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Aim It has been suggested that one approach to identifying motor impairment in children is to use the Child Behavior Checklist (CBCL) as a screening tool. The current study examined the validity of the CBCL in identifying motor impairment.
Method A total of 398 children, 206 females and 192 males, aged from 3 years 9 months to 14 years 10 months were assessed on the McCarron Assessment of Neuromuscular Development to determine their motor ability. Parents completed the CBCL.
Results The ‘Clumsy’ item on the CBCL was found to predict motor ability independent of the child’s age, sex, and scores on other items of the CBCL. However, the sensitivity of the ‘Clumsy’ item in terms of identifying motor impairment was found to be a low 16.7% compared with specificity of 93.2%. The item ‘Not liked’ was also found to be a significant predictor of motor impairment.
Interpretation Although the ‘Clumsy’ and ‘Not liked’ items were found to have a relationship with motor ability, they should not be relied upon to categorize children as motor impaired versus not impaired. It is possible that these items may be better indicators of motor impairment in children with developmental disorders such as attention-deficit-hyperactivity disorder, but clinical samples are needed to address this.
Poor motor coordination accompanies many developmental disorders, including attention-deficit-hyperactivity disorder (ADHD),1,2 autism spectrum disorders,3 and reading disorder.4 It is the core deficit in developmental coordination disorder (DCD), described by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)5 as ‘a marked impairment in the development of motor coordination that significantly interferes with academic competence or daily living skills’. Children with DCD have low self-perception and self-worth6,7 and higher levels of anxiety8 and depression.9 These children are less likely to engage in physical activity,10 with consequences for physical health and social adjustment. It is therefore important to know whether children with a diagnosed psychiatric disorder also have comorbid DCD or motor impairment to ensure that they receive the appropriate intervention.
Diagnosis of motor impairment is difficult as it is heterogeneous in nature,11 with impairments involving locomotion, ball skills, balance, or fine motor tasks such as handwriting or using a knife and fork. Although there is no criterion standard measure of motor impairment, several tests are commonly used for school-aged children. These include the Movement Assessment Battery for Children12 or the more recent 2nd version,13 the Bruininks–Oseretsky Test of Motor Proficiency14 or the more recent 2nd version15, and the McCarron Assessment of Neuromuscular Development (MAND).16 However, these require individual assessment and take 30 to 40 minutes to administer. In addition to these performance tests, there are screening measures for motor impairment which parents or teachers can fill in, such as the Developmental Coordination Disorder Questionnaire (DCDQ),17 which have proved effective in identifying children at risk of DCD.
In a recent study examining the relationship between parent-reported motor problems, autistic symptoms, and ADHD, Reiersen et al.18 used two items from the Child Behavior Checklist (CBCL)19– Item 36, ‘Gets hurt a lot, accident-prone’ and Item 62, ‘Poorly coordinated or clumsy’– to identify parent-reported motor impairment. It is significant that participants with or without ADHD who showed no endorsement of these items rarely had clinically significant levels of autistic symptoms. However, significant autistic symptoms were seen in over 70% of children with the combination of ADHD and endorsement of both CBCL motor items. The authors noted that they could not find any published studies examining the relationship between these two CBCL items and examination-based motor impairment, so it was unclear what type or degree of motor impairment was likely in children classified using the CBCL motor items. On the basis of the above study, the CBCL motor items do appear to have some utility in identifying children with ADHD who warrant further assessment for autistic features, but the relationship of these CBCL items with examination-based motor impairment is still unclear. The CBCL is widely used for screening purposes, and if the motor items identified by Reiersen et al. do predict poor motor skills, they would provide a cost-effective way of determining which children should be more fully assessed for motor impairment.
Item 62 has been previously linked with psychiatric disorder in a Norwegian study by Novik.20 Novik identified eight CBCL items that were most strongly related to psychiatric diagnoses (determined through interview). These included the item ‘Identifying poor coordination’ (item 62) plus the following items: l, ‘Acts too young for his/her age; 11, ‘Clings to adults or too dependent’; 12, ‘Lonely’; 19, ‘Demands attention’; 35, ‘Feels worthless or inferior’; 48, ‘Not liked’; and 103, ‘Unhappy, sad or depressed’. Most of the psychiatric disorders identified by Novik were emotional disorders, and as DCD has been linked with emotional problems in the past, it is not surprising that a relationship was found.
The aim of the current study was to determine whether the CBCL could be used effectively to screen for children with motor impairment. If it proved effective in identifying children at risk of motor problems this would provide a simple and reliable way for practitioners to identify comorbid motor impairment in children with other psychiatric disorders in order to determine suitable intervention. Given the link between motor impairment and emotional problems such as anxiety and depression, the items found by Novik20 to be linked with psychiatric disorders were also evaluated to ensure that the ‘motor’ items were more effective at picking up motor impairment than these other items. The MAND16 was used as the criterion measure.
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A quick and effective screening tool to identify motor impairment in children that is also reliable and valid would be helpful in clinical practice and in large research studies where individual assessment is costly and time-consuming. Two items from the CBCL, items 36 and 62, have been previously used as indicators of parent-reported motor problems in an ADHD-enriched sample of 851 child and adolescent twins.18 In that study, these CBCL items were associated with autistic-like social impairment, particularly in children with ADHD. This result was expected given previous reports of the association between motor problems and autistic symptoms, but it was unclear what type or degree of motor impairment the CBCL items might indicate. The current study partially supported the utility of item 62 as a significant predictor of motor ability. Item 36, however, was a redundant predictor and did not account for any unique variance in motor ability when considered in combination with item 62. The statistically non-significant result for item 36 reflected a weak effect size rather than low statistical power. After controlling for the other predictors, item 36 accounted for 0.001 of the variance in the NDI. This result suggested that item 36 does not provide a unique explanation of motor difficulties beyond the variance it shares with the items related to psychiatric disorders. The clinical significance of item 62, however, was also low for the current study population. The clinical outcome of using item 62 was a measure in which both the sensitivity (16.7%) and the positive predictive value (41.7%) were considerably lower than the acceptable level of 80% or more. Fewer than half of the participants identified from item 62 as having motor problems actually had these according to the MAND. Overall, the discrimination accuracy of the CBCL item was poor.
Item 62 was one of the eight items of the CBCL that Novik20 identified as being predictive of psychiatric disorders in a sample of 1170 children aged 4 to 16 years. By contrast, the current study showed item 62 to have poor sensitivity and positive predictive value for motor ability. We also found that another item, item 48 (‘Not liked’), explained unique variance in motor ability, although even when both items 48 and 62 were used to identify motor impairment, sensitivity and positive predictive value remained low at 31.1 and 38.9%, respectively.
A relationship between being liked and motor ability has been reported elsewhere. Chase and Dummer23 examined the determinants of social status in children and found that males rated athletic ability and physical appearance as the most important determinants of social status for males. Young females viewed physical appearance as the single most important determinant of social status for both males and females. It should be noted that children with poor motor ability are more often overweight,10 which may lead to low perceptions of their physical appearance. Other studies8 cite poor social support and poor peer integration in children with movement problems. Also, being described as ‘not liked’ may sometimes be a result of autistic-like social impairment, so the association between motor impairment and this CBCL item could be partly due to the high prevalence of motor impairment in autism spectrum disorders.
Novik20 also pointed out that both school psychologists and paediatricians in Norwegian schools now use the CBCL for screening behavioural and emotional problems, but warns that the predictive value depends on the prevalence of the disorder. Novik found a prevalence of 20% and suggested a that lower prevalence would reduce the predictive value. This may account for the low sensitivity and positive predictive values identified in the current study. Although the overall prevalence of motor impairment was 22.6%, 78% of these participants had only mild motor impairment. Only 5% of the total sample had moderate impairment and no individual had severe impairment. Also, caution should be used when speculating about the likely degree of motor impairment in the participants studied by Reiersen et al.18 since their sample was enriched for ADHD and the current sample was not. Future research should consider investigating the CBCL in a sample of children with more severe motor impairment, as well as in children with a variety of developmental disorders. Furthermore, some screening tools for motor impairment have been found to be less effective in children with developmental disorders such as ADHD, as symptoms may be misdiagnosed as clumsiness.24,25
In general, the use of screening instruments to identify motor impairment has had limited success. Recent instruments such as the DCDQ17 have focused on the performance of daily activities that require motor coordination to determine whether such activities have been disrupted. These behaviours are more easily recognized by parents and teachers and they generally cover several aspects of movement control. A recent investigation of the DCDQ25 found that this test had low specificity and sensitivity when the MAND was used as the criterion variable. However, the DCDQ was found to be accurate in identifying children with moderate or severe motor impairment. Since the current study did not include children with severe motor dysfunction on the basis of the MAND, it is still unclear how accurate the CBCL would be in identifying children with severe motor impairment. Given that the CBCL includes only the one item related specifically to motor ability, and given the very general nature of this item (i.e. ‘Poorly coordinated or clumsy’), it is not surprising that it lacks predictive validity in the sample studied here.
In conclusion, although the CBCL has excellent psychometric characteristics, is frequently used, and has well established norms, the current study does not support the use of the single ‘clumsy’ item to identify mild to moderate motor impairment in non-clinical populations.