12
The American Journal of Occupational Therapy 47 Development and Standardization of a “Do–Eat” Activity of Daily Living Performance Test for Children KEY WORDS • activities of daily living • ecosystem • motor skills disorders • reproducibility of results Naomi Josman, PhD, is Associate Professor, Department of Occupational Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel, Haifa 31905 Israel; [email protected] Ayelet Goffer, MSc, is Adjunct Lecturer, Department of Special Education, Faculty of Education, Oranim Academic College of Education, Kiryat Tivon. At the time of the study, she was master’s-degree student, Department of Occupational Therapy, University of Haifa, Mount Carmel, Haifa, Israel. Sara Rosenblum, PhD, is Chair and Senior Lecturer, Department of Occupational Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel, Haifa, Israel. BACKGROUND. The Do–Eat was developed to evaluate daily task performance abilities among children with developmental coordination disorder (DCD). This study investigated the tool’s reliability and validity. METHOD. Participants were 59 children ages 5 to 6.5 years; 30 children diagnosed with DCD according to the DSM–IV–TR; and a control group of 29 children, who were matched for age, gender, and sociodemographic background. RESULTS. Both the Do–Eat and the accompanying Parent Questionnaire yielded high internal consistency (αs = .89–.93). Construct validity was demonstrated by significant between-group differences on the Do-Eat (t [57] = 14.09, p < .001) and the Parent Questionnaire (t [57] = 3.64, p < .001). Significant correlations between children’s scores on the sensory–motor component of the Do–Eat and the Movement Assessment Battery for Children final score confirmed concurrent validity (r = −.86, p < .001). CONCLUSIONS. Results suggest that the Do–Eat is a reliable, valid tool for identifying children at risk for DCD. Josman, N., Goffer, A., & Rosenblum, S. (2010). Development and standardization of a “Do–Eat” activity of daily living performance test for children. American Journal of Occupational Therapy, 64, 47–58. Naomi Josman, Ayelet Goffer, Sara Rosenblum D evelopmentalcoordinationdisorder(DCD)ischaracterizedbymotorimpair- mentthatsignificantlyinterfereswithachild’sactivitiesofdailyliving(ADLs) and academic achievement (Criterion A and B of the Diagnostic and Statistical Manual of Mental Disorders, 4thed.,textrev.[DSM–IV–TR];AmericanPsychiatric Association[APA],2001;Dewey&Wilson,2001;Miyahara&Mobs,1995). ResearchanalyzingADLsofchildrenwithDCDhaspointedtoevidencethat thesechildrenparticipatelessthantheirpeersindailyhouseholdactivitiesandin educationalandsocialsettings(Cermak&Larkin,2002).Ayres(1985)claimed thatchildrenwithsensory–motordifficultieslearndailyskillslaterthantheirpeers anddosoinanineffectivemanner.Theybecomefrustratedwhiletryingtolearn newskillsand,asaresult,avoidparticipating.Thedifficultiesmanifestedinbasic dailyfunctionsareevidentindressing,personalhygiene,andeatingaswellasin instrumental ADLs (IADLs), such as preparing food (May-Benson, Ingola, & Koomar,2002). AstudyconductedbyMay-Benson(1999)focusedonchildrenwithdyspraxia duringschoolyearsandfoundthat71%ofchildrenhaddifficultyusingcutleryand tyingshoelaces,46%haddifficultydressingandbuttoning,and67%displayedmessy eating.Hoare(1994)foundthatyoungchildrenwithDCDhavedifficultiesrelated toeating,suchaschewingdifferenttypesoffood,pouringmilkintoaglass,cutting food,andclearingdishesfromthetable.Theyhavedifficultyeatingwithcutleryand tendtosoilthemselvesandtheirimmediatesurroundings.Themannerinwhich Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930031/ on 11/15/2018 Terms of Use: http://AOTA.org/terms

Development and Standardization of a “Do–Eat” Activity of ... · larly during the early-morning rush routine and at mealtimes (Missiuna, 2001). The significance of such children’s

  • Upload
    others

  • View
    1

  • Download
    0

Embed Size (px)

Citation preview

Page 1: Development and Standardization of a “Do–Eat” Activity of ... · larly during the early-morning rush routine and at mealtimes (Missiuna, 2001). The significance of such children’s

The American Journal of Occupational Therapy� 47

Development and Standardization of a “Do–Eat” Activity of Daily Living Performance Test for Children

KEY WORDS• activities of daily living• ecosystem• motor skills disorders• reproducibility of results

Naomi Josman, PhD, is Associate Professor, Department of Occupational Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel, Haifa 31905 Israel; [email protected]

Ayelet Goffer, MSc, is Adjunct Lecturer, Department of Special Education, Faculty of Education, Oranim Academic College of Education, Kiryat Tivon. At the time of the study, she was master’s-degree student, Department of Occupational Therapy, University of Haifa, Mount Carmel, Haifa, Israel.

Sara Rosenblum, PhD, is Chair and Senior Lecturer, Department of Occupational Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel, Haifa, Israel.

BACKGROUND. The Do–Eat was developed to evaluate daily task performance abilities among children with developmental coordination disorder (DCD). This study investigated the tool’s reliability and validity.

METHOD. Participants were 59 children ages 5 to 6.5 years; 30 children diagnosed with DCD according to the DSM–IV–TR; and a control group of 29 children, who were matched for age, gender, and sociodemographic background.

RESULTS. Both the Do–Eat and the accompanying Parent Questionnaire yielded high internal consistency (αs = .89–.93). Construct validity was demonstrated by significant between-group differences on the Do-Eat (t [57] = 14.09, p < .001) and the Parent Questionnaire (t [57] = 3.64, p < .001). Significant correlations between children’s scores on the sensory–motor component of the Do–Eat and the Movement Assessment Battery for Children final score confirmed concurrent validity (r = −.86, p < .001).

CONCLUSIONS. Results suggest that the Do–Eat is a reliable, valid tool for identifying children at risk for DCD.

Josman, N., Goffer, A., & Rosenblum, S. (2010). Development and standardization of a “Do–Eat” activity of daily living performance test for children. American Journal of Occupational Therapy, 64, 47–58.

Naomi Josman, Ayelet Goffer, Sara Rosenblum

Developmental�coordination�disorder�(DCD)�is�characterized�by�motor�impair-ment�that�significantly�interferes�with�a�child’s�activities�of�daily�living�(ADLs)�

and� academic� achievement (Criterion�A�and�B�of� the�Diagnostic and Statistical Manual of Mental Disorders, 4th�ed.,�text�rev.�[DSM–IV–TR];�American�Psychiatric�Association�[APA],�2001;�Dewey�&�Wilson,�2001;�Miyahara�&�Mobs,�1995).

Research�analyzing�ADLs�of�children�with�DCD�has�pointed�to�evidence�that�these�children�participate�less�than�their�peers�in�daily�household�activities�and�in�educational�and�social�settings�(Cermak�&�Larkin,�2002).�Ayres�(1985)�claimed�that�children�with�sensory–motor�difficulties�learn�daily�skills�later�than�their�peers�and�do�so�in�an�ineffective�manner.�They�become�frustrated�while�trying�to�learn�new�skills�and,�as�a�result,�avoid�participating.�The�difficulties�manifested�in�basic�daily�functions�are�evident�in�dressing,�personal�hygiene,�and�eating�as�well�as�in�instrumental�ADLs� (IADLs),� such� as�preparing� food� (May-Benson,� Ingola,�&�Koomar,�2002).

A�study�conducted�by�May-Benson�(1999)�focused�on�children�with�dyspraxia�during�school�years�and�found�that�71%�of�children�had�difficulty�using�cutlery�and�tying�shoelaces,�46%�had�difficulty�dressing�and�buttoning,�and�67%�displayed�messy�eating.�Hoare�(1994)�found�that�young�children�with�DCD�have�difficulties�related�to�eating,�such�as�chewing�different�types�of�food,�pouring�milk�into�a�glass,�cutting�food,�and�clearing�dishes�from�the�table.�They�have�difficulty�eating�with�cutlery�and�tend�to�soil�themselves�and�their�immediate�surroundings.�The�manner�in�which�

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930031/ on 11/15/2018 Terms of Use: http://AOTA.org/terms

Page 2: Development and Standardization of a “Do–Eat” Activity of ... · larly during the early-morning rush routine and at mealtimes (Missiuna, 2001). The significance of such children’s

48� January/February 2010, Volume 64, Number 1

they�eat�has�a�negative�impact�on�their�family�environment�at�mealtimes�and�is�used�as�a�justification�by�classmates�for�taunting�(Hoare,�1994).�When�children�with�DCD�get�to�school,�they�experience�difficulty�in�acquiring�writing�skills�(Benbow,�1995)�and,�over�time,�increasingly�fail�to�com-plete�written�tasks�and�assignments�in�a�reasonable�amount�of� time� (Benbow,�2002).�Because� of� impaired� function,�many�children�with�DCD�are�referred�for�occupational�or�physical� therapy� (Dunford,� Street,� O’Connell,� Kelly,� &�Sibert,� 2004;� Green� et� al.,� 2005;� Peters,� Henderson,� &�Dookun,�2004).

Reliable�assessment�tools�for�validating�the�DSM–IV–TR�criteria�for�diagnosis�of�a�child�with�DCD�referred�for�treatment�are�scarce;�although�this�state�of�affairs�has�been�documented�in�the�literature,�the�consequences�are�inade-quate�interventions�for�these�children�(Dewey�&�Wilson,�2001).�For�example,�research�into�the�course�of�treatment�of�children�with�DCD�over�several�years�found�that�by�age�8,�a�typical�child�with�DCD�has�been�referred�to�10�differ-ent�therapeutic�sources�within�the�medical�service.�These�sources�often�include�two�terms�of�treatment�in�occupa-tional� therapy� within� different� frameworks� (Missiuna,�Moll,�Law,�King,�&�King,�2006).�These�findings�demon-strate� the� need� to� develop� a� viable� assessment� tool� that�provides�a�clear�and�comprehensible�indication�of�the�func-tion�of� children�with�DCD�and� facilitates� the�design�of�tailored�intervention�goals�based�on�specific�demonstrated�needs�(Dunford�et�al.,�2004;�Miller,�Missiuna,�Macnab,�Malloy-Miller,�&�Polatajko,�2001).

According� to� the� literature,� functional� difficulties� of�children�with�DCD�manifest�themselves� in�the�children’s�ability�to�dress,�in�eating-related�activities,�and�in�handwrit-ing�difficulty.�The�assessment�tool�described�in�this�article�addresses�these�specific�areas.�The�need�for�viable�tools�that�address�function-related�difficulties�is�especially�amplified�by�the�research�literature,�which�has�documented�the�impaired�quality�of�life�of�the�child�and�his�or�her�family�resulting�from�these�difficulties� (Sprinkle�&�Hammond,�1997).�Because�these� children� cannot�perform�daily� functional� activities,�their�lives�and�those�of�their�families�are�fraught�with�intense�feelings�of�frustration�(Cermak�&�Larkin,�2002).�Parents�of�children�with�DCD�have�reported�that�accomplishing�tasks�requires�considerable�time�and�energy�(May-Benson,�1999),�and�severe�tensions�are�aroused�within�the�family,�particu-larly�during�the�early-morning�rush�routine�and�at�mealtimes�(Missiuna,�2001).

The�significance�of�such�children’s�incompetent�ADL�performance�has�previously�been�discussed.�Daving,�Andren,�and�Grimby�(2000)�indicated�that�independence�in�everyday�activities�actually�enhances�adaptation�to�the�environment�and�optimizes�function.�Likewise,�having�control�over�self-

care�activities�contributes�to�the�child’s�feelings�of�compe-tence� and� improves� integration� in� school� (Chapparo� &�Hooper,�2005).�Therefore,�impairments�in�everyday�func-tioning� interfere�with� the� child’s� ability� to�participate� in�family�and�school�activities�(Case-Smith,�1993).

In�light�of�this�evidence,�the�ability�to�assess�daily�activity�functioning�in�children�with�DCD,�emphasizing�quality�of�performance� and�participation,� is� imperative� (Cermak�&�Larkin,�2002;�May-Benson�et�al.,�2002).�However,�the�puz-zling�plight�of�children�with�DCD,�and�the�heterogeneous�nature�of�their�symptoms�and�presenting�difficulties�(comor-bidities),�make�the�process�of�assessment�extremely�compli-cated�and�raise�many�issues�regarding�the�adequacy�of�various�testing� methods� (Gibbs,� Appleton,� &� Appleton,� 2007;�Henderson� &� Barnett,� 1998;� Wann,� Mon-Williams,� &�Rushton,�1998;�Wilson,�2005).

Existing�methods�for�evaluating�the�performance�of�chil-dren�with�DCD�include�(1)�both�parent�and�teacher�ques-tionnaires—for�example,�the�Developmental�Coordination�Disorder� Questionnaire (Wilson,� Kaplan,� Crawford,�Campbell,�&�Dewey,�2000)�and�the�Children�Activity�Scale�Parent�and�Teacher�(ChAS–P–T;�Rosenblum,�2006)—and�(2)�assessment�tools—for�example,�the�Movement�Assessment�Battery�for�Children�(M–ABC;�Henderson�&�Sugden,�1992)�and�the�Bruininks–Oseretsky�Test (Bruininks�&�Bruininks,�2005;�for�a�discussion�regarding�evaluation�of�performance�in�children�with�DCD,�see�also�Henderson�&�Barnett,�1998;�Missiuna,�Rivard,�&�Bartlett,�2003,�2007).

Most�assessment�tools�developed�for�children�with�DCD�are�based�on� a� “bottom-up”� approach,�whereby� a� child’s�difficulties�are�evaluated�by�analyzing�gross�and�fine�motor�skills�(Mandich,�Polatajko,�Mancab,�&�Miller,�2001).�These�tests�exclude�any�evaluation�of�performance�related�to�daily�activities�(Crawford,�Wilson,�&�Dewey,�2001).�Moreover,�they�do�not�include�cognitive�performance�skills,�despite�the�importance�of�evaluating�the�relationships�between�cognition�and�sensory–motor�skills�(Ylvisaker�&�Szekeres,�1998)�and�their�relationship�to�performance�of�daily�tasks�(Katz,�2005).�In�addition�to�these�tools,�more�recent�tools�have�been�devel-oped,� based� on� a� “top-down”� approach� (e.g.,� Perceived�Efficacy�and�Goal�Setting�in�Young�Children;�Missiuna�&�Pollock,�2000);�however,�these�tools�do�not�address�IADLs.�Both�bottom-up�and�top-down�tools�for�children�with�DCD�described� here� raise� questions� regarding� their� ecological�validity�(Barnett�&�Peters,�2004).

According�to�Kvavilashvili�and�Ellis�(2004),�the�term�ecological validity�refers�to�both�the�task’s�degree�of�represen-tativeness�and�the�ability�to�generalize�test�results�to�ADLs�in�the�natural�environment.�In�that�context,�one�may�ask�what�relationships�exist�between�specific�tasks�(such�as�draw-ing�a�triangle�in�the�Beery–Buktenica�Developmental�Test�

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930031/ on 11/15/2018 Terms of Use: http://AOTA.org/terms

Page 3: Development and Standardization of a “Do–Eat” Activity of ... · larly during the early-morning rush routine and at mealtimes (Missiuna, 2001). The significance of such children’s

The American Journal of Occupational Therapy� 49

of�Visual–Motor�Integration�(Beery�&�Buktenica,�1997)�or�threading�beads� in�the�M–ABC)�and�the�child’s�everyday�home�or�school�performance�and�participation.�To�the�best�of�our�knowledge,� only�one� assessment� that� includes� the�child’s�ability�to�perform�functional�everyday�tasks�has�been�cited�as�a�possible�measure�for�children�with�DCD,�namely�the�Vineland�Adaptive�Behavior�Scale�(Sparrow,�Cicchetti,�&�Balla,�2005).�This�tool�was�actually�developed�for�assess-ing�children�with�mental�retardation�and�autism�(De�Bildt�et�al.,�2005)�but�was�not�initially�intended�for�children�with�atypical� brain�development� (Kaplan,�Wilson,�Dewey,�&�Crawford,� 1998)� or� specific� learning� disabilities� (Kirby,�Davies,�&�Bryant,�2005),�such�as�DCD.

In�summary,�a�review�of�the�literature�underscores�the�paucity�of�viable�top-down�tools�that�are�ecologically�valid�and�do�not�rely�solely�on�parental�reports.�Most�ADL�assess-ments�were�designed�for�children�with�complex�disabilities�and� are� inappropriate� for� children�with�DCD,� attention�deficit� hyperactivity� disorder,� and� learning� disabilities.�Moreover,�on�the�basis�of�several�citations�cited�earlier�in�this�article,�Missiuna�et�al.�(2007)�recently�indicated�that�an�accepted� standard� for� the� assessment� of� DCD� is� still�lacking.

This� article�presents� the�Do–Eat� (Goffer,� Josman,�&�Rosenblum,�2009)�as�an�assessment� tool� for� IADL�perfor-mance�among�children�with�DCD.�The�Do–Eat�is�an�ecologi-cally�valid�assessment�tool�that�focuses�on�food�preparation�and�on�drawing,�writing,� and� cutting.�The� assessment� is�based�on�both�top-down�and�bottom-up�approaches.�The�tool’s�purpose�is�to�evaluate�relevant�performance�areas�for�children�with�DCD�and�to�assist�in�establishing�customized�goals�and�objectives�for�intervention�with�these�children.�In�this�article,�we�describe�the�development�of�the�Do–Eat�and�report�respective�reliability�and�validity�measures,�specifically�interrater�and�internal�reliability�and�concurrent�and�con-struct�validity.

Method

Participants

Participants�included�59�children,�ages�5�to�6.5�years,�who�were�selected�for�the�study�as�a�convenience�sample.�We�used�this�constricted�age�group�to�reduce�the� likelihood�of�age�constituting�an�intervening�variable�in�the�study,�given�that�children’s�performance�abilities�improve�with�age.�All�study�participants�were�Hebrew� speakers�who� attended� regular�schools� and�preschools.�The� study�group� consisted�of�30�children�who�were�diagnosed�as�having�DCD,�as�defined�by�the�DSM–IV–TR�(APA,�2001)�and�on�the�basis�of�scoring�<15th�percentile�on�the�Movement�Assessment�Battery�for�

Children�(M–ABC;�Henderson,�&�Sugden,�1992).The�con-trol�group�consisted�of�29�children�who�were�matched�on�age,� gender,� and� sociodemographic�background�with� the�study�group.�In�both�groups,�77%�of�children�were�boys,�and�23%�were�girls.�No�significant�age�differences�between�the�groups�were�evident�(research�group�age�range�=�58–78�months,�mean�[M]�=�68.2�months,�standard�deviation�[SD]�=�5.19;�control�group�age�range�=�59–81�months,�M�=�68.8�months,�SD =�5.42).�On�the�basis�of� information�from�a�survey�that�is�routinely�done�in�the�Israeli�educational�sys-tem,�we�excluded�children�with�physical�or�communication�limitations� (cerebral�palsy,�pervasive�developmental�delay,�visual� impairment,� or�hearing� impairment)� and� children�with�mental�retardation�from�the�study.

All�of�the�children�in�both�groups�had�at�least�an�“ade-quate”� cognitive� and� meta-cognitive� performance� level,�based�on�the�results�of�the�mean�score�of�the�cognitive�and�meta-cognitive�items�of�the�ChAS–P–T�(see�the�description�of�this�measure�in�the�next�section).�The�mean�score�for�both�groups�on�both�questionnaires�was�greater�than�the�“almost�well”� performance� level� (for� the�Children�Activity� Scale�Parent� [ChAS–P]:� children�with�DCD,�M� =�4.02,�SD =�0.68;�typically�developing�children,�M�=�4.54,�SD�=�0.38;�for�the�Children�Activity�Scale�Teacher�[ChAS–T]:�children�with�DCD,�M�=�3.79,�SD�=�0.73;�typically�developing�chil-dren,�M�=�4.44,�SD =�0.54);�the�lowest�score�for�the�ChAS–P�was�2.29�(2�=�adequate),�and�the�lowest�score�for�the�ChAS–T�was�2.57.

Instruments

“Do–Eat” Questionnaire and Test. The�Do–Eat�is�an�eco-logical�test�administered�in�the�child’s�natural�surroundings,�such�as�the�family�kitchen�or�the�kindergarten.�The�child�is�asked�to�perform�three�tasks:�(1)�make�a�sandwich,�(2)�prepare�chocolate�milk,�and�(3)�fill�out�a�certificate�of�outstanding�performance�for�him-�or�herself�(see�Figure�1).�Throughout�the�child’s�performance,�he�or�she�receives�(1)�a�score�for�per-forming�the�task,�(2)�an�analysis�score�for�sensory–motor�skills,�and�(3)�an�analysis� score� for�executive� functions�(EF).�For�example,�the�task�performance�requires�pouring�milk�into�a�glass�as�part�of�preparing�chocolate�milk.�The�sensory–motor�analysis�skills�evaluated�are�motoricity,�posture�and�movement�relationships,�motor�planning,�bilateral� coordination,�fine�motor�coordination,�and�sensation.�The�EF�analysis�compo-nents�evaluated�are�attention,�initiation,�sequencing,�transi-tion�from�one�activity�to�another,�spatial�and�temporal�orga-nization,� inhibition,� problem� solving,� and� remembering�instructions�(see�the�Appendix).

Test�scores�range�from�1�(unsatisfactory performance)�to�5�(very good performance).�As�the�test�is�administered�to�the�child,� parents� simultaneously� complete� a� questionnaire�

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930031/ on 11/15/2018 Terms of Use: http://AOTA.org/terms

Page 4: Development and Standardization of a “Do–Eat” Activity of ... · larly during the early-morning rush routine and at mealtimes (Missiuna, 2001). The significance of such children’s

50� January/February 2010, Volume 64, Number 1

consisting�of�12�positive�statements�(e.g.,�“My�child�eats�and�drinks�without�getting�dirty”).�Parents�are�required�to�rank�each�statement�on�a�scale�ranging�from�1�(never, indi-cating�difficulties)�to�5�(always, indicating�very�good�per-formance).� The� following� outcome� measures� can� be�

obtained�from�the�tool:�an�overall�total�task�performance�score,�an�overall�score�analyzing�sensory–motor�skills,�and�an�overall�score�analyzing�EF�associated�with�task�perfor-mance.�The�test�also�provides�a�summary�test�score�that�incorporates�the�average�of�the�three�scores�and�a�summary�score�for�the�parent�questionnaire.

Recent�research�aimed�at�establishing�the�Do–Eat’s�dis-criminant�validity�among�three�age�groups�of�typically�devel-oping�children�(5–6,�6–7,�7–8)�and�gender�has�been�reveal-ing:�Significant�differences�were�obtained�between�age�groups�(F[2,�85]�=�8.38,�p�=�.000,�η2�=�.16),�for�gender�differences�(F[1,�85]�=�8.45,�p�=�.005,�η2�=�.09),�and�for�their�interaction�(F[2,�85]�=�3.61,�p =�.031,�η2�=�.08;�for�more�details,�see�Frisch�et�al.,�2009).

Movement Assessment Battery for Children.�The�M–ABC�(Henderson�&�Sugden,�1992)�was�designed�to�identify�and�evaluate�children�with�mild�to�moderate�motor�impairment.�This�assessment�enjoys�widespread�use�in�clinical�and�research�contexts�and�is�currently�considered�the�most�appropriate�tool�of�its�kind�for�evaluating�motor�impairment�(Crawford�et� al.,� 2001;� Geuze,� Jongmans,� Schoemaker,� &� Smits-Engelman,�2001;�Van�Waelvelde,�De�Weerdt,�De�Cock,�&�Smits-Engelsman,�2004).�The�battery�consists�of�two�parts:�(1)�a�test�that�is�performed�on�an�individual�basis�with�the�child�and�(2)�a�questionnaire�given�to�an�adult�who�knows�the�child�and�observes�him�or�her�on�a�daily�basis.�It�consists�of�eight�subtests�of�motor�function,�including�three�that�test�manual�dexterity,�two�that�assess�ball�skills,�and�three�that�assess� static� and�dynamic�balance.�The�battery�has� been�standardized�for�age,�providing�norms�for�children�ages�4�to�12�in�four�age-related�item�sets.�Children�can�score�between�0�and�5�on�each�item,�and�the�total�score�will�range�from�0�to�40,�with� increased� impairment� associated�with�higher�scores.�The�final�score�is�converted�to�a�percentile,�thus�serv-ing�as�a�criterion�for�determining�children�at�risk�for�DCD�(15th�percentile)�and�children�at�high�risk�for�DCD�(5th�percentile).

Extensive� information�on� the�M–ABC’s� validity� and�reliability�is�presented�in�the�manual�(Henderson�&�Sugden,�1992)�and�in�Henderson�and�Barnet�(1998).�The�M–ABC�was�translated�into�Hebrew�(translation�and�backtranslation)�with�the�publisher’s�permission.�In�this�study,�we�used�the�test�only,�without�the�questionnaire.

Children Activity Scale–Parent and Teacher. These�ques-tionnaires�were�developed�to�identify�children�ages�4�to�8�at�risk� for�DCD,�based�on� their�parents’�or� teacher’s� report�(Rosenblum,�2006)�or�both.�The�questionnaire�is�brief�and�requires�5�to�10�min�to�complete.�The�ChAS–P�includes�27�items�regarding�activities�that�have�been�found�to�be�defi-cient�among�children�with�DCD.�The�ChAS–T�includes�22�items�similar�to�those�of�the�ChAS–P�but�referring�to�the�

Figure 1. Do–Eat tasks: (A) preparing a sandwich, (B) preparing a milk drink, and (C) filling out a certificate of outstanding performance for self.

A

B

C

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930031/ on 11/15/2018 Terms of Use: http://AOTA.org/terms

Page 5: Development and Standardization of a “Do–Eat” Activity of ... · larly during the early-morning rush routine and at mealtimes (Missiuna, 2001). The significance of such children’s

The American Journal of Occupational Therapy� 51

school�environment.�The�items�address�issues�of�gross�and�fine�motor�activities,�learning,�organization�in�space�and�time�during�performance�of�daily� activities,� self-care,�mobility,�and�play.�The�parent�or�teacher�is�asked�to�rate�how�the�child�performs�certain�activities�in�comparison�to�his�or�her�peers�on�a�5-point�Likert�scale�(1�=�less adequately,�2�=�adequately,�3�=�almost well,�4�=�well, and�5�=�very well).�The�outcome�measure�is�an�average�score�ranging�from�1�to�5.�Children�who�obtain�a�mean� score� ranging� from�1� to�3.42�on� the�ChAS–T,� a� mean� score� ranging� from� 1� to� 3.82� on� the�ChAS–P,�or�both�are�categorized�as�possibly�having�DCD.

Seven� items�on�both� the�ChAS–P�and� the�ChAS–T�measure�learning�and�organization�abilities�in�various�envi-ronments�(e.g.,�Item�5,�“learning�new�movement�skills,”�or�Item�19,�“organization�in�time�and�space�in�preparation�for�eating”;�for�further�details,�see�Rosenblum,�2006).�We�com-puted�a�mean�score�for�those�seven�items�to�screen�for�the�cognitive� and�meta-cognitive� level� of�performance�of� the�participants�in�this�study.

Internal� consistency,� construct�validity,� and�concur-rent� validity� with� the� M–ABC� have� been� reported� and�suggest�that�the�ChAS–T�and�ChAS–P�are�reliable�tools�to�identify�children�at�risk�for�DCD�(for�further�details,�see�Rosenblum,�2006).

Procedure

The�Board�of�Education’s�Committee�on�Activities�Involving�Human�Subjects�approved�all�recruitment�and�intervention�procedures.�Parents�signed�a�consent�form�and�completed�both�the�ChAS–P�and�the�Do–Eat�questionnaires.�Teachers�filled�out�the�ChAS–T,�and�Ayelet�Goffer�collected�all�data.�Each�child�underwent�two�sessions:�(1)�testing�on�the�M–ABC�and�(2)�testing�on�the�Do–Eat.�All�assessments�were�conducted� either� at�home�or� at� school.�The�Do–Eat�was�conducted�in�a�kitchen�environment�or�in�a�room�with�a�sink,�faucet,�and�suitable�worktable.

Data Analysis

To�examine�whether� the�groups�with�and�without�DCD�differed�with�respect�to�the�M–ABC�items,�we�performed�frequency�and�Mann–Whitney�analyses.�We�computed�the�calculation�of�interrater�reliability�for�the�Do–Eat�test�overall�final�score�according�to�Polit�and�Hungler’s�(2003)�formula,�and�we�used�Cronbach’s�α�coefficient�to�compute�internal�consistency�for�Do–Eat�components.

We�analyzed�the�differences�between�the�group�with�DCD�and�the�control�group�by�means�of�a�t�test�for�nonequivalent�groups.�We�analyzed�the�questionnaire’s�concurrent�validity�with�Pearson�correlation�coefficients:�Respective�correlations�were�computed�between�the�Do–Eat�sensory–motor�com-ponent�score�and�the�M–ABC�overall�score�and�between�the�Do–Eat�and�ChAS–P�and�ChAS–T�overall�scores.�Likewise,�we�computed�Pearson�correlation�coefficients�to�determine�the�relationships�between�the�Do–Eat�test�and�Do–Eat�par-ent�questionnaire�overall�scores.

ResultsBefore�we�present�the�Do–Eat�reliability�and�validity�results,�we�describe�the�participants’�performance�on�the�eight�M–ABC� subtests.�As�presented� in�Table�1,�Mann–Whitney�analysis�applied�to�these�eight�items�yielded�statistically�sig-nificant�differences�between�the�children�with�and�without�DCD.�The�results�of�this�analysis�indicated�that�the�children�with�DCD� received� significantly�higher� scores� (i.e.,� per-formed�worse)�on�all�eight�M–ABC�subtests,�meaning�that�their�manual�dexterity,�ball�skills,�and�static�and�dynamic�balance�abilities�were�inferior�to�those�of�the�control�group.

Content and Face Validity

The�Do–Eat�tasks�were�selected�on�the�basis�of�the�respective�literatures�relating�to�functional�deficits�among�children�with�DCD.�This�background�included�(1)�structured�interviewing�

Table 1. A Comparison of Performance on the Eight Movement Assessment Battery for Children (M–ABC) Subtests for Children With and Without Developmental Coordination Disorder (DCD; Mann–Whitney Analysis)

Subtest M–ABC Item Description

Children With DCD (n = 30)

Children Without DCD (n = 29)

Z p <Mean SD Mean SD

Manual dexterity 1 Positioning coins in bank box 3.43 1.15 1.71 1.04 –5.04 .001Manual dexterity 2 Threading a lace 4.50 1.13 2.46 1.79 –4.87 .001Manual dexterity 3 Drawing a line into a trail 2.23 1.54 0.40 0.81 –4.66 .001Ball skills 1 Bouncing and catching a ball with one hand 2.80 1.39 0.46 0.93 –5.61 .001Ball skills 2 Throwing a bean bag into a box 2.76 1.56 0.30 0.46 –5.96 .001Static balance Standing on one leg 2.61 1.67 0.26 0.58 –5.72 .001Dynamic balance 1 Jumping on a rope 1.96 2.07 0.23 0.72 –3.77 .001Dynamic balance 2 Heel-to-toe walking on a line 2.76 1.61 0.10 0.30 –6.23 .001

Note. SD = standard deviation.

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930031/ on 11/15/2018 Terms of Use: http://AOTA.org/terms

Page 6: Development and Standardization of a “Do–Eat” Activity of ... · larly during the early-morning rush routine and at mealtimes (Missiuna, 2001). The significance of such children’s

52� January/February 2010, Volume 64, Number 1

of�teachers�and�parents�of�children�with�DCD�on�everyday�functioning;�(2)�observation�of�children�in�kindergarten�envi-ronments;�and�(3)�analysis�of�functional�tools�developed�for�adults,� such�as� the�Assessment�of�Motor�and�Process�Skills�(Fisher,� 1995)� and� the� Revised� Kitchen� Task� Assessment�(Baum�&�Edwards,�1993).

On� the�basis�of�Fisher� (1995)�and�Baum�&�Edwards�(1993),� the�Do–Eat’s�developers�decided�to� focus�on�three�main�activities�encompassing�the�main�areas�of�performance�in�which�children�with�DCD�characteristically�experience�dif-ficulties:�basic�activities�of�sustenance�(eating),�adaptation�to�the�environment�(dressing,�tying�apron),�and�crafting�(draw-ing,�writing,�and�cutting;�Perr,�2004).�Respective�task�require-ments� and� scoring� sheets�were�designed� and� constructed.�Each�of�the�three�tasks�was�scored�separately�and�included�three�measures:�activity�performance,�sensory–motor�perfor-mance�skills,�and�executive�function�performance�skills.

The�content�was�validated�by�five�expert�consultants�and�five�experienced�pediatric�occupational�therapists.�This�pro-cess�was�used� to�determine� the�degree�of� correspondence�between�the�tool�scenario�and�prescribed�instrument�objec-tives�and�the�consistency�of�both�content�and�face�validity,�as�described�by�Benson�and�Clark�(1982).

Three� experienced�occupational� therapists� (with�>10�years�of�experience�in�pediatric�practice)�were�subsequently�invited�to�evaluate�a�child�with�DCD,�videotape�the�evalu-ation�process,�and�then�rate�the�performance.�The�therapists�analyzed�their�evaluations�in�combination�with�the�video-taping,�approved�the�clarity�of�task�and�guidance�instruc-tions,�agreed�on�a�25-�to�30-min�per�child�allotment� for�evaluation�completion,�and�verified�that�the�tool�captured�a�reliable�and�satisfactory�profile�of�everyday�performance.�In�addition,�the�therapists�observed�that�using�Do–Eat�was�a�meaningful�experience,�revealing�unique�and�important�

everyday� child� activities.� In� addition,� completion�of� the�three�scoring�sheets�provided�them�with�further�insight�into�the�child’s�functioning.

Reliability and Validity Studies

Once�the�final�version�of�the�tool�was�established,�the�sub-sequent�phase�of�development�involved�a�preliminary�deter-mination�of�the�assessment�tool’s�reliability�and�validity.

Interrater reliability. An�interrater�reliability�test�was�con-ducted�for�all�assessment�items.�A�child�diagnosed�with�DCD�was�evaluated�and�videotaped�while�performing�the�Do–Eat.�Two�occupational�therapists�with�>10�years�of�experience�viewed�the�video�and�rated�performance�on�the�score�sheets,�contemporaneously� with� the� researcher� (Ayelet� Goffer).�These� raters�were� aware�of� the� study�objectives�but� con-ducted� their� evaluations� independently� of� one� another.�Moreover,�these�raters�were�not�members�of�the�initial�focus�groups�conducted�for�instrument�development.�A�high�inter-rater�reliability�was�obtained�(rs�=�.92–1)�among�all�three�assessors.

Internal consistency. Internal�consistency�was�evaluated�for�each�of�the�three�Do–Eat�components�on�the�basis�of�data�from�59�participants,�yielding�satisfactory�results.�High�internal�consistency�was�obtained�for�performance�skills�(α�=�.93),�sensory–motor�skills�(α�=�.90),�and�executive�func-tions�skills�(α�=�.89).�Internal�consistency�for�the�parents’�questionnaire�was�.91.�Differences�in�performance�between�the�two�groups�are�presented�in�Table�2.

Construct and concurrent validity. Construct�validity�for�the�Do–Eat�was�assessed�by�gauging�the�tool’s�ability�to�dis-tinguish�between�the�groups�of�children�with�and�without�DCD.�We�determined� concurrent� validity�by� comparing�Do–Eat�scores�with�those�on�the�M–ABC�(Henderson�&�Sugden,�1992)�and�the�ChAS–P�(Rosenblum,�2006).

Table 2. Performance of Both Groups on Do–Eat Components

Component

Children With DCD (n = 30) Children Without DCD (n = 29)

No. of Items Range of ScoresMean SD Mean SD

Tying an apron and making a sandwich Task performance 23.73 4.04 34.17 3.60 8 1–40 Sensory–motor 19.30 2.38 30.34 3.36 7 1–35 Executive functions 27.37 5.38 37.24 6.17 9 1–45Preparing chocolate milk Task performance 25.73 3.12 34.69 6.89 8 1–40 Sensory–motor 19.40 2.13 30.75 3.37 7 1–35 Executive functions 28.30 5.85 37.38 6.78 9 1–45Filling out a certificate Task performance 7.63 1.82 12.06 1.91 3 1–15 Sensory–motor 20.00 3.89 30.96 2.62 7 1–35 Executive functions 30.13 5.01 39.51 5.34 9 1–45

Note. DCD = developmental coordination disorder; SD = standard deviation.

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930031/ on 11/15/2018 Terms of Use: http://AOTA.org/terms

Page 7: Development and Standardization of a “Do–Eat” Activity of ... · larly during the early-morning rush routine and at mealtimes (Missiuna, 2001). The significance of such children’s

The American Journal of Occupational Therapy� 53

As�presented�in�Table�3,�the�t test�conducted�for�unre-lated� samples� showed� significant�differences�between� the�group�with�DCD�and� the� control� group�on� all�Do–Eat�components,�with�the�control�participants�displaying�better�performance.�We� found� significant�differences�on�perfor-mance�of�the�three�different�tasks�(t[57]�=�14.04,�p <�.001),�for�sensory–motor�skills�(t[57]�=�16.82,�p <�.001),�and�for�executive�functions�(t[57]�=�6.92,�p <�.001).�We�also�found�significant�differences�between� the� groups� for� the�overall�score�on�the�parents’�questionnaire�(t[57]�=�3.65,�p <�.001).

Concurrent validity.Correlation between the Do–Eat and the M–ABC. To�

establish� the� correlation�between� the�M–ABC�assessment�score�and�the�Do–Eat�assessment�score,�we�pinpointed�the�relationship�between�the�M–ABC�and�the�Do–Eat�sensory–motor�component�score�on�the�basis�of�the�rationale�that�the�M–ABC� essentially� addresses� sensory–motor� skills.� We�obtained�a�strong�negative�correlation�between�the�M–ABC�and�the�sensory–motor�score�for�the�overall�sample�(r =�−.86,�p <�.001).�Analysis�of�the�correlations�between�the�M–ABC�and�Do–Eat� sensory–motor� scores� for� each� study� group�indicated� a� weak� negative� significant� correlation� for� the�DCD�group�(r =�−.37,�p <�.001),�whereas�no�significant�cor-relation�was�obtained�for�the�control�group.

Correlation between Do–Eat and Children Activity Scale–Parent and Teacher. A significant�moderate�correlation�was�found�between�the�summary�scores�of�the�Do–Eat�test�and�the�ChAS–P�questionnaire�for�the�entire�sample�(r =�.56,�p =�.00).�We�found�no�significant�correlations�in�either�of�the�groups�(DCD�or�control).�An�examination�of�the�correlation�between� the�Do–Eat� test� and� the�ChAS–T�questionnaire�showed�a�high�correlation�throughout�the�entire�sample�(r =�.75,�p =�.00).�We�obtained�a�similar�trend�when�analyzing�the�correlations�in�each�group:�We�found�a�significant�high�correlation�for�the�DCD�group�(r =�.63,�p <�.001)�and�a�mod-erate�correlation�for�the�control�group�(r =�.40,�p <�.05).

Correlation between the Do–Eat test and the Do–Eat par-ents’ questionnaire. We�found�significant�moderate�correla-tions�between�the�Do–Eat�summary�score�and�the�Do–Eat�

questionnaire�final�scores�for�the�entire�sample�(r =�.54,�p <�.00).�In�the�DCD�group,�the�correlation�was�.41�(p <�.05),�whereas�for�the�control�group,�it�was�.40�(p <�.05).

DiscussionOur�objectives�in�this�study�were�to�describe�the�Do–Eat’s�development�and�establish�its�reliability�and�validity.�Both�objectives�were� supported.�We� established� the�Do–Eat’s�reliability�by� examining� interrater� reliability� and� internal�consistency.�A�high�rate�of�interrater�reliability�was�obtained�between�three�examiners�for�all�of�the�assessment�items.�This�concurrence�is�important�because�the�Do–Eat�is�based�on�a�structured�observation.�Dunn�(2000)�claimed�that�evaluat-ing�a�structured�observation�is�extremely�difficult�because�it�demands�that�the�evaluator�comprehensively�use�his�or�her�knowledge�and�skill�to�glean�significant�information�from�a�given�interaction�between�the�child�and�his�or�her�environ-ment.�The�internal�consistency�examination�found�a�high�degree�of�correspondence�between�the�items�analyzed�in�each�category�of�the�test�and�the�questionnaire.�This�high�item�correspondence�confirms�that�the�items�in�each�category�do�actually�evaluate�the�same�content�(Anastasi,�1997).

The�Do–Eat�distinguished�between�children�with�DCD�and�typically�developing�children,�thereby�allowing�one�to�draw� significant� conclusions� regarding� children’s� general�functioning� in� their� day-to-day� lives.�These�findings� are�especially�pertinent�in�light�of�the�dearth�of�performance-based�assessment�tools�for�children�in�general�(Bundy,�1993)�and�for�children�with�DCD�in�particular�(Cermak�&�Larkin,�2002).�The�important�implication�is�that�the�Do–Eat�enables�a�comparison�of�child� functioning� in�relation�to�peers�by�focusing�on�everyday�performance�in�natural�surroundings�(Kramer�&�Hinojosa,�1999).

Profile of Daily Functioning in Children With DCD

Disparities between children with DCD and children with intact development. As�noted�earlier,�we�had�two�reasons�for�choosing�to�focus�on�children�with�DCD�in�this�study:�The�first�related�to�the�DSM–IV–TR’s�definition�of�DCD,�and�the�second�related�to�the�heterogeneity�of�this�group�of�chil-dren.�The�DSM–IV–TR�definition�of�DCD�(APA,�2001)�implies�a�possible�cause–effect�relationship�between�deficits�in�motor� coordination� (Criterion�A)� and�daily� function–related�difficulties�(Criterion�B;�Geuze�et�al.,�2001).�These�links� were� not,� however,� specified� and� were� overlooked�because� of� the� lack� of� appropriate� assessment� tools.�Henderson�and�Barnett�(1998)�claimed�that�analysis�of�the�relationship�between�motor�impairment�and�daily�difficulties�is� contingent�on� the� availability� of� a� satisfactory� tool� for�assessing�a�child’s�limitations�in�performing�daily�tasks.

Table 3. A Comparison Between Children With and Without Developmental Coordination Disorder (DCD) for the Do–Eat Components Performance Skills and Parents’ Questionnaire Scores

Do–Eat Components

Children With DCD (n = 30)

Children Without DCD

(n = 29) t(57) p <

Task performance 57.17 81.93 14.04 .001Sensory–motor skills 59.30 92.52 16.82 .001Executive functions 85.57 114.17 6.92 .001Final score for Do–Eat parents’ questionnaire

54.37 62.21 3.65 .001

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930031/ on 11/15/2018 Terms of Use: http://AOTA.org/terms

Page 8: Development and Standardization of a “Do–Eat” Activity of ... · larly during the early-morning rush routine and at mealtimes (Missiuna, 2001). The significance of such children’s

54� January/February 2010, Volume 64, Number 1

The�Do–Eat�assessment�provides�relevant�information�regarding�these�links�between�motor�impairment�and�per-formance�of�daily�activities,�thus�supporting�the�handful�of�other�studies�that�have�addressed�everyday�functional�perfor-mance�using�alternate�methods�to�the�customary�question-naire�assessment.�Rodger�et�al.� (2003)�studied�motor�and�functional�ability�in�children�with�DCD�(ages�4–8);�everyday�functioning� was� analyzed� on� the� basis� of� the� Pediatric�Evaluation�of�Disability�Inventory�(Haley,�Coster,�Ludlow,�Haltiwanger,�&�Andrellos,�1992),�although�this�inventory�was�designed�to�evaluate�children�with�more�severe�limita-tions� than�DCD.�A�review�of� research�by�Missiuna�et�al.�(2007)�showed�that�children�with�DCD�performed�at�aver-age�levels�in�mobility�areas,�whereas�functioning�in�self-care�areas�was�<1�standard�deviation�from�the�average�point;�these�children�showed�difficulties�in�brushing�their�teeth,�cleaning�their�noses,�and�tying�shoelaces.�We�similarly�corroborated�these�findings�in�this�study:�Children�with�DCD�performed�significantly�more�poorly�than�typically�developing�children�on�several�types�of�everyday�functioning�and�activities.�These�findings�support�the�claim�for�a�link�between�coordination�deficits�and�impairment�of�daily�functions.

Evaluating�children�with�DCD�poses�a�significant�chal-lenge�because�of�the�heterogeneous�nature�of�this�population.�Missiuna� et� al.� (2007)� claimed� that� the�heterogeneity�of�children�with�DCD�is�represented�by�a�wide�range�of�varia-tion�in�their�manifestations�of�everyday�performance,�from�difficulties�in�performing�many�tasks�to�difficulties�on�spe-cific�tasks.�Burton�and�Miller�(1998)�therefore�emphasized�the�need�to�use�an�extensive�battery�of�assessments�to�provide�information� about� each� child’s� specific� functioning.�This�heterogeneity� is� likewise� characteristic�of�our�participants�with�DCD,�as�is�evident�from�their�scores.

Scores�ranged�from�260�to�163�points�on�the�Do–Eat�test�and�from�35�to�13.5�points�on�the�M–ABC.�This�wide�range�of� scores�demonstrates� the� significant� variability� in�children’s�functioning,�even�in�cases�with�similar�diagnoses.�These�differences� cannot�be� explained�by�one� score.�The�Do–Eat’s�content�and�structure�provide�a�detailed�view�of�diagnostic�information�that�goes�beyond�a�single�score.�By�reviewing�the�score�components,�one�can�pinpoint�the�spe-cific�nature�of�the�impairment�and�the�impact�of�each�com-ponent�and�performance�skill�on�the�child’s�general�func-tioning,� thus� highlighting� difficulties� and� functional�strengths.�The� study� results�point� to� a�disparity�between�children�with�DCD�and�typically�developing�children�on�all�skills� observed,� including� sensory–motor� skills,� executive�functions,�and�performance.

Regarding�cognitive�and�meta-cognitive�skills,�although�children� with� DCD� received� an� adequate� score� for� this�domain�on�the�Children�Activity�Scale�Parent�and�Teacher�

screening�tool,�they�performed�significantly�more�poorly�on�the�EF�component�of�the�Do–Eat�than�did�typically�develop-ing�children.�These�results�indicate�that�the�Do–Eat�is�indeed�sensitive� to� the� sensory–motor� and�EF� aspects� of�perfor-mance�among�children�with�DCD.�These�findings�underline�the�assertion�that�DCD�is�not�manifested�merely�in�motor�coordination�difficulties�but�that�it�is�a�multicharacteristic�deficit�with�a�significant� impact�on�functional�ability�and�everyday�participation�(Cermak,�Gubbay,�&�Larkin,�2002:�Kadesjo�&�Gillberg,�1999).

Score gap between children with DCD and typically develop-ing children on the DCD Parent Questionnaire. The�Do–Eat�evaluation�includes�a�test�and�a�questionnaire�aimed�at�pro-viding�an�extensive�functional�profile�that�may�significantly�serve�the�design�of�a�personal�intervention�plan.�This�com-bination�of�test�and�questionnaire�enables�both�components�to�validate�one�another.�The�parent�questionnaire�provides�information�about� functioning� in�general,� apart� from�the�testing� situation� (Glascoe�&�Dworkin,� 1995);� promotes�parental�cooperation�during�the�process;�and�focuses�on�the�client’s�needs�(Wilson�et�al.,�2000).�The�parent�questionnaire�significantly�identified�children�with�DCD,�a�finding�com-patible�with�reports�by�parents�of�children�with�DCD�that�underline�their�child’s�difficulties�with�daily�functioning�in�general�and�eating�in�particular�(Hoare,�1994).�Green�et�al.�(2005)�also�obtained� similar�findings:� the�Developmental�Coordination�Disorder�Questionnaire parent�questionnaire�(Wilson�et�al.,�2000)�distinguished�between�children�with�DCD�and�typically�developing�children,�and�children�with�DCD�scored�significantly�more�poorly.

Link between the Do–Eat and the M–ABC. We� found�a�strong�and�significant�correlation�between�the�M–ABC�and�Do–Eat�sensory–motor�skills�for�all�participants,�but�only�a�weak�correlation�was�evident�for�the�DCD�group.�The�cor-relation�between�M–ABC�and�the�Do-Eat�sensory�scale�was�–.86�for�the�entire�group�but�only�–.37�for�the�DCD�group.�This�result�implies�that�sensory–motor�performance�skills�do�not�fully�impair�the�ability�to�perform.�This�result�strength-ens�the�claim�that�assessing�DCD�only�via�sensory–motor�tasks�limits�a�fuller�depiction�of�daily�functioning�and�cannot�serve�as�a�viable�stand-alone�diagnostic�tool�(Green�et�al.,�2005).�We� found�no� significant� correlation�between�M–ABC� and� Do–Eat� sensory–motor� skills� for� the� typically�developing�group.�A�possible�reason�for�this�may�be�the�lack�of�variability�in�this�group,�given�the�constricted�age�range�of�the�children�tested�and�the�small�group�size.

Link between Do–Eat and the ChAS–T and ChAS–P. Correlations�between� the�ChAS–T�and�ChAS–P�and� the�Do–Eat�assessment�were�similar�to�those�reported�in�the�lit-erature�between� standardized� assessments� and�parent� and�teacher� questionnaires,� ranging� between� .40� to� .59�

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930031/ on 11/15/2018 Terms of Use: http://AOTA.org/terms

Page 9: Development and Standardization of a “Do–Eat” Activity of ... · larly during the early-morning rush routine and at mealtimes (Missiuna, 2001). The significance of such children’s

The American Journal of Occupational Therapy� 55

(Schoemaker,�Smith-Engelsman,�&�Jongmans,�2003;�Wilson�et�al.,�2000).�The�strength�of�correlations�is�usually�weak�to�moderate,� thus� supporting� the� currently� accepted�notion�that�although�questionnaires�may�have�advantages,�they�can-not�substitute�for�an�evaluation�process�(Wilson�et�al.,�2000).�In� recent� years,� the� viability� and� reliability�of�parent� and�educator� reports� on� child� functioning� have� been� widely�debated.�Wilson� et� al.� (2000)� claimed� that�many� factors�influence�questionnaire�validity,�such�as�coexisting�deficits,�thereby� confounding� reliable� questionnaire� reports.�Moreover,�a�questionnaire�is�susceptible�to�both�parents’�and�teacher’s�expectations�of�the�child,�as�well�as�those�of�profes-sionals�(Case-Smith,�1995).

In�addition,�questionnaire�responses�may�be�influenced�by�the�time�and� location�of�completion�(e.g.,� the�waiting�room�or�the�therapy�clinic;�Green�et�al.,�2005).�These�con-textual�effects�may�also�serve�to�clarify�our�study�findings.�As�presented� previously,� correlations� between� the� Do–Eat�assessment�and�the�teacher�questionnaire�(ChAS–T)�were�stronger�than�those�obtained�for�the�Do–Eat�and�the�parent�questionnaire� (ChAS–P).�By�contrast,�Rosenblum�(2006)�found�stronger�correlations�between�the�M–ABC�and�the�parent�questionnaire.�Likewise,�Green�et�al.�(2005)�showed�that�the�Developmental�Coordination�Disorder�Question-naire parent�questionnaire�enhanced�identification�of�DCD�compared�with� the�M–ABC� teacher� questionnaire.�This�disparity�may�be�attributable�to�the�fact�that�our�study�was�conducted�mainly� in�kindergarten� settings,� teachers�were�briefed�on�study�objectives�and�were�invited�to�participate�in�the�process,�and�teachers�informed�parents�and�allowed�sev-eral� to�observe� the�assessment�process.�Relationships�with�most�parents�were�limited,�with�the�exception�of�those�few�parents� of� children� who� were� the� researcher’s� clients.�Therefore,�teachers’� involvement�and�awareness�may�have�influenced�and�even�biased�their�questionnaire�reports.

In�summary,�the�analysis�of�the�relationships�between�the�overall�Do–Eat�score�and�other�assessment�tools�provides�evidence�of�a�significant�relationship.�Specifically,�significant�correlations�between�the�Do–Eat’s�sensory–motor�compo-nent�and�the�other�assessment�tools�were�obtained�for�both�the�total�sample�and�the�sample�of�children�with�DCD.�The�Do–Eat�evaluation�tool�therefore�shows�considerable�prom-ise�for�diagnosing�DCD,�substantially�advancing�our�under-standing�of�the�deficit�beyond�mere�functional�difficulties�in�areas�of�motor�coordination.

Limitations

Data�collection�for�the�study�and�the�Do–Eat�testing�process�was�conducted�by�Ayelet�Goffer,�who�was�also�involved�in�designing� and�developing� the� tool.�The� study� sampled� a�limited�number�of�children�(30�in�the�study�group�and�29�

in�the�control�group)�by�means�of�a�convenience�sample.�Therefore,� care�needs� to�be� exercised� in� generalizing�our�findings�and�future�research�hypotheses�to�other�groups�of�children.

Recommendations for Future Research

This�study’s�findings�underscore�the�Do–Eat’s�potential�to�distinguish� between� children� with� DCD� and� typically�developing�children�ages�5�to�6.5.�Future�studies�should�include�testing�children�diagnosed�with�DCD�who�are�>6.5�and�evaluating�children�with�learning�disabilities,�attention�deficit�hyperactivity�disorder,�or�both.� In� this� study,�we�examined�the�reciprocal�relationships�among�various�assess-ment�components.�Future�studies�should�examine�the�rela-tionships�among�sensory–motor�performance�skills,�execu-tive�functions,�and�general�performance.�A�study�to�evaluate�test–retest�reliability�is�being�conducted�in�the�near�future�to�explore�the�stability�of�scores�over�time�for�those�with�DCD�and�other�populations.�In�the�next�step�of�validating�the� Do–Eat,� a� large-scale� study� with� random� samples�should� be� conducted� to� build� norms� for� this� novel�instrument.� s

ReferencesAmerican�Psychiatric�Association.�(2001).�Diagnostic and statistical

manual of mental disorders�(4th�ed.,�text�rev.).�Washington,�DC:�Author.

Anastasi,�A.� (1997).�Psychological testing� (7th� ed.).�Englewood�Cliffs,�NJ:�Prentice�Hall.

Ayres,�J.�(1985). Developmental dyspraxia and adult onset apraxia.�Torrance,�CA:�Sensory�Integration�International.

Barnett,�A.,�&�Peters,� J.� (2004).�Motor�proficiency� assessment�batteries.�In�D.�Dewey�&�D.�Tupper�(Eds.),�Developmental motor disorders: A neuropsychological perspective (pp.�66–109).�New�York:�Guilford�Press.

Baum,�C.,�&�Edwards,�D.�F.�(1993).�Cognitive�performance�in�senile�dementia�of� the�Alzheimer’s� type:�The�Kitchen�Task�Assess-ment.�American Journal of Occupational Therapy, 5,�18–25.

Beery,�K.�E.,�&�Buktenica,�N.�A.� (1997).�Developmental Test of Visual–Motor Integration–Revised (VMI–R) test manual.�Cleveland:�Modern�Curriculum.

Benbow,�M.�(1995).�Principles�and�practices�of�teaching�handwrit-ing.�In�A.�Henderson�&�C.�Pehoski�(Eds.),�Hand function in the child�(pp.�255–281). St.�Louis,�MO:�Mosby.

Benbow,�M.�(2002).�Hand�skills�and�handwriting.�In�S.�A.�Cer-mak�&�D.�Larkin�(Eds.),�Developmental coordination disorder�(pp.�248–280).�Albany,�NY:�Delmar.

Benson,� J.,�&�Clark,�F.� (1982).�A�guide� for� instrument�devel-opment� and� validation.�American Journal of Occupational Therapy, 36, 789–800.

Bruininks,�R.�H.,�&�Bruininks,�B.�D.�(2005).�Bruininks–Oseretsky Test of Motor Proficiency: Manual�(2nd�ed.).�Boston:�Pearson�Assessments.

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930031/ on 11/15/2018 Terms of Use: http://AOTA.org/terms

Page 10: Development and Standardization of a “Do–Eat” Activity of ... · larly during the early-morning rush routine and at mealtimes (Missiuna, 2001). The significance of such children’s

56� January/February 2010, Volume 64, Number 1

Bundy,�A.�C.�(1993).�Assessment�of�play�and�leisure:�Delineation�of�the�problem.�American Journal of Occupational Therapy, 47, 217–222.

Burton,�A.�W.,�&�Miller,�D.�E.�(1998). Movement skill assessment. Champaign,�IL:�Human�Kinetics.

Case-Smith,�J.�(1993).�Pediatric occupation therapy and early inter-vention.�Boston:�Andover�Medical.

Case-Smith,� J.� (1995).�The� relationships� among� sensorimotor�components,�fine�motor�skill,�and�functional�performance�in�preschool�children.�American Journal of Occupational Therapy, 49,�645–652.

Cermak,�S.�A.,�Gubbay,�S.�S.,�&�Larkin,�D.�(2002).What�is�devel-opmental�coordination�disorder?�In�S.�A.�Cermak�&�D.�Lar-kin� (Eds.),�Developmental coordination disorder� (pp.�2–22).�Albany,�NY:�Delmar.

Cermak,�S.�A.,�&�Larkin,�D.�(2002).�Families�as�partners.�In�S.�A.�Cermak�&�D.�Larkin�(Eds.),�Developmental coordination disorder�(pp.�200–208).�Albany,�NY:�Delmar.

Chapparo,�C.�J.,�&�Hooper,�E.�(2005).�Self-care�at�school:�Percep-tions�of�6-year-old�children.�American Journal of Occupational Therapy, 59, 67–77.

Crawford,�S.�G.,�Wilson,�B.�N.,�&�Dewey,�D.�(2001).�Identifying�developmental�coordination�disorder:�Consistency�between�tests.� Physical and Occupational Therapy in Pediatrics, 20,�29–50.

Daving,�Y.,�Andren,�E.,�&�Grimby,�G.�(2000).�Inter-rater�agree-ment�using�the�Instrumental�Activity�Measure.�Scandinavian Journal of Occupational Therapy, 7, 33–38.

De�Bildt,�A.,� Serra,�M.,�Luteijn,�E.,�Krijer,�D.,�Sytema,�S.,�&�Minderaa,�R.�(2005).�Social�skills�in�children�with�intellectual��

Appendix. Scoring Example: Preparing Chocolate MilkScoring: 5 = excellent performance, 4 = good performance, 3 = fair performance, 2 = poor performance, 1 = very poor performance, 0 = not observed.

Child’s name: __________________________________________________

Task performanceTask Score (0–5) RemarksBringing box to the tableSpreading out items on the table Putting chocolate powder and milk in the glassMixing the drinkWashing handsCleaning the tableDrinking Overall score _____________________ = average score 7

Sensory–motor skills analysisSkills Score (0–5) RemarksMotoricityPosture and movement relationshipsMotor planningBilateral coordinationFine motor coordinationSensationOverall score _____________________ = average score 6

Executive functionsSkills Score (0–5) RemarksAttentionInitiationSequencingTransition from one activity to anotherSpatial and temporal organizationInhibitionProblem solvingRemembering instructionsOverall score _____________________ = average score 9

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930031/ on 11/15/2018 Terms of Use: http://AOTA.org/terms

Page 11: Development and Standardization of a “Do–Eat” Activity of ... · larly during the early-morning rush routine and at mealtimes (Missiuna, 2001). The significance of such children’s

The American Journal of Occupational Therapy� 57

disabilities�with�and�without� autism.� Journal of Intellectual Disability Research, 49, 317–328.

Dewey,�D.,�&�Wilson,�B.�N.�(2001).�Development�coordination�disorder:�What� is� it?�Physical and Occupational Therapy in Pediatric, 20,�5–27.

Dunford,�C.,�Street,�E.,�O’Connell,�H.,�Kelly,�J.,�&�Sibert,�J.�R.�(2004).�Are�referrals�to�occupational�therapy�for�developmen-tal�coordination�disorder�appropriate?�Archives of Disease in Childhood, 89,�143–147.

Dunn,�W.� (2000).�The� screening,�pre-assessment,� and� referral�process.�In�W.�Dunn�(Ed.),�Best practice occupational therapy: In community service with children and families (pp.�55–78).�Thorofare,�NJ:�Slack.

Fisher,�A.�G.� (1995).�Assessment of motor and process skills. Fort�Collins,�CO:�Three�Star�Press.

Frisch,�C.,�Goffer,�A.,�Koren,�A.,�Dotan-Schori,�G.,�Yakir-Catz,�N.,�Saad,�A.,�et�al.�(2009).�Establishing�construct�validity�for�the�Do–Eat:�Discriminating�between�ages�and�gender.�Israeli Journal of Occupational Therapy, 18, H117–H139.

Geuze,�R.�H.,�Jongmans,�M.�J.,�Schoemaker,�M.�M.,�&�Smits-Engelman,� S.�E.� (2001).�Clinical� and� research�diagnostic�criteria� for�developmental� coordination�disorders. Human Movement Science, 20,�7–47.

Gibbs,�J.,�Appleton,�J.,�&�Appleton,�R.�(2007).�Dyspraxia�or�devel-opmental� coordination�disorder?�Unrevealing� the� enigma.�Archives of Disabilities in Children, 92,�534–539.

Glascoe,�F.�P.,�&�Dworkin,�P.�H.� (1995).�The� role�of�parents�in�the�detection�of�developmental�and�behavioral�problems. Pediatrics, 95, 829–836.

Goffer,�A.,�Josman,�N.,�&�Rosenblum,�S.�(2009).�Do–Eat: Per-formance-based assessment tool for children.�Haifa,�Israel:�Uni-versity�of�Haifa.

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,�2–10.

Haley,�S.�M.,�Coster,�W.�J.,�Ludlow,�L.�H.,�Haltiwanger,�J.�T.,�&�Andrellos,�P.�J.�(1992).�Pediatric Evaluation of Disability Inventory: Development, standardization, and administration manual (Version�1.0).�Boston:�Trustees�of�Boston�University,�Center�for�Rehabilitation�Effectiveness.

Henderson,� S.�E.,�&�Barnett,�A.�L.� (1998).�The� classification�of�specific�motor�coordination�disorders� in�children:�Some�problems� to� be� resolved.� Human Movement Science, 17, 449–469.

Henderson,� S.�E.,�&�Sugden,�D.�A.� (1992).� Movement assess-ment battery for children. Kent,� England:� Psychological�Corporation.

Hoare,�D.�(1994).�Subtypes�of�developmental�coordination�disor-der.�Adapted Physical Activity Quarterly, 11, 158–169.

Kadesjo,�B.,�&�Gillberg,�C.� (1999).�Developmental� coordina-tion�disorder�in�Swedish�seven�year-old�children.�Journal of the American Academy of Child and Adolescent Psychiatry, 38,�820–828.

Kaplan,�B.� J.,�Wilson,�B.�N.,�Dewey,�D.,�&�Crawford,� S.�G.�(1998).�DCD�may�not�be�a�discrete�disorder.�Human Move-ment Science, 17,�471–490.

Katz,�N.�(2005).�Cognition and occupation in rehabilitation: Cogni-tive models for intervention in occupational therapy.�Bethesda,�MD:�AOTA�Press.

Kirby,�A.,�Davies,�R.,�&�Bryant,�A.� (2005).�Do�teachers�know�more�about�specific�learning�difficulties�than�general�practitio-ners?�British Journal of Special Education, 32, 122–126.

Kramer,�P.,�&�Hinojosa,�J.�(1999).�Domain�of�concern�of�occupa-tional�therapy:�Relevance�to�pediatric�practice.�In�P.�Kramer�&�J.�Hinojosa�(Eds.), Frame of reference for pediatric occupa-tional therapy (pp.�9–27).�Philadelphia:�Lippincott�Williams�&�Wilkins.

Kvavilashvili,�L.,�&�Ellis,� J.� (2004).�Ecological�validity�and�the�real-life/laboratory�controversy�in�memory�research:�A�criti-cal�and�historical�review.�History and Philosophy of Psychology, 6,�59–80.

Mandich,�A.�D.,�Polatajko,�H.�J.,�Mancab,�J.�J.,�&�Miller,�L.�T.�(2001).�Treatment�of�children�with�developmental�coordina-tion�disorder:�What�is�the�evidence? Physical and Occupational Therapy in Pediatrics, 20(3),�51–68.

May-Benson,�T.�(1999).�Preliminary validity evidence on the Test of Ideational Praxis.� Unpublished� interim� paper,� Boston�University.

May-Benson,�T.,�Ingola,�P.,�&�Koomar,�J.�(2002).�Daily�living�skills�and�developmental�coordination�disorder.�In�S.�A.�Cer-mak�&�D.�Larkin�(Eds.),�Developmental coordination disorder�(pp.�140–156).�Albany,�NY:�Delmar.

Miller,�L.�T.,�Missiuna,�A.,�Macnab,�J.�J.,�Malloy-Miller,�T.,�&�Polatajko,�H.�J.�(2001).�Clinical�description�of�children�with�developmental� coordination�disorder. Canadian Journal of Occupational Therapy, 68,�5–15.

Missiuna,�C.�(2001).�Children�with�developmental�coordination�disorder:� Strategies� for� success.�Physical and Occupational Therapy in Pediatrics,�20,�1–4.

Missiuna,�C.,�Moll,�S.,�Law,�M.,�King,�S.,�&�King,�G.�(2006).�Mysteries�and�mazes:�Parents’�experiences�of�children�with�developmental� coordination�disorder.�Canadian Journal of Occupational Therapy, 73,�7–17.

Missiuna,�C.,�&�Pollock,�N.�(2000).�Perceived�competence�and�goal�setting�in�young�children.�Canadian Journal of Occupa-tional Therapy, 67,�101–109.

Missiuna,�C.,�Rivard,�L.,�&�Bartlett,�D.�(2003).�Early�identification�and�risk�management�of�children�with�developmental�coordi-nation�disorder. Pediatric�Physical Therapy, 15, 32–38.

Missiuna,�C.,�Rivard,�L.,�&�Bartlett,�D.�(2007).�Exploring�assess-ment�tools�and�the�target�of�intervention�for�children�with�developmental�coordination�disorders.�Physical and Occupa-tional Therapy in Pediatrics, 26,�71–89.

Miyahara,�M.,�&�Mobs,�I.�(1995).�Developmental�dyspraxia�and�developmental�coordination�disorder.�Neuropsychology Review, 5,�245–268.

Perr,�A.�(2004).�Range�of�human�activity:�Self-care.�In�J.�Hinojosa�&�M.�L.�Blount�(Eds.),�The texture of life: Purposeful activities in occupational therapy� (2nd� ed.,� pp.�397–413).�Bethesda,�MD:�AOTA�Press.

Peters,�J.�M.,�Henderson,�D.�M.,�&�Dookun,�D.�(2004).�Provi-sion�for�children�with�developmental�coordination�disorder�(DCD):�Audit�of�the�service�provider.�Child: Care, Health, and Development, 30,�463–479.

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930031/ on 11/15/2018 Terms of Use: http://AOTA.org/terms

Page 12: Development and Standardization of a “Do–Eat” Activity of ... · larly during the early-morning rush routine and at mealtimes (Missiuna, 2001). The significance of such children’s

58� January/February 2010, Volume 64, Number 1

Polit,�D.,�&�Hungler,�B.� (2003).�Essentials of nursing research: Methods and application.�New�York:�Lippincott�Williams�&�Wilkins.

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 Sci-ence, 22,�461–478.

Rosenblum,�S.�(2006).�The�development�and�standardization�of�the�Children�Activity�Scales�(ChAS–P/T)�for�the�early�iden-tification�of�children�with�developmental�coordination�disor-der. Child: Care, Health, and Development, 32,�619–632.

Schoemaker,�M.�M.,�Smith-Engelsman,�B.,�&�Jongmans,�M.�J.�(2003).�Psychometric�properties�of�the�Movement�Assessment�Battery�for�Children�Checklist�as�a�screening�instrument�for�children�with�a�developmental�coordination�disorder.�British Journal of Educational Psychology, 73, 425–441.

Sparrow,�S.,�Cicchetti,�D.,�&�Balla,�D.�(2005).�Vineland Adaptive Behavior Scales.�Circle�Pines,�MN:�American�Guidance�Service.

Sprinkle,�J.,�&�Hammond,�J.�(1997).�Family,�health,�and�devel-opmental�background�of�children�with�developmental�coor-

dination�disorder.�Australian Educational and Developmental Psychologist,�14,�55–62.

Van�Waelvelde,�H.,�De�Weerdt,�W.,�De�Cock,�P.,�&�Smits-Engelsman,�B.�C.�M.�(2004).�Aspects�of�the�validity�of�the�Movement�Assessment�Battery�for�Children. Human Move-ment Science, 23, 49–60.

Wann,�J.�P.,�Mon-Williams,�M.,�&�Rushton,�K.�(1998).�Postural�control�and�coordination�disorders:�The�swinging�room�revis-ited.�Human Movement Science, 17,�491–513.

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, 484–493.

Wilson,� P.� H.� (2005).� Practitioner� Review—Approaches� to�assessment�and�treatment�of�children�with�DCD:�An�evalu-ative�review.�Journal of Child Psychology and Psychiatry, 46,�806–823.

Ylvisaker,�M.,�&�Szekeres,�S.�F.�(1998).�A�framework�for�cogni-tive� rehabilitation.� In�M.�Ylvisaker� (Ed.),�Traumatic brain injury rehabilitation� (pp.�125–158).�Boston:�Butterworth-�Heinemann.

CE-135

NEW

COMING SOON!SPCC

Early Childhood:� Occupational Therapy Services for Children Birth to FiveEdited by Barbara E. Chandler, PhD, OTR/L, FAOTA • Earn 2 AOTA CEUs (20 NBCOT PDUs/20 contact hours).

In this new SPCC, you will take an enlightening journey through occupational therapy with children at the earliest stage of their lives.

The course focuses on community-based programs and explores how federal legislation drives occupational therapy practice and how practitioners can articulate and demonstrate the profession’s long-standing exper-tise in transitioning early childhood development into occupational engagement in natural environments.

Look for this new SPCC on the AOTA Web site at www.aota.org/ce soon!

Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930031/ on 11/15/2018 Terms of Use: http://AOTA.org/terms