Ecological validity of the German Bruininks-Oseretsky Test of Motor Proficiency – 2nd Edition

Human Movement Science xxx (2016) xxx–xxx

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Human Movement Science journal homepage: www.elsevier.com/locate/humov

Full Length Article

Ecological validity of the German Bruininks-Oseretsky Test of Motor Proficiency – 2nd Edition Sabine Vinçon a,b,⇑, Dido Green b, Rainer Blank a, Ekkehart Jenetzky a,c a

Clinic for Child Neurology and Social Pediatrics, Child Centre Maulbronn, 75433 Maulbronn, Germany Department of Sport and Health Sciences, Oxford Brookes University, Oxford OX3 0BP, United Kingdom c Department of Child and Adolescent Psychiatry, University Medicine Mainz, 55131 Mainz, Germany b

a r t i c l e

i n f o

Article history: Received 20 February 2016 Revised 4 October 2016 Accepted 9 October 2016 Available online xxxx Keywords: Bruininks-Oseretsky Test of Motor Proficiency BOT-2 German DCD Daily activities Validity Parents

a b s t r a c t The diagnosis of Developmental Coordination Disorder (DCD) is based on poor motor coordination in the absence of other neurological disorders. In order to identify the presence of movement difficulties, a standardised motor assessment is recommended to determine the extent of movement problems which may contribute to deficits in daily task performance. A German version of the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (German BOT-2) was recently published. This study aimed to determine the ecological validity of the German BOT-2 by considering the relationship between assessment of fundamental motor skills with the BOT-2 and performance of everyday motor activities as evaluated by parents. This study used data obtained from the German BOT-2 standardisation study (n = 1.177). Subtests were compared with theoretically corresponding tasks via parental ratings of overall fine and gross motor abilities and performance in six typical motor activities. Non-parametric Jonckheere Terpstra test was used to identify differences in ordered contrasts. Subtests reflecting ‘Strength’, ‘Running Speed and Agility’, ‘UpperLimb Coordination’, ‘Balance’, and ‘Fine Motor Precision’ were associated with parental evaluation of gross motor skills (p < 0.001). The subtest ‘Fine Motor Integration’ significantly correlated with parental ratings of females’ fine motor skills. Parental ratings of males’ fine motor skills were associated with three further subtests. Regarding everyday motor activities, the first three fine motor BOT-2 subtests were associated with parent evaluations of drawing, writing and arts and crafts (p < 0.001). Gross motor subtests of ‘Bilateral Coordination’ and ‘Balance’ showed no relationship to bike riding or performance in sports. Subtests of ‘Upper-Limb Coordination’ and ‘Strength’ showed significant correlations with sports, ball games and cycling. The results of this study suggest that the closer the proximity in the nature of the motor skills assessed in the German BOT-2 to daily motor tasks, the stronger the relationship between the clinical test and parental report of everyday performance of their child. The body functions tested in the German BOT-2, and hypothesized to underpin certain skills, were not automatically relevant for specific activities undertaken by German children. Future research should investigate the relationships of the various BOT-2 constructs for diagnosis of DCD. Ó 2016 Elsevier B.V. All rights reserved.

⇑ Corresponding author at: Clinic for Child Neurology and Social Pediatrics, Child Centre Maulbronn, Knittlinger Steige 21, 75433 Maulbronn, Germany. E-mail address: [email protected] (S. Vinçon). http://dx.doi.org/10.1016/j.humov.2016.10.005 0167-9457/Ó 2016 Elsevier B.V. All rights reserved.

Please cite this article in press as: Vinçon, S., et al. Ecological validity of the German Bruininks-Oseretsky Test of Motor Proficiency – 2nd Edition. Human Movement Science (2016), http://dx.doi.org/10.1016/j.humov.2016.10.005

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S. Vinçon et al. / Human Movement Science xxx (2016) xxx–xxx

1. Introduction The daily life of a child is full of activities which require different motor demands such as drawing, cutting, dressing and playing ball. Fundamental motor skills are typically mastered during childhood through play and participation in daily activities. However skill acquisition may be influenced by personal and environmental factors enabling opportunities for participation and practice within an individual’s everyday performance (Cools, Martelaer, Samaey, & Andries, 2009; Foweather, 2010; Kakebeeke et al., 2013). Still, there are children who have persistent problems with the achievement and engagement in everyday activities due to movement impairments. Despite average intelligence and the absence of other medical or developmental conditions, children with Developmental Coordination Disorder (DCD) have difficulty acquiring and performing typical motor based tasks (American Psychiatric Association, 2013; World Health Organisation, 1992). Children with DCD present difficulties across all levels of the International classification of functioning, disability and health (ICF) (World Health Organisation, 2001): body functions/structures, activities and participation (Magalhaes, Cardoso, & Missiuna, 2011; Wilson, Ruddock, Smits-Engelsman, Polatajko, & Blank, 2013). Children with DCD have also been reported to be at higher risk of additional problems, including poor self-efficacy, psychosocial problems (Green, Baird, & Sugden, 2006; Missiuna, Moll, King, King, & Law, 2007) and overweight and obesity (Joshi et al., 2015). Finally, movement difficulties and their impact on daily task performance may persist into adulthood (Kirby, Williams, Thomas, & Hill, 2013; Tal-Saban, Ornoy, & Parush, 2014). Due to the extensive nature and consequences of coordination difficulties, early diagnosis of DCD is important. Early diagnosis may help to determine and implement appropriate intervention and offset potential negative impacts. Current evidence-based guidelines for the diagnostic process of DCD recommend assessment of motor skills (Criterion A) as well as impact on activities and participation (Criterion B) (Blank, Smits-Engelsman, Polatajko, & Wilson, 2012). To verify criterion A, it is recommended to use a valid, standardised, objective and norm referenced test to determine any limitations in motor skill (Blank et al., 2012). The Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2) (Bruininks & Bruininks, 2005) is recommended within current guidelines for DCD. The BOT-2 has recently been adapted and standardised for German speaking countries (German BOT-2) and normative values have been derived (Blank, Jenetzky, & Vinçon, 2014). In contrast, Criterion B requires identification of performance in everyday activities involving motor skills. However, the clinical utility of assessing performance across multiple environmental domains is restricted. Thus parent and teacher reports, via questionnaires and checklists, are more frequently used as these are able to focus on the child‘s activities and participation within individual contexts (Green et al., 2005). The degree to which test performance corresponds to real-world everyday performance represents ecological validity (Chaytor & Schmitter-Edgecombe, 2003). Two approaches have been conceptually defined to address the ecological validity of assessment instruments: verisimilitude and veridicality, reflecting the theoretical resemblance and empirical relationship of the test to everyday functioning respectively (Chaytor & Schmitter-Edgecombe, 2003). Identifying the ecological validity of movement skill assessments is important as we move away from purely diagnostic questions, especially in considering the impact on activity performance and participation in order to suitability plan intervention programmes. Motor assessments aim to provide information about overall movement capacity as well as specific motor areas. From the perspective of the ICF, assessments of motor skills of children (Criterion A), predominantly focus on fundamental skills (e.g. balance) or activities (e.g. throwing and catching) (Darsaklis, Snider, Majnemer, & Mazer, 2013). With respect to the BOT-2, the general construct of motor proficiency is divided into four broad motor composites of ‘Fine Manual Control’, ‘Manual Coordination’, ‘Body Coordination’ and ‘Strength and Agility’ with two subtests in each composite and 53 items in total (Bruininks & Bruininks, 2005). Standardised assessments of motor skills, while allowing for reliable replication to determine the relative risk of poor skills in comparison to age and gender related norms, potentially lack cultural validity. Items such as stringing blocks or walking forward on a line may have little relationship to real life activities in which motivations and situations of children differ (Brown & Chien, 2010; Kennedy, Brown, & Chien, 2012). This raises questions regarding the extent to which a standardised test situation and subsequent results can be considered ecologically valid and thus representative of the skills required for performance in daily life activities of children. This has particular resonance for the diagnosis of DCD in which the functional deficits of Criterion B are due to the movement impairments of Criterion A (American Psychiatric Association, 2013; Blank et al., 2012). For a diagnosis of DCD, the results of the standardised test, must be interpreted in the context of the skills demonstrated by the individual child in his or her daily life. In considering the relevance of a test result, parents often have the best perspective of their child’s abilities, providing external report in order to meet Criterion B (Gaines & Missiuna, 2007; Glascoe & Marks, 2011; Green et al., 2005). Parental view, garnered over time and across environmental contexts, may thus offer an ecological perspective which could be considered in conjunction with standardised assessments. Previous studies have compared standardised motor assessment to parent evaluations with equivocal results. Kennedy et al. (2012) found, in a small sample of 38 typical developing (TD) school-aged children, significant correlations between the BOT-2 Total Motor Composite and three of the four composites (excluding ‘Fine Manual Control’), and the Movement Assessment Battery, Second Edition (MABC-2) checklist completed by parents. In contrast, Brown and Lane (2014), with 50 TD children over a broader age range (7 to 16 years), found the BOT-2 composite ‘Fine Manual Control’ as well as ‘Manual Coordination’ to be moderately correlated with parent report on the MABC-2 checklist, whereas the two gross motor related

Please cite this article in press as: Vinçon, S., et al. Ecological validity of the German Bruininks-Oseretsky Test of Motor Proficiency – 2nd Edition. Human Movement Science (2016), http://dx.doi.org/10.1016/j.humov.2016.10.005

S. Vinçon et al. / Human Movement Science xxx (2016) xxx–xxx

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composites (‘Body Coordination’ and ‘Strength and Agility’) did not show any significant correlations with daily motor activities. Green et al. (2005) verified in their study that parental evaluations using the Developmental Coordination Disorder Questionnaire (DCDQ) (Wilson, Kaplan, Crawford, Campbell, & Dewey, 2000) correlated more strongly with performance on the MABC (1st Edition) motor test than with teacher report on the MABC checklist (Henderson & Sugden, 1992). In view of some discrepant findings between standardised motor assessments and parent or teacher perspectives of the child’s motor performance in daily life, there is a need to determine the ecological validity of motor assessments. This study aimed to ascertain the relationship between motor capacity and fundamental motor skills as assessed by the German version of the BOT-2 and the performance of everyday motor activities involving a variety of different aspects of motor control and motor learning as evaluated by parents. According to the theory and content of the BOT-2, the subtests were hypothesised to relate to parent appraisal of general fine and gross motor skills and ratings on six everyday motor activities. Subtests of the first two motor composites of the BOT-2 were classified as fine motor and the other two composites as gross motor. Fine motor activities of drawing, writing and arts and crafts, were hypothesised to relate to subtests 1 to 3 of the BOT-2, which included similar tasks. Skills in ball games should be related to ‘Upper-Limb Coordination’ which includes ball items using the upper extremity. Gross motor activities of riding scooter/bicycle and sports in general, were hypothesised to correlate to all gross motor related subtests (See Table 1). 2. Methods 2.1. Study design Data collected as part of the German BOT-2 standardisation study was used to consider the extent to which measured skills on the German BOT-2 corresponded to the performance of German speaking children in real-world everyday motor tasks as reported by their parents. Ethical approval was obtained by the Ethics Committee (S-597/2011) of University of Heidelberg, Germany in 2012. 2.2. Participants and data collection Complete data were available from 1.177 participants who had participated in the German BOT-2 standardisation study. Sampling methodology and procedures have been described previously (Blank et al., 2014). In brief, a population representative sample of children aged four to 14 years was recruited via letters of invitation through trained examiners in different regions in Germany, Austria and Switzerland between 2012 and 2013. Examiners were recruited and trained in the German BOT-2 assessment and study protocol during a one or two day training course by the study coordinator (SV). The majority of examiners were experienced Occupational Therapists and Physiotherapists (N = 60; 82%); the remainder were final year bachelor and master students in Sport Science or pediatric based University programmes (N = 13; 18%). In order to achieve a representative sample, examiners were asked to distribute information to children and adolescents through a variety of sources in their regions to cover a range of social and cultural backgrounds; inclusion of children from clinics due to motor problems or with psychopharmacological treatment was avoided. After informed consent was received, parents answered a detailed questionnaire regarding general information, sociodemographic background and habits and motor skills of their participating child. Children were then assessed with the full version of the German BOT-2 within one session. All data were gathered with an electronic data capturing system to enable merging of data across regions.

Table 1 Hypothesised relationships between BOT-2 with parent evaluations.

Please cite this article in press as: Vinçon, S., et al. Ecological validity of the German Bruininks-Oseretsky Test of Motor Proficiency – 2nd Edition. Human Movement Science (2016), http://dx.doi.org/10.1016/j.humov.2016.10.005

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2.3. Research instruments 2.3.1. Parent questionnaire Parental reports of the motor performance and skills of their child were included within a detailed questionnaire. Questions and response format were deliberately kept simple to allow for a lower level of parental education and in doing so, reduce response bias. 2.3.1.1. Fine and gross motor skills. To assess parental views on the general motor proficiency of their children, parents rated the fine and gross motor skills on an ordinal scale from one to ten; one representing very high skill and ten very awkward. The scale ratings were derived from the Canadian Occupational Performance Measure (Cusick, Lannin, & Lowe, 2007) to capture the parents’ global perspectives of their child’s motor competence and thus allow for variation in the type of activities typically undertaken by individual children and parental expectations for performance. 2.3.1.2. Specific motor activities. To gather information about parents’ views on the motor performance of their children during everyday motor activities, parents rated their child’s performance on six typical motor activities on a simple three-stage scale as less good, equally good or better in comparison to peers. The rating dimensions were derived from the DCDQ-07, as a reflection of the skill level the child may be expected to achieve within his/her peer group (Wilson et al., 2009). Responses were also available for children who had not yet had the opportunity to learn the task or the performance was not known. For data analysis, answers of I don’t know, not learnt yet and general system missing values were not included in comparisons. For equal representation across fine and gross motor tasks, three activities focused on fine motor proficiency (drawing, writing, arts and crafts) and three focused on gross motor proficiency (riding scooter/bicycle, playing ball games and sports in general). In view of the broad age range in this study (spanning eleven years) activities were chosen that were either possible for all age groups, or that older children may have performed in the past (e.g. drawing). All six motor activities were identified as being relevant for children in the German-speaking cultural context. The relevance of these tasks was agreed on via the expert opinion of professionals involved in the child centre in Maulbronn. Additionally, these activities were often named as common problems for children with DCD (Magalhaes et al., 2011; Missiuna et al., 2007) and frequently cited as a cause of concern in referrals to clinical services in Germany for children suspected of having DCD. 2.3.2. BOT-2 and German BOT-2 The BOT-2 (Bruininks & Bruininks, 2005), and the earlier version (Bruininks, 1978), are standardised motor assessments widely used by practitioners and researchers. The BOT-2 was designed to measure motor proficiency across a number of domains grouped into four composites based on the predominant involvement of the hands (‘Fine Manual Control’ and ‘Manual Coordination’) or whole/gross body functions (‘Body Coordination’ and ‘Strength and Agility’). The full version of 53 items, classified into eight subtests administered in approximately 1 h, provides an extensive assessment of the motor proficiency of children and adolescents. Although the items, structure, and underlying theory remains the same in the German BOT-2, published in 2014, expansion of the administrative procedures were required, particularly test item instructions, to obtain best possible standardisation (Blank et al., 2014). 2.4. Statistical analyses Descriptive statistics were presented in absolute and relative frequency. German gender-specific BOT-2 norm values were compared with parental report of their child’s fine and gross motor skills and six relevant activities. Because parental ratings were not standardised for gender and age, influence of these covariates was considered. Due to limited space we do not report all detailed age or gender-specific results; these are available upon request from the first author. Nonparametric statistical procedures were applied due to the ordinal ratings of the parental responses. Comparison between parental fine and gross motor ratings is reported with the Kendall tau b measure. The parent ratings of typical motor tasks and the German BOT-2 subtest scale scores were compared using the Jonckheere Terpstra test (J-T). Similar to the non-parametric Kruskal-Wallis test this trend test compares several independent samples from the same population, but in an ordered manner. To test for the influence of gender and age, a non parametric Mann-Whitney U test was used. Due to alpha error inflation in multiple testing, only a p-value below < 0.001 was considered as significant. 3. Results 3.1. Sample description Demographic characteristics of the participants are outlined in Table 2. Age of children ranged from four to 14 years (median 8.08 years; mean 8.59, SD 3.18) with equal distribution of gender in each year. Based on the German school system, three age groups were classified, representing kindergarten (four to six years), primary school (seven to ten years) and secondary school (11 to 14 years). Six year old children were included in the first age group one as the majority (61.2%) of the six

Please cite this article in press as: Vinçon, S., et al. Ecological validity of the German Bruininks-Oseretsky Test of Motor Proficiency – 2nd Edition. Human Movement Science (2016), http://dx.doi.org/10.1016/j.humov.2016.10.005

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S. Vinçon et al. / Human Movement Science xxx (2016) xxx–xxx Table 2 Description of participants. Variable Country data assessed Germany Austria Switzerland Children: Gender Female Male Children: Age in years Age group one (4–6) Age group two (7–10) Age group three (11–14) Children: School/Institution Type1 Kindergarten Primary school Secondary school Person answering questionnaire2 Mother Father Others Parents: Migration background Both parents residents One parent residents Both parents foreign Parents education No degree/Others Lower level secondary school Higher level secondary school

Number

Percentage

971 113 93

82.5% 9.6% 7.9%

606 571

51.5% 48.5%

470 ($: 243; #: 227) 391 ($: 206; #: 185) 316 ($: 157; #: 159)

39.9% 33.2% 26.9%

401 400 347

34.9% 34.8% 30.3%

1036 117 18

88.5% 10% 1.5%

999 113 65 Mother3 42 466 632

84.9% 9.6% 5.5% Mother 3.7% 40.9% 55.4%

Father4 53 434 634

Father 4.7% 38.7% 56.6%

Due to missing data: 1Total 1148; 21171; 3Total 1140; 4Total 1121.

Table 3 German BOT-2 normative sample: subtest total point scores. Variable Subtest Subtest Subtest Subtest Subtest Subtest Subtest Subtest

1 2 3 7 4 5 6 8

Fine Motor Precision Fine Motor Integration Manual Dexterity Upper-Limb Coordination Bilateral Coordination Balance Running Speed and Agility Strength

Min

Max

Median

Mean

SD

0 0 1 0 0 4 3 2

41 40 43 39 24 37 49 42

37 35 26 29 21 32 32 23

33.49 31.10 25.22 24.36 18.30 30.80 30.61 21.50

8.11 9.72 8.47 13.29 6.20 5.58 9.44 8.96

Skewness 1.271 1.231 0.245 0.516 1.062 1.422 0.500 0.202

year old participants were still attending kindergarten. The majority of parents (84.9%) were native to the assessed countries Germany, Switzerland or Austria. In only 5.5%, both parents were born in other countries, mostly from Europe. Approximately 95% of the parents finished their secondary school, the majority of them with a higher level of secondary schooling. Level of education was approximately equivalent between mothers and fathers (See Table 2 for participant demographics). 3.2. Standardised motor assessment Table 3 shows many children achieved the highest total point scores skewing the results (apart from subtest 6 which had a maximum of 52). Skewness was adjusted through standardisation for a mean of approximately 15 for all subtests. 3.3. Parental ratings of fine and gross motor skills Twenty-six fine motor and 24 gross motor parent ratings were missing. Thus, about 98% of the parents rated their child’s fine and gross motor skills. For both fine and gross motor skills, the vast majority of parents appraised their children from one to three, skilled to very skilled (76.1% for fine motor skills; 78.8% for gross motor skills), with only 1.5% (fine motor) and 1.2% (gross motor) of parents rating their child as having lower skill levels e.g. ratings of eight to ten. Parents reported better ability for females in fine motor (Z-value = 7.8; p < 0.001) but not in gross motor (Z-value = 1.2; p = 0.226) skills. There were no significant differences found within each gender on the distribution of ratings of motor skills across the three age groups. The comparison between the parental ratings for fine and gross motor skills showed that these were significantly associated (Kendall tau b = 0.421, p < 0.00001). In other words, children who were rated as skilled or awkward in fine motor skills were similarly evaluated by their parents in gross motor skills.

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3.4. German BOT-2 results in comparison with parental ratings of fine and gross motor skills The results of the comparison between German BOT-2 results and parental ratings of fine and gross motor skills are presented in Table 4. Due to the identified gender effect for parental ratings in fine motor skills, results for females and males are presented separately, whereas for gross motor skills, results are presented for both genders combined. The strongest association between the German BOT-2 in comparison with parental ratings of females’ fine motor skills is seen for subtest 2 ‘Fine Motor Integration’ (p < 0.001). In contrast, for the relationship between the German BOT-2 fine motor subtest results and the parental ratings of males’ fine motor skills, all but subtest 7 ‘Upper-Limb Coordination’ showed an association. As expected, subtests 1 ‘Fine Motor Precision’, 2 ‘Fine Motor Integration’ and 3 ‘Manual Dexterity’ were significantly correlated with parental ratings as well as subtest 5 ‘Balance’. For the parent ratings of gross motor skills, both genders combined, three of the four gross motor German BOT-2 subtests achieved significant correlations (except subtest 4 ‘Bilateral Coordination’ p = 0.032). In addition, subtest 1 ‘Fine Motor Precision’ and subtest 7 ‘Upper-Limb Coordination’ were correlated with the parental ratings of gross motor proficiency of the children (See Table 4). 3.5. Parental ratings of motor activities Approximately two thirds (63%–69%) of parents rated their children as equally good in performance of the six motor activities in comparison to their peers. Six to 17% of children were rated worse in performance than peers in fine motor activities drawing (17%) and writing (15%), and the gross motor activity of ball games (15%). In contrast, fewer children were rated as worse than their peers in riding scooter/bicycle (6%) and sports in general (7%). Most ratings for better performance in comparison to peers were given for these two gross motor activities (riding scooter/bicycle 26%; sports in general 24%) and 18–20% for the other four activities. In all motor activities, apart from sports in general (p = 0.383), a significant gender difference (p < 0.001) was seen between parental ratings of boys and girls regarding the level of performance. An age effect (p < 0.001) was found for ball games, riding scooter/bicycle and sports, but not for the fine motor activities. 3.6. German BOT-2 results in comparison with parental ratings of motor activities The results of comparisons between German BOT-2 results and the parental ratings of performance in six motor activities are presented in Table 5. The German BOT-2 fine motor subtests 1, 2 and 3 were significantly correlated with fine motor based activities of drawing, writing and arts and crafts. Subtest 6 ‘Running Speed and Agility’, a gross motor subtest, was also significantly correlated with parental evaluation of arts and crafts ability. Subtest 7 ‘Upper-Limb Coordination’ was closely associated with parental ratings for ball games. Report of skills in balls games also showed significant correlations with subtest 8 ‘Strength’ and subtest 6 ‘Running Speed and Agility’. Similar results were found for riding scooter/bicycle and sports in general. From the four gross motor subtests just two (‘Running Speed and Agility’ and ‘Strength’) correlated with the parental ratings. No significant relationship was seen between subtest 5 ‘Balance’ and 4 ‘Bilateral Coordination’ and parental ratings of riding scooter/bicycle. ‘Upper-Limb Coor-

Table 4 Comparison of German BOT-2 subtests scale scores (gender-specific norms) and parental view on fine and gross motor skills⁄.

7 Upper-Limb Coordination

4 Bilateral Coordination

5 Balance

6 Running Speed & Agility

8 Strength

-2.967

-3.590

-2.705

-2.150

-1.562

-2.456

-1.545

-1.533

.003

<0.001

.007

.032

.118

.014

.122

.125

1 Fine Motor Precision

3 Manual Dexterity

Gross motor subtests

2 Fine Motor Integration

Fine motor subtests

Female Finemotor N=593

Parental rating

Std. J-T Statistic p-Value Male Finemotor N=558 Std. J-T Statistic

-6.207

-4.153

-3.872

-1.657

-3.318

-3.625

-3.445

-2.635

p-Value

<0.001

<0.001

<0.001

.098

.001

<0.001

.001

.008

Std. J-T Statistic

-3.515

-2.271

-3.019

-5.236

-2.143

-3.608

-5.646

-7.260

p-Value

<0.001

.023

.003

<0.001

.032

<0.001

<0.001

<0.001

Both gender Gross motor N=1153

*The shaded fields represent the hypothesis-expected relationships; bold numbers indicate significant results. Std = Standardised; J-T = Jonckheere Terpstra.

Please cite this article in press as: Vinçon, S., et al. Ecological validity of the German Bruininks-Oseretsky Test of Motor Proficiency – 2nd Edition. Human Movement Science (2016), http://dx.doi.org/10.1016/j.humov.2016.10.005

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S. Vinçon et al. / Human Movement Science xxx (2016) xxx–xxx Table 5 Comparison German BOT-2 subtests scale scores (gender-specific norms) and parental ratings of motor activities⁄.

5 Balance

6 Running Speed and Agility

5.833

-3.442

2.725

2.372

3.316

-.674

<0.001

.001

.006

.018

.001

.500

8 Strength

4 Bilateral Coordination

6.751 <0.001

2 Fine Motor Integration

6.426 <0.001

1 Fine Motor Precision

7 Upper-Limb Coordination

Gross motor subtests

3 Manual Dexterity

Fine motor subtests

Good in drawing N=1123 Std. J-T Statistic p-Value Good in writing N=892 Std. J-T Statistic

Parental ratings

p-Value

4.674

4.796

3.801

.658

1.303

2.456

2.598

1.134

<0.001

<0.001

<0.001

.511

.193

.014

.009

.257

Good in arts and crafts N=1120 Std. J-T Statistic p-Value

7.488

5.074

5.547

-2.562

3.167

3.152

3.864

.982

<0.001

<0.001

<0.001

.010

.002

.002

<0.001

.326

-1.401

-.029

-.298

12.103

-.934

1.263

4.662

6.647

.161

.977

.766

<0.001

.350

.207

<0.001

<0.001

-.343

-.423

-.313

5.150

-.531

1.086

2.621

4.623

.732

.672

.754

<0.001

.595

.278

.009

<0.001

1.370

1.139

1.712

6.909

.689

2.361

7.173

8.036

.171

.255

.087

<0.001

.491

.018

<0.001

<0.001

Good in ball games N=1108 Std. J-T Statistic p-Value Good in riding scooter/bicycle N=1130 Std. J-T Statistic p-Value Good in sports N=1130 Std. J-T Statistic p-Value

*The shaded fields represent the hypothesis-expected relationships; bold numbers indicate significant results. Std = Standardised; J-T = Jonckheere Terpstra.

dination’, included in the fine-motor related composite, showed significant correlations with parental ratings of riding scooter/bicycle and sports in general. 4. Discussion This large study on healthy, non-disabled children between four and 14 years, investigated the ecological validity of the broad spectrum of the German BOT-2. Relationships between the subtests of the German BOT-2 and performance of everyday motor skills and activities, as evaluated by parents were mostly as hypothesized, albeit with some discrepancies found in relation to ‘Upper-Limb Coordination’, ‘Bilateral Coordination’ and ‘Balance’. 4.1. Relationship between fundamental motor skills assessed by the German BOT-2 and performance in everyday fine and gross motor skills The objective measurement across the fine and gross motor dimensions of the German BOT-2 corresponded to parental evaluation of fine and gross motor skills. ‘Strength’ in particular was seen to be associated with gross motor capacity and ‘Fine Motor Integration’ more with fine motor skills. However, the expected alignment of ‘Upper-Limb Coordination’ with the fine motor skill construct of the German BOT-2 was not found. There may be a number of reasons for this which may in part be related to the context of motor assessments undertaken on a single occasion of performance, whereas parents’ perspectives are built up from multiple impressions over a longer time frame. However, notable, with respect to the tasks within the ‘Upper-Limb Coordination’ subtest, is the focus on ball skills of throwing and catching. It is possible to conjecture that parents did not necessarily consider ball skills as ‘fine motor’ tasks and thus reported in relation to more specific ‘table-top’ activities such as handwriting, buttoning or sewing as evidenced by the stronger association with equivalent tasks in the German BOT-2 contained in the fine motor and manual dexterity subtests. Previous studies investigating parental perspectives have used questionnaires, including the DCDQ (Green & Wilson, 2008) or the MABC-2 Checklist (Brown & Lane, 2014; Kennedy et al., 2012). Although these questionnaires indirectly assess more general motor composites, individual questions capture daily life situations which are familiar to parents and appropriate to the culture in which the questionnaires were developed. In comparison, in the current study, parents were asked directly about global concepts of fine and gross motor. Thus, they were able to apply a more subjective interpretation of the context and tasks to define fine and gross motor abilities of their children. Peters, Barnett, and Hendersen (2001) pointed out the importance of language and explicit definitions of terms, highlighting a divergence in understanding of apparently Please cite this article in press as: Vinçon, S., et al. Ecological validity of the German Bruininks-Oseretsky Test of Motor Proficiency – 2nd Edition. Human Movement Science (2016), http://dx.doi.org/10.1016/j.humov.2016.10.005

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familiar terms such as clumsiness, dyspraxia and DCD, even by health professionals. It is possible that in this German study, lack of familiarity and definition of the terms gross and fine motor may have influenced the results with increased variability of reporting between parents. Missiuna and Pollock (2000) found parents (of school-age children) to be more focused on childrens’ fine motor activities in view of the importance of academic tasks over leisure activities of children. The gender differences in our study also suggest that parents may differentially evaluate girls and boys across fine motor activities. This may in part be due to the opportunities to observe, and hence evaluate skills of girls based on their more frequent engagement in fine motor, arts and crafts than gross motor sports activities and the reverse for boys. Without directly evaluating the frequency and enjoyment in participation across these tasks between genders, it is not possible to ascertain whether the differences in our outcomes were due to skill or experience. 4.2. Relationship between fundamental motor skills assessed by the German BOT-2 and performance in specific everyday motor activities Previous studies, including Brown and Lane (2014), Green and Wilson (2008) or Kennedy, Brown, and Stagnitti (2013), have demonstrated a relationship between motor capacity and activity performance. Whereas all these studies investigated the assessments as whole, or as individual constructs, this is the first study that examined the relationship between fundamental motor skills assessed by a standardised assessment and specific motor activities of daily life. While our hypothesized links between performance on the German BOT-2 fine motor subtests and everyday ‘fine-motor’ tasks was generally upheld, this study showed some interesting results for the gross motor activities of riding a scooter/ bicycle and performance in sports in general. From a theoretical perspective, riding a bike may be thought to be associated with motor functions of balance, body coordination and fitness. Yet, neither the German BOT-2 subtests ‘Balance’ or ‘Bilateral Coordination’, (including tasks requiring coordination of upper and lower extremities of both sides of the body), nor ‘Running Speed and Agility’ (including strength and potentially fitness), were significantly associated with parental ratings of capacity to ride a bike/scooter. Comparisons of ability measured across the domains of the ICF have important implications for intervention. Whereas traditional (process-oriented) therapy approaches focus more on motor functions and components of skills, task-oriented approaches focus on the motor activity and performance and specific (cultural and context dependent) demands of the task (Smits-Engelsman et al., 2013). Our results suggest that the performance of daily motor tasks may not necessarily be as dependent on general motor functions such as balance or bilateral coordination as hypothesised. The results of this study support the theory of task specificity, which considers an activity as a whole, thus an interaction between the child’s abilities (strengths and weaknesses), task difficulty and environmental supports. Within motor learning theories and motor skill acquisition, the concept of transfer of learning describes the transfer of a (motor) skill from one context to another or the transfer of one skill to a another related or different skill (Edwards, 2010; Polatajko & Mandich, 2004). Transfer in motor learning is seen to be more likely the more similar the tasks sharing common elements (Edwards, 2010). From this theoretical background, components tested in the German BOT-2 subtests ‘Balance’, ‘Bilateral Coordination’ and ‘Running Speed and Agility’ appear to be further from the gestalt of the activity of riding a bike which includes a number of other capacities. In contrast, the tasks of ‘Fine Motor Precision’ and ‘Fine Motor Integration’, involving a pencil and drawing, are more similar to the activities of drawing and writing and hence more directly related to the tasks parents were rating. Thus the parent ratings on the three fine motor tasks drawing, writing and arts and crafts and also ball games, were more closely aligned with assessment on similar subtests of the German BOT-2. Van der Linde et al. (2015) has taken this discussion forward by investigating assessments for children with DCD with respect to the ICF levels of activities and participation. They found that the BOT-2 includes items linked to leisure and play as well as productivity and school, but without direct assessment of specific school tasks such as writing. The results of the present study showed that although writing is not assessed explicitly within the German BOT-2, but rather indirectly via drawing shapes, the results of the subtests ‘Fine Motor Precision’, ‘Fine Motor Integration’ and ‘Manual Dexterity’ appear to be related to the parental evaluation of writing. Although Kennedy et al. (2012) highlighted the limited relevance of items of performance-based assessments to real-life context, somewhat in contrast, the current study suggests that the relationship between component-based assessment and performance in daily life increases when the component items are more similar to daily task activities. 4.3. Ecological validity From an ecological perspective, verisimilitude only requires that the test/test items are conceptually similar to everyday situations. Our study suggests that those tasks that were closer in construct and face validity to everyday tasks (e.g. folding or cutting paper of the BOT-2 to arts and crafts) were more predictive of real-world performance. In contrast those tasks that are theoretically linked to motor performance but conceptually different and or influenced by other factors such as environmental context or additional cognitive and perceptual skills showed a less clear association. Thus the static and dynamic balance and bilateral coordination items of the BOT-2 were not predictive of performance in riding a bike or scooter which require steering and navigating with differing environmental challenges.

Please cite this article in press as: Vinçon, S., et al. Ecological validity of the German Bruininks-Oseretsky Test of Motor Proficiency – 2nd Edition. Human Movement Science (2016), http://dx.doi.org/10.1016/j.humov.2016.10.005

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In contrast, the subtest ‘Running Speed and Agility’ correlated with most of the motor activities. These results are similar to the findings of Kennedy et al. (2012), who compared the BOT-2 and the M-ABC-2 checklist (as parental evaluation). In their sample, the BOT-2 composite ‘Strength and Agility’ had the strongest correlation with the MABC-2 checklist ‘Total Motor Score’. This corresponds to our own results which suggest that ‘Strength and Agility’ may reflect capacities underpinning a number of motor tasks. ‘Upper-Limb Coordination’, a subtest defined as a fine motor subtest in the BOT-2, showed similar parental ratings to gross motor activities, but not with the fine motor. As this subtest solely involves upper extremity ball skill tasks, it was decided in the German BOT-2 to rename this subtest as ball skills (Blank et al., 2014). Arguably, and somewhat depending on cultural background, ball games are not necessarily conceptualized as fine motor skills, but rather requiring both fine and gross motor skills e.g. cricket versus football (soccer). It is notable that in Germany, ball games are most often associated with skills involving kicking (football) rather than throwing and catching as assessed in the BOT-2. Therefore, the theoretical background of Bruininks, which classifies items according to the extremities and muscles which were involved (Bruininks and Bruininks, 2005), may be too simple a classification in view of the complexity of ball skills conceptualized by parents. The results of this study question the classification of this subtest within the fine motor construct. It is important to note that, even if a test appears similar to everyday tasks, there may still be aspects of the testing situation limiting applicability to real-world everyday motor performance (Chaytor and Schmitter-Edgecombe, 2003). In considering the results with respect to concepts of ecological validity, the focus of clinical assessments, such as the BOT-2, are on what the child does, but not on what they can do. What the child does in a contrived, if not artificial environment (e.g. quiet, minimal distractions, clinician prompted and supportive of response regardless of success) is not necessarily what the child may do in his or her everyday environment. Behaviour assessed in a few hours on a single day, may be influenced by multiple transient factors, not least anxiety. There is thus limited opportunity to consider the child’s strengths and how compensatory strategies may allow for successful performance in daily tasks. This may result in an underestimation of what can be achieved. A number of limitations of this study need to be considered when interpreting these results; importantly, the limited range of scoring of parental ratings. While parental viewpoints and subjective impressions are accrued over time and across contexts, this study was not able to determine reliability of report within and or between parents (paternal versus maternal perspectives). In contrast, objective measurement may show greater inter- and intra-rater reliability but only represents performance at a discreet time point and fails to take into account motivation and learning across contexts that may lead to an impression of skill or lack of skill evidenced in parent reports. Furthermore, due to the normative sample, the implications for children with DCD cannot be determined. In view of the extensive assessments required for the primary study, the German BOT-2 standardisation, the additional assessments and scale dimensions probing parent and potentially child perspectives of skills and participation were limited in order to facilitate completion. The study was also unable to take into consideration the educational level or family (e.g. sibling order) and social and environmental factors that may have influenced either parental reports or skill acquisition. While the questions were deliberately simplified with straightforward scaling dimensions, there may have been some variations in response patterns that could not be detected. A major strength of this study was the large sample and control for repeated measures (limiting p-values for significance). Despite this, the association between clinical assessment and everyday performance of motor skills via objective and subjective assessments has rarely been investigated.

5. Conclusion Overall, the results of this study provide an important contribution to further practice and application of assessments used to investigate motor proficiency of children and adolescents and performance of daily motor tasks. The concepts of ecological validity, verisimilitude and veridicality, of the German BOT-2 are evidenced through theoretical and empirical relationships to performance of some but not all everyday real-world motor tasks. This study supports the theory of task specificity in which underlying motor functions are not automatically relevant for performance of specific motor activities. Future research should investigate relationships between fundamental motor skills and daily activity performance and participation. Inclusion of a clinical sample will allow consideration of the validity of the German BOT-2 for clinical practice. Additionally, the results of this study raised questions regarding the validity and informal value of the two German BOT-2 gross motor subtests, ‘Bilateral Coordination’ and ‘Balance’. Future research to gain better insight and knowledge about the practical implication of these subtests should be conducted, especially for children with movement difficulties. Ecological validity of assessments should be considered for veracity in both the diagnostic formulation of DCD and in relation to any subsequent intervention planning.

Acknowledgement We would like to express our thanks to all participating parents, children and therapists and Pearson Assessment & Information GmbH, which sponsored the German BOT-2 standardisation study. The current study was part of the first authors’ master thesis in occupational therapy. With thanks to Carol Mytton for her support throughout this process. Please cite this article in press as: Vinçon, S., et al. Ecological validity of the German Bruininks-Oseretsky Test of Motor Proficiency – 2nd Edition. Human Movement Science (2016), http://dx.doi.org/10.1016/j.humov.2016.10.005

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Please cite this article in press as: Vinçon, S., et al. Ecological validity of the German Bruininks-Oseretsky Test of Motor Proficiency – 2nd Edition. Human Movement Science (2016), http://dx.doi.org/10.1016/j.humov.2016.10.005