Standardized+pediatric+gross+motor+examination+and+evaluation

__**Standardized Pediatric Gross Motor Examination and Evaluation**__ According to the Guide for Physical Therapy Practice, examination is the process of obtaining a history, performing relevant systems review, and selecting and administering sepcific tests and measures. Evaluation, therefore, is the dynamic process in which the physical therapist makes clinical judgments based on data gathered during the examination. While administering a standardized measure, the therapist simultaneously observes how the child is performing the task at hand, and evaluates the quality of movement and motor planning. These observations allow the therapist to identify areas of concern that require further examination. Recommendations are then made based on the results of the comprehensive examination (Tieman et al.)

Standardized gross motor testing is an important component of the examination process of pediatric patient management. Standardized assessments are one means of collecting data and information about a child's abilities, current level of function, achievement of milestones, impairments and functional limitations. A benefit of standardized assessments is that they give objective criteria to skills that could otherwise be subjective between clinicians or from parent report. The term “assessment” in early intervention and school settings refers to an ongoing process of collecting information to guide intervention planning.

Assessments of **__gross motor__** function and skills can include areas like motor reflexes, rolling, sitting, crawling standing, walking, stair climbing, reaching/grasping, running, jumping, and ball skills (kicking, throwing, catching). Within each area, a test may have multiple test items or skills that range in difficulty according to development. Dividing tests into sub-test or sub-areas with multiple tasks that generally follow typical development and incrementally increase in difficulty allows physical therapists to tease out specific skills and limitations to a child's overall function.

There are 2 major categories of standardized assessments:

__**Norm Referenced:**__ //ex: a child scoring in the 30th percentile performed equal to or better than 30% of the children tested in the sample//
 * These assessments have been performed on a large sample of typically developing children within the age range the test will be used on.
 * The sample is considered "normative" if it follows a bell shaped curve, with the majority of scores falling around the average and fewer scores falling in the extremes, which is still considered within the range of typical development
 * Scores are compared to the sample (child is "competing" against other children) and are reported as a percentile.
 * These assessments are used to determine eligibility of services and test items should not be used as goals or outcomes to track progress**

//ex: a child would score 50% if they achieve 10 out of 20 tasks administered// =**__List of Pediatric Gross Motor Assessments:__**=
 * __Criterion Referenced:__**
 * These assessments include skills that should act as references
 * Child's scores and success compared only to self (administered at multiple time points), not to performance of other children
 * Scores are reported as a percentage of items achieved
 * These assessments are used to track progress and may be used for task analysis or development of goals**

This link is a list of several standardized tests used with children and a brief description from the pediatrics section from the APTA.

=**__List of Visual Motor Assessments:__**= =**__List of Pediatric Functional Assessments & Screening Tools:__**= //PT student performing ASQ with his 5 yea﻿r old daughter:// media type="youtube" key="3PIERuRopFo" height="245" width="404"
 * **Bruininks-Oseretsky Test of Motor Proficiency, 2nd Ed (BOT-2)**
 * Developed in 1978 by Bruininks
 * Purpose: assess gross and fine motor skills
 * Short-form can be used to screen for identifying developmental problems
 * Assessment areas: running speed and agility, balance, bilateral coordination, strength, upper limb coordination, response speed, visual motor control, and upper limb speed and dexterity
 * Age: 4.5 to 14.5 years
 * Time to administer: 45 to 60 minutes for the complete test, 15 to 20 minutes for the short form
 * Performed by: physical therapists, occupational therapists, and PE teachers
 * Kit costs around $50
 * **Peabody Developmental Motor Scales, 2nd Ed (PDMS-2)**
 * Developed in 2000 by Folio and Fewell
 * Purpose: assesses qualitative and quantitative aspects of child's gross and fine motor skills, evaluates child's progress, research tool
 * Norm-referenced
 * Assessment areas: reflexes (birth to 11 months), stationary, locomotion, object manipulation (12 months to 6 years), grasping, and visual-motor integration
 * Age: birth to 6 years old
 * Time to administer: 45 to 60 minutes
 * Performed by: physical therapists, occupational therapists, diagnosticians, early intervention specialists, adapted P.E. teachers, and psychologists.
 * Kit costs around $500
 * [|Portions of PDMS-2 on home video]
 * **Clinical Observation of Motor and Postural Skills, 2nd Ed (COMPS)**
 * Developed in 2000 by Wilson, Pollock, Kaplan, and Law
 * Purpose: screen children for presence or absence of motor problems associated to posture and motor coordination deficits
 * Assessment areas: slow movements, rapid forearm rotation, finger-nose touching, prone extension posture, asymmetrical tonic neck reflex, and supine flexion posture
 * Age: 5 to 16 years old
 * Time to administer:15 to 20 minutes to administer
 * Performed by: physical and occupational therapists
 * Kit costs around $100
 * **Movement Assessment Battery for Children- 2nd Edition (MABC-2)**
 * Developed in 2007 by Henderson, Sugden, and Barnett
 * Purpose: identify and describe motor impairments in children that prevent school interaction, guides treatments of motor impairments
 * Assessment areas: manual dexterity, ball skills, and static and dynamic balance
 * Age: 3 to 16 years old
 * 3 age ranges: 3-6 years, 7-10 years, and 11-16 years
 * Time to administer: 20 to 40 minutes
 * Performed by: ??
 * Kit costs $1,100
 * **Alberta Infant Motor Scale (AIMS)**
 * Developed in 1994 by Piper and Darrah
 * Purpose: identify motor delay, evaluate change in motor performance over time due to child's maturation or therapeutic intervention,
 * Assessment areas: tested in four positions (supine, prone, sitting and standing), 58 gross motor skills assessed, observation of weight-bearing, posture and anti-gravity movement with each motor skill
 * Age: birth to 18 months
 * Time to administer: 20 to 30 minutes
 * Performed by: physical therapists
 * Kit costs around $85
 * **Denver II Developmental Screening Test (DDST-II)**
 * Developed in 1989 by William K. Frankenburg and J.B. Dodds
 * Purpose: 125-item standardized measure that is designed to determine whether a child’s development is within the normal range.
 * Assessment areas: Personal-Social (25 items), Fine Motor Adaptive (29 items), Language (39 items), and Gross Motor (32 items)
 * Age: birth to 6 months
 * Time to administer: 10 to 20 minutes with 1 to 2 minutes to score
 * Performed by: professional or paraprofessional
 * Kit costs > $100
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 * **Test of Infant Motor Performance (TIMP) (Heineman et al., Spittle et al.,** **[|TIMP - Elon University],[|TIMP - UIC DPT]**)
 * Developed in 1993 by Campbell, Osten, Kolobe, Fisher
 * Purpose: 42 items divided into 2 sections of observed items and elicited items
 * Assessment areas: assesses infant's postural control and function in relation to spatial orientations, perturbations, changing positions, and self-comforting
 * Age: 32 weeks PMA to 4 mos
 * Time to administer: 20-40 min
 * Performed by: physical therapists, occupational therapists, and other related health care professionals (early intervention, special care nursery)
 * Kit costs around $65 for test forms
 * **Bayley Scales of Infant Development, 2nd edition (BSID-II) [Tieman, B. et al 2005]**
 * Purpose: Assess fine and gross motor development and identify developmental delay or monitor developmental progress; cognitive and behavioral scale.
 * Norm-referenced
 * Age: 1month - 3.5years
 * Time: 25-60min
 * Performed by: Physical Therapist
 * **Toddler Infant Motor Evaluation (T.I.M.E.) [Tieman, B. et al 2005]**
 * Purpose: Identify delay in motor development and movement patterns
 * Norm-referenced
 * Age: 4months - 3.5years
 * Time: 10-55min
 * Performed by: Physical therapist guidance to parent for observance of parent-child interaction; parent interview component
 * **Pediatric Evaluation of Disability Inventory (PEDI)** **[Tieman, B. et al 2005]**
 * Purpose: Measure function, monitor rehabilitation progress and for use as an outcome measure
 * Norm-referenced and criterion-referenced
 * Age: 6months - 7.5years
 * Time: 20-60min
 * Performed by: Physical therapist through parent report,interview, or observation.
 * **Gross Motor Function Measure (GMFM) [Tieman, B. et al 2005]**
 * Purpose: Monitor gross motor function over time in child with cerebral palsy and identify intervention needs.
 * Criterion-referenced
 * Age: not specified
 * Time: 45-60min
 * Performed by: Physical Therapist
 * This you tube link has many videos of the different components of the GMFM. [|GMFM Videos]
 * Beery-Buktenica Developmental Test of Visual Motor Integration, 6th Ed (BEERY VMI)
 * Developed by Beery in 2006
 * Purpose: identify difficulties in integrating visual-perceptive and motor abilities
 * Copy drawings that increase in difficulty
 * Ages: 3 years to adult
 * Time to administer: 10 – 20 min
 * Wide Range Assessment of Visual Motor Abilities (WRAVMA)
 * Developed by Adams & Sheslow in 1995
 * Purpose: determine visual motor difficulties as a result of spatial skills, motor skills or a combination
 * Visual-Motor subset – copy designs
 * Visual-Spatial subset – matching figures
 * Fine Motor subtest – peg board task
 * Ages: 3 to 17 years
 * Time to administer: 15-30 min
 * Ages and Stages Questionnaire, 2nd Ed. (ASQ)
 * Purpose: identify areas of concern for developmental delay and further evaluation
 * Easy for parents to fill out on their own, part of well child pediatric visit
 * 30 items per age
 * Areas Assessed: language, personal-social, fine/gross motor, problem solving
 * Ages: birth to 5 years
 * Time to administer: 15 to 20 min for interview or parents can complete independently
 * School Function Assessment (SFA)
 * Developed by Coster, Deeney, Haltiwanger, Haley in 1998
 * Criterion referenced
 * Purpose: measures abilities and track progress in areas of school function (non-academic tasks)
 * Assessment Areas: level of participation, assistance or adaptations, activity performance in Likert Scale
 * Ages: elementary school (K to 6)
 * Time to administer: 1.5 to 2 hours
 * Pediatric Evaluation of Disabilities Inventory (PEDI)
 * Developed by Haley, Coster, Ludlow, Haltiwanger, Andrellos in 1992
 * Purpose: evaluate functional skills and abilities as well as adaptations and need for caregiver assistance
 * Assessment Areas: self-care, mobility, social
 * Questionnaire completed via parent interview
 * Ages: 6 mo to 7 years
 * Time to administer: 45-60 min


 * Quick Neurological Screening Test, 2nd Ed (QNST-II)
 * Developed by Mutti, Sterling, Martin, Spaulding in 1998
 * Purpose: Screen for neurological integration that relate to learning, sample maturity of motor development
 * Assessment Areas: manual dexterity, spatial orientation, fine- and gross-motor movements, visual tracking, and tactile perceptual activities
 * Task performance administration
 * Ages: 5 to 18 years
 * Time to administer: 20 min

=Routines-based Interview Tools= Routines-based interview questionnaires may help paint a more complete picture of a child's true functional ability when added to the gross motor assessment outcomes. the results from these tools can help determine intervention strategies and functional goals specific to the child.
 * Scale for Teachers' Assessment of Routines Engagement (STARE)
 * Scale for the Assessment of Teachers' Impressions of Routines and Engagement (SATIRE)
 * Routines-Based Interview (RBI)
 * Scale for Assessment of Family Enjoyment with Routines

The STARE and SATIRE are completed by the child's teacher, who may see the child for a significant portion of the day and may observe things that aren't noticed by the family. The RBI and SAFER, on the other hand, are completed by the family to give information on the child's abilities outside of school or day-care. You will find copies of each of these questionnaires below.

The following web page link contains additional information on many different assessment tests and screening tools. It gives a general definition of developmental tests, the purpose of tests, a description of developmental tests and how each one varies and different types of tests for different age groups. This web site also contains information for parents regarding any risk with developmental tests, how "normal" varies, and parental concern information. At the bottom of the page there are many resources for parents to utilize when further learning about developmental tests. []

=__**Pros and Cons of Standardized Motor Testing**__=
 * Pros:
 * Can be a guide for physical therapists on what areas to treat
 * Gives parents an idea of where their child stands compared to other children with similar conditions.
 * Standardized tests allow for progress to be tracked over time
 * Standardized tests can provide a comparison across groups
 * Cons
 * Physical therapists may only treat the deficits found by the standardized tests
 * Decreased time spend on other treatment areas because of time to administer standardized tests.
 * Can place stress on child, PT, and parent
 * Standardized tests can create a bias
 * May score 0 for skills child is unwilling rather than unable to perform causing inaccurate reflection of child's abilities.

When used appropriately, standard assessments are used as a screening tool to identify a developmental delay or as an ongoing assessment of the effect of treatment. There are many ways to misuse or misinterpret test results. Practicing test items is misuse of the assessment tool because the child will master the test and no necessarily have improvement in function. Assessments assume the child is performing at their max ability, however this is not always the case. Less experienced therapists may have difficulty giving good directions or children may decide they do not want to perform a skill; in these cases, the child may receive a 0 or half credit for the skill. Each skill the child is unwilling to perform results in a lower estimate of their ability and therefore misinterpretation of the result. Therapists should be aware of this possibility and take it into consideration when explaining a child's scores to the parents.

=**__Using Standardized Assessments in the Pediatric PT Clinic__**= Standardized assessments should be used by clinicians in the clinic to aid in identifying motor dysfunctions in the pediatric patient, for evaluating how effective an intervention is, and for predicting developmental outcome (Spittle et al., Tieman et al., Heineman et al.).

There are many different standardized tests available for use by clinicians in the pediatric clinic. Deciding on the most appropriate measure for each child should be based on the following questions: (Tieman et al.) - What is the purpose? - What are the characteristics of the child? - What are the developmental or functional areas to be examined? - In which setting will the examination occur? - What are the external constraints of testing?

Reliability and validity are two important concepts to consider when selecting measures to use in the clinic. Reliability is the accuracy and consistency or repeatability of measurements with mainly two types: inter-rater and intra-rater (test-retest) (Tieman et al.). Validity is the extent to which an assessment tool measures what it is intended to measure. The types of validity are construct, content, concurrent, and predictive (Tieman et al.). It is important to consider trying to implement standardized tests with good reliability and validity into your everyday pediatric practice as often as possible. Some pediatric tests that have demonstrated moderate to very good validity are the Bayley Scales of Infant Development II, Peabody Developmental Motor Scales, 2nd Edition, the Alberta Infant Motor Scale, and the Test of Infant Motor Performance (Heineman et al.). The Alberta Infant Motor Scale has great predictive validity when used in the later months of life (Spittle, et al.). The Peabody Developmental Motor Scales, 2nd edition has demonstrated good test-retest reliability, while the Alberta Infant Motor Scale shows very good intra-observer and inter-observer reliability and excellent test-retest reliability (Heineman et al., & Spittle et al.). The Bayley Scales of Infant Development II and Test of Infant Motor Performance both have good inter-observer reliability (Heineman et al.).

=**__Do scores children receive accurately reflect their abilities? What factors may influence testing?__**= //S//tandardized assessment scores that children receive reflect the child's abilities on that specific test date. These scores are fairly accurate, especially with good validity and reliability, but tests are often based on subject observation by the therapist. A parent may state that they have seen their child perform that task at home, but if the therapists does not see the task in the clinic it will not be scored on certain tests. Factors that could negatively influence the child's testing scores include the interest or behavior of the child, environmental noise or distractions, and rapport or observation skills of the clinician (Tieman, et al.). It is also important for the clinician to have an adequate background and experience in child development and disabilities and a working knowledge of the standardized assessments they intend to use in the clinic. =**__References:__**=
 * Some tests, such as the Bayley III, provide confidence intervals that can be helpful in reporting results to parents and physicians. For instance, a child has a composite score of 97 on the Bayley and a confidence interval selected at 90% is 91-104. This means that if the child was tested 10 times, her score would be between 91-104 for 9 of those times. This can be a nice way of telling parents that we acknowledge there may be factors influencing performance on any given day of testing, so the child may score slightly higher or lower within this confidence interval range.
 * Tieman, B., et al "Assessment of Motor Development and Function in Preschool Children" __Mental Retardation and Developmental Disabilities Research Reviews__ 11 (2005) 189-196.
 * Connolly, Barbara H., and Patricia C. Montgomery. //Therapeutic Exercise in Developmental Disabilities. 3rd ed. Thorofare, NJ:SLACK Incorporated, 2005.//
 * Spittle, A.J. et al. "A systematic review of the clinimetric properties of neuromotor assessments for preterm infants during the first year of life" __Developmental Medicine & Child Neurology__ 50 (2008) 254-266.

=**__Pediatric Motor Tests Cheatsheet__****__﻿__**= I have compiled a chart for all of the standardized tests that we have talked about. I've included the reference (norm or criterion), age group, discription, and advantages/disadvantages. I hope this can help you organize all the information.

(BOTMP) || Norm || 4.5 to 14.5 years || Gross motor Fine motor || 48 items in 8 subtests (running speed and agility, balance, bilateral coordination, strength, upper-limb coordination, response speed, visual-motor control, and upper-limb speed and dexterity) || Able to separate gross and fine motor scores
 * Test || Reference || Ages || Assesses || Description || Advantages || Disadvantages ||
 * Bruininks-Oseretsky Test of Motor Proficiency

Can be used on older children || No cognitive

Lower Reliability

Takes a long time to administer ||
 * HINT || Norm || 3 to 12 months || Developmental delay || 22 items assessing neuromotor milestones, active and passive muscle tone, head circumference, stereotypic movement patterns, behavior interactions and caregiver’s assessment of the infant’s development || Comprehensive

Takes caregiver into account || Poor predictive validity || Only takes 15-20 min || Only a screening test
 * Miller First Step || Norm || 2 yrs 9 months to 6 yrs 2 months || Risk for developmental delay in preschoolers || Assesses cognitive, communicate, physical, social-emotional, and adaptive function in the form of games || Fun for the child

Doesn’t assess motor ||
 * Bayley III (BSID) || Norm and Criterion || Birth to 42 months (3.5 years) || Developmental delay || A series of developmental play tasks consisting of motor (gross and fine), language, and cognitive portions and takes between 20-30 minutes to administer || Norm reference is taken from large sample (n=1700)

Can also be used to assess progress Has both motor and cognitive || Poor predictive validity

Requires extensive training to administer ||
 * Test of Infant Motor Performance (TIMP) || Norm || 32 weeks PMA to 4 months || Motor function and risk for developmental delay || 13 items scored pass/fail based on observation, and 29 items administered by the practitioner. Assesses infant’s ability to sustain postures in variety of spatial orientations, regain postural stability following perturbations, and make transitions between postures for orienting to interesting events and people, changing positions, and self-comforting. || Good for assessing premies

Good predictive validity || Not applicable for older babies ||
 * Movement Assessment of Infants (MAI) || Criterion || Birth to 12 months || Motor delay || 65 items related to muscle strength/tone, primitive reflexes, automatic reactions, and volitional movements. ||  || Over-identifies infants with motor delay ||
 * Denver II || Criterion || 1 week to 6.5 years || Developmental problems || Screening test encompassing 125 items in the personal-social, fine motor-adaptive, language, and gross motor domains || Very comprehensive || Poor specificity

Has a lot of items and takes long time to administer || (GMFM) || Criterion || 5 months to 16 years || Change in motor performance over time in children with CP || 88 items in five groups: lying and rolling; sitting; crawling and kneeling; standing; and walking, running, and jumping || Specific to CP
 * Gross Motor Function Measure

Also validated for Down’s Syndrome

Has a shorter version (GMFM-66) || High inter and test-retest reliability || and community-based settings || Does not give you specific motor deficits - not very useful for intervention planning ||
 * Peabody Developmental Motor Scales (PDMS-2) || Norm and Criterion || Birth to 7 years || Gross and fine motor || The gross motor scale includes reflexes, balance, non-locomotor, locomotor, and reception/propulsion of objects. The fine motor scale includes grasp, hand functions, eye-hand coordination, and manual dexterity. || Can be used on full term newborns || “Novel” items, may not be functional ||
 * Functional Independence Measure for Children (WeeFIM) || Criterion || 6 months to 12 years || Severity of disability and level of caregiver assistance needed || 18 items grouped into two major categories of function, motor, and cognition that are divided into six domains divided into subdomains: Motor, Self-care, Sphincter control, Transfers, Locomotion, Cognitive -Communication, and Social cognition || Can be applied uniformly across inpatient, outpatient,
 * Alberta Infant Motor Scale (AIMS) || Norm || Birth to 18 months || Risk for developmental delay in infants || 58 items related to posture, movement, and weight bearing in prone, supine, sitting, and standing positions. || Only takes 10-20 min to administer

Excellent reliability and validity

Can be used for premies || Only gives credits for items fully observed, not partially observed

Tester needs to be trained on identifying the items ||
 * Pediatric Evaluation of Disability Inventory (PEDI) || Norm ||  || Functional limitations || 197 items measuring functional skills in self-care, mobility, and social function and 20 items assess the extent of caregiver assistance and modifications needed || Can be used to identify treatment progress and recommends areas of new functional intervention ||   ||
 * Ages and Stages Questionnaire (ASQ) || Norm || 4 to 60 months || Developmental level of a child through parent report || 19 questionnaires each containing thirty items covering five areas of development: communication, gross motor, fine motor, problem solving, and personal-social || Allows you to get parental input and find out what they feel is important || Does not involve actual motor testing ||
 * Infant Neurological International Battery (INFANIB) || Criterion || Birth to 18 months || Abnormal neuromotor function || 20 items divided into 5 content domains (Spasticity, Vestibular function, Head and trunk control, French angles, and LEs) || Can be used for premies

Predicts need for further treatment ||  || =__**Resources**__= Here are some .pdf files for reference:



Link to APTA pediatrics chapter website: http://www.pediatricapta.org/

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