured with the Craftech Measuring Wheel (measuring distance

9999m and tolerance 0.2%m). The distance was measured from the start point to

the child‟s heel. This distance was regardless of the number of steps required to stop,

as this was considered to be a reflection of the child‟s walking speed.

77

Appendix G: MAND Sample Score Sheet

80

Appendix H: Formulae Used for Calculations

(a) TADL z Scores

The z score standardises each score in relation to the group and is calculated

using the mean and standard deviation of the group. The formula used in Microsoft

Excel is:

Where:- Z = standardised score X = mean

= score

= standard deviation

The individual task scores were then summed to create the final TADL z score total, as

shown in Appendix J. A TADL total z score of zero is considered average.

(b) Concurrent Validity of PADL-Q

Using Microsoft Excel, an evaluation of the accuracy of the PADL-Q

questionnaire was performed. Using the formula shown in Figure H.1, values of

sensitivity, specificity and positive and negative predictive values were calculated using

data from all 37 participants. DCD was indicated using a cut-off score of a total or

section average of <2.5 and the agreement value between the MAND and the PADL-Q

was set at ≥ 80% (Riggen et al., 1990). Raw data is presented in Appendix I.

MAND (McCarron, 1982)

DCD nDCD n Equation

PA

DL-Q

DCD a b a+b +ve Predictive Value )( ba

a

nDCD c d c+d -ve Predictive Value )( dc

d

n a+c b+d Total

Equation Sensitivity

)( ca

a

Specificity

)( db

d

Figure H1: Questionnaire validation calculations (Portney & Watkins, 1993, p. 80)

81

Appendix I: Raw Data

82

Subject ID MAND Age

Band (years) MAND Fine Motor Score

MAND Gross Motor

Score

MAND NDI

Score

PADL-Q ADL

Score

PADL-Q Play Pref.

Score

PADL-Q Move. Descr.

Score PADL-Q

Total Score TADL total

z score

DCD

Boy 1 4 9.5 30 46 81 153 30 23 206 -

2 29 6.0 16 49 73 155 35 28 218 3.878

3 33 8.0 39 29 75 146 37 33 216 5.165

4 35 5.5 39 40 83 140 23 26 189 7.803

5 38 7.5 38 42 84 156 34 24 214 4.182

6 42 8.5 17 21 54 165 40 24 229 -0.602

7 46 8.0 14 27 56 115 25 9 149 5.749

8 61 7.0 45 32 82 151 26 25 202 -

Total N 8 8 8 8 8 8 8 8 8 6

Mean - 7.50 29.75 35.75 73.50 147.63 31.25 24.00 202.88 4.36

sd - 1.31 12.37 9.94 12.06 15.08 6.18 6.85 24.82 2.80

Girl 1 9 9.0 23 18 56 110 23 26 159 -1.138

2 13 10.5 23 26 62 90 20 11 121 -

3 22 8.5 32 32 72 170 33 24 227 4.509

4 24 10.0 15 26 56 123 23 19 165 -1.220

5 27 10.0 13 16 49 107 33 11 151 4.575

6 39 9.0 39 34 79 150 34 13 197 -3.497

7 40 6.0 45 36 85 127 33 22 182 3.893

8 60 5.5 35 35 77 125 26 22 173 -

Total N 8 8 8 8 8 8 8 8 8 6

Mean - 8.56 28.13 27.88 67.00 125.25 28.13 18.50 171.88 1.19

sd - 1.86 11.46 7.72 13.01 25.16 5.72 6.02 31.65 3.55

Total N 16 16 16 16 16 16 16 16 16 12

Mean - 8.03 28.94 31.81 70.25 136.44 29.69 21.25 187.38 2.77

sd - 1.65 11.55 9.51 12.57 23.13 5.97 6.85 31.80 3.47

83

Table I.2: Raw Data for non-DCD children

Subject

ID MAND Age

Band (years) MAND Fine Motor Score

MAND Gross Motor Score

MAND NDI

Score

PADL-Q ADL

Score

PADL-Q Play Pref.

Score

PADL-Q Move. Descr.

Score

PADL-Q Total Score

TADL total z score

nDCD Boy 1 10 7.0 57 35 94 158 29 26 213 -

2 34 8.5 45 46 93 117 17 25 159 -2.442

3 45 5.5 56 36 94 142 24 24 190 5.382

4 48 6.0 54 53 106 119 26 20 165 1.315

5 51 7.5 70 70 137 171 26 24 221 -3.285

6 52 9.5 65 61 123 192 35 28 255 -

7 57 8.0 53 51 103 206 36 40 282 -3.581

8 59 8.0 55 60 113 187 37 35 259 -1.249

Total N 8 8 8 8 8 8 8 8 8 6

Mean - 7.50 56.88 51.50 107.88 161.50 28.75 27.75 218.00 -0.64

sd - 1.31 7.62 12.25 15.75 33.45 6.92 6.56 45.13 3.45

Girl 1 26 9.0 60 63 121 223 35 40 298 -4.667

2 32 6.0 74 68 138 173 33 38 244 -1.351

3 36 8.5 63 54 115 201 40 31 272 -4.609

4 47 5.5 59 42 101 131 38 28 197 -

5 53 10.0 70 63 130 221 37 40 298 -7.832

6 54 9.0 77 62 136 214 37 36 287 -5.367

7 56 10.0 80 71 146 210 31 40 281 -7.876

8 58 10.5 62 60 120 211 38 36 285 -

Total N 8 8 8 8 8 8 8 8 8 6

Mean - 8.56 68.13 60.38 125.88 198.00 36.13 36.13 270.25 -5.28

sd - 1.86 8.20 8.99 14.48 31.27 2.95 4.49 34.25 2.43

Total N 16 16 16 16 16 16 16 16 16 12

Mean - 8.03 62.50 55.94 116.88 179.75 32.44 31.94 244.13 -2.96

sd - 1.65 9.61 11.35 17.32 36.52 6.40 6.94 47.18 3.74

84

Table I.3: Raw Data for Unmatched non-DCD children and MAND Exclusion Children

Subject ID MAND Age

Band (years) MAND Fine Motor Score

MAND Gross Motor Score

MAND NDI

Score

PADL-Q ADL

Score

PADL-Q Play Pref.

Score

PADL-Q Move. Descr. Score

PADL-Q Total Score

TADL total z score

Unmatched nDCD

Boy 1 31 7.0 56 41 98 152 29 28 209 1.40

2 50 9.0 50 46 97 111 37 19 167 -4.37

Total N 2 2 2 2 2 2 2 2 2 2

Mean - 8.00 53.00 43.50 97.50 131.50 33.00 23.50 188.00 -1.48

sd - 1.41 4.24 3.54 .71 28.99 5.66 6.36 29.70 4.08

Total N 2 2 2 2 2 2 2 2 2 2

Mean - 8.00 53.00 43.50 97.50 131.50 33.00 23.50 188.00 -1.48

Sd - 1.41 4.24 3.54 .71 28.99 5.66 6.36 29.70 4.08

Exc because MAND of 86-90

Girl 1 28 7.5 42 40 86 176 33 32 241 .51

Total N 1 1 1 1 1 1 1 1 1 1

Mean - 7.50 42.00 40.00 86.00 176.00 33.00 32.00 241.00 .51

sd - . . . . . . . . .

Boy 1 41 6.0 47 38 88 105 31 18 154 5.89

2 43 6.0 48 36 87 142 31 17 190 9.28

Total N 2 2 2 2 2 2 2 2 2 2

Mean - 6.00 47.50 37.00 87.50 123.50 31.00 17.50 172.00 7.59

sd - .00 .71 1.41 .71 26.16 .00 .71 25.46 2.40

Total N 3 3 3 3 3 3 3 3 3 3

Mean 37.33 6.50 45.67 38.00 87.00 141.00 31.67 22.33 195.00 5.23

sd 8.145 .866 3.22 2.00 1.00 35.51 1.16 8.39 43.72 4.43

85

Appendix J: Test Statistics

One Sample Kolmogorov-Smirnov Tests

(a) MAND Sample Distribution

One-Sample Kolmogorov-Smirnov Test

37

93.24

26.045

.093

.093

-.064

.567

.904

N

Mean

Std. Deviation

Normal Parametersa,b

Absolute

Positive

Negative

Most Extreme

Dif f erences

Kolmogorov -Smirnov Z

Asy mp. Sig. (2-tailed)

MAND NDI

Score

Test distribution is Normal.a.

Calculated f rom data.b.

(b) PADL-Q Subsection and Total Sample Distribution

One-Sample Kolmogorov-Smirnov Test

37 37 37 37

155.27 31.22 26.08 212.57

36.666 5.898 8.473 47.574

.092 .159 .113 .087

.092 .109 .113 .078

-.083 -.159 -.079 -.087

.559 .969 .688 .529

.913 .304 .731 .942

N

Mean

Std. Deviation

Normal Parametersa,b

Absolute

Positive

Negative

Most Extreme

Dif f erences

Kolmogorov -Smirnov Z

Asy mp. Sig. (2-tailed)

PADL S1

Score

PADL S2

Score

PADL S3

Score PADL Total

Test distribution is Normal.a.

Calculated f rom data.b.

(c) TADL Sample Distribution

One-Sample Kolmogorov-Smirnov Test

33

.00000

4.755530

.126

.088

-.126

.723

.672

N

Mean

Std. Dev iation

Normal Parametersa,b

Absolute

Positive

Negative

Most Extreme

Dif f erences

Kolmogorov -Smirnov Z

Asy mp. Sig. (2-tailed)

TADL total

z score

Test distribution is Normal.a.

Calculated f rom data.b.