When testing a child with a known diagnosis, the examiner can make accommodations that help ensure a successful testing session. For example, the use of standardized tests with children who display autism spectrum disorder (ASD) can be challenging (National Research Council, 2001). However, many children with ASD can successfully complete a standard assessment, producing valid results when the examiner accommodates to the
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child’s restricted interests and preferred communication methods. For example, children with ASDs, such as Asperger’s syndrome, often prefer highly structured, repetitive activities.
The child may engage in a structured activity such as stacking or lining up blocks, but have no interest in an unstructured activity such as drawing. Young children who display ASD symptoms are most likely to engage if first presented with a puzzle, the pegs, the cube blocks, or coins in a slot items. These items are repetitive and structured, are likely to be of interest, and should be among the first items administered.
The test behaviors of some children with specific diagnoses also can demonstrate variability. For example, children with ASD often have scattered scores, with some skills above age level (e.g., coins in the bank or puzzles) and others below age level (e.g., drawing). A pattern of scattered item performance is typical of children with ASD and others who have narrowly focused interests and rigid activity preferences.
A retrospective review of clinical records found 9 percent of a clinic population of children with ASD had diagnosed muscle hypotonia and gross motor delay. Delayed acquisition of independent standing and walking skills was the primary gross motor finding (Ming, Brimacombe, & Wagner, 2007). Identifi- cation of gross motor delays in children with ASD is important to provide diagnostic information and appropriate treatment recommendations.
Children with ASD often do not follow verbal instructions.
Thus, when allowed by the item’s standardization, modeling and verbal cueing are likely to be more effective ways to communicate instructions. At times, exaggerated cueing and gesturing may be needed to maintain their interest and focus on the items. Pre-walking and walking motor items are less diffi- cult to administer with this population, since the children are more willing to engage with toys and objects than with people.
Once the child identifies an object of interest, the examiner can use this object to engage the child in testing activities without relying on verbal cueing. The administration of higher-level fine and gross motor items may be more difficult when a child with ASD does not attend to directions.
An examiner also may improve participation in testing by altering the testing environment and using increased physical
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cues. For example, the examiner can instruct the child to step over low obstacles in his or her path to assess single leg balance, initially jump holding the child’s hands to encourage sponta- neous jumping, ‘‘chase’’ the child to encourage running, place visual cues on the stepping path to attract attention, and utilize stairs without a rail or wall to test this skill without support while guarding closely for their safety. Imitation typically is a core deficit in this population. Thus, Item 65 on the Gross Motor Subscale, Imitates Postures, may be one of the most challenging to administer. Children with ASD are likely to fail this item if they refuse to attend to the examiner. Motor plan- ning and body awareness should therefore be assessed during spontaneous motor play (e.g., climbing on playground equipment).
Children with ASD often perform on their own terms, and examiners may need to wait for them to respond or to try an item a number of times in different ways. These children may have difficulty sustaining attention, and may need frequent breaks. Examiners often can succeed in administering the Bayley Scales and obtaining valid scores for children with ASD if they persevere, are patient and wait for the child’s response, adapt the sequence of items, are flexible about where the items are administered, minimize verbal cueing, give visual cues, and set up a reward system (e.g., give juice when child stays attentive and seated). The Bayley-III Adaptive Behavior Scale provides the parent’s report on children’s daily functional performance, giving context to how children use motor skills in daily living skills. Although parents report on the child’s functional skills in self-care, home and school living gives important insights into the child’s daily use of functional motor skills, observation of motor performance remains important for identifying the interventions that may be useful for improving motor skill.
Children with Cerebral Palsy
Deficits in postural control and balance have been identified in children with developmental disabilities. Children with cerebral palsy (CP) demonstrate deficits in anticipatory postural adjustments (feedforward postural control) as measured by
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electromyography and a force plate (Liu, Zaino, & McCoy, 2007). Deficits in postural control and balance during walking were studied in two groups of children with CP using three- dimensional motion analysis and force plates. Children with CP displayed distinct differences in their control of center of mass and center of pressure (Hsue, Miller, & Su, 2009). Children with CP also display underdeveloped postural control mechanisms and specific reliance on visual feedback for balance (Shimatani, Sekiya, Tanaka, Hasegawa, & Sadaaki, 2009).
Children with CP and poor postural stability need external support to perform testing items. For infants, external support can be provided by sitting on the parent’s lap or in an infant’s seat with support to both head and trunk. For older children, a chair with high back and arm rests (e.g., a Rifton˜ chair) should be used. The table height should allow the child to comfortably rest his or her arms on the table with elbows flexed to 90. Children with very low postural stability can remain in their own wheelchair with the fine motor items placed on a wheelchair tray.
Children with CP often exhibit slow or delayed responses, and should be given plenty of time to complete fine and gross motor items (i.e., for items that are not timed as part of the scoring criteria). Often children with CP attempt the fine motor tasks but are unable to meet the criteria (e.g., inaccurate tracing, drawing figures that do not meet criteria). Narrative descrip- tions of movement difficulties can complement the scaled scores to provide a comprehensive picture of the child’s abilities.
The reach and grasping pattern items should be adminis- tered to both hands and scored separately when a child with CP has asymmetrical involvement. This method provides infor- mation on the different levels of function for the right and left sides. Items that require coordination of two hands together often are challenging for such children and the examiner may, for example, decide to steady the paper for them so that they are more successful in drawing. The Bayley-III Administration Manualallows for these adaptations in administration.
The fine and gross motor growth curve often falls in the 5 to 10 percentile range for children with CP. As the scale’s motor skill
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demand increases (e.g., items for 30–42 months), children with CP may plateau, falling further below the typical growth curve.
Children with Visual Impairment
Accommodations also are likely to be needed to obtain optimal performance from children with visual impairments.
The Bayley-III Administration Manual provides guidance on testing children with visual impairment (see pages 224–225).
The lighting in the room should be natural sunlight if possible. The examiner should consult the parent on the effect of glare and whether low light or bright light is best.
A child can have loss of peripheral or central vision, and thus the examiner should position the test items where the child’s vision is best. Some of the Fine Motor items do not require vision, and can be used to determine grasping patterns, some tool use, and use of two hands together.
However, a number of the fine motor items cannot be adapted for children with low vision, and thus the scale cannot be administered and scored using the standard instructions in most cases.
The Fine Motor items and their tools are simple, and their use somewhat intuitive. Thus, their use can provide an estimate of the child’s fine motor development, and an indication whether fine motor skills are age appropriate. The child with visual impairment should exhibit age appropriate performance on items that allow the child to use haptic perception (e.g. grasping patterns, object transfer, and connecting blocks) and show delays on others (e.g. stringing beads, stacking blocks, drawing or cutting with scissors).
Facilitating movement and gross motor performance in children with visual impairments can be accomplished using toys, bright lights, and musical or sound features. Exam- iners should use their ability to localize sound as a means to encourage movement. For example, children may raise their head upright to listen to a sound, demonstrate a weight shift in sitting when reaching toward a sound made by a rattle or bell, crawl or walk toward a musical toy, or squat to retrieve a musical toy. Examiners should reduce all peripheral sounds in a child’s environment during testing to
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minimize confusion and increase attention and participation.
Additionally, sounds from a toy coming from one direction and the examiner’s voice from another direction may cause confusion. The examiner should provide simple and direct instructions to the child and repeat them as needed to encourage participation in testing. Finally, rapport with the child, established initially through free play activities, may be especially beneficial with children with visual impair- ments and contribute to establishing trust in the examiner and the testing environment.
Children with Intellectual Disability
Children with intellectual disability (ID) may need multi- sensory cueing to understand the test’s instruction.
Demonstrating or modeling the item to supplement verbal instructions should be considered. The administration instruc- tions for most fine motor items provide for modeling them. The examiner can repeat the demonstration and instructions for some items.
Children with ID may have a short attention span, and the examiner may need to use a verbal cue, pointing or tapping to help the child refocus on the task. The examiner may move to an easier item if the child becomes resistant to more difficult items, and later return to the more difficult items. Children with Down syndrome often do not comply with item administration.
When testing, the examiner can insert play opportunities to maintain their cooperation. When performance is charted on the Fine Motor Growth Chart, the progress of a child with ID may plateau at 30–36 months when the fine motor items require integration of visual and tactile perception (e.g., Item 49, Tactilely Discriminates Shapes; Item 53, Imitates Plus Sign) and cognitive skill (e.g., Item 46,Imitates Hand Movements; Item 52, Builds Bridge).
Using the Gross Motor Growth Chart, children with ID may show a plateau in gross motor skills when the items require them to follow specific instructions (e.g., hop on one foot, walk heel-to-toe). By age 3, the Gross Motor testing can be challenging for children who attend poorly or have cognitive and/or receptive communication difficulties that
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decrease their ability to follow directions. Testing higher- level gross motor skills requires children to attend to the examiner and follow simple directions. In these cases, every attempt should be made to accommodate to the child’s level of understanding by keeping commands as simple as possible, using more physical demonstrations, and engaging the child with interesting toys. Provision of both verbal cues and physical demonstration whenever possible will maximize the child’s ability to understand expectations.
Examiners should adapt test administration within the limits of standardized testing to elicit as many skills as possible. The use of careful adaptation, creativity, and problem-solving in item administration is likely to enhance accuracy of motor skill assessment when working with children with ID.