Contents. Movement Assessment Battery for children. Identification of Developmental Coordination Disorder. What is new? Extension of age range

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1 Identification of Developmental Coordination Disorder Marina Schoemaker University Medical Centre Groningen Centre for Human Movement Sciences Groningen Contents 1. Movement ABC-2 2. Early signs of DCD 3. Identification of DCD at school age 4. Relationship between different measuring instruments 5. Conclusion 10/21/ Revision of the Movement Assessment Battery for children Marina Schoemaker University Medical Centre Groningen Centre of Human Movement Sciences Groningen Movement Assessment Battery for children MABC-1 (1992) Henderson & Sugden MABC-2 (2007) Henderson, Sugden & Barnett 10/21/ Necessity for MABC-2 revision Norm data 15 years old (US data) Ambiguity in instructions Expansion of age range > 3-16 years Reduction of Age bands 4 -> 3 More comparable tasks per section task specificity Scores that can be used for research standard scores Hygiene plastic instead of wood What is new? Extension of age range 2nd edition of the Test of Movement ABC also includes 3-year-old-children! 3 and 4 year old children have norms per 6 months (not per year)

2 What is new? Reduction of age bands Age band 1 4,5,6 years Age band 2 7,8 years Age band 3 9,10 years Age band 4 11,12 years Primary uses of Movement- ABC2 10/21/ Identification Clinical exploration and intervention planning Treatment evaluation Research (select participants for experimental studies) Age band 1 3,4,5,6 years Age band 2 7,8,9,10 years Age band years Standardization sample 10/21/ Changes in scoring system (1) MABC-1: Per item: raw scores converted in score between 1 and 5. Total score: Summation of 8 item scores (0-40) Percentile ranks for different total scores Changes in scoring system (2) Standardscores Raw score Converted to Standard score (mean 10, sd 3) Total test score(tts) Sum of standard Scores converted to Standard scores Percentiles

3 Changes in scoring system 10/21/ /21/ Traffic light system: Manual Dexterity1 Manual Dexterity 2 Manual Dexterity 3 A&C: Catching A&C: Aiming Static Balance Dynamic Balance 1 Dynamic Balance 2 Age Band years Age Band years Age Band years Posting coins Placing Pegs Turning pegs Threading beads Bicycle Trail I Catching bean bag Throwing bean bag into box One-leg balance Jumping in squares Walking heels raised Threading Lace Bicycle Trail II Two-hand catch Throwing bean bag into mat One-board balance Hopping in squares Heel-to-toe walking Triangle with nuts and bolts Bicycle Trail III One-hand catch Throwing at wall target Two-board balance Zig-zag hopping Walking backwards 15 What is new? Age band 1 Material instructions different Tasks different 1. posting coins in a bank box (each hand), 2. threading beads; 3. drawing a line into a trail; different trail 4. catching a bean bag 5. throwing bean bag onto mat 6. standing on one leg ; 7. walking heels raised on a line 8. jumping on mats. Bicycle trails: age bands 1 and 2 10/21/ What is new? Material instructions different Tasks different 1. posting coins in a bank box (each hand), 2. threading beads; 3. drawing a line into a trail; different trail 4. catching a bean bag 5. throwing bean bag onto mat 6. standing on one leg ; 7. walking heels raised on a line 8. jumping on mats.

4 Throwing bean bag 10/21/ What is new? Material instructions different Tasks different 1. posting coins in a bank box (each hand), 2. threading beads; 3. drawing a line into a trail; different trail 4. catching a bean bag 5. throwing bean bag onto mat 6. standing on one leg ; 7. walking heels raised on a line 8. jumping on mats. What is new? Age band 2 Bicycle trail Throwing bean bag onto mat What is new? Age band 3 Turning pegs Triangle with nuts and bolts Bicycle Trail III One-hand catch Throwing at wall target Two-board balance Zig-zag hopping Walking backwards What is new? Age band 3 Turning pegs Triangle with nuts and bolts Bicycle Trail III One-hand catch Throwing at wall target Two-board balance Zig-zag hopping Walking backwards What is new? Age band 3 Turning pegs Triangle with nuts and bolts Bicycle Trail III One-hand catch Throwing at wall target Two-board balance Zig-zag hopping Walking backwards

5 What is new? Age band 3 Turning pegs Triangle with nuts and bolts Bicycle Trail III One-hand catch Throwing at wall target Two-board balance Zig-zag hopping Walking backwards Norms 2010: Dutch standardization of MABC-2 Dutch norms deviate from UK norms!! standardization in Norway is recommended. Why is early identification important? 10/21/2010 Decreased Physical fitness Less social Participation Decreased self-esteem 10/21/ At risk for co-morbidity 1. Early recognition of DCD 28 DCD is often not diagnosed until the age of 5 or 6. Reason: before that age, motor development can be rather variable. Little is known about possible risk factors! Early recognition of DCD is important Early Intervention Variability in motor development 102 typically developing children at 23 months Also measured at 9,11, 13,16 and 21 months Frequency of scores below the 16 th percentile Gross motor signs of DCD in the pre-school child: red flags 10/21/ Gross motor skills Fine motor skills 1 x 2 x 3 x 4 x 5 x Darrah et al., (2003) Early Human Development, 72(2), Delayed motor mile stones Falls often Difficulty jumping or skipping Dislikes climbing (anxious) Late riding tricycle; Cannot ride bicycle Fatigues easily

6 10/21/ Fine motor signs of DCD in the pre-school child Little interest in construction play Difficulty manipulating small objects (LEGO, puzzles) Difficulty using utensil (pencil, scissors) Difficulty with bimanual activities (doing up buttons, cutting) Instruments for 3-5 year old children Early Years Movement Skill (3-5 years) 23 items Limited information about reliability and validity MABC2 (2007): ageband 1: 3-5 years 10/21/ Recently developed questionnaire: Little DCD-Q 3-5 years of age 10/21/ items To be filled out by parents Cross cultural study (Canada, Israel, Brasil, Belgium, England, Germany, The Netherlands) Reliability and validity Proposed motor function assessment: prenatal period to age 5 years 1 Phase I: Screening for motor function difficulties in the preschool years Failure to meet motor milestones Ages and Stages Questionnaire Additional questions: Is there anything your baby/child is doing with their arms, legs or body movements that concerns you? Is there anything your baby/child is not doing with their arms, legs and body movements that concerns you? Is there anything that you have tried to teach your infant/child to do involving their hands or whole body movementthat has taken longer to learn than you think it should? 1 Rosenbaum et al. (2009) Proposed motor function assessment: prenatal period to age 5 years (2) Phase II: Proposed second-order assessment of children who fail a screening phase (administration of a motor test) Phase III: Protocol for specialist (clinical) assessment to detect the onset/offset of specific developmental motor disorders (dimensional measure(s) of motor difficulty) Diagnosis (CP, DCD, Muscular dystrophy etc.) Conclusion early identification of DCD 10/21/ Difficult before the age of 5 Before the age of 5: DCD should not ne diagnosed before the age of 5!! Variability of motor development before this age Gross motor development is essentially well established by about the age of 5 years (postural control skills and locomotor skills) Children with red flags need to be followed, as they may be at risk for DCD.

7 10/21/ Identification of DCD at school age Diagnostic Criteria for Developmental Coordination Disorder (DSM-IV) Criterion A. Performance in daily activities that require motor coordination is substantially below that expected given the person s chronological age and measured intelligence. Tests don t diagnose, people do! Criterion B. The disturbance in criterion A significantly interferes with academic achievement or activities of daily living. Criterion 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. Criterion D. If mental retardation is present, the motor difficulties are in excess of those usually associated with it. DSM Criterion A 10/21/ Leeds Criterion A. Diagnosis10/21/ 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. (DSM-IV-TR, 2000 p. 58). How do we measure criterion A? What is meant with substantially below? Developmental coordination disorder (DCD) is evident when there is a marked impairment in the performance of motor skills. Core aspects of the disorder include difficulties with gross and/or fine motor skills, which may be apparent in locomotion, agility, manual dexterity, complex skills (e.g. ball games) and /or balance. Individually administered and culturally appropriate, norm-referenced test of general motor competence. The cut off point at or below the 5th percentile. Checklists may be used as an initial screening tool. Children that score below the 15 th should be monitored Norm referenced motor tests 10/21/ Available tests BGMA Basic Gross Motor Assessment 10/21/ Advantages: Objective standardized Disadvantages: Snapshot Influence of performance variables (fatigue, anxiety) Time consuming Qualified tester is necessary BOT-2 M-ABC MAND PDMS-2 TGMD-2 ZNA Bruininks-Oseretsky Test 2nd ed. Movement Assessment Battery for Children McCarron Assessment of Neuromuscular Development Peabody Developmental Motor Scale 2nd ed. Test of Gross Motor Development Zurich Neuromotor Assessment

8 10/21/ Best rated tests 1 DSM Criterion B 10/21/ M-ABC 2001: used in 67% of the studies published until then Most popular test for DCD at the moment Reliable and valid TGMD-2 Not often used in DCD population Validity and reliability only demonstrated for TD group Bruininks- Oseretsky Test Used in 6% of the studies published until 2001 Reliability and validity have been critized Mainly used in USA The disturbance in criterion A significantly interferes with academic achievement or activities of daily living. (DSM-IV-TR, 2000 p. 58). academic achievement: writing and physical education activities of daily living: drawing/writing, dressing, locomotion, speech and use of tools/objects 1 Slater et al. (2010). Pediatric Physical Therapy Leeds Criterion B. Diagnosis 10/21/ Tests for measuring ADL? The specific skill of handwriting is usually affected, and is known to adversely affect academic achievement and should therefore be assessed. Assessment should reflect culturally relevant developmental norms relating to activities of daily living tasks and should include consideration of self-care, play, leisure and schoolwork (including handwriting, PE and tool use). MABC(2) test for motor skills, but not for ADL PEDI is not discriminative enough for use in children with DCD (School)-AMPS (Assessment of Motor and Process Skills) limited to functional skills at school How to measure criterion B? 10/21/ How to measure criterion B? 10/21/ At present no test of ADL has been developed. Questionnaires are used to assess functioning in ADL tasks Advantage: Performance across a larger time scale is taken into account Fast and easy to administer Disadvantage: Subjective, raters may lack sufficient knowledge to rate motor behavior (knowlegde of motor development) Parent-questionnaire DCD-Q Teacher-questionnaires Checklist-Movement ABC Motor Observation Questionnaire for Teachers (MOQ-T, previously called GMO) TEAF Child-questionnaire Children s self-perception of adequacy in and predilection for physical activity (CSAPPA)

9 10/21/ Checklist Movement-ABC2 Aim: assessment of motor performance of children in the school environment Section 1 The child is stationary and the environment stable Stand on one leg in a stable position. Section 2 The child is moving and the environment stable Skip or gallop a distance of 4.5 meter. Section A Age: children from 4 to 12 years of age To be filled out by teachers 30 questions, divided over 2 sections Checklist M-ABC: M reliable and valid (Schoemaker et al., submitted) Section 3 The child is stationary and the environment is changing Intercept and stop a moving object as it approaches. Section 4 The child is moving and the environment is changing Run to catch an Approaching ball. Section B 3 Sections 2 Motor section (A and B) 1 Non-motor section (section C: impulsiveness, distractibility, passiveness, upset by failure etc.) Scoring: Total Test Score (summed score for sections A and B) Interpretation: Traffic Light system MOQ-T Motor Observation Questionnaire for Teachers 10/21/ /21/ Aim: screening of movement problems at school by teachers age: 5-12 yrs filled in by: teacher; requested time 5 minutes 18 items, measuring 2 factors: General motor functioning handwriting Separate norms for age and gender MOQ-T (previously: GMO): reliable and valid (see Schoemaker et al, 2008) DCD-Q Developmental Coordination Disorder-Questionnaire Aim: screening of problems with gross and fine motor coordination. age: 8 to 14;6 yrs filled in by: parent(s); approximately 5 minutes 15 items; 3 factors: Motor control Fine motor skills / handwriting General coordination 10/21/ New instrument for ADL To develop an instrument to assess ADL in children with DCD Goals: Representative set of ADL Objective and systematic 30 Minutes DCD-Q Q : reliable and valid (see Wilson et al., 2000; Schoemaker et al., 2006)

10 10/21/ Development of a new measuring instrument for ADL skills To be used in addition to the M-ABC Literature study and expert interviews To compose a list of ADL skills that might be difficult for children with DCD Expert meeting The DCDDaily (Van der Linde, Van Netten, Schoemaker) DCDDaily: Motor assessment Reflect A normal day Self-maintenance (home) Productivity (school) Play 21 items 10/21/ Scoring: performance and speed (good, moderate, poor) DCDDaily-Questionnaire (child and parent) (Occupational model, Dunford et al., 2005; Reed and Sanderson, 1992) DCDDaily: items 10/21/ Movie 1 Home Cutting gingerbread Box and Bag Walk to school School Tinkering: folding, coloring, cutting Constructional play: Lego Handwriting Break Pooring a drink Walking with drink to table Shopping Dressing: socks, polo-shirt, trousers, body warmer Outdoor play activities Playing with marbles Hopping Discriminative ability 10/21/ DCD and 72 TD (6-8 years)

11 Discriminative ability (ndcd = 17; ntd = 69) Item scores 3 2,5 2 DCD TD How to use the DCD-Daily? To assist in assising criterion B To get an impression of problems with functional skills at home or at school To evaluate treatment Treatment: shift from process-oriented to more functional task-oriented approaches. 1,5 1 13* 10* 20* 8* 9* 5 7* 2* 6* 15* 17* 12* 18* 14* 4* 1* 11* 19* 21* 3 16* Items Conclusion Usefulness of questionnaires for identification of children with DCD? 10/21/ Present situation: Only questionnaires are available to assess ADL performance and to decide whether the performance of a child meets Criterion B. Two samples: Random sample (children from mainstream schools) Referred sample (50% children referred to child rehabilitation; 50% control children) Important aspects of a screening instrument: 10/21/ /21/ Sensitivity Specificity Can only be reliably determined if there is an accepted gold standard. Gold standard: a diagnostic test that is regarded as definitive A hypothetical ideal gold standard test has a : sensitivity, of 100% (it identifies all individuals with a disease; it does not have any false-negative results) specificity of 100% (it does not falsely identify someone with a condition that does not have the condition; it does not have any false-positive results). DCD: gold standard:???? does not exist! But: M-ABC is often used as a gold standard Sensitivity: The percentage of children who fail the M-ABC who are correctly identified by a screenings-instrument. In Table: a / (a+c) Questionnaire DCD (< 15th %) No DCD > 15 th % M-ABC DCD No DCD a b c d

12 10/21/ Sensitivity of the questionnaires (M-ABC is gold standard (15th % cut-off criterion)) Specificity: The percentage of children who pass the M-ABC who are correctly identified by a screenings-instrument. In Table: d / (b+d) Sensitivity Random sample Referred sample Questionnaire DCD (< 15th %) No DCD > 15 th % M-ABC DCD No DCD a b c d False positives Checklist 44%?? M-ABC 2 DCD-Q 29% 82% MOQ-T 39% 81% Specificity of the questionnaires (M-ABC is gold standard (15th % cut-off criterion)) Specificity Checklist M- ABC2 Random sample Referred sample 91%?? DCD-Q 89% 89% MOQ-T 89% 62% Conclusion 10/21/ Sensitivity of questionnaires: is good in referred sample, but too low for population screening (random sample) Specificity of questionnaires: Is good for population screening, Is good for DCD-Q in referred sample but slightly too low for MOQ-T in referred sample Why should we be careful to use the M-ABC as a gold standard? 10/21/ /21/ DCD is a heterogeneous disorder 2. M-ABC does not cover the full range of motor abilities that might be implicated.

13 Motor Abilities Prospective study M-ABC VMI BHK (handwriting) Motor performance 6 5 IQ-test (WISC-R) Child Behavior Check List Teacher Report Form 7 8 Outcome Prospective study (N=107, all referred) DCD M-ABC < 15th percentile M-ABC 86 (80%) 21 (20%) Medical problem 0 2 IQ < Non-DCD (M-ABC > 15th percentile Features of Non-DCD group 13 out of 19 non-dcd children had fine motor problems : Handwriting (BHK) Visuo-motor problems (VMI) Conclusion: When only the M-ABC is used for criterion A, children with fine motor disorders may be missed. Co-morbidity according to CBCLscores 58% 52% 3. What is the agreement between different measures designed to identify children with DCD? 10/21/ Participants: 10/21/ Teachers Parents Random sample: Referred sample: MOQ-T Children M-ABC DCD-Q 233 children (126 boys / 107 girls) Age range 5-11 years old Mean age: 8 years 1 months All attending meanstream schools 76 children (68 boys / 8 girls) Age range 5-11 years old Mean age: 7 years 3 months Referred to rehabilitation clinic for coordination problems.

14 Random sample M-ABC 15 th percentile DCD-Q MOQ-T Instruments identify partly the same partly different children 6% 3.8% 6.4% If 15 th centile is used, only 5% 4% of the children (n=10) are identified by all 4% measures (1.7 % (n=4) if 1.7% 4.7% the 5th centile is used) M-ABC does not identify 9.8% children with primarily fine motor problems (n=9) Using failure on the M- M-ABC N=21 ABC as the only criterion for DCD might lead to over-identification (21/233). Population sample (N=233) DCD-Q < 15 th % or MOQ-T < 15 th % 24% 56/233 M-ABC < 15 th % M-ABC < 5 th % 9 % 21/233 4 % 9/233 10/21/ Referred sample Referred sample (N=76) 10/21/ DCD-Q MOQ-T 1% 9% 13% 54% 7% 4% 5% M-ABC Overlap between measures is relatively large. 6.4% 13% of the children are not identified by the M- ABC because of fine motor problems Not all children referred to a rehabilitation clinic can be diagnosed as DCD (other developmental, school or educational problems) DCD-Q < 15 th % or MOQ-T < 15 th % 88% 67/76 M-ABC < 15 th % M-ABC < 5 th % 70% 53/76 51% 39/76 Conclusions 10/21/ Conclusion 10/21/ Some children fail on the MABC but do not have problems according to either parents or teachers. 2. Children with fine motor problems might be missed when only the M-ABC is used as an instrument to identify children with DCD. Identification of children with DCD: not as easy as it seems to be! Multiple measures are needed to identify children with DCD in a reliable way, according to the diagnostic criteria for DCD The development of new measuring instruments might be helpful in the identification process. 3. Multiple measures are recommended to be used to identify children with DCD

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