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.
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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.
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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
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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
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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
R e f e r e n c e s
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders. (Third ed., revised). Washington, DC, American Psychiatric
Association, 1987.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders. (Fourth ed.). Washington, DC, American Psychiatric Association,
1994.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders. (Fourth Edition, Text Revision). Washington DC, American
Psychiatric Association, 2000.
Bouffard, M., Watkinson, E. J., Thompson, L. P., Causgrove Dunn, J. L., & Romanow,
S. K. E. (1996). A Test of the Activity Deficit Hypothesis With Children With
Movement Difficulties. Adapted Physical Activity Quarterly, 13, 61-73.
Boyle, T. (2003). Concurrent Validity of Assessment Tools Used To Identify Children
With Developmental Coordination Disorder. Unpublished Honours Thesis, The
University of Western Australia, Perth, Australia.
Bruininks, R. H. (1978). The Bruininks-Oseretsky Test of Motor Proficiency. Circle
Pines, MN: American Guidance Service.
Burgman, I. (1998). Functional Measures and Pediatric Assessment. Physical and
Occupational Therapy in Pediatrics, 18(3/4), 109-121.
Burton, A. W., & Davis, W. E. (1996). Ecological task analysis: Utilizing intrinsic
measures in research and practice. Human Movement Science, 15, 285-314.
Burton, A. W., & Rodgerson, R. W. (2001). New Perspectives on the Assessment of
Movement Skills and Motor Abilities. Adapted Physical Activity Quarterly, 18,
347-365.
Cairney, J., Hay, J., Faught, B., Mandigo, J., & Flouris, A. (2005). Developmental
Coordination Disorder, Self-Efficacy Toward Physical Activity and Play: Does
Gender Matter? Adapted Physical Activity Quarterly, 22, 67-82.
Cantell, M. H., Smyth, M. M., & Ahonen, T. P. (1994). Clumsiness in Adolescence:
Educational, Motor, and Social Outcomes of Motor Delay Detected at 5 Years.
Adapted Physical Activity Quarterly, 11, 115-129.
Cantell, M. H., Smyth, M. M., & Ahonen, T. P. (2003). Two distinct pathways for
developmental coordination disorder: Persistence and resolution. Human
Movement Science, 22, 413-431.
Case-Smith, J. (1995). The Relationships Among Sensorimotor Components, Fine
49
Motor Skill, and Functional Performance on Preschool Children. American
Journal of Occupational Therapy, 49(7), 645-652.
Case-Smith, J. (1996). Fine Motor Outcomes in Preschool Children Who Receive
Occupational Therapy. American Journal of Occupational Therapy, 50(1), 52-
61.
Chambers, M. E., & Sugden, D. A. (2002). The Identification and Assessment of Young
Children with Movement Difficulties. International Journal of Early Years
Education, 10(3), 157-176.
Chapparo, C. J., & Hooper, E. (2002). When is it work? Perceptions of six year old
children. Work, 19, 291-302.
Chapparo, C. J., & Hooper, E. (2005). Self-Care at School: Perceptions of 6-Year-Old
Children. American Journal of Occupational Therapy, 59(1), 67-77.
Chapparo, C., & Ranka, J. (1997). Occupational Performance Model (Australia):
Definition of Terms. In C. Chapparo & J. Ranka (Eds.), Occupational
Performance Model (Australia) Monograph 1 (pp. 58-60). Sydney, Australia:
Occupational Performance Network, University of Sydney.
Chesson, R., McKay, C., & Stephenson, E. (1990). Motor/learning difficulties and the
family. Child: care, health and development, 16, 123-138.
Chia, S. H. (1997). The child, his family and dyspraxia. Professional Care of Mother &
Child, 7(4), 105-107.
Cousins, M., & Smyth, M. M. (2003). Developmental coordination impairments in
adulthood. Human Movement Science, 22, 433-459.
Crawford, S. G., Wilson, B. N., & Dewey, D. (2001). Identifying Developmental
Coordination Disorder: Consistency Between Tests. Physical and Occupational
Therapy in Pediatrics, 20(2-3), 29-50.
Davis, W. E. (1984). Motor Ability Assessment of Populations with Handicapping
Conditions: Challenging Basic Assumptions. Adapted Physical Activity
Quarterly, 1, 125-140.
Davis, W. E., & Burton, A. W. (1991). Ecological Task Analysis: Translating Movement
Behaviour Theory Into Practise. Adapted Physical Activity Quarterly, 8, 154-
177.
Dawdy, S. C. (1981). Pediatric Neuropsychology: Caring for the Developmentally
Dyspraxic Child. Clinical Neuropsychology, 3(1), 30-37.
Dewey, D., Crawford, S. G., & Kaplan, B. J. (2003). Clinical Importance of Parent
Ratings of Everyday Cognitive Abilities in Children with earning and Attention
Problems. Journal of Learning Disabilities, 36(1), 87-95.
Dewey, D., Kaplan, B. J., Crawford, S. G., & Wilson, B. N. (2002). Developmental
coordination disorder: Associated problems in attention, learning, and
50
psychosocial adjustment. Human Movement Science, 21, 905-918.
Dewey, D., Larkin, D., & Summers, J. (2004). A parent completed questionnaire:
Performance of Activities of Daily Living for Children Aged 5-10 Years.
Unpublished manuscript.
Dewey, D., & Wilson, B. N. (2001). Developmental Coordination Disorder: What Is It?
Physical and Occupational Therapy in Pediatrics, 20(2-3), 5-27.
Dunford, C., & Kelly, J. (2001). Does screening children referred for co-ordination
difficulties benefit the child and the occupational therapy process? NAPOT
Journal, 5, 12-14.
Dunford, C., Missiuna, C., Street, E., & Sibert, J. (2005). Children's Perceptions of the
Impact of Developmental Coordination Disorder on Activities of Daily Living.
British Journal of Occupational Therapy, 68(5), 207-214.
Dunford, C., Street, E., O'Connell, H., Kelly, J., & Sibert, J. R. (2004). Are referrals to
occupational therapy for developmental coordination disorder appropriate?
Archives of Disease in Childhood, 89, 143-147.
Dwyer, C. A. (1996). Cut Scores and Testing: Statistics, Judgement, Truth, and Error.
Psychological Assessment, 8(4), 360-362.
Evans, J., & Roberts, G. C. (1987). Physical Competence and the Development of
Children's Peer Relations. Quest, 39, 23-35.
Fisher, A. G. (1997). Multifaceted Measurement of Daily Life Task Performance:
Conceptualising a Test of Instrumental ADL and Validating the Addition of
Personal ADL Tasks. Physical Medicine and Rehabilitation: State of the Art
Reviews, 11(2), 289-303.
Folio, R. S., & Fewell, R. R. (1983). Peabody Developmental Motor Scales. Allen, TX:
DLM Teaching Resources.
Fox, A. M., & Lent, B. (1996). Clumsy Children: Primer on developmental coordination
disorder. Canadian Family Physician, 42, 1965-1971.
Gesell, A., Ilg, F. L., & Bates Ames, L. (1977). Five Years Old. In The Child From Five
to Ten (Revised ed., pp. 49-79). New York: Harper & Row.
Geuze, R. H. (2005). Motor impairment in DCD and activities of daily living. In D.
Sugden & M. Chambers (Eds.), Children with Developmental Coordination
Disorder (pp. 19-46). London: Whurr Publishers Ltd.
Geuze, R. H., Jongmans, M. J., Schoemaker, M. M., & Smits-Engelsman, B. C. M.
(2001). Clinical and research diagnostic criteria for developmental coordination
disorder: a review and discussion. Human Movement Science, 20, 7-47.
Gibson, R. C. (1996). The effects of dyspraxia on family relationships. British Journal of
Therapy and Rehabilitation, 3(2), 101-105.
Glascoe, F. P. (1997b). Parents' Concerns About Children's Development:
51
Prescreening Technique or Screening Test? Pediatrics, 99(4), 522-528.
Glascoe, F. P. (2000). Evidence-based approach to developmental and behavioural
surveillance using parents' concerns. Child: Care, Health and Development,
26(2), 137-149.
Glascoe, F. P., Altemeier, W. A., & MacLean, W. E. (1989). The Importance of Parents'
Concerns About Their Child's Development. American Journal of Diseases of
Children, 143, 955-958.
Glascoe, F. P., & Dworkin, P. H. (1995). The Role of Parents in the Detection of
Developmental and Behavioural Problems. Pediatrics, 95(6), 829-836.
Goshi, F., Demura, S., Kasuga, K., Sato, S., & Minami, M. (2000). Use of Subjective
Estimation in Motor Skill Tests of Young Children: Judgement Based on
Observation of Behaviour in Daily Life. Perceptual and Motor Skills, 90, 215-
226.
Green, D., Bishop, T., Wilson, B. N., Crawford, S., Hooper, R., Kaplan, B., & Baird, G.
(2005). Is Questionnaire-Based Screening part of the Solution to Waiting Lists
for Children with Developmental Coordination Disorder? British Journal of
Occupational Therapy, 68(1), 2-10.
Gubbay, S. S. (1975). A Survey of Developmental Clumsiness in Schoolchildren. In
The Clumsy Child: A Study of Developmental Apraxic and Agnosic Ataxia (pp.
94-145). London: W. B. Saunders Company Ltd.
Gubbay, S. S. (1978). The Management of Developmental Apraxia. Developmental
Medicine & Child Neurology, 20, 643-646.
Haley, S. M., Coster, W., & Binda-Sundberg, K. (1994). Measuring Physical
Disablement: The Contextual Challenge. Physical Therapy, 74(5), 443-451.
Haley, S. M., Coster, W. J., Ludlow, L., Haltiwanger, J., & Andrellos, P. (1992).
Pediatric Evaluation of Disability Inventory (PEDI). Boston, MA: Boston
University Center for Rehabilitation Effectiveness.
Hay, J. A., Hawes, R., & Faught, B. E. (2004). Evaluation of a Screening Instrument for
Developmental Coordination Disorder. Journal of Adolescent Health, 34, 308-
313.
Hayase, D., Mosenteen, D., Thimmaiah, D., Zemke, S., Atler, K., & Fisher, A. G.
(2004). Age-related changes in activities of daily living ability. Australian
Occupational Therapy Journal, 51, 192-198.
Hellgren, L., Gillberg, C., Gillberg, I. C., & Enerskog, I. (1993). Children with Deficits in
Attention, Motor Control and Perception (DAMP) Almost Grown Up: General
Health at 16 Years. Developmental Medicine & Child Neurology, 35, 881-892.
Henderson, L., Rose, P., & Henderson, S. (1992). Reaction Time and Movement Time
in Children with a Developmental Coordination Disorder. Journal of Child
52
Psychology and Psychiatry, 33(5), 895-905.
Henderson, S. E., & Barnett, A. L. (1998). The classification of specific motor
coordination disorders in children: some problems to be solved. Human
Movement Science, 17, 449-469.
Henderson, S. E., & Hall, D. (1982). Concomitants of Clumsiness in Young
Schoolchildren. Developmental Medicine & Child Neurology, 24, 448-460.
Henderson, S. E., & Sugden, D. A. (1992). Movement Assessment Battery for Children.
London: The Psychological Corporation.
Hoare, D. (1994). Subtypes of Developmental Coordination Disorder. Adapted Physical
Activity Quarterly, 11, 158-169.
Inomata, M., & Simizu, K. (1991). Ability of young children to button and unbutton
clothes. Journal of Human Ergology, 20(2), 249-255.
Kaplan, B. J., Wilson, B. N., Dewey, D., & Crawford, S. G. (1998). DCD may not be a
discrete disorder. Human Movement Science, 17, 471-490.
Knutson, L. M., Schimmel, P. A., & Ruff, A. (1999). Standard Task Measurement for
Mobility: Thirty-Second Walk Test. Pediatric Physical Therapy, 11, 183-190.
Larkin, D., & Cermak, S. A. (2002). Issues in Identification and Assessment of
Developmental Coordination Disorder. In S. A. Cermak & D. Larkin (Eds.),
Developmental Coordination Disorder (pp. 86-102): Delmar Thompson
Learning.
Larkin, D., Hands, B., Parker, H., Sloan, N., & Kendall, G. (2005). Language Difficulties
among Children with Low Motor Competence. Poster presented at the DCD-VI
International Conference, Trieste, Italy.
Lasky, P. A., & Eichelberger, K. M. (1985). Health-Related Views and Self-Care
Behaviours of Young Children. Family Relations, 34, 13-18.
Licari, M., Larkin, D., & Miyahara, M. (2006). The influence of developmental
coordination disorder and attention deficits on associated movements in
children. Human Movement Science, 25, 90-99.
Losse, A., Henderson, S. E., Elliman, D., Hall, D., Knight, E., & Jongmans, M. (1991).
Clumsiness in Children - Do They Grow Out of It? A 10-Year Follow-Up Study.
Developmental Medicine & Child Neurology, 33(55-68).
Maeland, A. F. (1992). Identification of Children With Motor Coordination Problems.
Adapted Physical Activity Quarterly, 9, 330-342.
Magill, R. A. (2004). Motor Control Theories. In Motor Learning and Control: Concepts
and Applications (Seventh ed., pp. 50-74). New York: McGraw Hill.
Mandich, A. D., Polatajko, H. J., & Rodger, S. (2003). Rites of passage: Understanding
participation of children with developmental coordination disorder. Human
Movement Science, 22, 583-595.
53
Marchiori, G. E., Wall, A. E., & Bedingfield, E. W. (1987). Kinematic Analysis of Skill
Acquisition in Physically Awkward Boys. Adapted Physical Activity Quarterly, 4,
305-315.
May-Benson, T., Ingolia, P., & Koomar, J. (2002). Daily Living Skills and
Developmental Coordination Disorder. In S. A. Cermak & D. Larkin (Eds.),
Developmental Coordination Disorder (pp. 140-156): Delmar Thomson
Learning.
McCarron, L. T. (1982). McCarron Assessment of Neuromuscular Development (1997
ed.). Dallas: McCarron-Dial Systems Inc.
Missiuna, C. (1994). Motor Skill Acquisition in Children with Developmental
Coordination Disorder. Adapted Physical Activity Quarterly, 11, 214-235.
Missiuna, C., & Polatajko, H. (1995). Developmental Dyspraxia by Any Other Name:
Are They All Just Clumsy Children? American Journal of Occupational Therapy,
49, 619-627.
Missiuna, C., & Pollock, N. (1995). Beyond The Norms: Need for Multiple Sources of
Data in the Assessment of Children. Physical and Occupational Therapy in
Pediatrics, 15(4), 57-71.
Msall, M. E., DiGaudio, K., Duffy, L. C., LaForest, S., Braun, S., & Granger, C. V.
(1994). WeeFIM. Normative sample of an instrument for tracking functional
independence in children. Clinical Pediatrics, 33(7), 431-438.
Msall, M. E., Tremont, M. R., & Ottenbacher, K. J. (2001). Functional Assessments of
Preschool Children: Optimizing Developmental and Family Supports in Early
Intervention. Infants and Young Children, 14(1), 46-66.
Newell, K. M. (1986). Constraints on the Development of Coordination. In M. G. Wade
& H. T. A. Whiting (Eds.), Motor Development in Children: Aspects of
Coordination and Control (pp. 341-360). Dordrecht, The Netherlands: Martinus
Nijhoff Publishers.
O'Dwyer, S. (1987). Characteristics of Highly and Poorly Co-ordinated Children. The
Irish Journal of Psychology, 8(1), 1-8.
Piek, J. P., & Edwards, K. (1997). The identification of children with developmental
coordination disorder by class and physical education teachers. British Journal
of Educational Psychology, 67 (Pt 1), 55-67.
Pless, M., Persson, K., Sundelin, C., & Carlsson, M. (2001). Children with
Developmental Co-ordination Disorder: A Qualitative Study of Parents'
Descriptions. Advances in Physiotherapy, 3, 128-135.
Polatajko, H. J., Fox, A. M., & Missiuna, C. (1995). An International Consensus on
Children with Developmental Coordination Disorder. Canadian Journal of
Occupational Therapy, 62(1), 3-6.
54
Polatajko, H. J., Mandich, A., & Martini, R. (2000). Dynamic Performance Analysis: A
Framework for Understanding Occupational Performance. American Journal of
Occupational Therapy, 54(1), 65-72.
Portney, L. G., & Watkins, M. P. (1993). Validity of Measurements. In Foundations of
Clinical Research: Applications to Practice. Connecticut: Appleton & Lange.
Rasmussen, P., & Gillberg, C. (2000). Natural Outcome of ADHD With Developmental
Coordination Disorder at Age 22 Years: A Controlled, Longitudinal, Community-
Based Study. Journal of the American Academy of Child and Adolescent
Psychiatry, 39(11), 1424-1431.
Revie, G., & Larkin, D. (1993a). Looking at Movement: Problems with Teacher
Identification of Poorly Coordinated Children. ACHPER National Journal, 40(4
(142)), 4-9.
Riggen, K. J., Ulrich, D. A., & Ozmun, J. C. (1990). Reliability and Concurrent Validity
of the Test of Motor Impairment - Henderson Revision. Adapted Physical
Activity Quarterly, 7, 249-258.
Rodger, S., Ziviani, J., Watter, P., Ozanne, A., Woodyatt, G., & Springfield, E. (2003).
Motor and functional skills of children with developmental coordination disorder:
A pilot investigation of measurement issues. Human Movement Science, 22,
461-478.
Rösblad, B., & von Hofsten, C. (1994). Repetitive Goal-Directed Arm Movements in
Children with Developmental Coordination Disorders: Role of Visual
Information. Adapted Physical Activity Quarterly, 11, 190-202.
Rose, B., Larkin, D., & Berger, B. G. (1997). Coordination and Gender Influences on
the Perceived Competence of Children. Adapted Physical Activity Quarterly, 14,
210-221.
Rosenblum, S. (2006). The development and standardisation of the Children Activity
Scales (ChAS-P/T) for the early identification of children with Developmental
Coordination Disorder. Child: care, health and development, 32(6), 619-632.
Schellekens, J. M. H., Scholten, C. A., & Kalverboer, A. F. (1983). Visually Guided
Hand Movements in Children with Minor Neurological Dysfunction: Response
Time and Movement Organisation. Journal of Child Psychology and Psychiatry,
24(1), 89-102.
Schoemaker, M. M., Flapper, B., Verheij, N. P., Wilson, B. N., Reinders-Messelink, H.
A., & de Kloet, A. (2006). Evaluation of the Developmental Coordination
Disorder Questionnaire as a screening instrument. Developmental Medicine &
Child Neurology, 48(8), 668-673.
Schoemaker, M. M., & Kalverboer, A. F. (1994). Social and Affective Problems of
Children Who Are Clumsy: How Early Do They Begin? Adapted Physical
55
Activity Quarterly, 11, 130-140.
Schoemaker, M. M., Smits-Engelsman, B. C. M., & Jongmans, M. J. (2003).
Psychometric properties of the Movement Assessment Battery for Children-
Checklist as a screening instrument for children with a developmental co-
ordination disorder. British Journal of Educational Psychology, 00, 425-441.
Schoemaker, M. M., van der Wees, M., Flapper, B., Verheij-Jansen, N., Scholten-
Jaegers, S., & Geuze, R. H. (2001). Perceptual skills of children with
developmental coordination disorder. Human Movement Science, 20, 111-133.
Shaw, L., Levine, M. D., & Belfer, M. (1982). Developmental Double Jeopardy: A Study
of Clumsiness and Self-Esteem in Children with Learning Problems.
Developmental and Behavioral Pediatrics, 3(4), 191-196.
Skinner, R. A., & Piek, J. P. (2001). Psychosocial implications of poor motor
coordination in children and adolescents. Human Movement Science, 20, 73-
94.
Smith, L. B., & Thelan, E. (2003). Development as a dynamic system. Trends in
Cognitive Sciences, 7(8), 343-348.
Smoll, F. L. (1974). Motor Impairment and Social Development. American Corrective
Therapy Journal, 28(1), 4-7.
Sonnander, K. (2000). Early identification of children with developmental disabilities.
Acta Paediatric Supplement, 434, 17-23.
Stott, D. H., Moyes, F. A., & Henderson, S. E. (1984). The Henderson Revision of the
Test of Motor Impairment. San Antonio, TX: The Psychological Corporation.
Sugden, D. A., editor (2006). Leeds Consensus Statement (2006): Developmental
Coordination Disorder as a Specific Learning Difficulty (ESRC Research
Seminar Series 2004 - 2005). Leeds, UK: University of Leeds.
Sugden, D., & Sugden, L. (1991). The Assessment of Movement Skill Problems in 7-
and 9-Year-Old Children. British Journal of Educational Psychology, 61, 329-
345.
Summers, J. (2002). [Play & Motor Competence in Children with and without DCD].
Unpublished raw data.
Summers, J., Dewey, D., & Larkin, D. (2005). Development of a measure of the
performance of activities of daily living in children with developmental
coordination disorder. Oral presentation at the DCD-VI International
Conference, Trieste, Italy.
Summers, J., Larkin, D., & Dewey, D. (2007a). Activities of Daily Living in Children with
Developmental Coordination Disorder: Dressing, Personal Hygiene, and Eating
Skills. Manuscript submitted for publication.
Summers, J., Larkin, D., & Dewey, D. (2007b). What Impact Does Developmental
56
Coordination Disorder Have on Daily Routines? Manuscript submitted for
publication.
Tan, S. K., Parker, H. E., & Larkin, D. (2001). Concurrent Validity of Motor Tests Used
to Identify Children With Motor Impairment. Adapted Physical Activity Quarterly,
18, 168-182.
Thelan, E. (1995). Motor Development: A New Synthesis. American Psychologist,
50(2), 79-95.
Thompson, L. P., Bouffard, M., Watkinson, E. J., & Causgrove Dunn, J. L. (1994).
Teaching Children with Movement Difficulties: Highlighting the Need for
Individualised Instruction in Regular Physical Education. Physical Education
Review, 17(2), 152-159.
Vreede, C. F. (1988). The need for a better definition of ADL. International Journal of
Rehabilitation Research, 11(1), 29-35.
Wagoner, L. C., & Armstrong, E. M. (1928). The Motor Control of Children as Involved
in the Dressing Process. Pedagogical Seminary and Journal of Genetic
Psychology, 35, 84-97.
Wall, A. E., McClements, J., Bouffard, M., Findlay, H., & Taylor, M. J. (1985). A
Knowledge-Based Approach to Motor Development: Implications for the
Physically Awkward. Adapted Physical Activity Quarterly, 2, 21-42.
Wall, A. E., Reid, G., & Paton, J. (1990). The Syndrome of Physical Awkwardness. In
G. Reid (Ed.), Problems in Movement Control (pp. 283-316). Amsterdam:
Elsevier Science Publishers.
Watkinson, E. J., Causgrove Dunn, J., Cavaliere, N., Calzonetti, K., Wilhelm, L., &
Dwyer, S. (2001). Engagement in Playground Activities as a Criterion for
Diagnosing Developmental Coordination Disorder. Adapted Physical Activity
Quarterly, 18, 18-34.
Weiss, M. R., & Duncan, S. C. (1992). The Relationship Between Physical
Competence and Peer Acceptance in the Context of Children's Sports
Participation. Journal of Sport & Exercise Psychology, 14, 177-191.
White, R. W. (1959). Motivation Reconsidered: The Concept of Competence.
Psychological Review, 66(5), 297-333.
Wilson, B. N., Kaplan, B. J., Crawford, S. G., Campbell, A., & Dewey, D. (2000).
Reliability and Validity of a Parent Questionnaire on Childhood Motor Skills.
American Journal of Occupational Therapy, 54(5), 484-493.
Wilson, P. H. (2005). Practitioner Review: Approaches to assessment and treatment of
children with DCD: an evaluative review. Journal of Child Psychology and
Psychiatry, 46(8), 806-823.
Wilson, P. H., Maruff, P., & Lum, J. (2003). Procedural Learning in Children with
57
Developmental Coordination Disorder. Human Movement Science, 22, 515-
526.
Wright, H. C., & Sugden, D. A. (1996a). The Nature of Developmental Coordination
Disorder: Inter- and Intragroup Differences. Adapted Physical Activity Quarterly,
13, 357-371.
Zittel, L. L. (1994). Gross Motor Assessment of Preschool Children with Special Needs:
Instrument Selection Considerations. Adapted Physical Activity Quarterly, 11,
245-260.
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 [email protected]
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 [email protected]
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 [email protected]
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.
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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.