See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/236226902

Detecting Differences in Activities of Daily Living Between Children With and

Without Mild Disabilities

Article in American Journal of Occupational Therapy · April 2013

DOI: 10.5014/ajot.2013.007013 · Source: PubMed

CITATIONS READS

16 346

4 authors, including:

Brigitte E Gantschnig Julie Page

Zurich University of Applied Sciences Schweizerisches Rotes Kreuz
46 PUBLICATIONS 147 CITATIONS 36 PUBLICATIONS 334 CITATIONS

SEE PROFILE SEE PROFILE

Ingeborg Nilsson
Umeå University
59 PUBLICATIONS 836 CITATIONS

SEE PROFILE

All content following this page was uploaded by Brigitte E Gantschnig on 07 January 2016.

The user has requested enhancement of the downloaded file.

Detecting Differences in Activities of Daily Living
Between Children With and Without Mild Disabilities
MeSH TERMS

activities of daily living

attention deficit disorder

developmental coordination
disorder

learning disorders

sensation disorders

task performance and analysis

validity of results
Brigitte E. Gantschnig, MScOT, is Research Officer,
Institute of Occupational Therapy, School of Health
Professions, Zurich University of Applied Sciences,
Technikumstrasse 71, Postfach, CH-8401 Winterthur
Switzerland; brigitte.gantschnig@zhaw.ch
Julie Page, PhD, is Professor and Head of Research and
Development, Institute of Occupational Therapy, School of
Health Professions, Zurich University of Applied Sciences,
Winterthur, Switzerland.
Ingeborg Nilsson, PhD, is Lecturer, Division of
Occupational Therapy, Department of Community
Medicine and Rehabilitation, Umeå University, Umeå,
Sweden.
Anne G. Fisher, ScD, is Professor, Division of
Occupational Therapy, Department of Community
Medicine and Rehabilitation, Umeå University, Umeå,
Sweden, and Affiliate Professor, Department of
Occupational Therapy, College of Applied Human
Sciences, Colorado State University, Fort Collins.
The American Journal of Occupational Therapy
Brigitte E. Gantschnig, Julie Page, Ingeborg Nilsson, Anne G. Fisher
OBJECTIVE. We evaluated whether the Assessment of Motor and Process Skills (AMPS) measures are
valid for detecting differences in activities of daily living (ADL) ability among children with and without mild
disabilities.
METHOD. Retrospective data from the AMPS database were analyzed using many-facet Rasch analyses and
forced regression analyses to evaluate for significant group differences.
RESULTS. Regression analyses of data for 10,998 children ages 4–15 who met the inclusion criteria
revealed significant Age · Group interaction effects (B ³ 0.23, T ³ 6.20, p £ .001). Post hoc t tests revealed
significant group differences in ADL ability at all ages beyond age 4. ADL process ability effect sizes were
moderate to large at all ages, and ADL motor ability was mostly moderate to large at ages 6 or older.
CONCLUSION. These findings support the validity of the AMPS measures when used to identify ADL
problems among children with mild disabilities.
Gantschnig, B. E., Page, J., Nilsson, I., & Fisher, A. G. (2013). Detecting differences in activities of daily living between
children with and without mild disabilities. American Journal of Occupational Therapy, 67, 319–327. http://dx.doi.
org/10.5014/ajot.2013.007013
C hildren with developmental coordination disorder (DCD), disorders of
attention (e.g., attention deficit hyperactivity disorder [ADHD]), specific
learning disabilities (LD; e.g., speech and language disorders, specific reading
disabilities), and sensory integrative (SI) dysfunction often have similar or
overlapping symptoms such as diminished attention, diminished motor
coordination, and reading or mathematical disturbances (American Psy-
chiatric Association [APA], 2000). Although the severity of children’s dis-
ability can vary, their symptoms are often not readily visible compared with
the more prominent symptoms of children with severe neurological or
cognitive disabilities (Pellegrino, 2007). Therefore, we use the term mild
disabilities when referring to this group of children. This term has pre-
viously been used in occupational therapy (Munkholm, Berg, Löfgren, &
Fisher, 2010) and educational research (Cook, 2001) to refer to such
children.
Children with mild disabilities also have in common that their primary
symptoms significantly interfere with activity of daily living (ADL) task per-
formance (APA, 2000; Barkley & Fischer, 2011). Previous research that has
examined ADL ability of children with mild disabilities has mainly been based
on self-report by the children or proxy report by their parents (Dunford,
Missiuna, Street, & Sibert, 2005; Dunn, Coster, Orsmond, & Cohn, 2009;
Rodger et al., 2003; Summers, Larkin, & Dewey, 2008; Wang, Tseng,
Wilson, & Hu, 2009). However, valid instruments for evaluating ADL
performance problems of children with mild disabilities are lacking (Blank,
Smits-Engelsman, Polatajko, & Wilson, 2012; Geuze, Jongmans, Schoemaker,
& Smits-Engelsman, 2001).
319
 The Assessment of Motor and Process Skills (AMPS;
Fisher & Jones, 2012a, 2012b) is an internationally
standardized observational assessment of ADLs in which
a person is rated on the quality of his or her performance
on 16 ADL motor and 20 ADL process items (perfor-
mance skills) observed during two chosen and relevant
ADL tasks that present a challenge. More specifically, the
ADL motor and ADL process items of the AMPS en-
compass small, observable units of ADL task performance
(e.g., grasping, choosing, and lifting a toothbrush and
then initiating brushing one’s teeth). When these actions
are linked together, they result in a chain of actions that
reflect ADL task performance, not underlying body
functions (Fisher, 2009). The ADL motor and ADL
process items are rated in terms of any observed increase
in physical effort or clumsiness, decrease in efficiency, and
decrease in safety or need for assistance during ADL task
performance. Afterward, the item scores for each ob-
served ADL task are entered into the AMPS scoring
program (AMPS Project International, 2010), which is
used to implement many-facet Rasch (MFR) analyses to
convert the person’s raw item scores into an ADL motor
ability measure and an ADL process ability measure. These
ADL ability measures are adjusted during the MFR
analysis to account for the challenge of the ADL tasks
observed and the severity of the rater who scored the
performance (Fisher & Jones, 2012a).
Extensive evidence supports the validity of the AMPS
ADL measures (Fisher & Merritt, 2012), including that
the AMPS is valid for people with diverse disabilities. For
example, Kottorp, Bernspång, and Fisher (2003) com-
pared 178 people with mild intellectual disabilities and
170 people with moderate intellectual disabilities and
found that the ADL motor and ADL process item hier-
archies remained stable between groups. When the ADL
performance of 50 children with spina bifida was com-
pared with that of a matched sample of children without
a diagnosis, the ADL motor and ADL process ability
measures were sensitive enough to discriminate between
groups (Peny-Dahlstrand, Ahlander, Krumlinde-Sundholm,
& Gosman-Hedström, 2009). The AMPS measures have
also been shown to detect age-related differences in ADL
ability in people ages 3–93 (Hayase et al., 2004) and to
be free of gender (Merritt & Fisher, 2003) and cross-
regional bias (e.g., Gantschnig, Page, & Fisher, 2012).
Earlier studies of observed ADL task performance
among children with mild disabilities have all used the
AMPS, and findings have varied. For example, Gol and
Jarus (2005) compared 24 children without a diagnosis or
symptoms suggestive of a mild disability and 27 children
with ADHD, ages 5–8, and found a significant difference
320
in mean ADL process ability between groups but no sig-
nificant difference in mean ADL motor ability. In con-
trast, significant differences were found in both mean
ADL motor and ADL process ability when White and
Mulligan (2005) compared ADL performance in 21
children without a diagnosis and 12 children with
ADHD (ages 5–13), and again when White, Mulligan,
Merrill, and Wright (2007) compared ADL performance
of 30 children without a diagnosis with that of 38 children
with sensory processing deficits (ages 5–13).
These conflicting results and small sample sizes support
the need to verify, with a larger, international sample,
whether the ADL motor and ADL process ability measures
of the AMPS are valid for identifying ADL problems
among children with mild disabilities. Therefore, our aim
in this study was to evaluate whether the ADL motor and
ADL process ability measures of the AMPS are valid for
detecting differences in ADL ability between (1) chil-
dren without a diagnosis or any symptoms suggestive of
having a mild disability and (2) children with mild
disabilities. More specifically, we hypothesized that the
two groups would differ significantly in ADL ability and
that differences could be detected at all ages from 4 to 15.
Method
Research Design
This study was a retrospective, cross-sectional study based
on data extracted from the international AMPS database
(Center for Innovative OT Solutions, Fort Collins, CO).
The use of preexisting, anonymous data from the AMPS
database for this study was approved by the Regional
Ethical Review Board, Faculty of Medicine, Umeå Uni-
versity, Sweden (Dnr03–509). The Ethics Committee of
Canton Zurich confirmed that the secondary analysis of
anonymous medical data does not need to be submitted
to the Ethics Committee in Switzerland.
Participants
The participants for this study were selected from the
international AMPS database in May 2011 if they met the
following inclusion criteria: (1) were between ages 4 and
15 yr; (2) were without a diagnosis, at risk for (i.e., not
diagnosed but having symptoms suggestive of a mild
disability) or diagnosed with mild disabilities (i.e.,
ADHD, DCD, LD, or SI); and (3) had no other neu-
rological disorders (e.g., traumatic brain injury, cerebral
palsy), pervasive developmental disorder, mental health
problem (e.g., childhood depression), or intellectual dis-
ability. We chose age 4 as the lower boundary because
May/June 2013, Volume 67, Number 3
although the AMPS database includes data for persons age
2 and older, the data for children with mild disabilities
at ages 2 and 3 were insufficient. We selected age 15 as the
upper boundary because both ADL motor and ADL
process abilities increase until age 15 and then plateau
between ages 16 and 50 (Hayase et al., 2004). Note that
the sample of children with mild disabilities in the AMPS
database includes children typical of those commonly re-
ferred to occupational therapy for evaluation or interven-
tion, but they may not be representative of the entire
population of children with mild disabilities because many
are not referred for occupational therapy services.
We excluded children who had been scored by raters
in an invalid manner (i.e., were not free of rater scoring
error, which can occur when raters are unexpectedly le-
nient or strict). For more details, see Fisher and Jones
(2012a, Chapter 14). An analysis with an anticipated
effect size of ³.80, a 5 .05, and power of .80 revealed
a needed sample size of 21 in each group for the prob-
ability of finding significant group differences when dif-
ferences really exist. We did not match the group of
children with mild disabilities with the group of children
without a diagnosis because of the preferred premise of
using the largest possible sample (Zumbo, 1999). Demo-
graphic data of the participants are presented in Table 1.
The participant data had been submitted to the AMPS
database by 4,678 occupational therapists from different
world regions who had taken AMPS training courses and
been calibrated as valid and reliable AMPS raters. All
participants were evaluated using the AMPS according to
standardized testing procedures as outlined in the AMPS
manuals (Fisher & Jones, 2012a, 2012b). These proce-
dures require that all participants be observed performing
two familiar and relevant ADL tasks that present at least
minimal challenge and are chosen by the participant from
among more than 120 ADL tasks included in the AMPS
manuals. All AMPS observations were carried out in na-
turalistic environments (e.g., kitchens, bedrooms), either
community based or clinical, and the AMPS rater en-
sured that the child was completely familiar with the test
environment before initiating the AMPS observations.
Data Analysis
We first generated the ADL motor and ADL process
ability measures for each child using FACETS, an MFR
analysis computer program (Linacre, 2011) that is used to
convert ordinal ADL motor and ADL process item raw
scores into linear ADL motor and ADL process ability
measures expressed in logits (log-odds probability units;
Bond & Fox, 2007). The specific feature of the MFR
model of the AMPS is that person ADL ability, rater
The American Journal of Occupational Therapy
severity, task challenge, and item difficulty are considered
simultaneously and are all estimated along the same linear
ADL motor and ADL process continua. We performed
two MFR analyses, one to generate the ADL motor ability
measures and one to generate the ADL process ability
measures. In each analysis, each rater’s severity, each ADL
task challenge, and each item difficulty was anchored at
preestablished values based on those in the current AMPS
scoring program (AMPS Project International, 2010).
We then implemented two forced regression analyses,
using PASW Statistics, Version 19.0 (PASW, Chicago), to
evaluate for significant differences in mean ADL motor
ability measures and mean ADL process ability measures
between groups. The model can be clarified with the
following equation:
Yi 5 b0 1 b1 groupi 1 b2 agei 1 b3 groupi 3 agei 1 ei
where Y is the mean ADL motor or mean ADL process
ability measure; age, group, and Group · Age are the
independent variables; b0 is the intercept; b1–3 are the
effects for group, age, and Group · Age interaction; and e
is the normally distributed error. We set the level of
significance for these analyses at a 5 .05.
Finally, we tested for differences in ADL motor and
ADL process ability measures between the groups by age
category using post hoc one-tailed t tests. We used Levene’s
tests to evaluate for equality of variances between groups.
When the results of Levene’s tests failed to support the
assumption of equality of variances between groups, we
used the t values for samples for which equality of var-
iances is not assumed. We used Bonferroni multiple
comparison corrections to avoid the risk of false pos-
itive results, which is known to be a conservative
method for ensuring a familywise a level of .05. With
12 comparisons each for ADL motor and ADL process,
the critical value for a was set at .004. As for stan-
dardized effect size, we calculated d as
M 12 M 2
d 5pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
ffi:
ðs12 1 s22 Þ=2
Cohen’s d provides an index of how much two groups
differ when compared with their pooled standard de-
viation. A value of .2 is considered to be a small effect
size; .5, moderate; and .8, large (i.e., the standardized
mean difference between groups is of crucial practical and
clinical importance; Cohen, 1988).
Results
Meeting the inclusion criteria were 10,996 children be-
tween ages 4 and 15 (mean 5 8.7, standard deviation 5
321
 Table 1. Demographic Data: Gender, Diagnosis, and Age Characteristics of Participants

322
Age, yr
Characteristic 4 5 6 7 8 9 10 11 12 13 14 15 Total
Gender, n (%)
Male 473 (48.7) 566 (48.8) 638 (51.9) 655 (51.9) 568 (50.4) 502 (48.6) 453 (47.7) 372 (41.6) 335 (45.8) 280 (43.3) 244 (48.3) 242 (49.8) 5,328 (48.5)
Female 499 (51.3) 595 (51.2) 592 (48.1) 607 (48.1) 558 (49.6) 530 (51.4) 496 (52.3) 522 (58.4) 397 (54.2) 367 (56.7) 261 (51.7) 244 (50.2) 5,668 (51.5)
Diagnoses, n (%)
Typical 911 (93.6) 1,041 (89.7) 1,035 (84.2) 1,035 (82.0) 924 (82.1) 875 (84.8) 833 (87.8) 811 (90.8) 661 (90.3) 594 (91.8) 454 (89.9) 440 (90.5) 9,615 (87.4)
Total mild 62 (6.4) 120 (10.3) 195 (15.8) 227 (18.0) 202 (17.9) 157 (15.2) 116 (12.2) 83 (9.2) 71 (9.7) 53 (8.2) 51 (10.1) 46 (9.5) 1,383 (12.6)
Risk 24 23 23 12 12 13 0 0 0 0 0 0 103
ADHD 0 21 54 56 66 56 51 30 29 27 24 22 440
DCD 3 13 21 25 20 18 9 6 10 6 5 2 138
LD 14 24 43 71 54 33 26 18 19 7 15 7 331
SI 16 28 37 38 23 18 16 22 4 2 1 7 212
Comorbid 5 11 17 25 27 19 14 7 9 11 6 8 159
World region, n (%)
NA 233 (24.0) 245 (21.1) 293 (23.3) 276 (21.9) 222 (19.7) 197 (19.1) 216 (22.8) 195 (21.8) 171 (23.4) 153 (23.7) 114 (22.5) 107 (22.0) 2,422 (22.0)
UK/Ireland 182 (18.8) 236 (20.3) 202 (16.4) 250 (19.8) 201 (17.8) 190 (18.4) 204 (21.5) 160 (17.9) 155 (21.2) 158 (24.4) 106 (21.0) 98 (20.2) 2,142 (19.5)
Nordic 191 (19.6) 285 (24.5) 314 (25.5) 328 (26.0) 310 (27.5) 304 (29.5) 276 (29.1) 252 (28.2) 203 (27.7) 181 (28.0) 152 (30.1) 135 (27.8) 2,931 (26.7)
SoCenAm 2 (0.2) 0 (0.0) 2 (0.2) 3 (0.2) 0 (0.0) 0 (0.0) 1 (0.1) 2 (0.2) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.2) 11 (0.1)
WEurope 64 (6.6) 64 (5.5) 65 (5.3) 85 (6.8) 72 (6.3) 68 (6.6) 48 (5.1) 43 (4.8) 35 (4.8) 23 (3.5) 21 (4.2) 19 (3.9) 605 (5.5)
ANZ 97 (9.9) 75 (6.6) 110 (8.9) 86 (6.8) 99 (8.8) 88 (8.5) 57 (6.0) 78 (8.7) 61 (8.4) 48 (7.4) 40 (7.9) 60 (12.4) 899 (8.2)
Asia 174 (17.9) 186 (16.0) 178 (14.5) 181(14.3) 144 (12.7) 123 (11.9) 105 (11.1) 142 (16.0) 82 (11.2) 76 (11.8) 60 (11.9) 58 (11.9) 1,509 (13.7)
MidEast 3 (0.3) 11 (0.9) 12 (1.0) 9 (0.7) 7 (0.6) 20 (1.9) 9 (0.9) 5 (0.5) 4 (0.5) 2 (0.3) 2 (0.4) 0 (0.0) 84 (0.8)
Africa 1 (0.1) 1 (0.1) 9 (0.7) 7 (0.5) 9 (0.8) 8 (0.8) 6 (0.6) 1 (0.1) 4 (0.5) 0 (0.0) 2 (0.4) 1 (0.2) 49 (0.4)
MEurope 20 (2.1) 51 (4.4) 38 (3.1) 26 (2.1) 49 (4.3) 29 (2.8) 20 (2.1) 9 (1.0) 11 (1.5) 5 (0.8) 5 (1.0) 1 (0.2) 264 (2.4)
SEurope 5 (0.5) 7 (0.6) 7 (0.6) 11 (0.9) 13 (1.5) 5 (0.5) 7 (0.7) 7 (0.8) 6 (0.8) 1 (0.1) 3 (0.6) 6 (1.2) 78 (0.7)
Total 972 (100) 1,161 (100) 1,230 (100) 1,262 (100) 1,126 (100) 1,032 (100) 949 (100) 894 (100) 732 (100) 647 (100) 505 (100) 486 (100) 10,996 (100.0)
Note. Typical 5 children without a diagnosis; mild 5 with mild disabilities; risk 5 children with symptoms suggestive of a mild disability; ADHD 5 attention deficit hyperactivity disorder; DCD 5 developmental coordination
disorder; LD 5 specific learning disabilities; SI 5 sensory integrative dysfunction; comorbid 5 children with two or more diagnosed mild disabilities. NA 5 North America; UK/Ireland 5 United Kingdom and Republic of
Ireland; Nordic 5 Nordic countries; SoCenAm 5 South and Central America and Caribbean; WEurope 5 Western Europe; ANZ 5 Australia and New Zealand; MidEast 5 Middle Eastern countries; MEurope 5 Middle Europe;
SEurope 5 Southern Europe.

May/June 2013, Volume 67, Number 3

3.2), 5,328 (48%) boys and 5,668 (52%) girls. Of these,
9,615 (87%) were children without a diagnosis and 1,383
(13%) were children at risk for or having mild disabilities.
The participants were from a variety of world regions (see
Table 1).
The mean ADL motor and ADL process ability measures
by age for each group are shown in Table 2. The results of
the first forced regression analysis revealed no significant
differences between groups in mean ADL motor ability
measures, B 5 0.021, 95% confidence interval (CI)
[20.061, 0.103], p 5 .308, t 5 0.503, df 5 10,994, R 2 5
.361. In contrast, we found a significant main effect for
age, B 5 0.139, 95% CI [0.129, 0.149], p < .001, t 5
26.187, df 5 10,994, R2 5 .361, and a significant Age ·
Group interaction effect, B 5 20.031, 95% CI [20.038,
20.021], p < .001, t 5 26.612, df 5 10,994, R2 5 .361
(Figure 1).
The second forced regression analysis revealed sig-
nificant differences between the two groups in mean ADL
process ability measures, B 5 20.166, 95% CI [20.242,
20.090], p < .001, t 5 24.296, df 5 10,994, R2 5 .367.
Moreover, we found a significant main effect for age, B 5
0.122, 95% CI [0.112, 0.132], p < .001, t 5 24.751,
df 5 10,994, R2 5 .367 and a significant Age · Group
interaction effect, B 5 20.027, 95% CI [20.035,
20.019], p < .001, t 5 26.204, df 5 10,994, R2 5 .367
(Figure 2).
Given the significant Age · Group interaction effects,
we proceeded to perform post hoc t test evaluations for
significant group differences in ADL motor and ADL
process ability at each age. With the exception of ADL
motor ability measures for 4-yr-olds, the children without
a diagnosis in all age groups had significantly higher mean
ADL motor and ADL process ability than did the chil-
dren with mild disabilities (t ³ 3.62, p < .001; see Table
2). Effect size calculations revealed that most ADL motor
effect sizes were medium to large beginning at age 7, and
ADL process effect sizes were medium at ages 4 and 5 and
large beginning at age 6 (see Table 2).
Discussion
As outlined earlier, our aim was to evaluate the validity
of the AMPS measures for identifying diminished ADL
ability among children with mild disabilities. Our results
suggest that the AMPS can be used to identify problems
with ADL task performance as early as age 4. The results
also suggest that the ADL process measures of the AMPS
are more sensitive than the ADL motor measures, because
significant differences were identified at all ages (4–15)
and, more important, the ADL process effect sizes were
The American Journal of Occupational Therapy
consistently moderate to large at all ages. These effect
sizes are important to consider because they provide an
index of the standardized group difference.
Moreover, in contrast to t values, effect sizes are in-
dependent of sample size. That is, although there might
be concern that we had too much power in our data and
overidentified group differences, the use of Cohen’s d
suggests that power was not an issue. Large effect sizes
found for ADL process ability as early as age 6 indicate
that the mean differences are of crucial practical and
clinical importance (Cohen, 1988). The large effect sizes
emerged at this age because the diagnoses of DCD and
ADHD can typically be assured at age 5 and older (APA,
2000; Blank et al., 2012).
Our results are also in line with those of earlier studies
showing significant differences in mean ADL process
ability measures among children without a diagnosis and
children with ADHD (Gol & Jarus, 2005; White &
Mulligan, 2005) and sensory processing deficits (White
et al., 2007). In contrast to our findings, Gol and Jarus
(2005) found no significant differences in mean ADL
motor ability measures between children without a di-
agnosis and children with ADHD.
This study is the first designed to evaluate the validity
of an ADL instrument for detecting problems in ADL task
performance over a wide age span and based on observed
quality of ADL task performance. An important clinical
finding is that it becomes clear that the problems of at least
some children with mild disabilities are clearly present
during adolescence. Although the Age · Group inter-
action effect might even suggest that the differences be-
tween groups increase with age, our results should be
interpreted with caution. That is, this study was based on
cross-sectional data. Moreover, we had no available method
to control for or evaluate the severity of each child’s dis-
ability, and the older children may possibly have been more
severely affected. Further research, based on a prospective
longitudinal design, is indicated to determine whether the
extent of problems with ADLs among children with mild
disabilities increase as ADL tasks become more challenging.
Although the significant interaction effect overrides
the nonsignificant group main effect for ADL motor ability,
it is noteworthy that there were proportionally more older
children without a diagnosis, whereas the largest pro-
portional sample sizes for the children with mild disabilities
were for those who were ages 6–10. More children were
also at risk in the younger age groups. These group dif-
ferences may have somewhat attenuated the mean differ-
ences in ADL motor ability between groups. We chose not
to match our sample on the basis of the preference for
using all available data (Zumbo, 1999).
323
 Table 2. Differences in Mean ADL Motor and ADL Process Abilities (Log-Odds Probability Units) Between Children Without a Diagnosis and Children With Mild Disabilities

324
Age, yr
Characteristic
and Diagnostic Group 4 5 6 7 8 9 10 11 12 13 14 15
ADL motor ability, M (SD)
Typical 1.14 (0.41) 1.29 (0.44) 1.42 (0.46) 1.56 (0.44) 1.65 (0.48) 1.79 (0.46) 1.85 (0.47) 1.96 (0.49) 2.11 (0.49) 2.18 (0.50) 2.25 (0.50) 2.30 (0.48)
Mild 1.07 (0.42) 1.16 (0.36) 1.22 (0.44) 1.34 (0.45) 1.42 (0.42) 1.50 (0.46) 1.68 (0.44) 1.60 (0.45) 1.68 (0.38) 1.81 (0.41) 1.85 (0.38) 1.87 (0.48)
Difference 0.07 0.13 0.20 0.21 0.23 0.29 0.17 0.36 0.43 0.37 0.40 0.43
t 1.36 3.63 5.57 6.94 6.91 7.30 3.84 6.46 8.77 5.15 6.80 5.87
df 971.00 1159.00 1228.00 1260.00 326.32 1030.00 947.00 893.00 730.00 645.00 503.00 484.00
p .305 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001
95% CI [2 0.03, 0.18] [0.06, 0.20] [0.13, 0.27] [0.16, 0.29] [0.17, 0.30] [0.21, 0.37] [0.09, 0.27] [0.25, 0.47] [0.32, 0.52] [0.22, 0.51] [0.28, 0.51] [0.29, 0.59]
Effect size, d 0.17 0.32 0.44 0.50 0.49 0.63 0.38 0.77 0.98 0.81 0.90 0.90
Median ADL motor ability
Typical 1.15 1.29 1.41 1.56 1.63 1.77 1.83 1.92 2.08 2.15 2.25 2.26
Mild 1.15 1.19 1.25 1.34 1.43 1.51 1.72 1.65 1.67 1.77 1.84 1.92
ADL process ability, M (SD)
Typical 0.26 (0.43) 0.45 (0.43) 0.58 (0.41) 0.71 (0.40) 0.79 (0.41) 0.93 (0.41) 0.98 (0.42) 1.07 (0.41) 1.13 (0.42) 1.20 (0.41) 1.27 (0.43) 1.30 (0.42)
Mild 0.03 (0.48) 0.13 (0.40) 0.23 (0.47) 0.31 (0.46) 0.38 (0.45) 0.48 (0.45) 0.64 (0.44) 0.56 (0.48) 0.58 (0.47) 0.70 (0.45) 0.74 (0.41) 0.77 (0.45)
Difference 0.23 0.32 0.35 0.40 0.41 0.45 0.34 0.51 0.55 0.50 0.53 0.53
t 4.03 7.68 9.76 12.98 10.32 12.48 8.19 10.63 10.53 8.53 8.34 8.09
df 971.00 1159.00 254.14 1260.00 1124.00 1030.00 947.00 893.00 730.00 645.00 503.00 484.00
p <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001
95% CI [0.12,0.34] [0.23, 0.39] [0.28, 0.42] [0.33, 0.45] 0[0.33, 0.49] [0.38, 0.52] [0.26, 0.42] [0.41, 0.60] [0.45, 0.66] 0[0.39, 0.62] [0.40, 0.65] [0.40, 0.66]
Effect size, d 0.53 0.77 0.83 0.92 0.95 1.05 0.79 1.14 1.23 1.16 1.26 1.22
Median ADL process ability
Typical 0.25 0.43 0.58 0.70 0.77 0.91 0.95 1.05 1.13 1.18 1.25 1.25
Mild 0.13 0.13 0.26 0.36 0.42 0.50 0.64 0.57 0.57 0.67 0.75 0.80
Note. The critical Bonferroni corrected value was set at a 5 .004. A d 5 0.2 is considered to be small; 0.5, moderate; 0.8, large. ADL 5 activity of daily living; CI 5 confidence interval; df 5 degrees of freedom; M 5 mean;
mild 5 mild disabilities or having symptoms suggestive of a mild disability; SD 5 standard deviation; typical 5 children without a diagnosis.

May/June 2013, Volume 67, Number 3


Figure 1. Graphic representation of differences in mean ADL motor
ability measures between groups with increasing age.
Note. Typical 5 children without a diagnosis; mild 5 mild disabilities or with
symptoms suggestive of a mild disability.
The use of a combined sample of children with ADHD,
DCD, LD, or SI dysfunction might be seen as another
potential limitation. We chose to include children with
different diagnoses because these children face similar risks
for ADL performance problems (APA, 2000). We recog-
nize, however, that differences among these groups also exist.
Another consideration when evaluating our results is
that children with ADHD, DCD, LD, or SI dysfunction
do not always have ADL performance problems (APA,
2000). Our sample did, however, include those who had
Figure 2. Graphic representation of differences in mean ADL
process ability measures between groups with increasing age.
Note. Typical 5 children without a diagnosis; mild 5 mild disabilities or with
symptoms suggestive of a mild disability.
The American Journal of Occupational Therapy
been referred for occupational therapy evaluation, in-
tervention, or both. It is possible, therefore, that our
sample included a higher proportion of those who do
have problems with ADLs. If this is true, they may not be
representative of all children with these diagnoses, but
our findings can likely be generalized to those children
who are referred for occupational therapy services.
The finding that problems with ADLs, especially ADL
process ability, can be identified as early as age 4 suggests
the possibility of developing intervention programs aimed
at minimizing problems with ADL task performance.
Future research needs to evaluate the efficacy of such
programs to determine whether children’s ADL problems
can be alleviated and whether the AMPS can be used to
document the effectiveness of such interventions.
Finally, that the ADL process measures are more
sensitive supports clinical observations and parental re-
ports that although these children, especially those with
DCD and SI dysfunction, are often described as being
clumsy, their major difficulties are related to spatial–
temporal organization of ADL task performance (e.g.,
slowness, buttons in the wrong holes, clothing back to
front, socks upside down, and shoes on the wrong feet;
Summers et al., 2008).
Implications for Occupational
Therapy Practice
The results of this study suggest that
• The AMPS ADL motor and ADL process measures
are valid for purposes of evaluating for ADL problems
among children with mild disabilities older than age 4.
• The detected problems in ADL performance of chil-
dren with mild disabilities are of crucial practical and
clinical importance and support the need to evaluate
ADL performance problems to design and implement
effective occupational therapy interventions that in-
crease children’s ADL abilities.
• At least some children with ADHD, DCD, LD, or SI
dysfunction have problems with ADLs that are present
as they enter adulthood. s
Acknowledgments
This study was funded by the Swiss National Science
Foundation (13DPD6-127161) and supported by the
Austrian, German, and Swiss Associations of Occupa-
tional Therapy. We especially thank André Meichtry and
Hans Stenlund for their statistical support. We also thank
all occupational therapists who collected data on their
clients and contributed to the AMPS validation process.
325
References
American Psychiatric Association. (2000). Diagnostic and sta-
tistical manual of mental disorders (4th ed., text rev.).
Washington, DC: Author.
AMPS Project International. (2010). AMPS computer-scoring
software (Version 9). Fort Collins, CO: Three Star Press.
Barkley, R. A., & Fischer, M. (2011). Predicting impairment
in major life activities and occupational functioning
in hyperactive children as adults: Self-reported executive
function (EF) deficits versus EF tests. Developmental Neuro-
psychology, 36, 137–161. http://dx.doi.og/10.1080/87565641.
2010.549877
Blank, R., Smits-Engelsman, B., Polatajko, H., & Wilson, P.;
European Academy for Childhood Disability. (2012). Euro-
pean Academy for Childhood Disability (EACD): Recom-
mendations on the definition, diagnosis and intervention of
developmental coordination disorder (long version). Develop-
mental Medicine and Child Neurology, 54, 54–93. http://dx.
doi.org/10.1111/j.1469-8749.2011.04171.x
Bond, T. G., & Fox, C. M. (2007). Applying the Rasch model:
Fundamental measurement in the human sciences (2nd ed.).
Mahwah, NJ: Erlbaum.
Cohen, J. (1988). Statistical power analysis for the social sciences
(2nd ed.). Hillsdale, NJ: Erlbaum.
Cook, B. G. (2001). A comparison of teachers’ attitudes to-
ward their included students with mild and severe disabil-
ities. Journal of Special Education, 34, 203–213. http://dx.
doi.org/10.1177/002246690103400403
Dunford, C., Missiuna, C., Street, E., & Sibert, J. (2005).
Children’s perceptions of the impact of developmental
coordination disorder on activities of daily living. British
Journal of Occupational Therapy, 68, 207–214.
Dunn, L., Coster, W. J., Orsmond, G. I., & Cohn, E. S.
(2009). Household task participation of children with
and without attentional problems. Physical and Occupa-
tional Therapy in Pediatrics, 29, 258–273. http://dx.doi.
org/10.1080/01942630903008350
Fisher, A. G. (2009). Occupational Therapy Intervention Process
Model: A model for planning and implementing top-down,
client-centered, and occupation-based interventions. Fort
Collins, CO: Three Star Press.
Fisher, A. G., & Jones, K. B. (2012a). Assessment of Motor and
Process Skills: Volume I. Development, standardization, and
administration manual (7th rev. ed.). Fort Collins, CO:
Three Star Press.
Fisher, A. G., & Jones, K. B. (2012b). Assessment of Motor and
Process Skills: Volume II. User manual (7th rev. ed.). Fort
Collins, CO: Three Star Press.
Fisher, A. G., & Merritt, B. K. (2012). Current standardiza-
tion sample, item and task calibration values, and validity
and reliability of the AMPS. In A. G. Fisher & K. B. Jones
(Eds.), Assessment of Motor and Process Skills: Vol. 1. De-
velopment, standardization, and administration manual
(7th rev. ed., pp. 15-11–15-82). Fort Collins, CO: Three
Star Press.
Gantschnig, B. E., Page, J., & Fisher, A. G. (2012). Cross-
regional validity of the Assessment of Motor and Process
Skills for use in middle Europe. Journal of Rehabilitation
326
Medicine, 44, 151–157. http://dx.doi.org/10.2340/16501977-
0915
Gol, D., & Jarus, T. (2005). Effect of a social skills training
group on everyday activities of children with attention-
deficit-hyperactivity disorder. Developmental Medicine
and Child Neurology, 47, 539–545. http://dx.doi.org/10.
1017/S0012162205001052
Geuze, R. H., Jongmans, M. J., Schoemaker, M. M., & Smits-
Engelsman, B. C. M. (2001). Clinical and research diag-
nostic criteria for developmental coordination disorder: A
review and discussion. Human Movement Science, 20, 7–47.
http://dx.doi.org/10.1016/S0167-9457(01)00027-6
Hayase, D., Mosenteen, D., Thimmaiah, D., Zemke, S., Atler,
K., & Fisher, A. G. (2004). Age-related changes in activ-
ities of daily living ability. Australian Occupational Therapy
Journal, 51, 192–198. http://dx.doi.org/10.1111/j.1440-
1630.2004.00425.x
Kottorp, A., Bernspång, B., & Fisher, A. G. (2003). Validity of
a performance assessment of activities of daily living for
people with developmental disabilities. Journal of Intellec-
tual Disability Research, 47, 597–605. http://dx.doi.org/
10.1046/j.1365-2788.2003.00475.x
Linacre, J. M. (2011). FACETS computer program for many-
facet Rasch measurement (Version 3.68.1) [Computer
software]. Beaverton, OR: Winsteps.com.
Merritt, B. K., & Fisher, A. G. (2003). Gender differences in
the performance of activities of daily living. Archives of
Physical Medicine and Rehabilitation, 84, 1872–1877.
http://dx.doi.org/10.1016/S0003-9993(03)00483-0
Munkholm, M., Berg, B., Löfgren, B., & Fisher, A. G. (2010).
Cross-regional validation of the School Version of the
Assessment of Motor and Process Skills. American Journal
of Occupational Therapy, 64, 768–775. http://dx.doi.org/
10.5014/ajot.2010.09041
Pellegrino, L. (2007). Patterns in development and disability.
In M. L. Batshaw, L. Pellegrino, & N. J. Roizen (Eds.),
Children with disabilities (6th ed., pp. 217–227). Balti-
more: Paul H. Brookes.
Peny-Dahlstrand, M., Ahlander, A. C., Krumlinde-Sundholm, L.,
& Gosman-Hedström, G. (2009). Quality of performance of
everyday activities in children with spina bifida: A popula-
tion-based study. Acta Paediatrica, 98, 1674–1679. http://dx.
doi.org/10.1111/j.1651-2227.2009.01410.x
Rodger, S., Ziviani, J., Watter, P., Ozanne, A., Woodyatt, G.,
& Springfield, E. (2003). Motor and functional skills of
children with developmental coordination disorder: A pi-
lot investigation of measurement issues. Human Movement
Science, 22, 461–478. http://dx.doi.org/10.1016/j.humov.
2003.09.004
Summers, J., Larkin, D., & Dewey, D. (2008). Activities of
daily living in children with developmental coordination
disorder: Dressing, personal hygiene, and eating skills.
Human Movement Science, 27, 215–229. http://dx.doi.
org/10.1016/j.humov.2008.02.002
Wang, T.-N., Tseng, M.-H., Wilson, B. N., & Hu, F.-C. (2009).
Functional performance of children with developmental co-
ordination disorder at home and at school. Developmental
Medicine and Child Neurology, 51, 817–825. http://dx.doi.
org/10.1111/j.1469-8749.2009.03271.x
May/June 2013, Volume 67, Number 3
White, B. P., & Mulligan, S. E. (2005). Behavioral and phy-
siologic response measures of occupational task performance: A
preliminary comparison between typical children and children
with attention disorder. American Journal of Occupational Ther-
apy, 59, 426–436. http://dx.doi.org/10.5014/ajot.59.4.426
White, B. P., Mulligan, S., Merrill, K., & Wright, J.
(2007). An examination of the relationships between
motor and process skills and scores on the Sensory
The American Journal of Occupational Therapy
View publication stats
Profile. American Journal of Occupational Therapy,
61, 154–160. http://dx.doi.org/10.5014/ajot.61.2.154
Zumbo, B. D. (1999). A handbook on the theory and methods of
differential item functioning (DIF): Logistic regression mod-
elling as a unitary framework for binary and Likert-type
(ordinal) item scores. Ottawa, ON: Directorate of Human
Resources Research and Evaluation, Department of Na-
tional Defence.
327