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Research Reports |
AK Doty, PT, PCS, is employed by Lawton (Okla) Public Schools. This work was completed in partial fulfillment of the requirements for her Master of Science degree from the University of Oklahoma Health Sciences Center. Address all correspondence to Ms Doty at 4813 SE Trenton, Lawton, OK 73501 (USA) (mariabe{at}juno.com)
IR McEwen, PhD, PT, PCS, is Presbyterian Health Foundation Presidential Professor, Department of Physical Therapy, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
D Parker, PhD, is Professor, Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center
J Laskin, PT, is Assistant Professor, Department of Physical Therapy, University of Montana, Missoula, Mont. At the time the study was completed, he was Adjunct Assistant Professor, Department of Physical Therapy, University of Oklahoma Health Sciences Center
Submitted May 1, 1998;
Accepted May 13, 1999
 | Abstract |
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Key Words: Ball-handling skills • Developmental delay • Peabody Developmental Motor Scales
| Introduction |
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 TopAbstract Introduction MethodResultsDiscussionConclusionReferences |
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Physical therapy given in the public schools has changed over the past 20 years as Congress, the courts, and public policy have modified and more fully defined the Individuals With Disabilities Education Act (IDEA).7 The education of students with disabilities, for example, is moving from isolated special schools and classrooms to inclusion of children with disabilities in their neighborhood schools with their peers.8 As children with disabilities have moved to more-inclusive settings, physical therapists have had to place greater emphasis on evaluation of the functional skills that children with disabilities need to participate in general education environments.8,9
The IDEA requires a multidisciplinary evaluation to determine the nature and extent of special education and related services needed by a child with a disability.7 Because the law requires that physical therapy services be provided to assist children with disabilities to benefit from their educational programs,7 physical therapists must evaluate skills important to children's functioning at school. Physical therapy evaluations should include observation of functional abilities in the natural environment (such as classrooms, cafeteria, bathrooms, hallways, physical education facilities, and the playground), evaluation of impairments as they affect function, and norm-referenced testing, when appropriate.8
One type of skill that is important for both social interaction on the playground and performance in physical education is ball-handling skills. These skills typically include throwing, catching, and kicking. Many physical educators consider ball-handling skills to be the most important motor skills taught in physical education because they are the cornerstones of many games.10–12 Unlike motor skills that develop naturally with general movement experiences, even children without disabilities need to be taught and to practice ball-handling skills to become proficient.13 For this reason, physical therapists may need to consider whether ball-handling skills are important for a child's educational program and, if so, to evaluate the child's proficiency.
A norm-referenced developmental test that measures ball-handling skills and is widely used by physical therapists is the Peabody Developmental Motor Scales (PDMS).14 The PDMS is both criterion- and norm-referenced and measures gross and fine motor development from birth through 83 months of age. The Gross Motor Scale consists of 170 items divided into 17 age levels, with 10 items at each age level. Items are grouped into reflex, balance, nonlocomotor, locomotor, and receipt and propulsion skill categories. The receipt and propulsion category measures ball-handling skills.
The developers of the PDMS recommend its use with children with disabilities, and the PDMS has an adequate number of test items at each age level.14 Through the years, the reliability and validity of measurements obtained with these scales have been under continued investigation.14–17 Generally, reliability has been shown to be acceptable.14
Although the PDMS is widely used and can be used to identify children with developmental delays,18 one criticism is that norm-referenced testing requires a standardized format of one-to-one testing by an examiner, so the results may not predict a child's performance when playing with other children.19 Haley et al20 demonstrated the importance of task context and environment from normative data for the Pediatric Evaluation of Disability Inventory.21 They found a difference in the scores of children with and without disabilities when the environment or the demands of the task, such as chair size or walking surface, were varied. The authors concluded that context-specific functional assessments need to be developed. Other researchers have found similar effects of context on performance of adults.22,23 People with hemiplegia22 and patients with rheumatoid arthritis,23 for example, performed more activities in the rehabilitation unit or hospital than they performed in their home environments.
To compare children's ball-handling skills during one-to-one testing conditions and in the natural environment with peers, their ball-handling skills would need to be measured under both conditions using the same measurement procedures. We contend that one-to-one testing is relatively easy to do. Using the same measurement procedures in some natural environments, such as during spontaneous game playing, however, is more difficult. Brown and Snell5 described 2 types of data gathered in natural environments: data obtained by direct testing and data obtained by observation under natural conditions. In direct testing, a child is presented with an opportunity to respond to a stimulus at a time that the child needs to use the skills being tested.5 In observational data collection, behaviors are observed when they naturally occur, with no constraints being placed on the activity sequence or the location of the activities.5 A disadvantage of this type of evaluation is that the desired behavior may not occur at the time of the observation.5 An advantage is that even when testing materials and environments are simulated to be similar to the true tasks or environment, the child's true performance may be different in the natural environment.5
The purpose of our study was to compare children's ball-handling skills under 2 conditions: one-to-one standardized testing and direct testing during a game with peers. The research questions were: (1) Is the performance of 5-year-old children with developmental delay on the PDMS receipt and propulsion items different during one-to-one testing than in a group setting with peers? (2) Is the performance of 5-year-old children without developmental delay on the PDMS receipt and propulsion items different during one-to-one testing than in a group setting with peers? and (3) If the performance of children within each group is different in the 2 test conditions, is the magnitude of the difference in the 2 scores the same between groups?
| Method |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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The inclusion criteria for subjects with developmental delay were the criteria used by the Oklahoma State Department of Education.25 The subjects demonstrated delay in one or more of the following developmental domains: adaptive, cognitive, communication, physical (including gross and fine motor), and social or emotional. Delays were documented using a combination of 2 of the following tests: Battelle Developmental Inventory,26 Birth to Three,27 Early Learning Accomplishment Profile,28 and PDMS.14 "Delay" was defined by (1) scores that were at least 2 standard deviations below the mean or indicated at least 50% delay in one area of development or (2) scores that were at least 1.5 standard deviations below the mean or that indicated at least a 25% delay in 2 areas of development. Children who were not independently ambulatory or who performed more than 3 standard deviations below the mean in any area were not included.
The inclusion criteria for subjects without developmental delay were that they were 5 years of age, attended general kindergarten classes, and did not receive special education, physical therapy, or occupational therapy. They also could not have a history of receiving these services or early intervention services and could not be in the process of evaluation for special education services.
Twenty children with developmental delay (10 boys and 10 girls) and 20 children without developmental delay (10 boys and 10 girls) met the inclusion criteria and participated in the study. Table 1 shows the percentage of delay in each developmental domain for the children with developmental delay, as documented in their school records. Informed written consent was obtained from the parents of all children participating in the study.
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The group testing in the gym consisted of 5 short games that included all of the PDMS receipt and propulsion items: (1) throw/catch a playground ball (items 68, 69, 78, 104, 116, 135, and 145), (2) throw/catch a tennis ball (items 83, 95, 122, 124, and 153), (3) bouncing game (items 112, 125, and 164), (4) throwing to a target game (items 123, 126, and 150), and (5) kicking the ball (items 77, 85, 103, 158, 162, and 163). Table 2 lists the specific skills that correspond to the item numbers. The isolated testing with the therapist consisted of the same items, administered in the same order. To aid in testing and scoring, colored tape was used to mark distances and 15-degree deviations on the floors prior to all sessions. Two score sheets for the tested items were developed. One score sheet was used to record all of the children's scores during the testing of each group, and the other score sheet was used to record each child's scores during the isolated testing.
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A pilot test was conducted to examine the testing procedures and to identify any needed changes. Three students with developmental delay and 3 students without developmental delay participated in the pilot test. Based on the pilot test, the following procedural changes were made prior to data collection: (1) The group size was changed from 6 subjects to 4 subjects due to difficulty scoring 6 children at one time, and (2) the standard verbal instruction for kicking the ball up was changed from "kick the ball" to "kick the ball up" because most of the children in both groups did not attempt to kick the ball up.
During data collection, all children were tested with their classes. Children in 4 morning and 4 afternoon classes for children with developmental delay and children in 2 morning and 1 afternoon kindergarten classes participated in the study. To control for possible order effects of testing, half of children with developmental delay and half of the children in kindergarten classes were chosen at random to be tested in the isolated setting first. The children in the other classes were tested in the group setting first. A group of children in kindergarten was tested first to control for the possibility of inflated scoring of the children with developmental delay if they were tested first, as discussed by Field.29
Group testing took place in the school gym and lasted approximately 40 minutes. During the group testing, the children wore front and back name tags and the researcher assisted the tester in keeping the children in their places and dealing with any problem behaviors that occurred. When the groups of children with developmental delay were tested, the group included one child from the kindergarten group who had been tested previously and was known to have age-appropriate throwing skills. This student threw the ball while all of the other children's catching skills were scored to ensure that the children's ability to catch was not influenced by a peer's poor throwing ability. Isolated testing took place in the school physical therapy room, using the same order of items and standardized instructions and praise as testing in the group setting. The researcher video-taped all sessions.
Reliability
To determine interrater reliability, the researcher and the tester simultaneously scored children's performance during group games and isolated testing. Although they stood near each other so they could observe children from the same angles, they could not see each other's score sheets. Intrarater reliability was determined by the researcher and the tester rescoring children's performance from the videotapes. All of the trials during the pilot test were examined for reliability to identify the need for changes in procedures and scoring that were made prior to the actual data collection. During data collection, one group session and one isolated session per week were scored by both the researcher and the tester and were rescored from the videotapes to determine reliability and identify any problems with observer drift.
Each set of observations (scores) was compared for interrater or intrarater agreement or disagreement, and the kappa statistic was calculated by group and isolated test setting. As shown in Table 3, the kappa statistics for interrater agreement were between .89 and .94 and the kappa statistics for intrarater agreement were between .84 and .91. Better interrater agreement than intrarater agreement is unusual30 and probably resulted from some difficulty scoring students from the videotapes; camera angles did not always give a clear view of students, and lights sometimes caused glare from the floor.
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A preliminary analysis was performed using a 3-way analysis of variance to determine whether differences existed in PDMS scores due to order of testing, sex, and developmental status. Then, a repeated-measures analysis of variance using a 3-factor design with the variables of sex, developmental status, and test setting was performed using SAS software.31,* An alpha level of .05 was used to determine statistical significance.
| Results |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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=38.75, SD=5.93) was higher than the mean score of children with delay (=29.25, SD=8.44; P=.0001). Regardless of developmental status, boys had a higher mean score (=38.45, SD=6.96) than girls (=29.55, SD=7.97; P=.0001).
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=31.35, SD=7.92) than in the group setting with peers (=27.15, SD=8.60), and this difference was statistically significant (F=8.97; df=1,19; P=.007). The effect size of a 3.1-point difference between the mean scores of children in the isolated test setting and the mean scores of children in the group test setting across developmental status was large, with a 76% probability of demonstrating a difference with 20 students in each group. Because the performance of the children without developmental delay did not differ in the 2 test conditions, we could not answer the third question about whether the difference in performance in the 2 conditions was greater for one group than for the other group.
Table 2 shows that no patterns appeared to exist in the types of ball skill items on which the children scored lowest or on which they performed differently under the 2 test conditions. They scored consistently higher on the test items at the developmentally younger end of the scale.
| Discussion |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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One difference between the isolated testing situation and the group game with peers was that, as in most standardized testing situations, the room in which the testing took place was relatively quiet and free from distractions. This was not the case when children were tested in the gym with their peers. One observed difference between the groups was that the children without developmental delay made comments suggesting that they were competing with each other during group games. Children with developmental delay did not make such comments, suggesting that if competition causes children to try harder to do well, then the children with developmental delay may not have benefited from the competition to the same extent as children without developmental delay.
Children in both groups appeared to imitate the behavior of other children. If the first student to throw the ball, for example, threw it poorly so that it bounced before reaching the catcher, the other children tended to throw the ball with the same pattern. Children also might have been influenced by the good skills of their peers during the group games. Research has shown that observation of peers can promote improvement in an imitator's skills.33 The children without developmental delay had better peer models than did the students with developmental delay. A limitation of this study was that for the group testing, the children with developmental delay were with other children with developmental delay. If they had been included with the children without developmental delay, they might have had better models and have performed better.
In the isolated test setting, the children did not have peer models, either good or poor. All children had the advantage of receiving the ball from the tester, who ensured that the child was ready and carefully threw the ball to optimize each child's chances of catching or kicking it successfully. This was not always the case in the gym environment with peers.
The finding that boys performed better than girls was not expected. Previous reports13,24 suggest that a sex difference does not occur before 6 years of age. In our study, boys without developmental delay performed best, followed, in order, by girls without developmental delay, boys with developmental delay, and girls with developmental delay. The boys with developmental delay had the same scores as girls without developmental delay. This may be a useful finding when planning group intervention. To avoid frustration and promote inclusion of 5-year-old boys with developmental delay in group games, it may be helpful to place them in a group that is not predominantly boys without developmental delay.
Because norm-referenced tests do not measure motor skills in natural environments, many authors advocate observation in natural environments to obtain information about children's disabilities and how they may be affected by societal limitations.5,19,20 The findings of our study may support the argument that observation in natural environments is important because, as Haley and colleagues stated,19 motor behaviors are more than just competencies unfolding over time; motor behaviors are responses to meet desired goals within specific physical and social contexts. For this reason, future research that compares direct testing with observation of children in naturally occurring situations for performing ball skills may reveal even greater differences in performance between the isolated test setting and observation in the natural environment than were found between the isolated test setting and a structured group test setting.
Two limitations of our study were the inclusion of only 5-year-old children, which prevents generalization to children of other ages, and the use of a relatively small sample. Another limitation was occurrence of some distracting behaviors during the group testing situations, but these behaviors are likely to occur in most natural environments. Finally, the effects of teaching ball-handling skills in isolated and group environments on task generalization should be investigated.
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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| Acknowledgments |
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| Footnotes |
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This research was approved by the Institutional Review Board of the University of Oklahoma Health Sciences Center.
Support for the research was provided by a preparation of related services personnel grant (#H029F30020) from the US Department of Education, Office of Special Education and Rehabilitative Services; an Interdisciplinary Leadership in Education for Health Professionals Caring for Children With Neurodevelopmental and Related Disabilities grant (MC409411) from the Maternal and Child Health Bureau; and a research grant from the Section on Pediatrics of the American Physical Therapy Association. The article, however, does not necessarily reflect the policies of these organizations, and official endorsement should not be inferred.
This research was presented in abstract format at the American Physical Therapy Association Combined Sections Meeting; Dallas, Tex; February 12–16, 1997.
* SAS Institute Inc, PO Box 8000, Cary, NC 27511. 
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