Functional assessment scales for children with disabilities

Redondo García MA, Conejero Casares JA. Child Rehabilitation. Society

Spanish Rehabilitation and Physical Medicine. 2012. Chapter 9. 61-66

Ma. Claudia Curtidor Pineda

Physical Medicine and
Rehabilitation Universidad El
Bosque
Introduction

• Broad concept) aims to include the assessment of all the skills that
the child needs to function in his or her daily life.

• Assess the child's competence in his or her environment and need for
help from another person

• The functional assessment of the child with disabilities defines what

the child does, not the deficits he or she presents.
 WHO disability assessment models
• 1980 International Classification of Impairments, Disabilities and Handicap – ICIDH – Developed to describe
long-term consequences of illness, trauma and other disorders.
• Paying greater attention to prevention, early detection and mitigation of obstacles in the physical and social
environment.

• 1983 ICIDH – 2

• 2001 International Classification of Functioning, Disability and Health (ICF) Oriented towards prevention,
promotion of participation, elimination and mitigation of physical and social obstacles and promotion of
facilitating elements.

• It incorporates social aspects and the impact of environmental factors on the person's functioning.

• 2007 ICF-CY Version for children and adolescents

 2007 ICF-CY Version for children and
teenagers
• First internationally agreed classification code to assess the health
status of children and young people

• It proposes to reflect the changes that occur in the first two decades
of life and the different roles they play when participating in social
interaction, which are different depending on age.
 2007 ICF-CY Version for children and
teenagers
1. Quantify important characteristics of the growth, health and development
of children and youth

2. Capture the effects of the physical and social environment

3. Establish health and social policies that improve the well-being of children

4. Framing the functioning and disability of children and young people in the
context of their daily activities
 Rating scales

• Standardized Assessment Tools

• Purposes:
• Diagnose: define the child's functionality
• Design therapeutic intervention plans
• Determine the effectiveness of the applied therapy
• Record changes in function over time and for research purposes
• Promote evidence-based practice
• Facilitate communication between different disciplines involved in the child
Types of scales
• Tests referring to the norm or normative evaluation tools
 Standardized tests whose purpose is to make a comparison between
results obtained from the child being tested and the normal values of the group at
that belongs by age.
• Criterion-related tests or content-related evaluation tools

They use a scoring system or achievement level to rate the performance of the
child in the activities it evaluates.
The frame of reference is the presence or absence of a defined characteristic,
more than the comparison with the general population.

Psychometric properties
• Requirements that a scale must meet to be applicable to the clinic

• Validity: Degree to which a scale measures what it purports to measure.

• Content validity: The scale includes all relevant aspects
• Construct validity: Ability to measure the concepts for which it was designed
• Criterion validity or concurrent validity: Examines whether the results agree with a Gold Standard
• Predictive validity: Ability to predict future functional situation
 Psychometric properties
• Reliability or reproducibility: Degree of confidence with which the
test measures a certain characteristic.
• Ability, in the absence of real changes, to always obtain the same result with repeated
measurements

• 1 -- 100% reliability
• 0 – There is no correlation
• Reliability coefficient values above 0.75 indicate good reliability

• Reliability between observers

• Intraobserver reliability
• Internal consistency: each item is related to each other and to the others.
Pediatric Gross Motor Function Scales

• Gross Motor Function Measurement (GMFM)

Russell 1989

Observational scale, carried out under precise instructions and under specific conditions.
It consists of 88 items (abbreviated 66 items) exclusively motor and grouped into 5
dimensions.
Lying and turning (17 items)
Sitting (20 items)
Crawling/Kneeling (14 items)
Standing (13 items)
Wandering, running, jumping (24 items)
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Pediatric Gross Motor Function Scales

• At 5 years of age, children without motor delay generally perform all items.
• It measures performance, but not the quality of movement.
• It measures what the child can or wants to do, not what they could do.

• Limitations: Does not assess qualitative changes

Not useful in severe disability
The test result depends on the child's ability to follow the
instructions
Scoring for many of the items is based on duration of the
movement or the time of maintenance in a position, but not reflects
the
Pediatric Gross Motor Function Scales
functional aspects
• Advantages
• Allows you to evaluate a child who requires orthoses and walking aids and
assesses the impact of these technical aids on the score.
 Gross Motor Function Classification System
(GMFCS)
• Palisano 1997 -- From GMFM
• Classification system for children with IMOC
• 5 levels of severity
• 4 age groups
• 1-2 years
• 2-4 years
• 4-6 years
• 6-12 years
Gross Motor Function Classification System (GMFCS)

10 If 13 13 14 15
 Functional Mobility Scale (FMS)
• Walking scale – Graham in 2004 – Royal Children's Hospital
Melbourne

• Assesses the child's ability to walk three distances: 5, 50 and 500 m.

• It classifies into 6 ordinal grades the level of assistance that the
child requires for mobility at each distance.
• It was developed in response to the observation that children with
CP frequently use different levels of assistance.
 Functional Mobility Scale (FMS)
• It has been designed to assess changes in a child's motor function
after orthopedic surgery.
• Also useful for documenting changes over time.
• Validated in a sample of 311 children affected by CP over 6 years of
age and has proven to be useful for evaluating children with other
motor disabilities.
 Gillette Functional Assessment Questionnaire
(FAQ)
• Developed in Minnesota.
• Standardized questionnaire that collects data from the medical history of the child with
walking disabilities, chronology and location of pain, treatments and therapies performed
and the child's degree of satisfaction.

• It consists of 10 levels, categorized in a parent survey.

• It assesses the child's mobility in different terrains and distances, from the absence of
walking at level 1 to a level of functionality equivalent to a child without motor disabilities,
at level 10.

• Validated in a sample of 44 children with illness. Neuromuscular

 Table 9-1. Most used gross motor function scales
Scam Age Utility Limitations Advantages
Does not assess qualitative Widely used in clinical and
GMFM 5 months -16 years Evaluates changes in motor
changes research
function in CP Not useful in severe disability

GMFCS 1-12 years It is a motor function Not useful for assessing Very widespread
classification system in PC changes in crotor function
Has predictive value for motor
function
FMS > 6 years Describes motor function in PC Not useful in small children Includes use of technical aids
FAQ Not specified Describes motor function in the Does not include use of It can be applied in a
environment, in CP and other technical aids complementary way with FMS
disorders
FAQ: Giílette Functionaf Assesíment Questionnaire; FMS: Function! Mobility Scale; GMFC5: Gross Motor Function Classification System; GMFM: Gross Motor Function Measurement;
CP cerebral palsy .
 Pediatric Fine Motor Function Scales
• Assessment of the manipulative function in children with motor
disabilities is complex.
Manual Ability Classification System (MACS)
• Very simple classification system of manipulative skills for children
with CP.
• Karolinska Institute in Sweden 2006

• Assesses the performance of both hands together in holding and

supporting everyday objects in daily life, evaluating whether the
child needs assistance or adaptations.

• It is applied through a survey to parents or caregivers.

 Manual Ability Classification System
(MACS)
• Describes 5 global levels
• Level 1: There is no limitation in performing basic activities of daily living but there may
be some limitation in manual tasks that require speed and acuity, up to Level 5, in
which the child requires full assistance.

• Applicable between 4 – 18 years

• Correlation between MACS and GMFCS 49% in a sample of 164 children.

• Fine and gross motor skills do not evolve in parallel in many cases and must be
classified independently.
 almost the. same activities as Level I, but the quality of execution is poor or execution is
slower. Functional differences between the manas can limit the effectiveness of the
execution. Children at level II commonly try to simplify the manipulation of objects, for
example by using a surface for support, instead of manipulating objects.
. objects with both hands.

What do you need to know to use MACS?

The child's ability to manipulate objects in important daily
activities, for example during play and free time, eating, and
dressing.
In what situation is the child independent and what amount
of support and adaptation does he or she need?
I. Manipulates objects easily and successfully. Mostly, limitations in
the ease of performing manual tasks that require speed and acuity.
However, no limitations in inanual abilities, no restriction of independence
in daily activities.
II. Manipulates most objects but with a slight reduction in
quality and/or speed of achievement. Certain
activities may be avoided or obtained with some difficulty; Alternate forms
of execution of manual skills can be used, usually there is no restriction
on the independence of activities of daily living.
III. Manipulates objects with difficulty; needs help
preparing and modifying activities. The execution is
slow and you achieve them with limited success in quality and quantity.
The activities are carried out regardless of whether they have been
organized or adapted.
IV. Manipulates a limited selection of easily manipulated
Distinctions between Levels II and III
Children at: level II manipulate most objects, -without
However, the quality of execution is slow OR reduced. The children in
Level Ill commonly need help preparing for the activity and
require adjustments in their environment because their ability to
reaching and manipulating objects is limited. They can't run
certain skills and their degree of independence is
related to support in the environment
Distinctions between Levels ill and IV
Children in level III can perform selected activities if the
situation is prepared in advance and if they have supervision and time
enough. Children in Level N need continuous help during
activities and participate at best only in parts of
an activity.
4
Distinctions between Levels IV and V
Children in Level IV perform part of an activity, however
They continually need help.
Girls in level V could at best participate with a simple
movement in special situations, for example, pressing a button
or, sometimes holding undemanding objects.

objects in adapted situations. Executes part of the

activities with effort and with limited success. It requires continuous
support and assistance and/or adapted equipment even for partial
achievements of the activity.

V. He does not manipulate objects and has severely

limited ability to perform even simple actions.
Requires full assistance.

Distinctions between Levels I and II

l Children in Level I have limitations in the manipulation of very small, heavy or fragile
objects that demand detailed fine motor control, □ excellent hand coordination. Limitations
may also involve performance in new and unfamiliar situations. Children in level II perform
 Melbourne Assessment of Unilateral Upper
Limb Function (MUUL)
• Randall et al 2001
• Objective: Measure changes in manual function
over time and assess the quality of unilateral
manual function.

• 16 items (Reaching in several planes, pressing,

tracing, releasing, manipulation, pointing,
pronosupination, transfer from one hand to
another and hand to mouth)

• Children between 2.5 and 15 years

• Verbal instruction and demonstration

fteiH Tarsk

1 Reach forwards
2 Reach forwards to an elevated position
3 Reach sideways to an elevated position
4 Grasp of crayon
5 Drawing grasp
6 Release of crayon
7 Grasp of pellet
8 Relcase of pellet
9 Manipulation
10 Pointing
11 Reach EQ brush from forchead to back of neck
12 Palm to bottom
13 Pronation/s upination
14 Hand to hand transfer
15 Reach to opposite shoulder
16 Hand to mouth and down
 Quality of Upper Extremity Skills Test
(QUEST)
• DeMATteo et al 1992
• Evaluates movement patterns and manual function in children with
cerebral palsy

• 36 items - Function of the upper extremity in four dimensions:

dissociated movements, grasping, protective extension and weight
support.

• It assesses each upper limb separately and requires a time of 30

minutes.
 Shriners Hospital for Children Upper
Extremity Evaluation (SHUEE)
• Davids et al 2006
• Tool that incorporates different subscales of traditional measures
of movement intervals and muscle tone, together with analysis of
dynamic position and the ability to clamp and release.

• 15 minutes
 Assisting Hand Assessment (AHA)
• Karolinska Institute 2003

• Effectiveness in bimanual activities of children with unilateral neurological disability.

• Evaluate through play with standardized toys.

• 22 items

• 4 levels of quality of execution.

• Application up to 12 years old.

 Abilhand-Kids Questionnaire
• Arnould 2004 Belgium
• Parent Questionnaire

• 21 items that describe common manual activities of daily life.

• The AHA and Abilhand scales assess performance: ability to execute tasks
in a real context of daily life (assess what the child does)
 Table 9-2. Most used manual function scales
Scale Age Utility Limitations Advantages

MACS 4-7 years Manipulative skill rating system Its stability over time has not In addition to being a
on PC been investigated. classification system, it is
useful for establishing
therapeutic objectives.
MUUL 5-15 years Rate the unilateral manual High price Assess qualitative and
foundation on PC and others quantitative aspects
Long application time Excellent properties
psychometric
QUEST 18 months-8 years Assess mobility and unilateral Assesses movement patterns Free on the web ■
manual function in CP and press quality, not ability

SHUEE 3-16 years Assess mobility and unilateral
manual function in CP
AHA 18 months- 12 years Evaluates manual function in
bimanual activities in unilateral
CP and obstetric brachial palsy
Precise use of video Free on the web
High price Values execution, compared to
the others, which value
capacity

Requires training Excellent psychometric

properties
6-15 years Assess overall manual ability in It only has discriminative value Free on the web
ABILHAND
basic activities on PC

ABILHAND: Abilhand Kids Questionnai!-^; AH A: Assisting Hand Assessment; MACS: Manual Abifity Cfassitication System; MUUL: Melbourne Assessment of Unilarerai Upper Limb
Function; CP: cerebral palsy ; QUEST: Quality of Upper Extremity Skills Test; SHUEE: Sh-nners Hospital for Children Upper Extremity Evaluation.
 Pediatric functional performance scales
• They systematically describe and measure the abilities and
limitations of children with disabilities in the ABCs and define how
they function in their usual environment.

• They are useful for establishing therapeutic objectives

 Functional Independence Measure for
Children (WeeFIM)
• University at Buffalo 1991

• Assesses the degree of task completion by measuring the impact of

disability and independence difficulties at home, school and
community.

• Applicable in neuromotor and developmental disorders between 6

months and 7 years of age. It can be applied to older children, who
do not exceed 7 years of mental age.
 Functional Independence Measure for
Children (WeeFIM)
• 18 items
• Self-care
• sphincter control
• Mobility
• Locomotion
• Communication
• social intelligence
 Pediatric Evaluation of Disability Inventory
(PEDI)
• Boston University 1992

• Identify the level of functionality of the child with significant motor impairments or with a
combination of motor and cognitive disabilities.

• Useful in pediatric rhb programs or other intervention programs to evaluate and detect
changes.

• Interview with father and caregivers.

• It consists of 197 items, it assesses 3 dimensions (functional ability, need for assistance and
need for technical aids).
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