A Perceptual-Motor Intervention Programme for Grade 1-Learners with Developmental Coordination Disorder By Monique de Milander Magister Artium In fulfillment of the requirements for the degree Philosphiae Doctor in Human Movement Science, Kinderkinetics in the Faculty of Humanities, Department of Exercise and Sport Sciences at the University of the Free State Promotor: Prof. F.F. Coetzee Co-Promotor: Prof. A. Venter Bloemfontein February 2015 Declaration Declaration I declare that this thesis hereby submitted by me for the philosophiae doctor degree at the University of the Free State is my own independent work, except to the extent indicated in the reference citatians and has not previously been submitted by me at another University/Faculty. I further more cede copyright of the thesis in favour of the University of the Free State. Furthermore, the co-authors of the articles in this thesis, Prof. Derik Coetzee and Prof. Andre Venter hereby give permission to the candidate, Ms. Monique de Milander to include the articles as part of a Ph.D. thesis. The contribution (advisory and supportive) of these co-authors was kept within reasonable limits, thereby enabling the candidae to submit this thesis for examination purposes. The thesis, therefore seres as fulfilment of the requirements for the Ph.D. degree in Kinderkinetics (Human Movement Science) in the Department of Exercise- and Sport Sciences in the Faculty of Humanities at the University of the Free State. Signed on this _____________________day of ______________________2015. ___________________ ___________________ Prof. F.F. Coetzee Prof. A. Venter Supervisor Co- Supervisor ___________________ M. de Milander Student i Acknowledgements Acknowledgements I wish to express my sincere graditude and appreciation to the following people for their assistance in this study. The study would have not been possible without their help. My Heavenly Father for giving me the necessary abilities in order to complete this study. Jehovah Jireh! My family for all their support throughout this study. My supervisor, Prof. F.F. Coetzee your guidance, motivation and assistance was appreciated. Your positivity towards me throughout the study meant a great deal to me. My co-supervisor, Prof. A. Venter for all your support, knowledge, input and valuable time. I really appreciate it. Prof. K. Esterhuyse and Mrs. M. Viljoen for their input with the statistical analysis of the data. Mrs. E. Verster and Mrs. M. Esterhuyse for the translation of the abstract and for the proofreading of the thesis. Mrs. R. Vrey for assisting in collecting information with regard to the study. The principals and teachers of all the schools that took part in the study. All the parents and children who took part in the study without you the study wouldn’t have been possible. To Alretha Buys and the Kinderkinetics honours students of 2012 and 2013 for all your assistance with the fieldwork. Monique de Milander February 2015 ii Tribute TRIBUTE Throughout my whole life, there’s always been one person who’s always been able to influence my life, and help to mend the goals that I have wanted to do throughout my entire life. Literally everything that I’ve ever wanted to be, she’s supported. She always said, as long as I’m doing what I love to do, and then I should pursue a future in the career I decided I wanted to be, which sometimes changed every other week as I was growing up. This amazing, supporting, loving, and encouraging woman was my mother. She was one of the strongest women I’ve ever known throughout my life so far, even though I’m pretty sure she’ll always be the strongest person in my life. I dedicate this thesis to my mother (Judy Louw), who passed away during the completion of my studies. By finishing this degree, not only will I be able to do what I always wanted to do and love doing, I’m also able to make her as proud as she can be. 18/11/1951-17/07/2013 iii Summary Summary A Perceptual-motor intervention programme for grade 1 learners with Developmental Coordination Disorder Background Developmental coordination disorder (DCD) is recognised as one of the most common developmental dysfunctions during childhood. Developmental coordination disorder is diagnosed in children who experience significant difficulties in motor learning and in the performance of functional motor tasks that are critical for success in their daily lives. However, one of the major concerns regarding children with DCD is that they are often not formally diagnosed, but rather described by their parents and teachers as lazy or awkward. In an attempt to identify children with DCD, several research tools, such as questionnaires for screening purposes and norm-referenced tests to measure the degree of movement difficulties, can be used. Even though children will not outgrow this disorder as previously believed, children can be helped by means of various interventions. Aims The first aim of this study was to determine the prevalence of DCD among Grade 1 children in Bloemfontein. The second aim was to establish the ability of parents to identify Grade 1 children with DCD at home; in addition the third aim was to iv Summary establish the ability of teachers in identifying Grade 1 children with DCD in the classroom. The fourth aim was to explore the influence of DCD on learning related skills. Aim five and six was to determine if the application of a perceptual- motor intervention as well as a sport stacking intervention will significantly improve the motor proficiency status of Grade 1 children identified with DCD independently. Method Participants For the purpose of aim 1, 559 participants’ between the ages of 5 and 8 years took part in this study. There were n=321 girls and n=238 boys. Aim 2 include 410 participants and consisted of n=226 girls and n=184 boys, whilst aim 3 had 506 participants and there were n=289 girls and n=217 boys. Furthermore, aim 4 had 347 participants including n=190 girls and n=157 boys. Aim 5 and 6, which relates to the two interventions used in this study was as follows. Seventy six (76) participants took part in the perceptual-motor intervention. The group consisted of girls (n=34) and boys (n=42) classified with DCD. The intervention had a pre-test/post-test experimental design (n=36) with a control group (n=40). With reference to the sport stacking intervention, 18 children between the ages of 6 and 7 years took part in this study. The group consisted of girls (n=6) and boys (n=12) classified with DCD. This intervention also had a pre-test/post-test experimental design (n=10) with a control group (n=8). Measuring instruments The instrument used to assess the participants motor proficiency levels and to identify symptoms of DCD was the Movement Assessment Battery for Children-2 (MABC-2 Test). This test includes manual dexterity, balance as well as aiming and catching, in addition the three sub-tests constitute a total test score. In order to determine if parents possess the ability to identify symptoms of DCD at home the Developmental Coordination Disorder Questionnaire ’07 (DCDQ’07) was used. v Summary With the purpose of determining if teachers possess the ability to identify DCD in the classroom the Movement Assessment Battery for Children-2 Checklist (MABC-C) was used. It is designed to identify primary school children likely to have movement difficulties. The Aptitude Test for School Beginners (ASB) was administered by qualified teachers to all participating children in the first two months of the school year. A requirement of the ASB is that it must be presented and completed in a child’s mother tongue. The ASB is a norm-based instrument and consists of eight sub- items, which include perception, spatial skills, reasoning, numerical skills, gestalt, coordination, memory and verbal comprehension. Each sub-item is evaluated by means of a standard score out of five. An evaluation score of 1 is regarded as below average and an evaluation score of 5 as above average. The aim of the ASB is to obtain a differentiated picture of certain aptitudes of grade 1 children. Data analysis Analysis of the data was done by a biostatistician using Statistical Analysis Software Version 9.1.3. Descriptive statistics, namely frequencies and percentages, were calculated for categorical data. Medians and percentiles were calculated for numerical data. Median differences were tested by calculating p- values using the signed-rank test. The Chi-square statistics were used to test for proportion differences. This was used to determine the prevalence of DCD (article 1), as well as for learning related skills and DCD (article 4) and for the sport stacking intervention (article 6). Furthermore, data analysis was performed using the Statistical Package for the Social Sciences (SPSS) for Windows (SPSS version 16.0), in order to determine if parents and teachers possess the ability to identify children with DCD. The convergent validity of the classification of motor problems (no motor difficulties or motor difficulties) using the MABC-2 Test and the classification of motor difficulties (no motor difficulties or motor difficulties) by the parents of the participants using the DCDQ’07 and the teachers using the MABC-C, the kappa (k-) coefficient was used. Finally, the Mann-Whitney-U test vi Summary was used to compare differences between the experimental- and control group with reference to the perceptual-motor intervention for children with DCD (article 5). Probability level of 0.05 or less was taken to indicate statistical significance. Results The results of aim 1 revealed the prevalence of DCD amongst Grade 1 learners in Bloemfontein is estimated to be 15%. The results also indicate that boys have a significantly higher (p=0.050) prevalence of DCD although marginally when compared to their female counterparts. Aim 2 indicated a 15% convergent validity between the MABC-2 Test and the DCDQ’07, similar results were obtained for aim 3, indicating a 11% convergent validity between the MABC-2 Test and the MABC-C. Therefore, it can be argued that parents using the DCDQ’07 and teachers using the MABC-2 could not identify children with DCD at home or in the classroom. The results in aim 4 indicated the prevalence of DCD to be 12%. Additionally, DCD had a significant effect (p=0.050) on five of the eight learning- related subtypes, namely reasoning, numerical skills, gestalt, coordination and memory. Furthermore, the results of aim 5 indicated that a perceptual-motor intervention only improved balance as a sub-test of the MABC-2 Test. Interesting to note is that children taking part in Physical Education classes presented by the teachers also prove to be beneficial. In contrast, aim 6 (sport stacking intervention for DCD) showed that the intervention had a significant effect (p=0.050) on two of the three sub-tests, namely manual dexterity, balance, as well as the total test score. This suggests that sport stacking can be used as an effective intervention programme for children with DCD. Conclusions The results revealed that the school age children in the current study had a higher incidence of DCD (15%) compared to the findings reported in the literature (5-6%). This information is important, and indicates that appropriate screening tools should be used to identify children earlier. Unfortunately the reliability of the MABC-C and the DCDQ’07 completed by parents and teachers to identify vii Summary children with DCD was found to be low. Therefore it is recommended that specific norms should be developed for South African children. Furthermore, the results revealed that children with DCD do struggle with learning related skills. This knowledge enables teachers to address the specific needs of children with DCD. It can be concluded that perceptual-motor interventions have more often than not positive effects on children with DCD; however it is recommended that a combination of the bottom-up approach and top-down approach should be used for optimal results. Key words: Developmental Coordination Disorder, Movement Assessment Battery for Children - 2, Movement Assessment Battery for Children - 2 Checklist, Developmental Coordination Disorder Questionnaire ‘07, Aptitude Test for School Beginners, Children viii Opsomming Opsomming ’n Perseptueel-motoriese intervensieprogram vir graad 1-leerders met Ontwikkelingskoördinasiesteurnis Agtergrond Ontwikkelingskoördinasiesteurnis (developmental coordination disorder – DCD) word erken as een van die mees algemene ontwikkelingsdisfunksies tydens die kinderjare. Ontwikkelingskoördinasiesteurnis word gediagnoseer in kinders wat beduidende probleme ervaar met motoriese leer en in die uitvoering van funksionele motoriese take wat deurslaggewend vir sukses in hul daaglikse lewens is. Een van die vernaamste bekommernisse met betrekking tot kinders met DCD is egter dat hulle dikwels nie formeel gediagnoseer word nie, maar eerder deur hul ouers en onderwysers as lui of lomp beskryf word. Verskeie navorsingsinstrumente, soos vraelyste vir siftingsdoeleindes en normverwysde toetse om die mate van bewegingsprobleme te meet, kan gebruik word ten einde kinders met DCD te probeer identifiseer. Selfs al sal kinders nie die versteuring ontgroei, soos vantevore geglo is nie, kan hulle gehelp word deur middel van verskeie intervensies. Doelstellings Die eerste doelwit van hierdie studie was om die voorkoms van DCD onder graad 1- leerders in Bloemfontein te bepaal. Die tweede doelstelling was om die vermoë van ouers om graad 1-leerders met DCD tuis te identifiseer, te bepaal; daarbenewens was die derde doelstelling om die vermoë van onderwysers om graad 1-leerders met DCD in die klaskamer te identifiseer, te bepaal. Die vierde doelstelling was om die invloed van DCD op leerverwante vaardighede te ondersoek. Doelstellings vyf en ix Opsomming ses was om te bepaal of die toepassing van ’n perseptueel-motoriese intervensie sowel as ’n sportstapelingsintervensie graad 1-leerders wat onafhanklik met DCD gediagnoseer is se status van motoriese vaardigheid beduidend sal verbeter. Metode Deelnemers Vir doelstelling een het N=559 deelnemers tussen die ouderdomme van vyf en agt jaar aan hierdie studie deelgeneem. Daar was n = 321 meisies en n = 238 seuns. Doelstelling twee het 410 deelnemers gehad, saamgestel uit n = 226 meisies en n = 184 seuns, terwyl doelstelling drie 506 deelnemers gehad het, bestaande uit n = 289 meisies en n = 217 seuns. Voorts was daar 347 deelnemers vir doelstelling vier, saamgestel uit n = 190 meisies en n = 157 seuns. Vir doelstellings 5 en 6, wat verband hou met die twee intervensies wat in hierdie studie gebruik is, was die syfers soos volg. Sewe-en-sestig (76) deelnemers het aan die perseptueel- motoriese intervensie deelgeneem. Die groep het uit meisies (n = 34) en seuns (n = 42) wat met DCD geklassifiseer is, bestaan. Die studie het ’n voortoets-natoets- eksperimentele ontwerp gehad (n = 36) met ’n kontrolegroep (n = 40). Met betrekking tot die sportstapelingsintervensie het 18 kinders tussen die ouderdomme van ses en sewe jaar aan die studie deelgeneem. Die groep het uit meisies (n = 6) en seuns (n = 12) wat met DCD geklassifiseer is, bestaan. Hierdie studie het ook ’n voortoets-natoets- eksperimentele ontwerp (n = 10) met ’n kontrolegroep (n = 8) gehad. Meetinstrumente Die instrument wat gebruik is om die deelnemers se vlakke van motoriese vaardigheid te assesseer en om DCD te identifiseer was die Bewegingsassesseringsbattery vir Kinders-2 (“Movement Assessment Battery for Children-2” – MABC-2-toets). Hierdie toets sluit handvaardigheid, balans en mik-en- vang in, en daarbenewens vorm die drie subtoetse saam ’n totale toetstelling. Ten einde te bepaal of ouers oor die vermoë beskik om DCD tuis te identifiseer, is die Ontwikkelingskoördinasiesteurnissvraelys ’07 (“Developmental Coordination Disorder Questionnaire ’07” – DCDQ’07) gebruik. x Opsomming Ten einde vas te stel of onderwysers oor die vermoë beskik om DCD in die klaskamer te identifiseer, is die Bewegingsassesseringsbattery vir Kinders-2: Kontrolelys (“Movement Assessment Battery for Children-2 Checklist” – MABC-C) gebruik. Dit is ontwerp om laerskoolkinders wat waarskynlik bewegingsprobleme het, te identifiseer. Die Aanlegtoets vir Skoolbeginners (ASB) is in die eerste twee maande van die skooljaar vir al die deelnemende kinders deur gekwalifiseerde onderwysers afgeneem. ’n Vereiste van die ASB is dat dit in die kind se moedertaal aangebied en voltooi moet word. Die ASB is ’n normgebaseerde instrument en bestaan uit agt subitems, wat persepsie, ruimtelike vaardighede, redenering, numeriese vaardighede, gestalt, koördinasie, geheue en verbale begrip insluit. Elke subitem word deur middel van ’n standaardtelling uit vyf geëvalueer. ’n Evaluasietelling van een word as ondergemiddeld beskou en ’n evaluasietelling van vyf as bogemiddeld. Die doel van die ASB is om ’n gedifferensieerde beeld van sekere aanlegte van graad 1-leerders te verkry. Data-analise Data-analise is deur ’n biostatistikus gedoen met die gebruik van Statistical Analysis Software, weergawe 9.1.3. Beskrywende statistieke, naamlik frekwensies en persentasies, is vir kategoriese data bereken. Mediane en persentiele is vir numeriese data bereken. Mediaanverskille is getoets deur p-waardes te bereken met gebruik van die betekenderang-toets. Die chi-kwadraatstatistieke is gebruik om vir proporsieverskille te toets. Dit is gebruik om die voorkoms van DCD te bepaal (artikel 1), sowel as vir leerverwante vaardighede en DCD (artikel 4), en vir die sportstapelingsintervensie (artikel 6). Voorts is data-analise gedoen deur middel van die Statistical Package for the Social Sciences for Windows (SPSS weergawe 16.0). Ten einde te bepaal of ouers en onderwysers oor die vermoë beskik om kinders met DCD te identifiseer. Die konvergerende geldigheid van die klassifikasie van motoriese probleme (geen motoriese probleme of motoriese probleme) deur middel van die MABC-2-toets en die klassifikasie van motoriese probleme (geen motoriese probleme of motoriese probleme) deur die ouers van die deelnemers deur middel van die DCDQ’07 en die onderwysers deur middel van die MABC-C, is die kappa- (k-) koëffisiënt gebruik. Laastens is die Mann-Whitney U-toets gebruik om verskille xi Opsomming tussen die eksperimentele en die kontrolegroep met betrekking tot die perseptueel- motoriese intervensie vir kinders met DCD te vergelyk (artikel 5). ’n Waarskynlikheidsvlak van 0.05 of minder is gebruik om statistiese beduidendheid aan te dui. Resultate Die resultate van doelstelling een het getoon dat die voorkoms van DCD onder graad 1-leerders in Bloemfontein op 15% bepaal is. Die resultate dui ook daarop dat seuns ’n beduidend hoër (p=0.050) voorkoms van DCD het as meisies, hoewel margimaal. Doelstelling twee het ’n konvergerende geldigheid van 15% tussen die MABC-2-toets en die DCDQ’07 aangedui; soortgelyke resultate is vir doelstelling 3 verkry, waar ’n konvergerende geldigheid van 11% tussen die MABC-2-toets en die MABC-C aangedui is. Dit kan dus aangevoer word dat ouers wat die DCDQ’07 gebruik het en onderwysers wat die MABC-C gebruik het, nie kinders met DCD tuis of in die klaskamer kon identifiseer nie. Die resultate van doelstelling 4 het getoon dat die voorkoms van DCD 12% is. Daarbenewens het DCD ’n beduidende effek (p = 0.050) gehad op vyf van die agt leerverwante subtipes, naamlik redenering, numeriese vaardighede, gestalt, koördinasie en geheue. Verder het die resultate van doelstelling 5 getoon dat ’n perseptueel-motoriese intervensie slegs balans as ’n subtoets van die MABC-2-toets verbeter het. Dit is interessant om daarop te let dat kinders se deelname aan Liggaamlike Opvoeding-klasse wat deur onderwysers aangebied is, ook voordelig bewys is. In teenstelling hiermee het doelstelling ses (sportstapelingsintervensie vir DCD) getoon dat die intervensie ’n beduidende effek (p = 0.050) op twee van die drie subtoetse, naamlik handvaardigheid en balans, sowel as op die totale toetstelling gehad het. Dit dui daarop dat sportstapeling as ’n effektiewe intervensieprogram vir kinders met DCD gebruik kan word. Gevolgtrekkings Die resultate het getoon dat die kinders van skoolgaande ouderdom in die huidige studie ’n hoër voorkoms van DCD (15%) gehad het as die bevindings wat in die literatuur gerapporteer word (5%-6%). Hierdie inligting is belangrik, en dui daarop dat geskikte siftingsinstrumente gebruik moet word om kinders vroeër te identifiseer. Ongelukkig is daar gevind dat die betroubaarheid van die MABC-C en die DCDQ’07 wat deur ouers en onderwysers voltooi is om kinders met DCD te kan identifiseer, xii Opsomming laag is. Dit word daarom aanbeveel dat spesifieke norme vir Suid-Afrikaanse kinders ontwikkel moet word. Voorts het die resultate getoon dat kinders met DCD wel problem ervaar met leerverwante vaardighede. Hierdie kennis stel onderwysers in staat om aan die spesifieke behoeftes van kinders met DCD aandag te gee. Daar kan tot die gevolgtrekking gekom word dat perseptueel-motoriese intervensies gewoonlik ’n positiewe uitwerking op kinders met DCD het; daar word egter aanbeveel dat ’n kombinasie van die onder-na-bo- en bo-na-onder-benaderings gebruik moet word vir optimale resultate. Sleutelwoorde: Ontwikkelingskoördinasiesteurnis, Bewegingsassesseringsbattery vir Kinders-2, Bewegingsassesseringsbattery vir Kinders-2: Kontrolelys, Ontwikkelingskoördinasiesteurnisvraelys ‘07, Aanlegtoets vir Skoolbeginners, Kinders xiii Table of Contents Table of Contents Declaration ................................................................................................ i Acknowledgements .................................................................................. ii Tribute ......................................................................................................... iii Summary .................................................................................................... iv Opsomming ................................................................................................ ix Table of Contents .................................................................................... xiv List of Tables ............................................................................................. xxii List of Figures ........................................................................................... xxiii List of Abbreviations ............................................................................... xxvi CHAPTER 1 PROBLEM STATEMENT AND AIM OF THE STUDY 1.1 Introduction ....................................................................................... 1 1.2 Problem Statement .......................................................................... 3 1.3 Research questions ......................................................................... 5 1.4 Aims .................................................................................................. 5 1.5 Structure of thesis ............................................................................ 6 1.6 Ethical considerations ...................................................................... 9 1.7 Explanation on how confidentiality was ensured ........................ 9 1.8 References .......................................................................................... 10 xiv Table of Contents CHAPTER 2 LITRATURE REVIEW ON DEVELOPMENTAL COORDINATION DISORDER 2.1 Introduction ......................................................................................................... 17 2.2 Terminology and Definitions ......................................................................... 17 2.3 Prevalence of Developmental Coordination Disorder .......................... 18 2.4 Characteristics of comorbidity .................................................................... 19 2.5 Etiology ................................................................................................................ 20 2.6 Basic principles of neurophysiology ........................................................ 22 2.6.1 The Central Nervous System ....................................................................... 23 2.6.1.1 Spinal cord ......................................................................................................... 23 2.6.1.2 Brain stem ........................................................................................................... 23 2.6.2.1 Midbrain. ............................................................................................................... 24 2.6.2.2 Pon.s... ...................................................................................................................... 24 2.6.2.3 Medulla ................................................................................................................ 24 2.6.3 Cerebellum. .......................................................................................................... 24 2.6.4 Thalamus. ............................................................................................................. 24 2.6.5 Hypothalamus .................................................................................................... 24 2.6.6 Basal ganglia .................................................................................................... 25 2.6.7 Cerebral cortex .................................................................................................. 25 2.6.8 Corpus callosum ................................................................................................ 26 2.6.2 Peripheral nervous system ............................................................................ 26 2.6.3 Major psychomotor problems related to the nervous system ........... 27 2.7 Diagnosis. ............................................................................................................. 28 2.8 Assessments. ...................................................................................................... 30 2.8.1 Devevelopmental Coordination Disorder Questionnaire’0…7. ................ 33 2.8.1.1 Psychometric properties of the Developmental Coordination Disorder Questionnaire ’07............................................................ ........... 33 2.8.1.1.1 Reliability. ............................................................................................................ 33 2.8.1.1.2 Validity.. ................................................................................................................ 34 2.8.1.1.3 Gender factor.s... ................................................................................................. 34 xv Table of Contents 2.8.1.1.4 Sensitivity and Specificit.y.. ............................................................................. 34 2.8.2 Movement Assessment Battery for children-2 Checklist. ..................... 35 2.8.2.1 Psychometric properties of the Movement Assessment Battery for children-2 Checklist............................................ ................... 35 2.8.2.1.1 Reliabilit.y.. ............................................................................................................ 35 2.8.2.1.2 Validity ............................................................................................................... 36 2.8.2.1.3 Gender factor.s... ................................................................................................. 36 2.8.2.1.4 Sensitivity and Specificit.y.. ............................................................................. 36 2.8.3 Movement Assessment Battery for C hildren-2 Perforamance Test ....................................................................................................….. 37 2.8.3.1 Psychometric properties of the Movement Assessment Battery for Children-2 PerformanceTest........................................................ 37 2.8.3.1.1 Reliabilit.y.. ....................................................................................................... ..... 37 2.8.3.1.2 Validity.. ................................................................................................................ 38 2.8.3.1.3 Sensitivity and Specificit.y.. ............................................................................. 38 2.9 Interventions.. ...................................................................................................... 39 2.9.1 Task orientated approach.. .............................................................................. 40 2.9.2 Process orientated approach. ........................................................................ 40 2.9.3 Research findings on interventions. ............................................................ 41 2.1 Perceptual-motor skills... .................................................................................. 43 2.11 Conclusion. .......................................................................................................... 43 2.12 Reference..s.. .............................................................................................. 45 xvi Table of Contents CHAPTER 3 ARTICLE 1: PREVALENCE OF DEVELOPMENTAL COORDINATION DISORDER AMONGST GRADE 1 LEARNERS Abstract / Opsomming ....................................................................................... 57 Introduction ......................................................................................................... 58 Methodology ………..……………………………………………………………….... 59 Study design ......................................................................................................... 59 Participants ........................................................................................................... 60 Measuring instruments ......................................................................................... 60 Statistical analysis of data .................................................................................... 61 Results .……...................................................................................................... 61 Discussion of results ......................................................................................... 65 Conclusion .......................................................................................................... 67 Acknowledgements ............................................................................................ 67 References .......................................................................................................... 68 CHAPTER 4 ARTICLE 2: THE COMPETENCY OF PARENTS TO IDENTIFY GRADE 1 CHILDREN WITH DEVELOPMENTAL COORDINATION DISORDER AT HOME Abstract / Opsomming ....................................................................................... 73 Introduction ......................................................................................................... 74 Methodology ……….………………………………………………………………..... 77 Study design ......................................................................................................... 77 Participants ........................................................................................................... 78 Measuring instruments ......................................................................................... 78 Statistical analysis of data .................................................................................... 79 Results ................................................................................................................. 80 Discussion of results ......................................................................................... 85 Conclusion .......................................................................................................... 88 xvii Table of Contents Limitations …………………………………………………………………………….. 89 Acknowledgements ............................................................................................ 89 References .......................................................................................................... 90 CHAPTER 5 ARTICLE 3: THE ABILITY OF SOUTH AFRICAN TEACHERS TO IDENTIFY GRADE 1 CHILDREN WITH DEVELOPMENTAL COORDINATION DISORDER IN THE CLASSROOM Abstract / Opsomming ..................................................................................... 96 Introduction ………………………………………………………………………………….. 97 Method …………………………………………………………………...................... 102 Participants ……………………………………………………………………………………. 102 Measures ............................................................................................................ 104 Group Allocation ................................................................................................. 106 Data analysis ...................................................................................................... 107 Results ............................................................................................................... 107 Discussion …………………………………………………………………………… 110 Conclusion …………………………………………………………………………… 113 Limitations of study ……………………………………………………………… 114 Recommendations for Future Research ........................................................ 114 Acknowledgements ………………………………………………………………… 115 References ........................................................................................................ 116 xviii Table of Contents CHAPTER 6 ARTICLE 4: THE PREVALENCE AND EFFECT OF DEVELOPMENTAL COORDINATION DISORDER ON LEARNING RELATED SKILLS IN GRADE 1 CHILDREN IN SOUTH AFRICA Abstract / Opsomming ................................................................................... 124 Introduction …………………………………………………………………………. 125 Method ............................................................................................................. 127 Participants ....................................................................................................... 127 Ethical consideration ........................................................................................ 128 Measuring instrument ....................................................................................... 128 Procedure ……………………………………………………………………………. 129 Data Analysis ................................................................................................... 130 Results ............................................................................................................ 130 Discussion …………………………………………………………………………. 133 Conclusion …………………………………………………………………………. 135 Limitation ........................................................................................................ 135 Implications for school health ………………………………………………….. 136 Acknowledgements ........................................................................................ 136 References ...................................................................................................... 137 CHAPTER 7 ARTICLE 5: PERCEPTUAL-MOTOR INTERVENTION FOR DEVELOPMENTAL COORDINATION DISORDER IN GRADE 1 CHILDREN Abstract / Opsomming ..................................................................................... 142 Introduction ....................................................................................................... 143 Methodology …………………………………………………………...................... 146 Study design ....................................................................................................... 146 xix Table of Contents Participants ......................................................................................................... 147 Measuring instruments ....................................................................................... 148 Statistical analysis of data .................................................................................. 148 Results ………………………………………………………………………………… 149 Discussion ........................................................................................................ 154 Conclusion ........................................................................................................ 157 Limitations ........................................................................................................ 157 Acknowledgements .......................................................................................... 157 References ........................................................................................................ 158 CHAPTER 8 ARTICLE 6: SPORT STACKING INTERVENTION PROGRAMME FOR CHILDREN WITH DEVELOPMENTAL COORDINATION DISORDER Abstract / Opsomming ................................................................................. 163 Introduction .................................................................................................. 164 Research problem ………………………………………………………………. 166 Material and methods ................................................................................... 166 Study design .................................................................................................. 166 Participants .................................................................................................... 167 Ethical considerations ................................................................................... 167 Measuring instruments ................................................................................... 168 Analysis of data .............................................................................................. 168 Results ........................................................................................................... 168 Discussion of results ................................................................................... 172 Limitations ………………………………………………………………………. 173 Conclusion .................................................................................................... 173 Acknowledgements ....................................................................................... 174 References .................................................................................................... 175 xx Table of Contents CHAPTER 9 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS 9.1 Summary.................................................................................................. 178 9.2 Conclusions…………………………………………………………………... 185 9.2.1 Research question 1………………………………………………………….. 185 9.2.2 Research question 2………………………………………………………….. 186 9.2.3 Research question 3………………………………………………………….. 186 9.2.4 Research question 4………………………………………………………….. 187 9.2.5 Research question 5………………………………………………………….. 187 9.2.6 Research question 6…………………………………………………………......... 188 9.3 Recommendations and limitations……………………………………….. 188 9.5 References……………………………………………………………………. 191 APPENDICES Appendix A: Premission from Department of Education .............................. 192 Appendix B: Feedback from Department of Education .............................. 195 Appendix C: Informed Consent Form .......................................................... 197 Appendix D: Child Assent Form ................................................................... 201 Appendix E: Summary of intervention programmes ..................................... 203 Appendix F: Guidelines for authors: The African Journal for Physical, Health Education, Recreation and Dance .............................................. 232 Appendix G: Guidelines for authors: South African Journal for Research in Sport, Physical Education and Recreation ................................ 241 Appendix H: Guidelines for authors: Adapted Physical Activity Quarterly ..... 247 Appendix I: Proof of language editing ........................................................ 252 xxi List of Tables List of Tables CHAPTER 2 Table 2.1: Diagnostic criteria for DCD from the American Psychiatric Association, 5th ed. (2013:47)..................................................... 28 T able 2.2: Interpretation of the total score adapted from Wilson and Crawford (2007:7)....................................................................... 32 C HAPTER 3 Table 3.1: The mean procedure of the MABC-2 results................ ............. 60 C HAPTER 4 Table 4.1: Frequency distribution of the participants according to gender and race ..…………………………………………………………... 91 Table 4.2: Convergent validity of motor problems between the MABC-2 test and the parents using the DCDQ’07………………………… 94 C HAPTER 5 Table 5.1: Frequency distribution of the participants according to gender and race ................................................................................................ 117 Table 5.2: Convergent validity of motor problems between the MABC-2 Test and the judgement of the parents using the MABC-C .............................................................................................. 119 xxii List of Tables CHAPTER 7 Table 7.1: Frequency distribution for the participants according to gender and race ............................................................................................... 160 Table 7.2: Frequency distribution for the participants according to gender and race for the experimental and control groups ........................ 160 Descriptive statistics regarding the pre- and post-test scores for Table 7.3: the total group, boys, girls, Caucasian children and Black children in the experimental and control group ………………… 163 CHAPTER 8 Table 8.1: Median results of two groups: comparison of pre- and post-test 183 xxii List of Figures List of Figures CHAPTER 1 Figure 1.1: Structure of thesis ......................................................................... 7 CHAPTER 2 Figure 2.1 Perceptual motor process adapted from Missuina (2003:3) .. 21 Figure 2.2: Limbic system adapted from Gamon and Bragdon (2003:1) .. 25 CHAPTER 3 Figure 3.1: Prevalence of DCD in Grade 1 learners ..................................... 61 Figure 3.2: Traffic light categories for girls .................................................... 62 Figure 3.3: Traffic light categories for boys .................................................... 62 Figure 3.4: Prevalence of DCD in Grade 1 learners according to race groups.. 63 CHAPTER 6 Figure 6.1: Prevalence of DCD in Grade 1 learners ...................................... 140 Figure 6.2: Traffic light categories for girls .................................................... 141 Figure 6.3: Traffic light categories for boys .................................................... 141 Figure 6.4: Learning related skill scores of the ASB expressed as a % by degree of motor difficulties ........................................................ 142 xxiii List of Figures CHAPTER 7 Figure 7.1: Traffic light categories for girls ................................................... 164 Figure 7.2: Traffic light categories for boys .................................................. 164 CHAPTER 8 Figure 8.1: Pre-test placements using the traffic light system by group ........ 186 Figure 8.2: Post-test placement using the traffic light system by group ........ 186 xxiv List of Abbreviations List of Abbreviations Developmental Coordination Disorder DCD Movement Assessment Battery For Children MABC Original Version Movement Assessment Battery For Children-2 MABC-2 Test Developmental Coordination Disorder Questionnaire DCDQ Original Version Developmental Coordination Disorder Questionnaire ’07 DCDQ’07 Movement Assessment Battery for Children-2 Checklist MABC-C Aptitude Test for School Beginners ASB Motor difficulties MD No Motor difficulties NMD At risk AR Severe motor difficulties SMD Sample size n Manual Dexterity MD Aiming and Catching AC Balance B Total Test Score TTS Experimental group Ex Control group Con Standard deviation sd xxvi Chapter 1 – Problem statement and aim of the study CHAPTER 1 Problem statement and aim of the study 1.1 Introduction.......................................................................................... 1 1.2 Problem statement............................................................................... 3 1.3 Research question............................................................................... 5 1.4 Aim........................................................................................................ 5 1.5 Structure of thesis............................................................................... 6 1.6 Ethical considerations......................................................................... 9 1.7 Explanation on how confidentiality was ensured............................. 9 1.7 References............................................................................................ 10 1.1 Introduction Developmental coordination disorder (DCD) can be defined as a “marked impairment in the development of motor coordination that is not explicable in terms of general intellectual retardation or of any specific congenital or acquired neurological disorder” (Henderson, Sugden & Barnett, 2007:6). Missiuna, Rivard and Bartlett (2006:72) state that children with DCD experience significant difficulties in motor learning and in the performance of functional motor tasks that are critical for success in their daily lives, such as activities at home, at school and during play. DCD is therefore a disorder that influences children’s daily activities, although no obvious cause is evident. A large number of school-aged children have been identified with motor proficiency problems. Literature indicates that DCD affects 5-6% of school-age children (American 1 Chapter 1 – Problem statement and aim of the study Psychiatric Association, 5th edition (APA), 2013:74; Gaines & Missiuna, 2006:326; Prado, Magalhães & Wilson, 2009:237). Gender also plays a role with regard to DCD. Literature indicates that boys experience more problems than girls, with a boy-girl ratio of 2:1 (Wright & Sugden, 1996a:1099). According to Wessels, Pienaar and Peens, (2008:494) the ratio is 2-3:1. Although children diagnosed with DCD have certain difficulties, with motor dysfunction being the core of all the problems, the children are a heterogenic group (Gillberg, 1998:107; Geuze, Jongmans, Schoemaker & Smits- Engelsman, 2001:7; Dewey, & Wilson, 2001:9). This implies that no two children are the same and negative effects experienced by each child thus differ. Major concerns relating to DCD are the considerable harmful effects associated with this disorder. Developmental coordination disorder influences children’s daily activities at home (dressing and using various tools), during play (running, riding a bicycle, swimming and ball games) and at school (writing and cutting activities) (Schoemaker, Smits-Engelsman & Jongmans, 2003:426; Sugden & Wright, 1998, cited in Iversen, Ellertsen, Tytlandsvik & Nodland 2005:67). Secondary problems associated with DCD are physical health, such as obesity and lower aerobic levels due to lower activity levels (Tsiotra, Nevill, Lane & Koutedakis, 2009:186; Cantell, Smyth & Ahonen, 2003:413.), and social, emotional and academic problems (Piek & Edwards, 1997:55; Cantell et al., 2003:413). Other co-occurring problems linked to DCD are attention deficit hyperactivity disorder (ADHD) (Pitcher, Piek & Hay, 2003:525; Watemberg, Waiserberg, Zuk & Lerman-Sagie, 2007:920; Wessels et al., 2008:494), speech and language disorders (Gaines & Missiuna, 2006:325), and visual-motor deficits (Wilmut, Brown & Wann, 2007:47). Even though children will not outgrow this disorder as previously believed (Losse, Henderson, Elliman, Hall, Knight & Jongmans, 1991:55; Henderson & Henderson, 2002 cited in Sherrill, 2004:548; Sugden & Chambers, 2006:521), Barnett’s (2008:114-115) five-step assessment process may be used for identifying children with motor difficulties. The first step focuses on using questionnaires for screening and identifying children with motor problems. The second step entails using norm-referenced tests for measuring the child’s motor performance. The third step of this motor assessment 2 Chapter 1 – Problem statement and aim of the study process entails formally diagnosing DCD by assessing the qualitative and quantitative performance in motor tasks. The fourth step focuses on understanding the nature of the condition. The final step involves planning an intervention programme. The importance of various intervention programmes for children with DCD was reported in only a few studies such as those done by Iversen et al., (2005:67), Pienaar and Lennox (2006:69) with regard to intervention on DCD and Attention Deficit Hyperactive Disorder (ADHD); as well as Sugden and Chambers (2006:520) to determine improvement in motor performance. The literature thus indicates various types of intervention programmes that can be used to improve motor proficiency among children with DCD. However, according to Davidson and Williams, (2000:10), Sugden and Chambers, (2003:546), Pienaar and Lennox (2006:79), as well as Van Waelvelde, (2009:224) research is still inadequate with regard to the effectiveness of intervention programmes for children with DCD. 1.2 Problem statement Even though researchers have shown an increased interest in DCD, this disorder is not fully understood and many questions still remain regarding the aetiology or the reason for this disorder, suitable screening tools for early identification and appropriate intervention approaches (Barnett, 2008:113; Peters & Henderson, 2008:97). Children diagnosed with DCD have common symptoms, but the degree of motor difficulties varies from childhood to adolescence, and between children (Barnett, 2008:113; Peters & Henderson, 2008:97). In addition to these medical and educational systems, DCD in children is often not identified (Gaines & Missiuna, 2006:325; Missiuna, Moll, King, King & Law, 2007:82). According to Kamps (2005:100) DCD is under-diagnosed, due to the high costs of formal tests, time consuming processes and long waiting periods (Piek & Edwards, 1997:55; Junaid, Harris, Fulmer & Carswell, 2000:158; Loh, Piek & Barrett, 2009:39). Screening instruments should be used at an early age in order to identify children who might have motor difficulties (Junaid et al., 2000:159; Loh et al., 2009:38). Independent use of questionnaires is not recommended (Junaid et al., 2000:158), but numerous 3 Chapter 1 – Problem statement and aim of the study sources of information gathered from parents and teachers by means of questionnaires can assist to identify young children in need of further assessment from professionals using normative instruments (Missiuna & Pollock, 1995:57; Wright & Sugden, 1996a:1099). Additional reasons for early identification are firstly, to implement intervention as soon as possible as young children are more willing to take part (Pienaar, 1994 cited in Pienaar & Lennox, 2006:70) and secondly, because optimal outcomes for children with DCD are associated with early interventions (Polatajko, Fox, & Missiuna, 1995:3). Interventions are not only important to improve current motor abilities and quality of life but also to prevent the development of secondary impairments associated with DCD (Sugden & Chambers, 2003:546; Missiuna et al., 2006:73; Gaines & Missiuna, 2006:325). Two obstacles affect interventions. The first obstacle, as stated earlier in this chapter, is that research with regard to the effectiveness of intervention programmes on children with DCD is still inadequate (Davidson & Williams, 2000:10; Sugden & Chambers, 2003:546; Pienaar & Lennox, 2006:79 and Van Waelvelde, 2009:224). The second obstacle relates to intervention approaches. Two intervention approaches usually used among researchers are process orientated and task orientated approaches (Sugden & Chambers, 2003:546). Literature indicates controversies between these two approaches. Researchers such as Sims, Henderson, Hulme, and Morton (1996a:976), as well as Sugden and Wright (1998:35) noticed improvements when using the process orientated approach. On the other hand, Wright and Sugden (1996a:1099) report significant differences between pre- and post-test results using the task orientated approach. From the above statement it is clear that both approaches can be successful, but it is still not clear which approach would be most beneficial for children with DCD. In conclusion, it is clear that DCD is a broad concept. Researchers as well as the public need to understand the term DCD and the negative effects associated with this disorder. Parents and teachers need to recognise the importance of a screening process, and their role in assisting professionals to identify young children who have motor difficulties. Children can receive formal assessments promptly and follow appropriate intervention approaches if they are identified timeously. 4 Chapter 1 – Problem statement and aim of the study 1.3 Research questions The following questions arise: 1. What is the prevalence of DCD amongst grade 1-learners in Bloemfontein? 2. Do parents have the competency to identify DCD in grade 1-learners at home? 3. Do teachers have the competency to identify DCD in grade 1-learners in the classroom? 4. Does DCD influence the learning-related skills of grade 1-learners? 5. Will the application of a perceptual-motor intervention programme improve the status of grade 1-learners classified with DCD? 6. Will the application of a sport stacking intervention programme improve the status of grade 1-learners classified with DCD? 1.4 Aims The specific aims of this study are to: Determine the prevalence of DCD among grade 1-learners in Bloemfontein; Establish the ability of parents in identifying grade 1-learners with DCD at home; Establish the ability of teachers in identifying grade 1-learners with DCD in the classroom; Explore the influence of DCD on learning-related skills of grade 1-learners. 5 Chapter 1 – Problem statement and aim of the study Determine if a perceptual-motor intervention will significantly improve the motor proficiency status of grade 1-learners identified with DCD; and Determine if a sport stacking intervention will significantly improve the motor proficiency status of grade 1-learners identified with DCD. 1.5 Structure of thesis This thesis is presented in nine parts. Chapter 1 introduces the problem statement, research questions and aims of this study. Chapter 2 focuses on a literature review with regard to DCD. Chapters 3 to 8 are presented in article format and the research methods will be discussed in each article. Article titles are as follows: Chapter 3: To investigate the prevalence of DCD amongst grade 1-learners in Bloemfontein. Chapter 4: To establish the competency of parents to identify grade 1-learners with DCD at home. Chapter 5: To establish the ability of South African teachers to identify grade 1- learners with DCD in the classroom. Chapter 6: The prevalence and effect of DCD on learning-related skills in grade 1-learners in South Africa. Chapter 7: Perceptual-motor intervention for DCD in grade 1-learners. Chapter 8: Sport stacking intervention programme for children with DCD. The final chapter is a collective summary, conclusion, and recommendations of the study. Chapter 9 is followed by appendices. Referencing is done according to the Harvard method and a list of references is presented at the end of each chapter. The thesis is submitted in article format, as approved by the senate of the University of the Free State (UFS), according to the guidelines for post-graduate studies. Chapters 1, 2 and 9 have been written according to the prescribed standards of the UFS Guidelines for References. The articles have been prepared for publication in accredited peer- reviewed journals. Articles have been written according to the guidelines to authors of the various journals (see the relevant appendices). Article 1 was prepared for the African Journal for Physical, Health Education, Recreation and Dance. Articles 2; 4; 5 and 6 were prepared for the South African Journal for Research in Sport, Physical Education and Recreation. In addition article 6 was prepared for an international Journal, namely the Adapted Physical Activity Quarterly. For the purpose of quality and 6 Chapter 1 – Problem statement and aim of the study examination, the font and spacing is kept the same throughout the thesis. The tables and figures are also placed in the text and not at the end of each article as prescribed. The results of the research articles in Chapters 3 to 8 are presented and interpreted in each chapter respectively. The structure of the thesis is presented in Figure 1.1. 7 Chapter 1 – Problem statement and aim of the study Perceptual-motor intervention programme for Grade 1 learners with Developmental Coordination Disorder Chapter 1: • Introduction, problem statements, research questions, aims, structure of dissertation and references. Chapter 2: • Literature review on developmental coordination disorder. Chapter 3: • Article 1: The prevalence of developmental coordination disorder amongst grade 1-learners in Bloemfontein. Chapter 4: • Article 2: The competency of parents to identifying grade -1 learners with developmental coordination disorder at home. Chapter 5: • Article 3: The ability of South African teachers in identifying grade -1 learners with developmental coordination disorder in the classroom. Chapter 6: • Article 4: The prevalence and effect of developmental coordination disorder on learning-related skills in grade -1 learners in South Africa. Chapter 7: • Article 5: Perceptual-motor intervention for developmental coordination disorder in grade -1 learners. Chapter 8: • Article 6: Sport stacking intervention programme for children with developmental coordination disorder. Chapter 9: • Summary, conclusions and recommendations. Appendices Figure 1.1: Structure of the thesis 8 Chapter 1 – Problem statement and aim of the study 1.6 Ethical considerations Privacy is considered as essential, therefore subjects were evaluated individually and their information treated confidentially. Each child and parent signed an informed consent document which outlines the aim and procedures of the study. Participants received this document in the language of their choice (either Afrikaans or English). Participation was voluntary and the subject could withdraw at any time during testing or intervention. Approval was obtained from the Ethics Committee of the Faculty of Health Sciences (ECUFS57/2012). 1.7 Explanation on how confidentiality was ensured Participants were placed alphabetically, and each received a unique number. This unique number ensured that each participant was compared to him- or herself. In order to compare the DCD experimental group to the DCD control group as well as the participants without DCD, all participants participated in some form of intervention. The control group participated in a physical activities programme and the experimental group participated in the perceptual-motor intervention programme. This procedure prevented the exclusion of certain participants or emphasising the participants with DCD. Regarding the post-test, all participants participated in the post-test (even the participants without DCD) in order to ensure confidentiality. Upon completion of the project every participant received a report with regard to their motor proficiency. 9 Chapter 1 – Problem statement and aim of the study 1.8 REFERENCES APA (AMERICAN PSYCHIATRIC ASSOCIATION). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. BARNETT, A.L. (2008). Motor assessment in developmental coordination disorder: from identification to intervention. International Journal of Disability, Development and Education, 55(2): 113-129. CANTELL, M.H., SMYTH, M.M. & AHONEN, T.P. (2003). Two distinct pathways for developmental coordination disorder: persistence and resolution. Human Movement Science, 22:413-431. DAVIDSON, T. & WILLIAMS, B. (2000). Occupational therapy for children with developmental coordination disorder: a study of the effectiveness of a combined sensory integration and perceptual-motor intervention. British Journal of Occupational Therapy, 63(10):10-17. DEWEY, D. & WILSON, B.N. (2001). Developmental Coordination Disorder: what is it? Physical Occupational Therapy Pediatrics, 20:5-27. GAINES, R. & MISSIUNA, C. (2006). Early identification: are speech/language-impaired toddlers at increased risk for Developmental Coordination Disorder? Child: Care, Health and Development, 33(3):325-332. GEUZE, R.H., JONGMANS, M.J., SCHOEMAKER, M.M. & SMITS-ENGELSMAN, B.C.M. (2001). Clinical and research diagnostic criteria for Developmental Coordination Disorder: a review and discussion. Human Movement Science, 20(7):7-47. GILLBERG, C. (1998). Hyperactivity, inattention and motor control problems: prevalence, comorbidity, and background factors. International Journal of Phoniatrica, Speech Therapy and Communication Pathology, 50(3):107-117. 10 Chapter 1 – Problem statement and aim of the study HENDERSON, S.E. & HENDERSON, L. (2002). Toward an understanding of developmental coordination disorder. Adapted Physical Activity Quarterly, 19, 12-31. In Sherrill, C. (ed.). (2004). Adapted physical activity, recreation, and sport: crossdisciplinary and lifespan (6thed.). Boston:McGraw-Hill. p. 548. HENDERSON, S.E., SUGDEN, D.A. & BARNETT, A.L. (2007). Movement assessment battery for children-2 (2nd ed.). London: Harcourt Assessment. IVERSEN, S., ELLERTSEN, B., TYTLANDSVIK, A. & NODLAND, M. (2005). Intervention for 6-year-old children with motor coordination difficulties: Parental perspectives at follow-up in middle childhood. Advances in Physiotherapy, 7:67-76. JUNAID, K.A., HARRIS, S.R., FULMER, K.A. & CARSWELL, A. (2000). Teachers’ use of the MABC Checklist to identify children with motor coordination difficulties. Pediatric Physical Therapy, 12:158-163. KAMPS, P. (2005). The source for developmental coordination disorder (DCD). East Moline, IL: Lyngui Systems. LOH, P.R., PIEK, J. P. & BARRETT, N.C. (2009). The use of the Developmental Coordination Disorder Questionnaire in Australian children. Adapted Physical Activity Quarterly, 26:38-53. LOSSE, A., HENDERSON, S.E., ELLIMAN, D., HALL, D., KNIGHT, E. & JONGMANS, M. (1991). Clumsiness in children – do they grow out of it? A 10-year follow-up study. Developmental Medicine and Child Neurology, 33(1):55-68. MISSIUNA, C. & POLLOCK, N. (1995). Beyond the norms: need for multiple sources of data in the assessment of children. Physical and Occupational Therapy in Pediatrics, 15(4):57-71. 11 Chapter 1 – Problem statement and aim of the study MISSIUNA, C., MOLL, S., KING, S., KING, G. & LAW, M. (2007). A trajectory of troubles: Parents’ impressions of the impact of Developmental Coordination Disorder. Physical & Occupational Therapy in Pediatrics, 27(1):81-101. MISSIUNA, C., RIVARD, L. & BARTLETT, D. (2006). Exploring Assessment Tools and the target of intervention for children with Developmental Coordination Disorder. Physical & Occupational Therapy in Pediatrics, 26(1/2):71-89. PETERS, J.M. & HENDERSON, S.E. (2008). Understanding Developmental Coordination Disorder and its impact on families: The contribution of single case studies. International Journal of Disability, Development and Education, 55(2):97-111. PIEK, J.P. & EDWARDS, K. (1997). The identification of children with Developmental Coordination Disorder by class and physical education teachers. British Journal of Educational Psychology, 67:55-67. PIENAAR, A.E. (1994). The incidence and treatment of gross motor deficiencies among 6-9 year-old children in the junior primary phase. Unpublished Ph.D. dissertation. Potchefstroom: P.U. for C.H.E. In Pienaar, A.E. & Lennox, A. 2006. Die effek van ʼn motoriese intervensie program gebaseer op ʼn geïntegreede benadering vir 5- tot 8- jarige plaaswerkerkinders met DCD: Flagh-studie. South African Journal for Research in Sport, Physical Education and Recreation, 28(1):69-83. PIENAAR, A.E. & LENNOX, A. (2006). Die effek van ʼn motoriese intervensie program gebaseer op ʼn geïntegreede benadering vir 5- tot 8-jarige plaaswerkerkinders met DCD: Flagh-studie. South African Journal for Research in Sport, Physical Education and Recreation, 28(1):69-83. PITCHER, T.M., PIEK, J.P. & HAY, D.A. (2003). Fine and gross motor ability in males with ADHD. Developmental Medicine and Chid Neurology, 45:525-535. 12 Chapter 1 – Problem statement and aim of the study POLATAJKO, K., FOX, M. & MISSIUNA, C. (1995). An international consensus on children with developmental coordination disorder. Canadian Journal of Occupational Therapy, 62:3-6. PRADO, M.S.S., MAGALHÃES, L.C. & WILSON, B.N. (2009). Cross-cultural adaptation of the Developmental Coordination Disorder Questionnaire for Brazilian children. Revista Brasileira de Fisioterapia, 13(3):236-243. SCHOEMAKER, M.M., SMITS-ENGELSMAN, B.C.M. & JONGMANS, M.J. (2003). Psychometric properties of the Movements Assessment Battery for Children-Checklist as a screening instrument for children with a developmental co-ordination disorder. British Journal of Education Psychology, 73(3):425-441. SIMS, K., HENDERSON, S.E., HULME, C. & MORTON, J. (1996). The remediation of clumsiness. I: An evaluation of Laszlo’s kinaesthetic approach. Developmental Medicine and Child Neurology, 38:976-987. SUGDEN, D.A. & CHAMBERS, M.E. (2003). Intervention in children with Developmental Coordination Disorder: the role of parents and teachers. British Journal of Education Psychology, 73:545-561. SUGDEN, D.A. & CHAMBERS, M.E. (2006). Stability and change in children with Developmental coordination disorder. Child: Care, Health and Development, 33(5):520- 528. SUGDEN, D.A. & WRIGHT, H.C. (1998). Motor coordination disorders in children. Thousand Oaks, CA: Sage Publications, Inc. In Iversen, S., Ellertsen, B., Tytlandsvik, A. & Nodland, M. 2005. Intervention for 6-year-old children with motor coordination difficulties: Parental perspectives at follow-up in middle childhood. Advances in Physiotherapy, 7:67-76. 13 Chapter 1 – Problem statement and aim of the study TSIOTRA, G.D., NEVILL, A.M., LANE, A.M. & KOUTEDAKIS, Y. (2009). Physical fitness and Developmental Coordination Disorder in Greek children. Pediatric Exercise Science, 21: 186-195. VAN WAELVELDE, H. (2009). Developmental Coordination Disorder: de diagnosestelling. Jaarboek Fysiotherapie Kinesitherapie. 3: 224-233. WATEMBERG, N., WAISERBERG, N., ZUK, L. & LERMAN-SAGIE, T. (2007). Developmental coordination disorder in children with attention-deficit-hyperactivity disorder and physical therapy intervention. Developmental Medicine & Child Neurology, 49(12):920-925. WESSELS, Y., PIENAAR, A.E. & PEENS, A. (2008). Geslags- en rasverskille by 6- en 7-jarige kinders met ontwikkelingskoördinasieversteurings (“DCD”) in leerverwante vaardighede en ADHD. Tydskrif vir Geesteswetenskappe, 48(4):493-504. WILMUT, K., BROWN, J.H. & WANN, J.P. (2007). Attention disengagement in children with Developmental Coordination Disorder. Disability and Rehabilitation, 29(1): 47-55. WRIGHT, H.C. & SUGDEN, D.A. (1996a). A two-step procedure for the identification of children with developmental coordination disorder in Singapore. Developmental Medicine and Child Neurology, 38,1099-1105. WRIGHT, H.C. & SUGDEN, D.A. (1998). A school based intervention program for children with Developmental Coordination Disorder. European Journal of Physical Education, 3(1):35-50. 14 Chapter 2 – Literature review on developmental coordination disorder CHAPTER 2 Literature review on developmental coordination disorder 2.1 Introduction.............................................................................................. 17 2.2 Terminology and Definitions.................................................................. 17 2.3 Prevalence of Developmental Coordination Disorder.......................... 18 2.4 Characteristics of comorbidity............................................................... 19 2.5 Etiology.................................................................................................... 20 2.6 Basic principles of neurophysiology.................................................... 22 2.6.1 The Central Nervous System.................................................................. 23 2.6.1.1 Spinal cord............................................................................................... 23 2.6.1.2 Brain stem................................................................................................ 23 2.6.2.1 Midbrain.................................................................................................... 24 2.6.2.2 Pons.......................................................................................................... 24 2.6.2.3 Medulla..................................................................................................... 24 2.6.3 Cerebellum............................................................................................... 24 2.6.4 Thalamus.................................................................................................. 25 2.6.5 Hypothalamus.......................................................................................... 25 2.6.6 Basal ganglia............................................................................................ 25 2.6.7 Cerebral cortex........................................................................................ 25 2.6.8 Corpus callosum...................................................................................... 26 2.6.2 Peripheral nervous system..................................................................... 26 2.6.3 Major psychomotor problems related to the nervous system............ 27 15 Chapter 2 – Literature review on developmental coordination disorder 2.7 Diagnosis.................................................................................................. 28 2.8 Assessments............................................................................................ 30 2.8.1 Developmental Coordination Disorder Questionnaire ’07 (DCDQ’07) 33 2.8.1.1 Psychometric properties of the Developmental Coordination Disorder Questionnaire ’07 (DCDQ’07).................................................. 33 2.8.1.1.1 Reliability.................................................................................................. 33 2.8.1.1.2 Validity...................................................................................................... 34 2.8.1.1.3 Gender factors......................................................................................... 34 2.8.1.1.4 Sensitivity and Specificity...................................................................... 34 2.8.2 Movement Assessment Battery for children-2 Checklist.................... 35 2.8.2.1 Psychometric properties of the Movement Assessment Battery for 35 children-2 Checklist................................................................................. 2.8.2.1.1 Reliability.................................................................................................. 35 2.8.2.1.2 Validity...................................................................................................... 36 2.8.2.1.3 Gender factors......................................................................................... 36 2.8.2.1.4 Sensitivity and Specificity...................................................................... 36 2.8.3 Movement Assessment Battery for children-2 Performance Test...... 37 2.8.3.1 Psychometric properties of the Movement Assessment Battery for 37 children-2 Performance Test.................................................................. 2.8.3.1.1 Reliability.................................................................................................. 37 2.8.3.1.2 Validity...................................................................................................... 38 2.8.3.1.3 Sensitivity and Specificity...................................................................... 38 2.9 Interventions............................................................................................ 39 2.9.1 Task orientated approach....................................................................... 40 2.9.2 Process orientated approach................................................................. 40 2.9.3 Research findings on interventions....................................................... 41 2.10 Perceptual-motor skills........................................................................... 43 2.11 Conclusion............................................................................................... 44 2.12 References............................................................................................... 45 16 Chapter 2 – Literature review on developmental coordination disorder 2.1 Introduction The aim of Chapter 2 is to summarise the main issues regarding DCD. Developmental coordination disorder is very complex and diverse, and to assist children with this disorder, researchers need to grasp the total process. This implies a sound background knowledge on what DCD is, from detection to intervention. 2.2 Terminology and definitions According to Missiuna, Moll, King, King and Law (2007:82), Orton first recognised children with movement difficulties in 1937. Since Orton had recognised children with movement difficulties, it took nearly 25 years before studies and systematic experimental work were presented in the literature (Walton, Ellis & Court, 1962:603). Various terms were used previously to label children with movement difficulties, such as syndrome of clumsiness, awkward, dyspraxic and perceptual motor difficulties, (Sugden & Chambers, 2003:546; Missiuna et al., 2007:82; Sugden, Kirby & Dunford, 2008:173). However, these labels have been replaced with a new term accepted across the world, known as developmental coordination disorder (DCD) (Sugden et al., 2008:173). Although there are various definitions of DCD, two definitions are generally used. The International Classification of Diseases (World Health Organisation [WHO], 1992:196) defines DCD as follows: “The main feature of this disorder is a serious impairment in the development of motor coordination that is not solely explicable in terms of general intellectual retardation or of any specific congenital or acquired neurological disorder (other than the one that may be implicit in the coordination abnormality). It is usual for the motor clumsiness to be associated with some degree of impaired performance on visuo-spatial cognitive tasks”. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.) (American Psychiatric Association [APA], 2013:74) states that the fundamental features of DCD include a significant impairment in the development of coordination and interferes with academic performance and daily activities. The difficulties are not due to a general medical condition (such as mental retardation or cerebral palsy), thus, DCD 17 Chapter 2 – Literature review on developmental coordination disorder can be seen as a disorder that influences children’s academic performance as well as activities of daily living. 2.3 Prevalence of developmental coordination disorder A significant number of school-aged children have been identified with motor proficiency problems. Literature findings indicate that DCD affects 5-6% of school- age children (APA, 2013:74; Gaines & Missiuna, 2006:326; Prado, Magalhães & Wilson, 2009:237). According to Wilmut, Brown & Wann (2007:47) the prevalence of DCD is even higher at 5-10%. Developmental coordination disorder affects children all over the world. Researchers in the United Kingdom estimated the prevalence between 4-5% (Lingam, Hunt, Golding, Jongmans & Emond, 2009:694). According to Hamilton (2002:1435) 6% of children in the United States of America are diagnosed with DCD. Junaid, Harris, Fulmer & Carswell (2000:158) found that approximately 8 to 15% of Canadian children have some form of coordination problems. America and Europe have a higher prevalence than the United Kingdom and New Zealand: between 5 and 19% of children have been found to have motor problems (Miler, Missiuna, Macnab, Malloy-Miller & Polatajko, 2001:6). The real prevalence of DCD among younger developing children might even be higher, since medical as well as educational systems frequently fail to identify this disorder in young children (Gains & Mussiuna, 2006:325; Missiuna et al., 2007:82; Miyahara, Yamaguchi & Green, 2008:355). Gender also plays a role in the prevalence of DCD. The literature indicates that boys experience more problems compared to girls, with a boy-girl ratio of 2:1 (Wright & Sugden, 1996a:1100). Wessels, Pienaar and Peens, (2008:494) found the ratio to be 2-3:1. Furthermore, Rivard, Missuina, Hanna and Wishart (2007:634) estimated that the gender difference could even be as high as 3-4:1. Hoare & Larkin (1991:3) also found that more boys than girls attend remedial programmes for DCD (9:1), supporting the belief that boys experience problems with DCD more often. Although gender related differences do occur, researchers need to take into consideration that it is a normal phenomenon in children’s attainment of motor skills. 18 Chapter 2 – Literature review on developmental coordination disorder Literature indicates that girls perform better in fine motor skills, while boys are better at gross motor skills (Gallahue & Ozmun, 2006:255). Junaid and Fellowes (2006:8) mention that, when using the Movement Assessment Battery for Children, girls outperform the boys with regard to manual dexterity items and the boys were superior on the ball skills items. No differences between the balancing skills of boys and girls were noted. Junaid and Fellowes (2006:9) also argue that these differences are due to the disparity between the attainment of motor skills among boys and girls. Although children diagnosed with DCD have specific difficulties with motor ability, which is the core of all related problems, the children are a heterogenous group (Gillberg, 1998:107; Geuze, Jongmans, Schoemaker, Smits-Engelsman, 2001:7; Dewey, & Wilson, 2001:9; Missiuna, 2003:10; Sugden & Chambers, 2003:546; Peters & Henderson, 2008:97). This implies that no two children with the same ‘label’ are similar in all aspects of their development and the negative effects experienced could vary between children. 2.4 Characteristics of comorbidity For better understanding of the characteristics of comorbidity between different developmental disorders, Pennington (2006:404) explains the overlap between various disorders by means of a multiple deficit model: “(1)The etiology of a complex behavioural disorder is multifactorial and involves the interaction of multiple risk and protective factors, which can either be genetic or environmental; (2) these risk and protective factors alter the development of cognitive function necessary for normal development thus producing behavioural symptoms that define these disorders; (3) no single etiological factor is sufficient for a disorder and few may be necessary; (4) consequently comorbidity among complex behavioural disorders is to be expected because of shared etiologic and cognitive risk factors; and (5) the liability distribution for a given disease is often continuous and quantitative, rather than being discrete and categorical, so that the threshold for having the disorder is somewhat arbitrary”. 19 Chapter 2 – Literature review on developmental coordination disorder This model implies that DCD would have its own profile of risk factors and that some of these factors are shared by other disorders, resulting in comorbidity. Various researchers describe DCD as multidimensional in nature, as noted in the following paragraphs. Major concerns relating to DCD are the considerable harmful effects associated with this disorder. Developmental coordination disorder influences children’s daily activities at home (self-care tasks), during play (running, riding a bike, swimming and ball games) and in school (writing and cutting activities) (Schoemaker, Smits- Engelsman & Jongmans, 2003:426; Gaines & Missiuna, 2006:325; Sudgen & Wright, 1998, cited in Iversen, Ellertsen, Tytlandsvik & Nodland, 2005:67). Secondary problems associated with DCD are physical health issues such as obesity and lower aerobic capacity due to lower activity levels (Tsiotra, Nevill, Lane & Koutedakis, 2009:186; Cantell, Smyth & Ahonen, 2003:413.); social, along with emotional problems, due to withdrawal or exclusion from peers, as well as academic problems such as difficulty with tracing, writing and learning (Piek & Edwards, 1997:55; Cantell et al., 2003:413; Wilmut et al., 2007:47). Other co-occurring problems linked to DCD are speech and language disorders (Missiuna, 2003:2; Gaines & Missiuna, 2006:325), visual-motor deficits, (Wilmut et al., 2007:47) and attention deficit hyperactivity disorder (ADHD) (Pitcher, Piek & Hay, 2003:525; Watemberg, Waiserberg, Zuk & Lerman-Sagie, 2007:920; Wessels, et al., 2008:494). Although children with DCD experience countless problems, the reason(s) therefore are still unclear. 2.5 Etiology According to Sugden et al., (2008:176) etiology is derived from a Greek word meaning: “giving a reason for”. Although researchers do not know the exact cause of DCD (Hamilton, 2002:1436; Visser, 2003:481), a variety of factors have been implicated. These factors include genetics, birth trauma, developmental delays, as well as perceptual problems (Hoare & Larkin, 1991:5). Missiuna (2003:3) is of the opinion that motor difficulties can occur during the four stages of information 20 Chapter 2 – Literature review on developmental coordination disorder processing. Thus, there is no straightforward answer as to why children have motor coordination difficulties. Cluster analyses have been used to identify subgroups of children with DCD (Macnab, Miller & Polatajko, 2001:49; Visser, 2003:482). Subgroups of DCD tend to find disparities between children’s performance with reference to sensorimotor measurements. Visser (2003:480) is of the opinion that subgroups of DCD would give a better understanding of the nature of DCD. During 1994, three studies were conducted. In the first, according to Hoare (1994 cited in Visser, 2003:483), five subtypes of children with DCD were identified using measurements such as visual perception, visual-motor integration, manual dexterity, kinaesthetic acuity, and balance and running speed. On the other hand, Dewey and Kaplan (1994, cited in Visser, 2003:483) identified four subtypes using balance, bilateral coordination, upper limb coordination, transitive gestures and motor sequencing. Finally, Miyahara (1994, cited in Visser, 2003:483) identified four subtypes, but they were different from those identified by Dewey and Kaplan. Miyahara (1994, cited in Visser, 2003:483) made use of running speed, agility, balance, strength, upper limb speed and dexterity. Although discrepancies were found across these three studies, one subtype, characterised by difficulties in all sensorimotor measures, was evident. Discrepancies might be due to sample differences, differences in the variables used as well as the statistical procedures (Macnab et al., 2001:49). Due to these discrepancies, some researchers are of the opinion that cluster analysis should be discarded because the subtypes do not give researchers a better understanding pertaining to the reasons for DCD (Visser, 2003:483). Other researchers call for the justification of previously defined subtypes, since it can be used as a valuable approach if sufficient information is available (Macnab et al., 2001:49). Visser (2003:483) states that additional studies are needed to distinguish subtypes in terms of underlying deficits or comorbidities, the reason being that subtypes of DCD vary with respect to comorbidities. (Cf. 2.4: Comorbidity characteristics). Missiuna (2003:3-4) also states that coordination difficulties can occur at various stages as children process information in order to execute a movement. Children continuously receive information from the environment through different senses. The 21 Chapter 2 – Literature review on developmental coordination disorder first reason for these coordination difficulties may be a result of a child finding it hard to interpret and to integrate the information received from the various senses (vision, touch, balance and sound). The second reason may arise from finding it difficult to choose the type of motor action appropriate for the current situation. Thirdly, children struggle to form a plan of action in the correct sequence. Finally, a message is sent to the muscles with reference to the speed, force, direction and distance in order to perform a movement. It is sometimes expected to alter the message to guide and control the movement while it is taking place. Figure 2.1 represent the perceptual- motor process. ACTION PLANING SYSTEM Receives information Process 1 Process 2 Process 3 Process 4 • Interpre- • Decides • Organise tation and on a plan plan into • Sight integration of action motor • Message • Sound compo- send to • Balance nents muscles • Muscle • Touch and action performed RECEIVES AND MODIFY FEEDBACK Figure 2.1: Perceptual-motor process Adapted from Missuina, 2003:3. 2.6 Basic principles of neurophysiology Sherril (2004:263) is of the opinion that it is important to take the central nervous system (CNS) into consideration when managing children who have DCD, in order to illustrate the complexity of the distribution of functions that determines effective motor control within the CNS, the various components are mentioned with a brief description of their role in motor control, and by default in DCD. 22 Chapter 2 – Literature review on developmental coordination disorder The nervous system is divided into two parts, namely the central nervous system (CNS) consisting of the brain and spinal cord, and the peripheral nervous system (PNS). The brain and spinal cord are located within the skull and vertebral canal where it is protected. The brain includes the cerebrum, cerebellum and brain stem. The PNS includes sensory receptors, nerves, plexuses and ganglia (Meij & Van Papendorp, 1997:42; Sherill, 2004:263; Van Putte, Regan & Russo, 2011:370). 2.6.1 Central nervous system 2.6.1.1 Spinal cord The spinal cord is formed by sensory and motor fibres. The fibres with similar functions are grouped together in order to form tracts. Tracts that conduct impulses to the brain are known as ascending or sensory tracts, while the descending or motor tracts carry impulses from the brain towards the spinal cord (Meij & Van Papendorp, 1997:45; Van Putte et al., 2011:370). Motor coordination and control are determined by the speed with which the impulses are carried up and down these tracts (Sherrill, 2004:295). 2.6.1.2 Brain stem The brain stem consists of three parts, namely the midbrain, the pons and the medulla oblongata. (Meij & Van Papendorp,1997:43). The brain stem helps to control reflexes. Except for vision and smell, the brain stem comprises all the sensory modalities (Sherrill, 2004:296). In the brain stem is the reticular formation which consists of a multi-synaptic network of various nerve cells and fibres which connects the midbrain, pons, as well as the medulla oblongata with each other. It consists of a motor nucleus with ascending connections to the thalamus and the cerebral cortex in addition to descending connections to the spinal cord. Impulses from the muscles, joints and collateral fibres from the main sensory pathways reach the reticular formation which is situated in the upper part of the brain stem. As a result of its exceptional location it is able to monitor all the incoming and outgoing information. It is also known as the reticular activating system, because the reticular formation is stimulated by incoming 23 Chapter 2 – Literature review on developmental coordination disorder impulses and activates the cerebral cortex (Meij & Van Papendorp, 1997:45; Sherrill, 2004:296; Van Putte et al., 2011:370). 2.6.1.3 Midbrain The midbrain’s function is to transmit impulses important for righting and postural reactions (Sherrill, 2004:296). 2.6.1.4 Pons The pons forms a bridge between the medulla and the cerebellum. This is an important component of the brain stem since it regulates reflex control of the head, neck as well as the eyes and it plays a role in regulating coordination, in addition to posture (Sherrill, 2004:296). 2.6.1.5 Medulla The medulla is situated in the upper part of the spinal cord. The function of the medulla is to regulate respiration, heart rate as well as blood pressure. It is also important for tongue movement and speech (Sherrill, 2004:296). 2.6.2 Cerebellum The cerebellum is situated posterior from the pons and medulla oblongata. It is connected to the brain stem by means of three bundles of nerve fibres. It consists of three parts, namely the vestibule-cerebellum, spino-cerebellum and cerebro- cerebellum. The function of the vestibule-cerebellum is to control muscle tone, balance as well as the coordination of eye movements. The spino-cerebellum receives information (feedback) from proprioreceptors with reference to tension in muscles, joints and tendons. It is also important in order to execute fine motor coordination skills. The cerebro-cerebellum is necessary for the planning and practicing of complex motor tasks (Meij & Van Papendorp, 1997:56; Sherrill, 2004:296; Van Putte et al., 2011:491). 24 Chapter 2 – Literature review on developmental coordination disorder 2.6.3 Thalamus The thalamus’ function is to act as a servomechanism in order to relay sensory impulses in the regulation of arousal in relation to activity. All the impulses of the senses are relayed through the thalamus except for smell (Sherrill, 2004:296). 2.6.4 Hypothalamus The hypothalamus is formed from a variety of structures as well as nuclei at the base of the brain and midbrain. Functions associated with the hypothalamus include controlling of appetite and body temperature, regulation of the autonomic nervous system and the production of hormones in order to control the endocrine glands (Meij & Van Papendorp, 1997:44; Sherrill, 2004:296). 2.6.5 Basal ganglia According to Sherrill (2004:296) the basal ganglia help with posture as well as slow movements. According to Diamond (2000:49), the basal ganglia is important for movement control, such as selecting the proper movement, the appropriate muscles to perform a movement, or the appropriate force with which to execute the movement. Children with DCD find it difficult to perform adequate, fluent and sufficient motor skills and find it hard to avoid unwanted patterns (Gillberg & Kadesjo, 2003:59). 2.6.6 Cerebral cortex The cortex is responsible for the higher level functions such as voluntary movements, perception, thought, memory in addition to creativity. The cortical areas are named according to the function the specific area needs to perform. The sensory area interprets impulses from the various sensory receptors. The association areas link the sensory and motor input and create associations important for verbalisation, memory, reasoning, judgment and creativity. Voluntary movements are controlled by the motor and premotor areas (Sherrill, 2004:297). 25 Chapter 2 – Literature review on developmental coordination disorder 2.6.7 Corpus callosum The function of the corpus callosum is to connect the cerebral hemispheres with one another. This allows the transfer of learning from the one side to the other (Sherrill, 2004:297). Figure 2.2 represent the limbic system. Figure 2.2: Limbic system Adapted from Gamon and Bragdon, 2003:1 2.6.8 Peripheral nervous system The peripheral nervous system (PNS) can be divided into two subdivisions, called the sensory division and the motor division. The sensory division sends action potentials from a sensory receptor towards the central nervous system (CNS). The motor division sends action potentials from the CNS to the muscles. Furthermore, the motor division can be divided into the somatic nervous system (SNS) which controls all voluntary movements and this system is also responsible for sensory perception. The autonomic nervous system (ANS) is responsible for the visceral organs such as the heart and digestive tract. The ANS is further subdivided into a sympathetic division which regulates physical activity in contrast to the parasympathetic division which regulates resting functions (Van Putte et al., 2011:371). 26 Chapter 2 – Literature review on developmental coordination disorder Thus, the sensory division of the PNS detects stimuli from various senses and by means of an action potential the information is sent to the CNS. The CNS receives the input and processes, and stores the incoming information in order to create an appropriate response. After the execution of the skill, propriokinaesthetic feedback takes place with the intention of evaluating the movement. The motor division of the PNS conducts action potentials from the CNS to the various muscles in order to execute a movement (Van Putte et al., 2011:371). 2.6.9 Major psychomotor problems related to the nervous system According to Sherrill (2003:264), various psychomotor problems are related to the nervous system. 1. Muscle or postural tone irregularities: Refers to abnormal amount of tension within a muscle or muscle group. It can be divided into hypotonus (too little tension in the muscles) and hypertonus (too much tension in the muscle). 2. Sensory input system problems: Problems are experienced by the structure or the function of the sensory organs or the nerve fibres responsible for carrying impulses to the brain. This aspect is also further divided into hypersensitivity or hyposensitivity. 3. Sensory and perceptual central processing problems: Refers to difficulty translating the input into appropriate output, thus organisational problems occur in the brain. 4. Reflex integration problems: Is involuntary and predictably change within a muscle as a response to various sensory inputs. 5. Postural reaction problems: Denotes automatic responses to a sensory input in order to maintain the body parts in alignment, to have efficient control, maintain the upright position and prevent one to fall. 6. Associated movement: Refers to a movement in conjunction with another body part which is not directly involved in the movement. 7. Stereotypes: Refers to rhythmical, patterned movements of various body parts, but without purpose. 8. Ataxia: Is motor clumsiness associated with balance and coordination problems. 27 Chapter 2 – Literature review on developmental coordination disorder 9. Spasticity: originates either from the cerebral cortex or spinal cord and is associated with impairment of voluntary movements. Adapted from: Sherrill, 2003:264 It is clear from the literature that the causes for DCD are still largely unknown and that a complex relationship exists between DCD and other developmental disorders. These overlapping influences prevent professionals to make a clear-cut diagnosis of DCD. 2.7 Diagnosis In order to make a scientific, clinical or sound clinical diagnosis of DCD, one can make use of the DSM-5, diagnostic criteria for DCD (APA, 2013:74). Four criteria are given and should be taken into consideration before a final decision can be made. Table 2.1 provides the diagnostic criteria for DCD. 28 Chapter 2 – Literature review on developmental coordination disorder Table 2.1: Diagnostic criteria for DCD A. Performance in daily activities that require motor coordination is substantially below that expected given the person’s chronological age and measured intelligence. This may be manifested by marked delays in achieving motor milestones (e.g., walking, crawling, and sitting), dropping things, “clumsiness”, poor performance in sports, or poor handwriting. B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living. C. The disturbance is not due to a general medical condition (e.g., cerebral palsy, hemiplegia, or muscular dystrophy) and does not meet criteria for a Pervasive Developmental Disorder. D. If Mental Retardation is present, the motor difficulties are in excess of those usually associated with it. Diagnostic criteria for DCD Adapted from: APA, 2013:47. According to Barnett (2008:119), Criteria A and B relate to motor difficulties as well as the extent to which these motor difficulties influence a child’s daily activities. Criteria C and D focus on differential diagnoses and exclude children with motor difficulties coupled with medical conditions. Thus, children who meet Criteria A and B are normally referred due to an alleged movement difficulty; but the application of Criteria C and D can change the current diagnosis considerably (Peters & Henderson, 2008:98). Consequently, if movement difficulties are suspected, it is recommended that children should undergo screening assessments. If necessary, children should be referred to a professional in order to conduct norm-referenced assessments to determine the extent of the movement difficulties experienced by these children (Peters & Henderson, 2008:98). 29 Chapter 2 – Literature review on developmental coordination disorder 2.8 Assessments According to the South-African pocket Oxford Dictionary (2005:46), “assessment” can be defined as: “to evaluate or estimate the value, importance, or quality of”. Assessments can therefore evaluate children’s motor proficiency levels or determine the quality of these movements. Assessments for DCD can be done by means of several instrument tools, such as questionnaires for screening purposes such as the Developmental Coordination Disorder Questionnaire (DCDQ) and the Movement Assessment Battery for Children-2 Checklist (MABC-C); and norm-referenced test (Movement Assessment Battery for Children-2 (MABC-2 Test) to measure the degree of movement difficulties (Barnett, 2008:117). Due to the high costs involved with norm-referenced tests, time consuming processes and long waiting periods (Piek & Edwards, 1997:55; Junaid et al., 2000:158; Loh, Piek & Barrett, 2009:39) screening tools can be used in order to identify children who might have motor difficulties (Junaid et al., 2000:159; Loh et al., 2009:38). Barnett (2008:115) argues that the validity and reliability in assessments are crucial for motor assessments to be useful. Therefore, validity implies that the assessment instrument measures what it claims to measure and reliability indicates that similar results will be obtained across time and between different examiners (Barnett, 2008:115). Test developers are responsible for the validity and reliability of their assessment instruments. The validity and reliability of questionnaires have been investigated and it was found that the DCDQ is valid and reliable and can be used for boys and girls (Wilson, Kaplan, Crawford, Campbell & Dewey, 2000:491; Schoemaker, Flapper, Verheij, Wilson, Reinders-Messelink, & De Kloet, 2008:671), although it had been recommended that the questionnaire can be used with confidence for children between the age sof 8 to 14 years and 6 months only (Wilson et al., 2000:491). In 2009 Wilson and colleagues conducted another study using the same instrument and concluded that children as young as 5 years of age can be screened (Wilson, Crawford, Green, Roberts, Aylott & Kamplan, 2009:185). Brazilian researchers adapted the language and two of the items in the questionnaire due to cultural differences. Still the questionnaire was found to be equivalent to the original DCDQ. 30 Chapter 2 – Literature review on developmental coordination disorder The DCDQ-Brazil also demonstrated validity and reliability (Prado, Magalhàes & Wilson; 2009:242). In contrast, Loh et al., (2009:51) found that the DCDQ had a low sensitivity in detecting children with mild motor difficulties. With regard to the reliability and validity of the MABC-C, Junaid et al. (2000:163) found that in comparison with the MABC Test, the MABC-C showed a lack of sensitivity. A similar finding was obtained by Schoemaker et al. (2003:439), who stated that it was only applicable to children up to 6 years of age. In the age group 7 to 9 there was a limitation with regards to either the sensitivity or specificity, resulting in a large percentage of false positives. Although these limitations were observed by Schoemaker and colleagues, they still recommend the use of the 15th percentile as the cut-off criterion for screening purposes. The use of questionnaires such as DCDQ and the MABC-C is encouraged by Missiuna & Pollock, (1995:57), as well as Wright and Sugden (1998:37), who state that numerous sources of information should be used to gather information from parents and teachers. Questionnaires may be used to identify young children in need of further assessment from professionals, using normative assessment tools subsequently. The use of these questionnaires has both limitations and advantages. Some of the limitations of these questionnaires are the following: Wilson et al., (2000:491) indicate a 27% agreement between the therapist and the DCDQ, demonstrating that the questionnaire did not identify children as frequently as a therapist with regard to motor difficulties. Results described by Loh et al. (2009:48), also indicate that the DCDQ was insufficient in distinguishing children with motor difficulties from those who did not experience any difficulties. A study by Junaid et al. (2000:162), concludes that the independent use of the MABC-C cannot be justified, because children at risk for motor difficulties based on the MABC Test were not identified. Green et al., (2005:2) came to the same conclusion, stating that it was not beneficial to use teachers to identify children with motor difficulties. Another limitation arising from using questionnaires with parents of children with attention deficit/hyperactivity disorder (ADHD) was that they tended to indicate that their children experienced motor problems while norm-reference standardised tests indicated the opposite (Kroenke, 2001 cited in Wilson et al., 2009:185). Similar 31 Chapter 2 – Literature review on developmental coordination disorder findings were obtained by Loh et al. (2009:47) in a study conducted among Australian children, because the questionnaire was not able to differentiate the ADHD symptoms. An advantage of the DCDQ was the positive results obtained from a study done by Green et al. (2005:3). The researchers concluded that parents could identify DCD, if no other developmental problems were present. Another advantage is that the limitations (subtests needed to be changed and different cut-off scores for various ages need to be established) were revealed. The questionnaire was revised (DCDQ’07) in order to improve the ability to identify children with motor difficulties (Wilson, Kaplan, Crawford & Roberts, 2007:1). Although the DCDQ was originally developed in Canada, cross-cultural adaptations of the DCDQ have been made and similar results were obtained as those in Canada (Prado et al., 2009:241). Another alternative was established for the MABC-C, using physical education teachers instead of the class teachers, since the physical education teachers could be more experienced in observing children in a changing environment (Piek & Edwards, 1997:65). The results of Piek and Edwards’ study (1997:65) conclude that the physical education teachers identified more children with motor difficulties compared with the class teachers. Even if the advantages are few, the independent use of questionnaires by researchers is not recommended (Junaid et al., 2000:158; Schoemaker et al., 2003:425). Schoemaker et al. (2003:425) are of the opinion that it is more beneficial to identify all the children with potential DCD, even if some children present false positives. Using a norm-referenced standardised test after the screening process will correct the false positive diagnoses. The researcher makes the argument that it is ethically more responsible to over-identify children than to fail to identify the children who need interventions. Screening tools for DCD include the DCDQ’07 (Wilson & Crawford, 2007:17) and the MABC-C (Henderson,Sugden & Barnett, 2007:114). Norm-referenced instruments that can be used are the Bruininks-Oseretsky Test of Motor Proficiency or the Movement Assessment Battery for Children-2 (MABC-2 Test) (Henderson et al., 2007:114). Further discussion is limited to the DCDQ’07, MABC-C and the MABC-2 Test, as these assessment instruments were used in the current study. 32 Chapter 2 – Literature review on developmental coordination disorder 2.8.1 Developmental Coordination Disorder Questionnaire’07 (DCDQ’07) This questionnaire is a brief parent questionnaire intended to screen for DCD in children between 5 and 15 years of age (Wilson & Crawford, 2007:7). The original DCDQ was developed at the Alberta Children’s Hospital in the late 1990s (Wilson & Crawford, 2007:7). A later revision was developed and is known as the DCDQ’07. The questionnaire consists of 15 items (motor skills) where children either use their hands or move around in order to complete the skill. Children’s performance on each is rated by the parent in terms on a likert scale from one to five. A rating of one indicates ‘not at all like your child’ whereas a five indicates ‘extremely like your child’ (Wilson et al., 2007:1-3). The rating values are summed to provide a total score. The interpretation of the total score, as well as the cut off scores, varies between three different age groups. (See Table 2.2). Table 2.2: Interpretation of the total score Age group: Indication of DCD Probably not DCD Cut off scores or suspect DCD 5 year 0 months to 15-46 47-75 Sensitivity=75.0% 7 years 11 months Specificity=71.4% 8 year 0 months to 15-55 56-75 Sensitivity=88.6% 9 years 11 months Specificity=66.7% 10 year 0 months 15-57 58-75 Sensitivity=88.5% to 15 years Specificity=75.6% Interpretation of the DCDQ’07 total score Adapted from: Wilson and Crawford, 2007:7 2.8.1.1 Psychometric properties of the Developmental Coordination Disorder Questionnaire’07 (DCDQ’07) 2.8.1.1.1 Reliability According to Baechle and Earle (2008:240), reliability refers to a measure of the degree of consistency or repeatability of a test. A test must be reliable to be valid, because highly variable results have little meaning. 33 Chapter 2 – Literature review on developmental coordination disorder The internal consistency, according to Wilson et al. (2009:184), was sound (Cronbach’s alpha coefficient is 0.89). Corrected item-total correlations varies between 0.42 and 0.67 (p<0.001). With regard to the test-retest reliability, the original version (Canadian) of the DCDQ did not include a measure of test-retest reliability. Although two translated versions of the DCDQ have found a high reliability of 0.94 in the Chinese version (Tseng, Fu, Wilson & Hu, 2010:39) and 0.97 among Brazilian children(Prado et al., 2009:240). According to Wilson and Crawford (2010:23) the reliability between inter-rater assessments had not been conducted. 2.8.1.1.2 Validity Validity refers to the degree to which a test or test item measures what it is supposed to measure; this is the most important characteristic of testing (Baechle & Earle, 2008:239). Wilson and Crawford (2010:23) investigated the construct validity of the DCDQ by assessing a group of 136 children with DCD or who were suspected of having DCD. These children scored significantly lower on the DCDQ’07 when compared to 96 children without DCD (F (1,230) = 81.7, p <0.001). A concurrent validity exists between the DCDQ’07 and the MABC (r = 0.55, p <0.001), as well as the Visual Motor Integration Test (r = 0.42, p <0.001). 2.8.1.1.3 Gender factors Wilson et al. (2009:189), as well as Wilson and Crawford (2010:23) established that the DCDQ scores do not differ significantly between girls and boys (F (1,284) = 0.8, p = 0.37). In contrast, Tseng et al. (2010:40), state that the mean value of the total score was affected, with girls having a higher mean DCDQ total compared to boys. 2.8.1.1.4 Sensitivity and specificity Sensitivity refers to the ability of the parents and teachers using the checklist to correctly identify children with moderate- (amber zone) and severe (red zone) motor 34 Chapter 2 – Literature review on developmental coordination disorder problems (Ellinoudis, Kyparisis, Gitsas and Kourtesis (2009:291). According to Ellinoudis et al., 2009:291), specificity refers to the ability of the parents and teachers using the checklist to correctly identify children with no motor difficulties (green zone). When using the age related cut-off scores for the three adjusted age groups, the overall sensitivity and specificity are 84.6% and 70.8% respectively (Wilson et al., 2009:189). 2.8.2 Movement Assessment Battery for Children-2 Checklist According to Henderson et al. (2007:114) the Movement Assessment Battery for Children-2 Checklist (MABC-C) is designed to identify primary school children likely to have movement difficulties. The MABC-C consists of three sections; Section A and B address progressively more complex interactions between children and their physical environment. Section C concerns non-motor factors that may adversely affect children’s movement. This is done by means of a list of specific motor behaviours that can be observed in an everyday setting such as a classroom or playground. Children’s performance proficiency on each item in the MABC-C is rated by an adult observer. The ratings are summed to provide a total score, which is then mapped onto a ‘traffic light’ system indicating whether children fall into the age- expected normal range (also known as the green zone), show signs of some minor movement problems that need to be monitored (the amber zone) or is highly likely to have more serious movement problems (red zone). 2.8.2.1 Psychometric properties of the Movement Assessment Battery for Children-2 Checklist 2.8.2.1.1 Reliability Research conducted on the original MABC is as follows: the internal consistency, according to Schoemaker et al. (2003:430), was very high (Cronbach’s alpha coefficient is 0.96) for all 48 items. With regard to Section 1 the coefficient was 0.83; Section 2 was 0.90; Section 3 was 0.88 and Section 4 was 0.85, indicating that the checklists measure the same construct. Since their study made use of the new 35 Chapter 2 – Literature review on developmental coordination disorder version of the MABC-C, Henderson et al. (2007:154) concluded that they had been unable to collect reliability data on the new Movement ABC-2 Checklist. The researchers consider the overlap in content of the old and the new checklist to be sufficient. 2.8.2.1.2 Validity Schoemaker et al., (2003:431) investigated the construct validity of the checklist since it is expected that the scores should increase from Sections 1 to 4. Alpha was set at 0.008 in order to correct for multiple comparisons. The results indicate that Section 1 differed significantly from Section 2, F(1,119) = 13.44, p<0.001; Section 2 also differed significantly from Section 3, F (1,119) = 71.874. p <0.001. A trend only towards significance was found between Section 3 and Section 4, F(1,119) = 9.877, p= 0.002. According to Schoemaker et al. (2003:437), concurrent validity exists between the MABC Checklist and the MABC performance test (r= 0.44). 2.8.2.1.3 Gender factors Henderson et al. (2007:153) found that girls had a 20% difference on Section A of the new version, indicating a statistically significant difference between boys and girls (Chi square=17.7 df = 1, p<0.001). Section B did not indicate a statistically significant gender difference (Chi square=0.16, df = 1, p= 0.69). With regards to the total motor score, no significant gender difference was observed (Chi square = 0.24, df = 1, p = 0.64). 2.8.2.1.4 Sensitivity and specificity: Best results were obtained when the 15th percentile was used as the cut-off criterion for the checklist. The overall sensitivity was 80% in all age groups, except for children aged 8-years of age. This indicates that the checklist did not identify a large number of 8-year old children on the MABC with motor problems. The specificity was 90% for 6-year old children; for the remaining age groups the specificity rates were 36 Chapter 2 – Literature review on developmental coordination disorder poor. This indicates that children in the older age groups will pass the MABC performance test but fail on the checklist (Schoemaker et al., 2003:437). 2.8.3 Movement Assessment Battery for Children-2 Performance Test The Movement Assessment Battery for Children-2 (MABC-2 Test) is a standardised test (Henderson et al., 2007:114) and requires children to perform a series of motor tasks in a specified manner. In addition to age-related norms, the test also provides qualitative information on how children approach and perform the tasks. The MABC- 2 Test assesses the participants’ motor proficiency levels and identifies children with DCD. The first assessment component of this test battery contains a total of 24 items organised into three sets of eight tasks. Each set is designed for use with children of a different age band. The eight tasks are grouped under three headings, namely manual dexterity (MD), balance (B) and aiming and catching (AC) (Henderson et al., 2007:114). Age-adjusted standard scores and percentiles are provided, as well as a total score for each of the three components of the test. The total test score can be interpreted by cut-off point in terms of a ‘traffic light’ system. The green zone indicates performance in a normal range (> 15th percentile), while the amber zone indicates a child as being at risk and needing to be carefully monitored (5th – 15th percentile). The red zone is an indication of definite motor impairment (< 5th percentile). 2.8.3.1 Psychometric properties of the Movement Assessment Battery for Children-2 Performance Test 2.8.3.1.1 Reliability The only literature available with reference to the psychometric properties of the MABC-2 is found in the test’s manual, as well as in limited, and more often than not, unpublished studies (Mayson, 2007:4).The authors of the original Movement Assessment Battery for Children (MABC) believe the item content of each edition of the MABC to be adequately comparable and thus feel that studies that used the MABC are still relevant (Mayson, 2007:2). According to Henderson et al. (2007:136), the reliability for the scaled scores were measured by means of Pearson’s product 37 Chapter 2 – Literature review on developmental coordination disorder moment correlations. With regard to the components, the coefficients exceeded the criterion of >70. Manual dexterity was r = 0.77; aiming and catching was r = 0.84 and balance r = 0.73. The reliability coefficient for the total test scores was 0.80 (Henderson et al., 2007:136; Mayson, 2007:3). With reference to the test-retest reliability, as well as the inter-rater assessments, the coefficient was as high as 0.95 (Henderson et al., 2007:133-34; Mayson, 2007:3). 2.8.3.1.2 Validity A large volume of research literature is available with regards to the validity of the original MABC. Unfortunately, there is currently a lack of research with reference to the MABC-2 (Mayson, 2007:3). Henderson et al. (2007:144) state that the MABC performance test is a valid test to use. The authors observed the correlations between the test components which ranged between 0.25 and 0.36, indicating a relatively low correlation. A moderate to good correlation was established between the test components and the total test score 0.65 and 0.73 (Mayson, 2007:3). 2.8.3.1.3 Sensitivity and specificity: The best results were obtained when the 15th percentile was used as the cut-off criterion for the MABC performance test (Schoemaker, 2003:437). In conclusion, the various assessment tools, namely the DCDQ’07, MABC-C and the MABC-2 Test are all reliable and valid tools for the assessment of movement difficulties and can therefore be used to assess the children in this study. Subsequently, if movement difficulties are identified by the various screening assessments as well as the norm reference test, it is recommended that children should undergo interventions. Children should be referred to a professional to initiate the appropriate intervention. 38 Chapter 2 – Literature review on developmental coordination disorder 2.9 Interventions Even though children will not outgrow this disorder, as previously believed (Losse, Henderson, Elliman, Hall, Knight & Jongmans, 1991:55; Henderson & Henderson, 2002 cited in Sherrill, 2004:548; Sugden & Chambers, 2003:521), children can be helped by means of intervention programmes. Intervention can be defined as “the action of intervening to improve or control a situation” (South-African pocket Oxford Dictionary 2005:472). However, for an intervention programme to be either a failure or successful, it is important to take into consideration the dynamic interaction between the child, environment and the task (Sugden & Henderson, 2007:3). This implies that the development of a child is a complex process consisting of various personal characteristics, such as the cognitive, social, linguistic, emotional and motor characteristics. These personal characteristics interact with one another over a period of time. Therefore, if a child experiences difficulty in one of these characteristics it will influence or be influenced by the other (Sugden & Henderson, 2007:3). According to Sugden and Henderson, (2007:3): “the environment in which a child operates has a crucial role to play in the success, or failure of any intervention programme”. Examples include at home, school support, health services as well as recreational facilities. On the other hand the task can be seen as learning a particular skill for a particular context and later on using the new learned skill in a various circumstances (Sugden & Henderson, 2007:3). Two intervention approaches normally used among researchers are the task orientated and process orientated approaches (Sugden & Chambers, 2003:546; Auxter, Pyfer & Huettig, 2005:118). Selecting an intervention approach depends on various factors, including the amount of time available, age and level of readiness of the children, capabilities and experience of the facilitator as well as the number of individuals available to assist in the intervention (Auxter et al., 2005:118). The task and process orientated approaches are discussed, with emphasis on the perceptual-motor aspect of the process orientated approach since this intervention was used in the current study. 39 Chapter 2 – Literature review on developmental coordination disorder 2.9.1 Task orientated approach A task orientated approach is also known as a top-down approach, or to teach specific skills. This approach focuses on a skill causing the problem and differs from the process orientated approach, since there is no emphasis on the underlying process (Sugden & Chambers, 2003:547; Bernie & Rodger, 2004:24; Niemeijer, Schoemaker, Smits-Engelsman, 2006:1223). According to Auxter et al. (2005:120), this approach emphasises the teaching of skills and behaviours that are crucial for children to function independently in a community as they get older. If the skill is mastered, it should be practiced in a variety of conditions to ensure that children will be able to use the specific skill in different situations. This approach is ideal for children older than 12 years of age as well as children with physical disabilities (Auxter et al., 2005:122). 2.9.2 Process orientated approach The process orientated approach is also known as the bottom-up or developmental approach. The aim of this approach is to improve the underlying process which is not developed fully for their age. This includes sensory functions, attention and planning and is considered a prerequisite for the attainment of motor skills. It can therefore be considered to eliminate motor deficiencies (Sugden & Chambers, 2003:546; Bernie & Rodger, 2004:24). According to Auxter et al. (2005:123) the underlying principle of this approach is to ensure that the supporting building blocks and integration processes are functioning optimally in order to facilitate skill development. For clearer understanding of this approach, a summary of the levels of motor functioning are addressed. The levels of motor functioning consist of four levels. According to Auxter et al. (2005:118), the first level is the basic neurological building blocks and entails that the sensory input system should function efficiently. Sensory input systems include the primitive and postural reflexes, the vestibular, kinesthetic, tactile, and auditory systems, as well as refractive and orthoptic vision. 40 Chapter 2 – Literature review on developmental coordination disorder The second level focuses on the integration processes, and quality movement experiences are crucial. The integration processes consists of three aspects: physical fitness (strength, flexibility, muscular and cardiovascular endurance); motor fitness (agility, power, speed and coordination), in addition to perceptual motor fitness (balance, laterality, directionality and cross-lateral integration) (Auxter et al., 2005:119). The third level, according to Auxter et al. (2005:119), refers to functional skills. Functional skills relate to functional living skills such as locomotor skills (running, hopping, jumping and skipping) or object control skills (kicking, catching, throwing and striking). Finally, sports skills are specific skills necessary for sports participation, such as dribbling a ball, spiking a ball or diving. All the levels are interrelated and each level contributes to sound motor functioning (Auxter et al., 2005:119). In the following paragraphs various research findings on interventions are discussed in more detail. 2.9.3 Research findings on interventions Researchers traditionally used bottom-up approaches by means of sensory integration and perceptual motor training in children with DCD (Bernie & Rodger, 2004:24; Sugden et al., 2008:183). These approaches aimed to improve children’s processing abilities or performance components and are still being used as an intervention by many therapists (Missiuna, Rivard & Bartlett, 2006:79; Sugden et al., 2008:183). According to Hamilton (2002:8), the most frequently used approaches were perceptual-motor therapy, sensory-integration therapy and kinesthetic training and all of these more often than not produced positive results. Due to a lack of support for the bottom-up approach, new approaches, known as the cognitive or top-down approach, emerged (Bernie & Rodger; 2004:24). More researchers are in favour of this approach (Sugden et al., 2008:183). These new approaches are based on theoretical concepts of motor learning and cognition. 41 Chapter 2 – Literature review on developmental coordination disorder Motor learning is based on a conscious understanding of the processes involved when a motor problem needs to be solved. Thus, the interaction between the task environment and the child needs to be taken into consideration (Perry,1998:6). Cognition approaches use direct skill teaching, but differ in the sense of the unique problem-solving framework, attempting to help children generalise from the learning of one skill to the next (Missiuna et al., 2006:82). According to Missiuna et al. (2006:80) and Sugden et al. (2008:183), even if the task-specific approach is aimed at increasing children’s participations, it is preferable to consider how children can perform a specific task in a variety of real-life situations, rather than in one specific setting (splinter skills). Therefore, one should consider how to modify the task or to adapt the environment in order for children to participate and improve their learning capabilities. A specific cognitive approach, Cognitive Orientation to Occupational Performance, has been examined successfully in clinical settings. Sugden et al. (2008:82) are of the opinion that on-going research will determine if this approach can be used effectively in other settings. Sugden and Chambers (1998:139) propose that most interventions are successful with a good number of children diagnosed with DCD. This statement was supported by findings from the same authors (Sugden & Chambers, 2003:558), observing that interventions done by parents and teachers can also be successful. The researchers found that a 7-week intervention (task-orientated approach) conducted by parents and teachers helped a majority of children to obtain scores above the 15th percentile. Miyahara et al., (2008:360) used university students in a clinical setting to apply a task-orientated approach and found that 40% of the participants improved beyond the cut-off scores. Intervention by means of a combination of the bottom-up and top- down approach through intense physical activity, conducted by Watemberg et al. (2007:924), concluded that 50% of the participants with DCD scored above the cut- off scores (>15 percentile) after a 4 week intervention. It is clear that controversies exist between these different approaches and there is still not enough evidence to prove that one specific intervention approach is superior 42 Chapter 2 – Literature review on developmental coordination disorder to another (Miller, Polatajoko, Missiuna, Mandich, Macnab, 2001:204; Miyahara et al., 2008:360). It is therefore recommended that these two approaches (bottom-up and top-down) should be combined in order to treat children with DCD (Peters & Wright, 1999:205; Davidson & Williams, 2000:496). 2.10 Perceptual-motor skills According to Johnstone and Ramon (2011:v) perceptual-motor skills permit sensory information to be successfully obtained and understood with appropriate reaction. Thus, “perceptual” refers to obtaining information and “motor” deals with the outcome of the movement. Therefore perceptual-motor activities require children to use the brain and body together in order to accomplish tasks. Johnstone and Ramon (2011:v) also state that meeting children’s gross motor needs will improve their academic readiness, as well as their overall behaviour. Neural pathways are built by means of physical activity. This process refers to the connections by which information travels through the brain. A child with more neural pathways will be able to learn more easily (Cf. 2.4: Basic principles of neurophysiology). Early intervention is very important in order to develop perceptual- motor skills. A perceptual-motor intervention targets components such as laterality (unilateral, bilateral and cross-lateral activities), balance, body image, tracking, spatial relations, locomotor as well as manipulative skills. Taking part in perceptual-motor activities enables children to develop greater levels of body control and encourages greater effort in all areas of the school curriculum. Children with sufficient perceptual-motor skills enjoy better coordination, greater body awareness, stronger intellectual skills, as well as a more positive self-image (Johnstone & Ramon, 2011:v). In addition to perceptual-motor interventions, sport stacking was launched in a South African setting in January 2009. Sport stacking is already recognised as a sport by more than 18 nations, including Australia and Germany in addition to South Africa (Krog, 2008:1). According to the World Sport Stacking Association (2009:1), sport 43 Chapter 2 – Literature review on developmental coordination disorder stacking is defined as a sport where 12 specialised cups are used to build formations. A participant is called a stacker. Stackers must stack cups in predetermined sequences, competing against the clock or another player (Gibbons, Hendrick & Bauer, 2007:1). 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Psychometric properties of a Chinese version of the Developmental Coordination Disorder Questionnaire in community-based children. Research in Developmental Disabilities, 31(1):33-45. TSIOTRA, G.D., NEVILL, A.M., LANE, A.M. & KOUTEDAKIS, Y. (2009). Physical fitness and developmental coordination disorder in Greek children. Pediatric Exercise Science, 2(2):186-195. UDERMANN, B.E.; MAYER, J.M.; MURRAY, S.R. & SAGENDORF, K. (2004). Influence of cup stacking on hand-eye coordination and reaction time of second- grade students. Perceptual and Motor Skills, 98: 409-414. VAN PUTTE, C., REGAN, J. & RUSSO, A. (2011). Seeley’s anatomy and physiology. (9th ed.). Boston: McGraw-Hill. VISSER, J. (2003). Developmental coordination disorder: a review of research on subtypes and comorbidities. Human Movement Sciences, 22(4-4):479-493. WALTON, J.N., ELLIS, E. & COURT, S.D.M. (1962). Clumsy children: developmental apraxia and agnosia. Brain, 85(3):603-612. WATEMBERG, N., WAISERBERG, N., ZUK, L. & LERMAN-SAGIE, T. (2007). Developmental coordination disorder in children with attention-deficit-hyperactivity 53 Chapter 2 – Literature review on developmental coordination disorder disorder and physical therapy intervention. Developmental Medicine & Child Neurology, 49(12):920-925. WESSELS, Y., PIENAAR, A.E. & PEENS, A. (2008). Geslags- en rasverskille by 6- en 7-jarige kinders met ontwikkelingskoördinasieversteurings (‘DCD’) in leerverwante vaardighede en ADHD. Tydskrif vir Geesteswetenskappe, 48(4):493-504. WILMUT, K., BROWN, J.H. & WANN, J.P. (2007). Attention disengagement in children with developmental coordination disorder. Disability and Rehabilitation, 29(1):47-55. WILSON, B.N., KAPLAN, B.J., CRAWFORD, S.G., CAMPBELL, A., & DEWEY D. (2000). Reliability and validity of a parent questionnaire on childhood motor skills. American Journal of Occupational Therapy, 54:484-493. WILSON, B.N. & CRAWFORD, S.G. (2007). The Developmental Coordination Disorder Questionnaire (DCDQ). Administration manual for the DCDQ’07 with psychometric properties.[online]. Available at: http://www.dcdq.ca/ [Accessed December 2011]. WILSON, B.N., CRAWFORD, S.G., GREEN, D., ROBERTS, G., AYLOTT, A. & KAMPLAN, B.J. (2009). Psychometric properties of the Revised Developmental Coordination Disorder Questionnaire. Physical and Occupational Therapy in Pediatrics, 29(2):182-202. WILSON, B.N., KAPLAN, B.J., CRAWFORD, S.G., & ROBERTS, G. (2007). The Developmental Coordination Disorder Questionnaire (DCDQ). [online]. Available at: http://www.dcdq.ca/ [Accessed December 2011]. WORLD HEALTH ORGANISATION. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. (10threv.ed.) 54 Chapter 2 – Literature review on developmental coordination disorder [online]. Available at http://www.who.int/classifications/icd/en/bluebook.pdf[Accessed Accessed 20 November 2013]. WORLD SPORT STACKING ASSOCIATION (2009). “Official Rule Book version 5.0.” Hyperlink: [http://www.worldsportstackingassociation.org/pdf/WSSARuleBookv4.0.pdf]. Retrieved on 3 April 2010. WRIGHT, H.C. & SUGDEN, D.A. (1996). A two-step procedure for the identification of children with developmental coordinationdisorder in Singapore. Developmental Medicine and Child Neurology, 38(12):1099-1105. WRIGHT, H.C. & SUGDEN, D.A. (1998). A school based intervention program for children with Developmental Coordination Disorder. European Journal of Physical Education, 3(1):35-50. 55 Article 1: Developmental Coordination Disorder in Grade 1-learners CHAPTER 3 ARTICLE 1: Developmental Coordination disorder in Grade 1-learners Accepted for publication African Journal for Physical, Health Education, Recreation and Dance (AJPHERD) Volume 20(3:1), September 2014, pp. 1075-1085. Developmental Coordination Disorder in Grade 1-learners MONIQUE DE MILANDER, FREDERIK F. COETZEE AND ANDRÈ VENTER Department of Exercise and Sport Sciences, University of the Free State, P.O. Box 339, Bloemfontein 9300, South Africa. E-mail: demilanderm@ufs.ac.za 56 Article 1: Developmental Coordination Disorder in Grade 1-Learners ABSTRACT Since the 1900’s the scientific community has acknowledged a large group of children who develop well intellectually but experienced movement skill difficulties. Developmental Coordination Disorder (DCD) is defined as children who experience motor coordination difficulties which impedes functional performance and interfere with their academic achievement, physical- and psychological development as well as activities of daily living. Therefore, the purpose of the study was; to determine the prevalence of DCD amongst Grade 1 learners, to establish the boy-girl ratio regarding DCD and the prevalence of DCD amongst various ethnic groups. Five-hundred and fifty nine learners between the ages of 6 and 8 years took part in this study. There were n=321 girls (57%) and n=238 boys (43%) of various ethnical groups, which consisted of 57.4% Caucasian, 39.7% Black, 2.50% Mixed-race, 0.3% Hispanic and 0.1% Indian children. The Movement Assessment Battery for Children-2 (Movement ABC-2) was used to determine DCD. The results indicated that 85% participants had no motor difficulties (green zone), 8% of children in the group were identified with moderate motor difficulties (amber zone), while 7% were identified with severe motor difficulties (red zone). With regard to the boy-girl ratio, the boys had 9% moderate difficulties and 10% severe difficulties in contrast to 7% moderate difficulties and 5% severe difficulties amongst the girls. With reference to ethnical groups, 5.3% of Caucasian learners fell in the amber zone and 5.3% in the red zone, 10.6% of Black learners fell in the amber zone and 9.7% in the red zone, 14.2% Mixed-race learners fell in the amber zone and 21.4% in the red zone. The conclusions drawn from the results suggest that the prevalence of DCD amongst Grade 1 learners in Bloemfontein is estimated to be 15%. The results also indicate that boys have a significantly higher (p=0.0507) prevalence of DCD although marginally when compared to their female counterparts. Keywords: Developmental coordination disorder, Movement Assessment Battery for Children-2, Grade 1 Learners 57 Article 1: Developmental Coordination Disorder in Grade 1-Learners Developmental Coordination Disorder in Grade 1-Learners INTRODUCTION Developmental coordination disorder (DCD) can be seen as a disorder that influences children’s daily living activities, although no obvious cause is evident. Developmental coordination disorder can be defined as a: “marked impairment in the development of motor coordination that is not explicable in terms of general intellectual retardation or of any specific congenital or acquired neurological disorder” (Henderson et al., 2007). According to Missiuna et al. (2007), DCD also include children that experience significant difficulties in motor learning and in the performance of functional motor tasks that are critical for success in their daily lives such as activities at home, school and during play. Developmental coordination disorder affects children all over the world. Researchers in the United Kingdom estimated the prevalence between 4-5% (Lingam et al., 2009). According to Hamilton (2002) 6% of children in the United States of America are diagnosed with DCD. Junaid et al., (2000) found that approximately 8-15% of Canadian children have some form of coordination problems. America and Europe have a higher prevalence than the United Kingdom and New Zealand. Between 5-19% of children have been found to have motor problems (Miler et al., 2001). The real prevalence of DCD among children might even be higher, since medical as well as educational systems frequently fail to identify this disorder in young children (Gains & Mussiuna, 2006; Missiuna et al., 2007; Miyahara et al., 2008). Gender also plays a role with regard to DCD. Literature indicates that boys experience more problems than girls, with a boy-girl ratio of 3:1 (Hoare & Larkin, 1991) and 2:1 (Wright & Sugden, 1996). Reported in previous studies, according to Wessels et al. (2008) the ratio is 2-3:1. Although children diagnosed with DCD have certain difficulties, with motor dysfunction being the core of all the problems, the children are a heterogenic group (Gillberg, 1998; Geuze et al., 2001; Dewey & Wilson, 2001). This implies that no 58 Article 1: Developmental Coordination Disorder in Grade 1-Learners two children are the same and that negative effects experienced could vary between children. Major concerns relating to DCD are the considerable harmful effects associated with this disorder. Developmental coordination disorder influences children’s daily activities at home (dressing and using various tools), normal play (running, riding a bike, swimming and ball games) and in school (writing and cutting activities) (Schoemaker et al., 2003; Sudgen & Wright, 1998). Secondary problems associated with DCD are physical health, such as obesity and lower aerobic levels due to lower activity levels (Cantell et al., 2003; Tsiotra et al., 2009), social, emotional and academic problems (Piek & Edwards, 1997; Cantell et al., 2003). Other related problems linked to DCD are attention deficit hyperactivity disorder (ADHD) (Pitcher et al., 2003; Watemberg et al., 2007; Wessels et al., 2008); speech and language disorders (Gaines & Missiuna, 2006), as well as visual-motor deficits (Wilmut et al., 2007). METHODOLOGY Study design This empirical study made use of quantitative and qualitative approach to collect data. The study involved one testing procedure in order to determine the prevalence of DCD amongst Grade 1 learners in Bloemfontein. In addition, the boy-girl ratio regarding DCD as well as the prevalence of DCD amongst various ethnic groups were determined. The cut-off scores used in this study was based on Henderson et al’s. (2007) recommendations, which are as follows: severe motor difficulties (≤5th percentile), moderate motor difficulties (5th-15th percentile) or children having no motor difficulties (>15th percentile). The participants were tested at their schools by eight Kinderkineticists who are familiar with the testing procedures of the relevant instrument. Each Kinderkineticist was responsible for one of the eight subtests to ensure consistency across the study. 59 Article 1: Developmental Coordination Disorder in Grade 1-Learners Participants Initially 13 schools in the Bloemfontein area were targeted to take part in the research project but only seven schools eventually agreed to participate. The Department of Education as well as the principals of each school gave permission for the research to be conducted on the school premises during the life orientation periods. Approval had been obtained from the Ethics Committee of the Faculty of Health Sciences, University of the Free State (ECUFS57/2012). The parents of the participants completed an informed consent form for each child participating in this study. All children in the identified classes were considered for inclusion into the study. Exclusion criteria included a child in the age group outside the expected range from 5-8 years, parental permission not obtained or the informed consent form not completed fully or parents indicating that they would be relocating during the study. Five-hundred and fifty nine (n=559) learners in Grade 1 (the youngest being 5 years and 8 months old and the oldest 8 years and 4 months old) took part in the study. The study consisted of boys (n=238) and girls (n=321) who belonged to various ethnic groups (Caucasian: n=320; Black: n=222; Mixed race: n=14; Hispanic: n=2; and Indian: n=1). Measuring instruments The Movement Assessment Battery for Children-2 (Movement ABC-2) is a standardised test (Henderson et al., 2007) and the reliability coefficient for the total test scores was 0.80 (Henderson et al., 2007; Mayson, 2007). Unfortunately research on validity is only available with regards to the original MABC (Mayson, 2007). Henderson et al., (2007) state that the original MABC performance test is a valid test to use. The authors observed the correlations between the test components which ranged between 0.25 and 0.36, indicating a relatively low correlation. Although, a moderate to good correlation was established by Mayson (2007) between the test components and the total test score 0.65 and 0.73. The Movement ABC-2 requires children to perform a series of motor tasks in a specified manner. In addition to age-related norms, the test also provides qualitative information on how children should approach and perform the tasks. The Movement ABC-2 60 Article 1: Developmental Coordination Disorder in Grade 1-Learners assesses the subject’s motor proficiency levels and diagnoses children with DCD. The first assessment component of this test battery contains 24 items organized into three sets of eight tasks. Each set is designed for use with children of a different age band. The eight tasks are grouped under three headings, namely manual dexterity (MD), balance (B) as well as aiming and catching (AC) (Henderson et al., 2007). Age-adjusted standard scores and percentiles are provided, as well as a total test score for each of the three components of the test. The total test score can be interpreted in terms of a ‘traffic light’ system. The green zone indicates performance in a normal range (>15th percentile), while the amber zone indicates that a child is at risk and needs to be carefully monitored (5th-15th percentile). The red zone is an indication of definite motor impairment (≤5th percentile). Statistical analysis of data The researchers captured data electronically in Microsoft Office Excel 2007. Analysis of the data was done by a biostatistician using Statistical Analysis Software Version 9.1.3. Descriptive statistics, namely frequencies and percentages, were calculated for categorical data. Medians and percentiles were calculated for numerical data. Median differences were tested by calculating p-values using the signed-rank test. The Chi- square statistics were used to test for proportion differences. Probability level of 0.05 or less was taken to indicate statistical significance. RESULTS Table 3.1 represents the numerical data of the mean procedure for the various subtests of the Movement ABC-2 results. 61 Article 1: Developmental Coordination Disorder in Grade 1-Learners Table 3.1: The mean procedure of the Movement ABC-2 results. Variable n Lower Median Upper Quartile Quartile MD 551 5.0 16.0 37.0 AC 551 37.0 63.0 84.0 B 551 37.0 50.0 75.0 TTS 551 16.0 37.0 63.0 Abbreviations: n = sample size, MD = Manual Dexterity, AC = Aiming and Catching, B = Balance, TTS = Total Test Score Table 3.1 shows the results of the 551 children specific to each subtest using the median procedure. The lower quartile represents the 25th percentile, which means that 75% of the children will obtain better results. The upper quartile is the 75th percentile, thus implying that only 25% would obtain better results. The data in Table 3.1 indicates that the median score for manual dexterity was 16 with an interquartile range of 5 to 37. With reference to aiming and catching, the median score was 63 and the interquartile range was 37 to 84. Balance has a median score of 50 and ranged between 37 and 75. The total test score was derived from the three subtests. The median was 37 and the interquartile range was 16 to 63. It is clear that children had the greatest difficulty performing the manual dexterity subtest. The distribution of the children according to the traffic light system (degree of motor difficulty) according to the MABC-2 test is illustrated in Figure 3.1. 62 Article 1: Developmental Coordination Disorder in Grade 1-Learners 8% 7% 85% No motor difficulties Moderate motor difficulties Severe motor difficulties Figure 3.1: Prevalence of DCD in Grade 1 learners Figure 3.1 presents the percentages with regard to the traffic light system. Green indicates no motor difficulties (85%), amber indicates moderate motor difficulties (8%) and the red zone indicates severe motor difficulties or DCD (7%) amongst Grade 1 learners in Bloemfontein. It is interesting to note that more children are experiencing motor difficulties then previously indicated. The distribution of the girls and boys according to the traffic light system (degree of motor difficulty) according to the MABC-2 test is shown in Figures 3.2 and 3.3 7% 5% 10% 9% 88% 81% No motor difficulties No motor difficulties Moderate motor difficulties Moderate motor difficulties Severe motor difficulties Severe motor difficulties Figure 3.2: Traffic light categories for Figure 3.3: Traffic light categories for girls. boys. 63 Article 1: Developmental Coordination Disorder in Grade 1-Learners As expected Figures 3.2 and 3.3 indicated that boys had a significant (p=0.0507) higher prevalence of DCD than girls, although marginally. Eighty eight per cent (88%) of the girls fell in the green zone compared to 81% of boys. With reference to the amber zone, 7% of girls had moderate motor difficulties in contrast to 9% of boys. The red zone indicates that 5% of girls had severe motor difficulties compared to 10% of boys. The distribution of the various ethnic groups according to the traffic light system (degree of motor difficulty) based on the MABC-2 Test is shown in Figure 3.4. 100 100 89.3 79.6 64.2 Green Zone Amber Zone 21.4 10.69 14.2 .7 Red Zone 5.3 5.3 0 0 0 0 Caucasion Black n=222 Mixed race Hispanic n=1 Indian n=1 n=320 n=14 Figure 3.4: Prevalence of DCD in Grade 1 learners according to ethnic groups While 89.3% of Caucasian children experienced no motor difficulties, 79.6% of Black children, 64.2% Mixed-race children and both the Hispanic and Indian child fell in the green zone (Figure 4). With regards to the amber zone, 5.3% of Caucasian children experienced motor difficulties, 10.6% of Black children and the percentage were even higher for the Mixed-race children 14.2%. Observing the red zone, 5.3% of Caucasian children experienced severe motor difficulties, 9.7% of Black children and again the percentage was higher for the Mixed-race children at 21.4%. There was a statistically significant difference (p=0.0192) in DCD between the various ethnic groups. 64 Article 1: Developmental Coordination Disorder in Grade 1-Learners DISCUSSION OF RESULTS DCD affects children all over the world, but the prevalence differs substantially in various countries. In the current study, it was found that at least 15% of the sample had moderate to severe motor difficulties. These statistics are in contrast to various findings reported in the literature where the researchers state that DCD affects more or less 5- 6% of school-age children (APA, 2000; Gaines & Missiuna, 2006; Prado et al., 2009). Researchers in the United Kingdom estimated the prevalence between 4-5% (Lingam et al., 2009), which is much lower than the 15% found in the present study. Wilmut et al. (2007) found a higher prevalence of DCD (5-10%), but this is still 5% lower than that obtained in the current study. The research findings of Junaid et al. (2000) correlate best with that of the current study. These researchers found approximately 8-15% of Canadian children to have some form of coordination problems. Studies in America and Europe found an even higher prevalence of DCD, estimated at 5-19% (Miller et al., 2001). According to Gains & Mussiuna, (2006), Missiuna et al., (2007) and Miyahara et al., (2008) medical- and education systems often fail to identify DCD in young children and therefore the prevalence might be higher. The current study found that boys exhibit significant (p=0.0507) more moderate to severe motor difficulties compared to girls, with a boy-girl ratio of 1.6:1. However, this ratio is smaller compared to other research findings. The literature also indicates that boys experience more problems compared to girls, with a boy-girl ratio of 2:1 (Wright & Sugden, 1996). Wessels et al. (2008) found the ratio to be 2-3:1. Furthermore, Rivard et al. (2007) estimated that the gender difference could even be as high as 3-4:1. Hoare and Larkin (1991) also found that more boys than girls are attending remedial programmes for DCD (9:1), supporting the belief that boys experience more problems as found in the current study. 65 Article 1: Developmental Coordination Disorder in Grade 1-Learners Although gender differences do occur, researchers need to take into consideration that gender differences are a normal phenomenon in the attainment of motor skills among children. Literature indicates that girls perform better in fine motor skills, whilst boys are better at gross motor skills (Gallahue & Ozmun, 2006). Junaid and Fellowes (2006) reported that, when using the MABC, girls outperformed the boys with regard to manual dexterity items and the boys were superior on the ball skills items. No differences were established between the balancing skills of boys and girls. Junaid and Fellowes (2006) also argue that these differences are due to the disparity between the acquisition of motor skills between boys and girls. Limited research is reported on the difference between various ethnic groups. The current study indicates that Caucasian children experienced less moderate- and severe motor difficulties (5.3%). Similar findings were reported by Wessels et al., (2008) on a smaller population sample of 99 children in Potchefstroom, North West Province. The Caucasian learners had a 9% prevalence of moderate motor difficulties and 5% severe motor difficulties. The Black learners of the current study demonstrate a 10.6% moderate motor difficulties and 9.7% severe motor difficulties. This higher prevalence amongst Black learners is supported by Wessels et al., (2008) who reported an even higher prevalence of moderate motor difficulties (15%) and severe motor difficulties (17%). With reference to the Mixed-race a higher prevalence were established in the current study, moderate motor difficulties (14.2%) and severe motor difficulties (21.4%). Contrary Wessels et al., (2008) found that the Mixed-race had the lowest prevalence of moderate motor difficulties (5%) and severe motor difficulties (1%) respectively. The current research indicates a trend towards a higher prevalence in Black learners with a suggestion of even a higher prevalence in learners of Mixed-race. Wessels et al., (2008) stated that socio economic status may be a reason for differences between ethnic groups and the prevalence of DCD. A limitation in the current study was the unequal distribution between the various ethnic groups, which could have influenced the prevalence of DCD and should be therefore taken into consideration in future research. 66 Article 1: Developmental Coordination Disorder in Grade 1-Learners CONCLUSION The prevalence of DCD (15%) of school age children in the current study was higher compared to the findings reported in the literature (5-6%). It is also clear that although minor differences do exist in relation to gender, boys still have a significant higher incidence of DCD. Finally, it can be concluded that the research identified a trend towards a higher prevalence of DCD in Black- and Mixed-race learners. ACKNOWLEDGEMENTS Thank you to the principals, staff members and children at the primary schools where the study was conducted. 67 Article 1: Developmental Coordination Disorder in Grade 1-Learners REFERENCES AMERICAN PSYCHIATRIC ASSOCIATION (1994). 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Geslags- en rasverskille by 6- en 7-jarige kinders met ontwikkelingskoördinasieversteurings (“DCD”) in leerverwante vaardighede en ADHD. Tydskrif vir Geesteswetenskappe, 48(4);493-504. WILMUT, K., BROWN, J.H. & WANN, J.P. (2007). Attention disengagement in children with Developmental Coordination Disorder. Disability and Rehabilitation, 29(1);47-55. WRIGHT, H.C. & SUGDEN, D.A. (1996). A two-step procedure for the identification of children with developmental coordination disorder in Singapore. Developmental Medicine and Child Neurology, 38(12);1099-1105. 71 Article 2: The competency of parents to identify Grade 1-learners with DCD at home CHAPTER 4 ARTICLE 2: The competency of parents to identify grade 1- learners with developmental coordination disorder at home Accepted for publication South African Journal for Research in Sport, Physical Education and Recreation, Volume 37(3), April 2015, pp. in press The competency of parents to identify Grade 1-learners with developmental coordination disorder at home MONIQUE DE MILANDER, FREDERIK F. COETZEE AND ANDRÈ VENTER Department of Exercise and Sport Sciences, University of the Free State, P.O. Box 339, Bloemfontein 9300, South Africa. E-mail: demilanderm@ufs.ac.za (Received: 23 June 2014) 72 Article 2: The competency of parents to identify Grade 1-learners with DCD at home ABSTRACT Developmental Coordination Disorder (DCD) is recognised as one of the most common developmental dysfunctions during childhood and a large number of children between six and twelve years of age are identified with DCD. The aim of the study was to examine the convergent validity of the classification of motor difficulties by Kinderkineticists-in-training using the Movement Assessment Battery for Children-2 (MABC-2 Test) and the classification of motor difficulties by the parents of the participants using the DCD Questionnaire ’07 (DCDQ’07), in order to determine if parents possess the competency to identify Grade 1- learners with DCD at home. Four hundred and ten (N = 410) Grade 1-learners between the ages of five and eight years took part in this study. There were n = 226 girls (55%) and n = 184 boys (45%). The ethnic groups that took part consisted of 67% Caucasian and 33% Black children. The results indicated 91% specificity for the DCDQ’07. In contrast, the sensitivity was only 23%. The kappa coefficient of 0.151 indicated a 15% convergent validity between the two assessment tools. Therefore, it can be argued that parents using the DCDQ’07 could not identify children with DCD at home. Keywords: Developmental Coordination Disorder (DCD), Movement Assessment Battery for Children-2 (MABC-2 Test), Developmental Coordination Disorder Questionnaire’07 (DCDQ’07), Grade 1-learners 73 Article 2: The competency of parents to identify Grade 1-learners with DCD at home The competency of parents to identify Grade 1-learners with Developmental Coordination Disorder at home INTRODUCTION Developmental Coordination Disorder (DCD) is recognised as one of the most common developmental dysfunctions during childhood (Ellinoudis et al., 2009). Literature indicates wide debate with regard to the prevalence of DCD (Giagazoglou et al., 2011) and varies with regard to the diagnostic criteria that are used (Carslaw, 2011). According to the American Psychiatric Association (APA) (2013), DCD affects 5%-6% of school-age children between five and eleven years of age, while Wilmut et al. (2007) indicated the prevalence of DCD between 5%-10%. In South Africa (Bloemfontein metropolitan area) the prevalence of DCD was even higher, as it was found that 15% of learners had DCD (De Milander et al., 2014). Alarmingly, Pienaar (2004) as well as Wessels et al. (2008) reported that children in the North West province of South Africa had a significantly higher prevalence of DCD, reported as 61% and 52% respectively. Pienaar (2004) concluded that the norms of the Movement Assessment Battery for Children should be adjusted for South African children. DCD can be defined as a marked impairment in the development of motor coordination that is not explicable in terms of general intellectual retardation or in terms of any specific congenital or acquired neurological disorder (APA, 2013). It is diagnosed in children who experience significant difficulties in motor learning and in the performance of functional motor tasks that are critical for success in their daily lives such as activities at home (dressing themselves), school (handwriting) and during play (ball skills) (Edwards et al., 2011; Asonitou et al., 2012). These difficulties can be viewed as clumsiness, for example dropping objects, in addition to the slow and inaccurate performance of motor skills such as catching objects, using scissors or taking part in sports (APA, 2013). Zwicker et al. (2012) argue that one of the major concerns regarding children with DCD is that they are often not formally diagnosed, but rather described by their parents and teachers as lazy or awkward. Furthermore, it is stated that the reason for not diagnosing these children is the lack of awareness of the disorder. The use of questionnaires is 74 Article 2: The competency of parents to identify Grade 1-learners with DCD at home encouraged by Missiuna and Pollock (1995), as well as Wright and Sugden (1998), who stated that numerous tools should be used to gather information from parents and teachers. Questionnaires may be used to identify young children in need of further assessment by professionals using normative assessment tools; however, the use of these questionnaires has both limitations and advantages. In an attempt to identify children with DCD, several research tools, such as questionnaires for screening purposes and norm-referenced tests to measure the degree of movement difficulties, can be used (Barnett, 2008). In view of the high costs of norm-referenced tests, time-consuming processes and long waiting periods, screening tools are a cost-effective way of identifying children who might have DCD (Loh et al., 2009). Several screening tests and questionnaires have been developed to gather information, specifically from parents and teachers, concerning children’s functional motor performance, for example the Movement Assessment Battery for Children Checklist (MABC- C) and the Developmental Coordination Disorder Questionnaire ’07 (DCDQ’07) (Schoemaker et al., 2012). The validity and reliability of the original DCD-Q has been investigated and it has been found that this questionnaire is a valid and reliable tool which can be used for boys and girls (Schoemaker et al., 2008), although it has been recommended that the test can be used with confidence for children between the ages of eight years and fourteen years and six months only (Wilson et al., 2000). In 2009 Wilson and colleagues conducted another study using the same instrument and concluded that children as young as five years of age can be screened (Wilson et al., 2009). Brazilian researchers adapted the language and two of the items in the questionnaire due to cultural differences. The resulting questionnaire was found to be equivalent to the original DCD-Q. The DCDQ-Brazil also demonstrated acceptable validity and reliability (Prado et al., 2009). In contrast, Loh et al. (2009) found that the DCD-Q had a low sensitivity in detecting children with mild motor difficulties. With regard to the limitations of the original DCD-Q, Wilson et al. (2000) indicated a 27% convergent validity between the therapist and the DCD-Q, demonstrating that the questionnaire did not identify children with motor difficulties as frequently as a therapist. Loh et al. (2009) also indicated that the DCD-Q was insufficient in distinguishing children with 75 Article 2: The competency of parents to identify Grade 1-learners with DCD at home motor difficulties from those who did not experience any difficulties. Additionally, studies using parents’ reports have produced conflicting results (Faught et al., 2008). Another limitation arising from using questionnaires for learners with DCD are parents of children with attention deficit/hyperactivity disorder (ADHD) was that they tended to indicate that their children experienced motor problems, while norm-referenced standardised tests indicated the opposite (Wilson et al., 2009). Similar findings were obtained by Loh et al. (2009) in a study conducted among Australian children, because the questionnaire does not differentiate the ADHD symptoms. Relating to advantages of the DCD-Q, positive results were obtained from a study done by Green et al. (2005). The researchers concluded that parents could identify DCD if no other developmental problems were present. Additional advantages of the questionnaire is that children might be identified before they enter school, thus preventing secondary impairments associated with DCD (Missiuna et al., 2006), such as physical health problems due to lower activity levels (Tsiotra et al., 2009), social problems, emotional problems due to withdrawal or exclusion from peers, as well as academic problems such as difficulties with tracing, writing and learning (Wilmut et al., 2007). The DCD-Q was revised in order to improve the ability to identify children with motor difficulties and is now known as the DCDQ’07 (Wilson et al., 2007). Changes included lowering the age range to children between the ages of five and seven years, modifying the items to ensure a better understanding of the activity as well as developing a new scoring method (Wilson et al., 2009). According to Wilson et al. (2009), the validity of the DCDQ’07 was also found to be good. Although the DCDQ’07 was originally developed in Canada, cross-cultural adaptations of this questionnaire have been made and similar results were obtained as those in Canada (Prado et al., 2009). Although there are a few advantages, the independent use of questionnaires by researchers is not recommended (Junaid et al., 2000; Schoemaker et al., 2003). Schoemaker et al. (2003) are of the opinion that it is more beneficial to identify all the children with potential DCD, even if some children present false positives. Using a norm-referenced standardised test after the screening process will correct the false positive diagnoses. They make the 76 Article 2: The competency of parents to identify Grade 1-learners with DCD at home argument that it is ethically more responsible to over-identify children than to fail to identify the children who need interventions (Schoemaker et al., 2003). Therefore, the aim of the study was to examine the convergent validity of the classification of motor difficulties by Kinderkineticists-in-training using the MABC-2 Test and the classification of motor difficulties by the parents of the participants using the DCDQ’07, in order to determine if parents possess the competency to identify Grade 1-learners with DCD at home. The DCDQ’07, used in the current study, has only had limited testing on South African children. METHODOLOGY Study design This comparative study made use of quantitative data. The study involved one testing procedure by means of the Movement Assessment Battery for Children-2 (MABC-2 Test) in order to identify DCD among Grade 1-learners (N=410). The participants were tested at their schools during the Life Orientation periods by Kinderkineticists-in-training who had been trained to use the instrument. Each Kinderkineticist-in-training was responsible for one subtest in order to have consistency across the study. In addition, a parent of each participant completed the DCDQ’07. The next step was to compare the specificity and the sensitivity of the two measuring instruments. According to Ellinoudis et al. (2009), specificity refers to the ability of the parents using the DCDQ’07 to correctly identify children with no motor difficulties (green zone) as identified by the MABC-2 Test, while sensitivity refers to the ability of the parents using the DCDQ’07 to correctly identify children with moderate (amber zone) and severe (red zone) motor problems (Ellinoudis et al., 2009). The results of the MABC-2 Test scores were compared to the results of the DCDQ’07 in order to determine the convergent validity between the two measuring instruments and to establish the competency of parents to identify DCD in children at home, thereby aiding professionals in early identification. 77 Article 2: The competency of parents to identify Grade 1-learners with DCD at home Participants Initially 13 schools in the Bloemfontein area were targeted to take part in the research project, but only seven schools eventually agreed to participate and the study thus made use of an availability sample. The Department of Education of the Free State province as well as the principal of each school gave permission for the research to be conducted on the school premises during the Life Orientation periods. Approval had been obtained from the Ethics Committee of the Faculty of Health Sciences, University of the Free State (ECUFS57/2012). The participants were treated in accordance with the ethical guidelines outlined by the Ethics Committee of the Faculty of Health Sciences. The parents/legal guardians of the participants completed an informed consent form for each child participating in this study. In addition, the children signed an assent form. Recruitment was targeted at children with and without DCD via the seven participating schools who had permission to take part in the study (inclusion criteria). Exclusion criteria included a child in the age group outside the expected range (younger than five years and older than eight years), parental permission not obtained, the informed consent form not fully completed, or parents indicating that they would be relocating during the study. Children who were absent during the testing procedure were also excluded due to incomplete testing. Additionally, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, (DSM-5) (APA, 2013) was used to exclude children who had associated symptoms according to the criteria for DCD as stated in the DSM-5. Children with motor difficulties should not meet criterion C (disturbance is not due to a general medical condition, for example, cerebral palsy, hemiplegia, or muscular dystrophy and does not meet criteria for a Pervasive Developmental Disorder) or criterion D (if mental retardation is present, the motor difficulties are in excess of those usually associated with it). None of the children met the criteria and therefore all of them were included for further data analysis. Measuring instruments According to Henderson et al. (2007), the Movement Assessment Battery for Children-2 (MABC-2 Test) requires children to perform a series of motor tasks in a specified manner. In addition to age-related norms, the test also provides qualitative information on how children should approach and perform the tasks. The MABC-2 Test is used to assess the subject’s 78 Article 2: The competency of parents to identify Grade 1-learners with DCD at home motor proficiency levels and to diagnose DCD in children. The first assessment component of this test battery contains 24 items organised into three sets of eight tasks. Each set is designed to use with children of a different age band. For the current study age band 1 and age band 2 were used. The eight tasks are grouped under three headings, namely manual dexterity (MD), balance (B) as well as aiming and catching (AC) (Henderson et al., 2007). Age-adjusted standard scores and percentiles are provided, as well as a total test score for each of the three components of the test. The total test score can be interpreted in terms of a “traffic light” system. The green zone indicates performance in a normal range (> 15th percentile), while the amber zone indicates that a child is at risk and needs to be carefully monitored (5th-15th percentile). The red zone is an indication of definite motor impairment (≤5th percentile). Thus, high standard scores on the MABC-2 Test represent good performance. The MABC-2 Test is a valid and reliable tool to use with a reliability coefficient for the total test scores of 0.80 (Henderson et al., 2007). The DCDQ’07 is a brief parent questionnaire intended to screen for DCD in children between five and fifteen years of age (Wilson & Crawford, 2007; Loh et al., 2009). The questionnaire consists of 15 items divided into three different categories (Wilson & Crawford, 2007). According to Wilson and Crawford (2007), the first category is “control during movement” and contains items relating to motor control while either the child or an object is in motion. The second category refers to “fine motor and handwriting” and the third category relates to “general coordination”. A child’s performance on each item is rated by the parent on a scale rating from one to five. A rating of one indicates “not at all like your child”, whereas a five indicates “extremely like your child” (Wilson et al., 2007). The ratings are calculated to provide a total score. The interpretation of the total score, as well as the cut-off scores, differs for the three different age groups specified. The DCDQ’07 is a valid and reliable tool to use with a reliability coefficient of 0.89 (Wilson et al., 2009). Analysis of data The principle researcher used Microsoft Excel to electronically capture data from the MABC- 2 Test as well as the DCDQ’07. Data analysis was performed by a statistician using the Statistical Package for the Social Sciences (SPSS) for Windows (SPSS version 16.0). In 79 Article 2: The competency of parents to identify Grade 1-learners with DCD at home order to determine the convergent validity of the classification of motor problems (no motor difficulties or motor difficulties) using the MABC-2 Test and the classification of motor difficulties (no motor difficulties or motor difficulties) by the parents of the participants using the DCDQ’07, the kappa (k-) coefficient was used. This coefficient supplies information with regard to the convergent validity between the two measuring instruments. The higher the coefficient (whether it is a negative or a positive value), the greater the convergent validity between the two measuring instruments. A decision was made in an arbitrary way to assign a code 1 for the group that is identified with motor difficulties and a code 2 for no motor difficulties. This was done due to the fact that the DCDQ’07 has only a “yes” or a “no” option and thus the MABC-2 Test was adapted to two categories, namely the green zone (no motor difficulties) and the amber zone (at risk) and red zone (severe difficulties) grouped together for motor difficulties present. Further analysis was done on these two categories only. Whether the correlation coefficient is a positive or a negative value can be ignored due to the codes that have been chosen in an arbitrary way. A negative correlation only indicates that the average of the group with code 3 is lower than that of the group with code 1, while a positive correlation indicates the opposite. The practical importance of the results was also investigated. As standard of practical significance, the effect size was calculated. Effect sizes (r) were calculated to determine the practical significance of the results according to Cohen (1988) by dividing the differences in the mean by the largest standard deviation of the test results. For the interpretation of practical significance, the following guideline values need to be used when the effect size is interpreted: r = 0.1: small effect; r = 0.3: medium effect and r = 0.5: large effect (Steyn, 1999). A probability level of 0.05 or less was taken to indicate statistical significance. RESULTS Table 4.1 indicates the frequency distribution of the participants according to gender and race. Four hundred and ten children (N = 410) between the ages of five and eight years took part in the study. The study consisted of boys (n = 184) and girls (n = 226), as well as an ethnic group distribution of Caucasian (n = 273) and Black (n = 137). The mean age for the children was six years and seven months with a standard deviation of 0.4. The minimum age 80 Article 2: The competency of parents to identify Grade 1-learners with DCD at home was five years and eight months and the maximum age was eight years. As shown in Table 4.1, the majority of the participants consisted of Caucasian children (66.6%), with a greater representation of girls (55.1%) than boys (44.9%) for the whole group. The gender distribution is more or less equal between the two ethnic groups. TABLE 4.1: Frequency distribution of the participants according to gender and race Gender Race Total Caucasian Black Boys 128 (46.9%) 56 (40.9%) 184 (44.9%) Girls 145 (53.1%) 81 (59.1%) 226 (55.1%) Total 273 (66.6%) 137 (33.4%) 410 (100.0%) Table 4.2 presents the convergent validity between the classifications of motor difficulties by means of the MABC-2 Test and the identification of motor difficulties by the parents using the DCDQ’07 for the total group, two gender and race groups (Caucasian and Black) independently. Finally, the convergent validity between the two measuring instruments with regard to Caucasian boys and girls as well as Black boys and girls was established. Specificity of the MABC-2 Test and the parent-completed DCDQ’07 As shown in Table 4.2, the specificity between the MABC-2 Test and the parent-completed DCDQ’07 is 91% (324/356) for the total group. Similar findings with regard to a high specificity were also established for boys 92% (139/151) and girls 90% (185/205). The specificity for Caucasian children was higher (93%, 227/243) than for Black children (86%, 97/113), and higher for Caucasian boys (96%, 105/110) than for Black boys (83%, 34/41). The results for the girls also indicated a higher specificity for the Caucasian girls (92%, 122/133) than for the Black girls (88%, 63/72). 81 Article 2: The competency of parents to identify Grade 1-learners with DCD at home Sensitivity of the MABC-2 Test and the parent-completed DCDQ’07 Table 4.2 shows that the sensitivity for the total group was 23% (12/52), indicating that the parents could not identify their children with motor problems. With regard to the boys, a higher sensitivity (32%, 10/31) was established than for their female counterparts (10%, 2/21). The results indicate similar findings comparing the Caucasian children (21%, 6/28) to the Black children (25%, 6/24). It is interesting to note that a higher sensitivity was established for the Caucasian boys (31%, 5/16) and the Black boys (33%, 5/15) than for the Caucasian girls (8%, 1/12) and the Black girls (11%, 1/9). Convergent validity of the MABC-2 Test and the parent-completed DCDQ’07 As shown in Table 4.2, the calculated k-coefficient of 0.151 is on the 1% level and provides a small effect size, which means that the findings are of insignificant practical importance. There was, however, a significant difference of p = 0.002. The results indicate that there was only a 15% convergent validity between the two measuring instruments after correcting for chance for the total group. The results for the boys indicate that the calculated k-coefficient of 0.275 is on the 1% level and provides a medium effect size, which means that the findings are of average practical importance with a significant difference of p = 0.000. The convergent validity is only 28%. In contrast, the girls have a much lower k-coefficient of 0.002, which is not on the 5% level and therefore not significant, and no significant difference occurs (p = 0.973). The calculated k-coefficient for the Caucasian children is 0.164 with a significant difference of p = 0.006, although it is on the 1% level and provides a small effect size, which means that the findings are of insignificant practical importance. The convergent validity is 16% and in contrast to the Black children is not on the 5%-level and therefore not significant and indicates a k-coefficient of 0.112 with no significant difference (p = 0.189). The calculated k-coefficient of 0.318 for Caucasian boys is on the 1% level and provides a medium effect size, which means that the findings are of average practical importance. In this case the k-coefficient indicates that there is a 32% convergent validity between the two measuring instruments after correcting for chance and indicates a significant difference of p = 0.000. These findings provide evidence that the convergent validity of these two measuring instruments is reasonably high for Caucasian boys. In the case of Black boys, the 82 Article 2: The competency of parents to identify Grade 1-learners with DCD at home results indicate that the k-coefficient of 0.174 is not on the 5% level and therefore no significant difference occurs (p = 0.189). For the girls the results indicate that the k- coefficient of 0.001 for the Caucasian girls and the k-coefficient of 0.013 for the Black girls are not on the 5% level and therefore insignificant for both groups. No significant differences were observed for the Caucasian girls (p = 0.994) or for the Black girls (p = 0.905). It can be concluded that there is also no significant convergent validity between the two measuring instruments (MABC-2 Test and the DCDQ’07) for the various variables, except for Caucasian boys. 83 Article 2: The competency of parents to identify Grade 1-learners with DCD at home TABLE 4.2: Convergent validity of motor problems between the MABC-2 test and the parent-completed DCDQ’07 Total group Boys Girls Caucasian children Black children MABC-2 TEST MABC-2 TEST MABC-2 TEST MABC-2 TEST MABC-2 TEST DCDQ’ MD NMD Total DCDQ’ MD NMD Total DCDQ’ MD NMD Total DCDQ’ MD NMD Total DCDQ’ MD NMD Total 07 07 07 07 07 MD 12 32 44 MD 10 12 22 MD 2 20 22 MD 6 16 22 MD 6 16 22 (23.1%) (32.3%) (9.5%) (21.4%) (25.0%) NMD 40 324 364 NMD 21 139 160 NMD 19 185 204 NMD 22 227 249 NMD 18 97 115 (91.0%) (92.1%) (90.2%) (93.4%) (85.8%) Total 52 356 408 Total 31 151 182 Total 21 205 226 Total 28 243 271 Total 24 113 137 k-coefficient = 0.151, p = 0.002 k-coefficient = 0.275, p = 0.000 k-coefficient = 0.002, p = 0.973 k-coefficient = 0.164, p = 0.006 k-coefficient = 0.112, p = 0.189 Effect size (r) = 0.151 (small) Effect size (r) = 0.280 (medium) Effect size (r) = 0.001 (small) Effect size (r) = 0.165 (small) Effect size (r) = 0.112 (small) Caucasian boys Caucasian girls Black boys Black girls MABC-2 TEST MABC-2 TEST MABC-2 TEST MABC-2 TEST DCDQ’ MD NMD Total DCDQ’ MD NMD Total DCDQ’ MD NMD Total DCDQ’ MD NMD Total 07 07 07 07 MD 5 5 10 MD 1 (8.3%) 11 12 MD 5 7 12 MD 1 9 10 (31.3%) (33.3%) (11.1%) NMD 11 105 116 NMD 11 122 133 NMD 10 34 44 NMD 8 63 71 (95.5%) (91.7%) (82.9%) (87.5%) Total 16 110 126 Total 12 133 145 Total 15 41 56 Total 9 72 81 k-coefficient = 0.318, p = 0.000 k-coefficient = 0.001, p = 0.994 k-coefficient = 0.174, p = 0.189 k-coefficient = 0.013, p = 0.905 Effect size (r) = 0.329 (medium) Effect size (r) = 0.001 (small) Effect size (r) = 0.175 (small) Effect size (r) = 0.013 (small) Abbreviations: MD = Motor difficulties; NMD = No Motor difficulties 84 Article 2: The competency of parents to identify Grade 1-learners with DCD at home DISCUSSION The purpose of the study was to examine the convergent validity of the classification of motor difficulties by Kinderkineticists-in-training using the MABC-2 Test and the classification of motor difficulties by the parents of the participants using the DCDQ’07, in order to determine if parents possess the competency to identify Grade 1-learners with DCD at home. This convergent validity was determined for the total group (N = 410) as well as for the two genders and the specific race groups (Caucasian and Black) independently. Finally, the convergent validity between the two measuring instruments with regard to Caucasian boys and girls as well as Black boys and girls was established. The research set out to provide possible answers to the questions pertaining to the specificity and sensitivity of the DCDQ’07 when completed by parents – an area in which a limited amount of research has been done (Schoemaker et al., 2006). No other studies have been conducted to compare the specificity and sensitivity between the parent-completed DCDQ’07 and the MABC-2 Test in order to determine the convergent validity of the identification of DCD among different ethnic groups (Caucasian and Black), thus no comparisons could be made with previous research. Although the design of this study used the revised DCDQ’07, previous findings on the original DCD-Q are also discussed, but are limited to the findings for the total group. As is shown in Table 2, the current study indicates that the convergent validities for the boys and girls were 32% and 10% respectively, indicating that the boys had a convergent validity of average practical importance and the girls showed no convergent validity at all. According to the original DCD-Q, gender did not influence the scores in older age groups (nine years to fourteen years and six months) (Wilson et al., 2000; Schoemaker et al., 2006). However, for the younger age groups (four to eight years) boys scored significantly lower than girls. Similar findings were observed by Nakai et al. (2011) as well as Rivard et al. (2014), the researchers finding significant differences between gender groups: the girls scored constantly higher than the boys. In contrast, a study on Brazilian children (N = 30) concluded that there were no significant differences in the total scores of the different genders when the 85 Article 2: The competency of parents to identify Grade 1-learners with DCD at home original DCD-Q was used (Prado et al., 2009). In order to correct this discrepancy, separate impairment scores by age and gender were developed for the revised DCDQ’07. Specificity of the MABC-2 Test and the parent-completed DCDQ’07 for the total group As can be seen in Table 2, the study succeeded in showing that the parents could identify a large percentage of children without motor difficulties, specificity of 91% (324/356), when using the age- related cut-off scores for the three adjusted age groups. Similar to the results of this study, the majority of previous research reported a high specificity on the original DCD-Q. The current study correlates with the findings of Wilson et al. (2000), who reported an even higher specificity of 95% (20/21), as well as Schoemaker et al. (2006), who tested a clinic-referred sample (N = 110) and found an 84% (42/50) specificity on the original DCD-Q. Schoemaker et al. (2006) also conducted the study on a population-based sample (N = 322) and found a higher specificity of 89% (218/246). Prado et al. (2009) adapted the DCD-Q for Brazilian children and found an 87% specificity, which correlates with the current study. However, several authors have proposed lower specificity on the original DCD-Q. Wilson et al. (2000) reported lower specificity on the original DCD-Q (71%) than the current study for the DCDQ’07. Civetta and Hillier (2008) indicated that the specificity of the original DCD-Q on a total of 460 children in Australia was only 62%. Tseng et al. (2010) indicated a lower specificity of 54% on the Chinese version of the original DCD-Q, while Green et al. (2005) found an even lower specificity of only 19%. With reference to the revised DCDQ’07, Wilson et al. (2009) established a 71% specificity with the DCDQ’07, while Parmar et al. (2014) established a higher specificity of 92%. Furthermore, in another recent study, Caravale et al. (2014) adapted the DCDQ’07 for Italian children (N = 26) and found a specificity of 96%. It is clear that conflicting results still occur and it is therefore recommended that the DCDQ’07 should be adapted to each country in order to adjust for cultural differences; in addition, larger samples should be tested. 86 Article 2: The competency of parents to identify Grade 1-learners with DCD at home Discussion on the sensitivity of the MABC-2 Test and the parent-completed DCDQ’07 for the total group This study indicates that a large percentage of children with motor difficulties could not be identified by the parents, showing a sensitivity of only 23% (Table 2), which correlates with Loh et al. (2009), who found that the original DCD-Q had a low sensitivity in detecting children with mild motor difficulties. Schoemaker et al. (2006) also found a low sensitivity of 29% (22/76) with regard to a population-based sample (N = 322). However, several authors have proposed higher sensitivity when using the original DCD-Q. Civetta and Hillier (2008) established 72% sensitivity for the original DCD-Q, while Tseng et al. (2010) found similar results of 73%. Wilson et al. (2000) found that the original DCD-Q had a high sensitivity of 86%, which correlates with research conducted by Schoemaker et al. (2006), who established a sensitivity of 82% (49/60) on the clinic-referred sample (N = 110), as well as with research done by Prado et al. (2009) with the Brazilian version, in which a sensitivity of 87% was reported. The highest sensitivity was established by Green et al. (2005), who found an even higher sensitivity of 93% among a sample of 98 children. With reference to the revised DCDQ’07, Wilson et al. (2009) differ from the current study and found a higher sensitivity of 85%, as did Caravale et al. (2014), who established 88% sensitivity. However, a recent study conducted by Parmar et al. (2014) found a very low sensitivity of 21% on the DCDQ’07, which correlates with the findings of this study. Similar to the results with regard to specificity, the results for sensitivity differ between various authors since conflicting results occur. It is therefore recommended that more research should be conducted on this topic. In addition, the researchers propose that the norms might be adapted in order to address each country’s specific needs. The k-coefficient for the present study (0.151) differs from Schoemaker et al. (2006), who established a k-coefficient of 0.65 for the clinic-referred sample and 0.21 for the population- based sample, while Green et al. (2005) found a lower k-coefficient of 0.14. 87 Article 2: The competency of parents to identify Grade 1-learners with DCD at home Discussion on the convergent validity of the MABC-2 Test and the parent-completed DCDQ’07 for the total group An overall analysis of the convergent validity between the MABC-2 Test and the DCDQ’07 in Table 2 indicates that the DCDQ’07 completed by the parents has a convergent validity of 15% (8/52) with the MABC-2 Test in identifying children with motor difficulties, and therefore the convergent validity is low (small effect). These results correlate with research conducted by Wilson et al. (2000), who established 27% convergent validity (4/15), as well as Crawford et al. (2001), who demonstrated that the questionnaire did not identify children with motor difficulties as frequently as a therapist. These results correlate with a recent study by Parmar et al. (2014), who also used the revised DCDQ’07 and performed an ROC analysis, concluding that the convergent validity between the MABC-2 Test and the DCDQ’07 was low. The findings of Schoemaker et al. (2006) are in contrast with the current study, with a convergent validity of 83% (91/110) for the clinic-referred sample. For the population-based sample the convergent validity was lower, but at 75% (240/322) still higher than in the current study. CONCLUSIONS The aim of the study was to examine the convergent validity of the classification of motor difficulties by Kinderkineticists-in-training using the MABC-2 Test and the classification of motor difficulties by the parents of the participants using the DCDQ’07, in order to determine if parents possess the competency to identify grade 1 children with DCD at home. To our knowledge, this is the first study in South Africa to assess the competency of the parents to use the DCDQ’07 to correctly identify children with motor difficulties. This study showed only a 15% convergent validity between the MABC-2 Test and the DCDQ’07 as completed by the parents. The ability of parents in the Bloemfontein area, Free State province, to use the DCDQ’07 to correctly identify children with motor difficulties was therefore found to be low. Thus, the DCDQ’07 is useful to screen children without DCD, although the purpose of a screening tool is to identify children with a specific condition. The current study demonstrates 88 Article 2: The competency of parents to identify Grade 1-learners with DCD at home the need for further research in identifying efficient and effective assessment screening tools for parents to help professionals in the early identification of motor difficulties. It is clear from the research that a screening tool alone will rarely identify all children with DCD and that the DCDQ’07 may not be the best screening tool for parents to identify DCD in children at home. It is therefore recommended that specific norms should be established for South African children. LIMITATIONS This study had some limitations. A comparison between the DCDQ’07 and the MABC-2 Checklist, which can also be completed by the parents, could have been conducted to determine which screening questionnaire yields the best results. The parents who took part in the current study were not specifically taught how to complete the DCDQ’07. The large number of parents may have affected the reliability of the scores according to the DCDQ’07. Furthermore, since this was a population-based sample, criterion B of the diagnostic criteria for DCD, which states that the academic performance of the children should also be considered (APA, 2013), was not used . It should also be recognized that the current study recruited children from the Bloemfontein metropolitan area only. 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Physical fitness and developmental coordination disorder in Greek children. Pediatric Exercise Science, 21(2): 186-195. 93 Article 2: The competency of parents to identify Grade 1-learners with DCD at home WESSELS, Y.; PIENAAR, A.E. & PEENS, A. (2008). Geslags- en rasverskille by 6- en 7- jarige kinders met ontwikkelingskoördinasieversteurings (“DCD”) in leerverwante vaardighede en ADHD. Tydskrif vir Geesteswetenskappe, 48(4): 493-504. WILMUT, K.; BROWN, J.H. & WANN, J.P. (2007). Attention disengagement in children with developmental coordination disorder. Disability and Rehabilitation, 29(1): 47-55. WILSON, B.N. & CRAWFORD, S.G. (2007). “Administration manual for the DCDQ’07 with psychometric properties.” The Developmental Coordination Disorder Questionnaire (DCDQ). Hyperlink [http://www.dcdq.ca/]. Retrieved on 11 December 2011. WILSON, B.N.; CRAWFORD, S.G.; GREEN, D.; ROBERTS, G.; AYLOTT, A. & KAPLAN, B.J. (2009). Psychometric properties of the revised Developmental Coordination Disorder Questionnaire. Physical & Occupational Therapy in Pediatrics, 29(2): 182-202. WILSON, B.N.; KAPLAN, B.J.; CRAWFORD, S.G.; CAMPBELL, A. & DEWEY D. (2000). Reliability and validity of a parent questionnaire on childhood motor skills. American Journal of Occupational Therapy, 54(5): 484-493. WILSON, B.N.; KAPLAN, B.J.; CRAWFORD, S.G. & ROBERTS, G. (2007). The Developmental Coordination Disorder Questionnaire (DCDQ). Hyperlink [http://www.dcdq.ca/]. Retrieved on 11 December 2011. WRIGHT, H.C. & SUGDEN, D.A. (1998). A school based intervention programme for children with developmental coordination disorder. European Journal of Physical Education, 3(1): 35-50. ZWICKER, J.G.; MISSIUNA, C.; HARRIS, S.R. & BOYD, L.A. (2012). Developmental coordination disorder: A review and update. European Journal of Paediatric Neurology, 16(6): 573-581. 94 Article 2: The competency of parents to identify Grade 1-learners with DCD at home 1 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom CHAPTER 5 ARTICLE 3: The ability of teachers in identifying grade 1 learners with motor coordination difficulties in the classroom Prepared for publication: Adapted Physical Activity Quarterly The ability of South African teachers in identifying Grade 1 learners with developmental coordination disorder in the classroom MONIQUE DE MILANDER, FREDERIK F. COETZEE AND ANDRÈ VENTER Department of Exercise and Sport Sciences, University of the Free State, P.O. Box 339, Bloemfontein 9300, South Africa. E-mail: demilanderm@ufs.ac.za (Received: 27 August 2014) 95 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom ABSTRACT Developmental coordination disorder (DCD) is a motor disorder of unclear etiology which severely interferes with a child’s ability to perform daily motor tasks. The aim of the study was to examine the convergent validity of the Movement Assessment Battery for Children – Checklist (MABC-C) when completed by teachers with the Movement Assessment Battery for Children – Test (MABC-2) when completed by Kinderkineticists, in order to determine if teachers possess the competency to identify grade 1 children with DCD in the classroom. Five hundred and forty five (N = 545) grade 1 children in South Africa between the ages of five and eight years took part in this study. There were 234 girls and 311 boys. The ethnic groups that took part consisted of 321 Caucasian and 224 Black learners. The MABC-C demonstrated a specificity of 70.3% and a sensitivity of 46.5%. The convergent validity between the two assessment tools when completed by teachers indicated a kappa coefficient of 0.110 (11%), and thus had a small effect size (r = 0.125). Therefore, it can be argued that teachers using the MABC-C could not identify children with DCD in the classroom. Keywords: Developmental Coordination Disorder, Movement Assessment Battery for Children-2, Movement Assessment Battery for Children-2, Checklist, Children 96 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom The Ability of South African Teachers to Identify Grade 1 Children with Developmental Coordination Disorder in the Classroom INTRODUCTION Developmental coordination disorder (DCD) is a neurodevelopmental disorder affecting approximately 1.8%–6% of school-aged children (Parmar, Kwan, Rodriguez, Missiuna, & Cairney, 2014). Children with DCD will execute coordinated motor skills significantly below the level expected based on the child’s chronological age. This is not accounted for by their age, intellect or neurological disorders, and the impact is evident in their daily activities at home (self-care tasks), during play (running, riding a bike, swimming and ball games), and in academic performance in school (writing and cutting activities). These difficulties can be viewed as clumsiness, for example dropping objects, in addition to the slow and inaccurate performance of motor skills such as catching objects, using scissors or taking part in sports (American Psychiatric Association, 2013; Gaines & Missiuna, 2007; Schoemaker, Smits-Engelsman, & Jongmans, 2003). Children with DCD share a common feature, namely experiencing difficulty in motor skills necessary for progress in both formal and informal learning experiences in a school environment (Sugden & Chambers, 2003). The impaired ability to control functional movements often continues throughout the school years, evidence that children do not outgrow this disorder (Henderson & Henderson, 2002; Losse et al., 1991; Sugden & Chambers, 2003). According to Parmar et al. (2014) it is important to identify DCD early in a child’s life to allow for proper and timely intervention and support, and to reduce the negative secondary consequences associated with this condition. Although early identification of DCD is recommended, Schoemaker, Niemeijer, Flapper, and Smits-Engelsman (2012) stated in this regard that correct identification is impeded by the lack of a universally accepted criterion standard for DCD. Children with DCD can be assessed in a variety of ways, and consequently there is presently no gold standard assessment instrument (Kirby & Sugden, 2010). Hillier (2007) came to the same conclusion, arguing that none 97 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom of the tests was sufficient for all the different children being assessed, since children with DCD were a heterogenic group. Assessment tools can be either a screening test to identify children at risk for some type of developmental problem or a diagnostic test which provides clinical information regarding movement competencies and assists in designing treatment programs (Wilson, 2005). In an attempt to identify children with DCD, several instruments, such as motor questionnaires for screening purposes and norm-referenced tests to measure the degree of movement difficulties (Barnett, 2008), can be used. Due to the high costs of norm-referenced tests, the time-consuming process, and long waiting periods in order for children to be assessed (Junaid, Harris, Fulmer, & Carswell, 2000; Loh, Piek, & Barrett, 2009; Piek & Edwards, 1997), screening tools can be used in order to identify children who might have DCD (Loh et al., 2009; Junaid et al., 2000). In this regard, several screening tests and questionnaires have been developed to gather information, specifically from parents and teachers, concerning functional motor performance of children, for example the Movement Assessment Battery for Children-2 Checklist (MABC-C) and the Developmental Coordination Disorder Questionnaire ’07 (DCDQ’07) (Schoemaker et al., 2012). The instruments used in this study were the Movement Assessment Battery for Children-2 Performance Test (MABC-2 Test), conducted by trained Kinderkineticists in order to diagnose DCD, as well as the MABC-C, completed by the children’s teachers. The MABC-2 Test was developed by Henderson, Sugden, and Barnett (2007) and requires children to perform a series of motor tasks (involving manual dexterity, balance, and ball skills) in a specified manner. In addition to age-related norms, the test also provides qualitative information on how children should approach and perform the tasks. The MABC-2 Test is used to assess motor proficiency levels and to diagnose DCD in children. The MABC-C is designed to identify primary school children likely to have movement difficulties. The MABC-C consists of three sections. Sections A and B address progressively more complex interactions between children and their physical environment. Section C concerns non-motor factors that may adversely affect children’s 98 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom movement. The checklist contains a list of specific motor behaviors that can be observed in an everyday setting such as a classroom or playground and is used to assess self-care skills, classroom skills and physical education/recreational skills (Henderson et al., 2007). The advantages of these screening tools are that children might be identified during the early stages of their school career, which may minimize the prevention of secondary impairments associated with DCD (Missiuna, Rivard, & Bartlett, 2006; Sugden & Chambers, 2003). Secondary impairments include physical health problems due to lower activity levels (Tsiotra, Nevill, Lane, & Koutedakis, 2009), social problems, along with emotional problems, due to withdrawal or exclusion from peers, as well as academic problems related to aspects such as drawing and tracing, poor handwriting, cutting with scissors and learning difficulties (Hamilton, 2002; Wilmut, Brown, & Wann, 2007). South-Africa is a very diverse country and, according to Gallahue and Ozmun (2006), motor development can be influenced by the individual, the task and the environment. According to Pienaar (2004), South Africa consists of an assortment of different population groups, as well as children from a variety of socio-economic statuses (SES). Furthermore, Pienaar (2004) argues that the diversity can impact the use of assessment tools standardized on populations from different backgrounds, particularly with regard to the child’s socio-economic influences and how this factor can affect the development of children in South Africa. The socio-cultural context in which a child is reared forms certain demands for his/her motor development, favoring specific aspects of motor development and impairing others (Venetsanou & Kambas, 2010). Robinson and Goodway (2009) stated that children who grew up in disadvantaged environments showed deficits mostly due to a lack of opportunities. Pienaar (2004) conducted a study on 688 children from a low SES, and the results revealed that more than half of the participants had motor difficulties. Another study by Pienaar, Labuschagne, and Peens (2007) showed that 5- to 6-year-old South African children from low SES displayed 99 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom developmental deficits of up to 12 months in comparison with children of the same age from more privileged environments. A contributing factor to poor motor proficiency levels amongst South African children, may be a result of the lack of Physical Education (PE) in the school curriculum. Physical Education had been discarded from South African schools as a stand-alone subject and integrated with Life Orientation (LO) as part of a learning area (Rajput and Van Deventer, 2010; Cleophas 2014). The majority of South African children did not have the opportunity to take part in PE prior to the new regime and it was further argued that the post-apartheid regime was more concerned with promoting mass participation (Cleophas, 2014; Rajput & Van Deventer, 2010). However, currently most of South African children still do not receive purposeful PE in their schools (Cleophas, 2014). It can be concluded that children will not develop their fundamental motor skills if they do not receive opportunities for practice, encouragement, as well as instructions (Gallahue & Ozmun, 2006). It is important to note that a wide range exists with regard to the prevalence of DCD across the globe in the literature (Hamilton, 2002; Pienaar, 2004; Gaines & Missiuna, 2007; Wilmut et al. 2007; Wessels, Pienaar, and Peens, 2008; De Milander, Coetzee, & Venter, 2014). The difference in prevalence might be due to the assessment tool used, the population and age being research for a specific topic. Research indicates that DCD affects 5%–6% of school-age children (Gaines & Missiuna, 2007). According to Wilmut et al. (2007), the prevalence of DCD is 5%–10%. Hamilton (2002) found that 5%–15% of school-aged children had coordination difficulties serious enough to interfere with social integration as well as academic performance. In the Free State province of South-Africa the prevalence is even higher, as it was found that 15% of children had moderate to severe motor difficulties (De Milander, Coetzee, & Venter, 2014). Alarmingly, Pienaar (2004), as well as Wessels, Pienaar, and Peens (2008), also used the MABC and reported a significantly higher prevalence of DCD in the North West province of South Africa—61.2% and 52% 100 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom respectively. This clearly indicates that South African children appear to have more motor difficulties compared to other parts of the world. There is also a difference in the prevalence of DCD between boys and girls. The literature indicates that boys experience more severe problems with regard to DCD compared to girls, with a boy:girl ratio of 2:1 (Wright & Sugden, 1996). Rivard, Missiuna, Hanna, and Wishart (2007) even estimated that the gender difference could be as high as 3–4:1. Hoare and Larkin (1991) also found that more boys than girls attended remedial programs (9:1), supporting the notion that more boys experience these problems than girls. These findings correlate with that of research done in South Africa, which found the ratio to be 2:1 (de Milander et al., 2014), while Wessels et al. (2008) estimated the ratio at 2–3:1. However, studies using these screening tools have produced conflicting results (Faught et al., 2008). Thus, it is still not clear which screening test is better to use and whether teachers can screen for or identify children with DCD (Schoemaker, Flapper, Reinders- Messelink, & de Kloet, 2008). Although various authors have conducted studies using these screening tools (Civetta & Hillier, 2008; Green et al., 2005; Prado, Magalhães & Wilson, 2009; Schoemaker, Flapper, Verheij, Wilson, Reinders-Messelink & de Kloet, 2006), their research has not been conducted in South Africa. It is clear from the literature that discrepancies exist between the results from other parts of the world with regard to the prevalence of DCD and the results from South- Africa. This may be due to the diversity of the South African people as well as the lack of Physical Education (PE) between 1994 and 2011 in schools. The Curriculum Assessment Policy Statements (CAPS) according to the Department of Basic Education with regard to PE states that teachers should develop children’s gross- and fine motor skills in addition to perceptual development (Department of Basic Education, 2011). The personnel should focus on perceptual activities which include aspects such as locomotor, rhythm, balance and laterality. According to a study done by de Milander, Coetzee and Venter, (2015) the researchers concluded that a perceptual-motor 101 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom intervention only improved balance. However, participation in PE classes presented by teachers also proved to be beneficial. The results of this study will be provided to the Department of Education in the Free State province in order to indicate the importance of Physical Education in our schools. It is therefore important to investigate the use of screening tools by the teachers with the purpose to determine if the teachers have the competency to identify children with DCD in the classroom. This study will aid researchers in determining whether the MABC-C will be beneficial for teachers in South Africa. In addition, the identified children can undergo norm reference tests and, if necessary, remedial programs from Kinderkineticists as soon as possible (Peens, Pienaar & Nienaber, 2008; de Milander, du Plessis & du Randt, 2014; de Milander et al., 2015) The aim of the study was to examine the convergent validity of the Movement MABC-C when completed by teachers with the MABC-2 when completed by Kinderkineticists, in order to determine if teachers possess the competency to identify grade 1 children with DCD in the classroom. METHOD Participants The Department of Education of the Free State province as well as the principal of each school gave permission for the research to be conducted on the school premises during the Life Orientation periods. Approval had been obtained from the Ethics Committee of the Faculty of Health Sciences, University of the Free State (ECUFS57/2012). The participants were treated in accordance with the ethical guidelines outlined by the Ethics Committee of the Faculty of Health Sciences. The parents of the participants completed an informed consent form for each child participating in this study. In addition, the children signed an assent form. Furthermore, the teachers gave consent to take part in the study by means of completing the MABC-C. The selection of the seven mainstream schools was part of a larger randomly selected sample of 13 schools who were invited to participate. The participating schools were 102 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom located within a 30-km radius of the University of the Free State. A total of 806 recruitment letters containing the participant information sheet, parent/guardian consent form, a child assent form, and a reply envelope were distributed to prospective participants between the ages of six and eight years from the seven consenting schools. Of these, 545 children returned the relevant documents to the school and were recruited for participation. This indicates a 68% response rate. There were 234 girls and 311 boys. The ethnic groups that took part consisted of 321 Caucasian and 224 Black learners. The mean age for the children was six years and seven months with a standard deviation of 0.4. The minimum age was five years and eight months and the maximum age was eight years. All children in the participating primary schools were considered for inclusion in the study. Exclusion criteria included a child in the age group outside the expected range of five to eight years, parental permission not obtained or the informed consent not completed fully, or parents indicating that they would be relocating during the study. Additionally the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, (DSM-5) (American Psychiatric Association, 2013) was used to exclude children who had associated symptoms according to the criteria for DCD. Children with motor difficulties should meet criterion C (disturbance is not due to a general medical condition, for example, cerebral palsy, hemiplegia, or muscular dystrophy and does not meet criteria for a Pervasive Developmental Disorder) or criterion D (if mental retardation is present, the motor difficulties are in excess of those usually associated with it). None of the children met the criteria and therefore all of them were included for further data analysis. A total of 28 teachers were involved in this study. As stated earlier, PE was discarded from South African schools in 1994. Thus, there was a difference in the training of the different teachers on their way to becoming a pre-school or foundation phase teacher. From the 28 teachers, 13 had received training where they completed a higher professional educational diploma over a period of four years, with PE included in the curriculum. The remaining 15 teachers were in possession of a four-year Baccalaureus 103 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom Educationis degree (pre-school and foundation phase). This curriculum included two modules addressing motor development (developmental games and developmental play); however, they did not receive formal training in PE. It is compulsory for all teachers in South Africa to register at the South African Council of Education. This study made use of quantitative data. The study involved one testing procedure by means of the MABC-2 Test in order to identify DCD among grade 1 children. The participants were tested at their school by research staff (Kinderkineticists) who were trained to use the relevant instrument. All research staff underwent a rigorous training program created by the lead investigator and reviewed by a Kinderkineticist with extensive training and professional experience with children. In total, each of our research assistants received a minimum of 8 hours of preparatory training, and at least 6 hours of in-field observation/supervision. Each Kinderkineticist was responsible for one subtest in order to have consistency across the study. In addition, each participant’s teacher completed the MABC-C. The principal researcher explained the procedure for the completion of the MABC-C to each head of department (HOD). The HOD explained the procedure in detail to the grade 1 teachers at each school they were responsible for. The teachers observed the children in their classrooms for a period of six months and had two months to complete the MABC-C. Since there were seven schools involved, each teacher had to observe her own class and assess each child. The number of children per class ranged between 25 and 32. The teachers were not informed of the results from the MABC-2 Test obtained by the Kinderkineticists and therefore could not have been influenced in any manner. The results of the MABC-2 Test were compared to the results of the MABC-C to establish the ability of teachers to identify DCD in children and aid professionals in early identification. Measures The Movement Assessment Battery for Children-2 (MABC-2 Test). The MABC-2 Test was developed by Henderson et al. (2007) and requires children to perform a series of motor tasks in a specified manner. In addition to age-related norms, the test also provides qualitative information on how children should approach and perform the 104 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom tasks. The MABC-2 Test is used to assess the participants motor proficiency levels and to diagnose DCD in children. The first assessment component of this test battery contains 24 items organized into three sets of eight tasks. Each set is designed for use with children of a different age band. The eight tasks are grouped under three headings, namely manual dexterity (MD), balance (B) as well as aiming and catching (AC) (Henderson et al., 2007). Age-adjusted standard scores and percentiles are provided, as well as a total test score for each of the three components of the test. The total test score can be interpreted in terms of a “traffic light” system. The green zone indicates performance in a normal range (> 15th percentile), while the amber zone indicates that a child is at risk and needs to be carefully monitored (5th–15th percentile). The red zone is an indication of definite motor impairment (≤ 5th percentile). The MABC-2 Test is a standardized test (Henderson et al., 2007) and the reliability coefficient for the total test scores was 0.80 (Henderson et al., 2007; Mayson, 2007). Unfortunately, research on validity is only available with regard to the original MABC (Mayson, 2007). Henderson et al. (2007) state that the original MABC Performance Test is a valid test to use. The authors observed the correlations between the test components, which ranged between 0.25 and 0.36, indicating a relatively low correlation. Still, a moderate to good correlation was established by Mayson (2007) between the test components (0.65) and the total test score (0.73). In a more recent study conducted by Ellinoudis, Evaggelinou, Kourtessis, Konstantinidou, Venetsanou and Kambas (2011) the researchers found Cronbach's alpha coefficient values were .51 (manual dexterity), .70 (aiming and catching) and .66 (balance) Furthermore, the researchers established that the correlation coefficients between each test item and the total score were moderate. These results indicate that the MABC-2 is a reliable and valid tool in order to assess motor difficulties amongst children. The Movement Assessment Battery for Children-2 Checklist (MABC-C). As stated by Henderson et al. (2007), the MABC-C is designed to identify primary school children likely to have movement difficulties. The MABC-C consists of three sections. Sections A and B address progressively more complex interactions between children and their 105 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom physical environment. Section C concerns non-motor factors that may adversely affect children’s movement. The checklist contains a list of specific motor behaviors that can be observed in an everyday setting such as a classroom or playground. The children’s performance in each item in the MABC-C is rated by an adult observer in terms of how proficiently it is executed. The ratings are summed to provide a total score, which is then mapped onto a traffic light system indicating whether children fall into the age- expected normal range (green zone), show signs of some minor movement problems that need to be monitored (amber zone) or is highly likely to have more serious movement problems (red zone). According to Schoemaker et al. (2003), the original MABC-C is a valid and reliable tool to use with a reliability coefficient of 0.96 for all 48 items. Since their study made use of the new version of the MABC-C, Henderson et al. (2007) argued that they had been unable to collect reliability data on the new MABC-C. The researchers considered the overlap in content of the old and the new checklist to be sufficient. Group Allocation The assessment of learners with and without motor difficulties was based on the cut-off scores of the MABC-2 Test (Henderson et al., 2007). Children who had a performance in the normal range (> 15th percentile) were classified as children without motor difficulties, while children at risk (5th–15th percentile) as well as those with an indication of definite motor impairment (≤ 5th percentile) were grouped together as children with motor difficulties. The results indicated that 71 children (38 boys and 33 girls) were identified as children with motor difficulties. On the MABC-C, children who scored up to the 85th percentile were considered as children with no motor difficulties. Children with results between the 85th and 94th percentile were at risk and were combined with the definite motor impairment group, who obtained scores of at or above the 95th percentile, as the children with motor difficulties (Henderson et al., 2007). Based on the cut-off scores, 33 children (20 boys and 13 girls) were identified as children with motor difficulties. Thus, the current study had two categories: no motor difficulties and motor 106 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom difficulties. The children were grouped accordingly and the results of the MABC-2 Test were compared to the findings of the MABC-C to determine the convergent validity. Data Analysis The principal researcher captured the data from the MABC-2 Test as well as the MABC- C electronically using Microsoft Excel. Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) for Windows (SPSS version 16.0, SPSS Inc., Chicago, IL). In order to achieve the aim of this study, namely to examine the convergent validity of the classification of motor problems (no motor difficulties/motor difficulties) using the MABC-2 Test and the classification of motor difficulties (no motor difficulties/motor difficulties) by the teachers of the participants using the MABC-C, the kappa (k-) coefficient was used. This coefficient supplies information with regard to the convergent validity between the two measuring instruments. The higher the coefficient (whether it is a negative or a positive value), the greater the convergent validity between the two measuring instruments. The practical importance of the results was also investigated. As standard of practical significance, the effect size was calculated. The following guideline values need to be used when the effect size is interpreted (Steyn, 1999): r = 0.1: small effect; r = 0.3: medium effect and r = 0.5: large effect. A probability level of 0.05 or less was taken to indicate statistical significance. RESULTS Table 5.1 presents the convergent validity between the classifications of motor difficulties by means of the MABC-2 Test and the identification of motor difficulties by the teachers using the MABC-C for the total group, gender and race groups (Caucasian and Black) independently. Finally, the convergent validity between the two measuring instruments with regard to Caucasian boys and girls as well as Black boys and girls was established. 107 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom TABLE 5.1: Convergent validity of motor problems between the MABC-2 Test and the teachers-completed MABC-C Total group Boys Girls Caucasian children Black children MABC-2 TEST MABC-2 TEST MABC-2 TEST MABC-2 TEST MABC-2 TEST MABC- MD NMD Total MABC- MD NMD Total MABC- MD NMD Total MABC- MD NMD Total MABC- MD NMD Total C C C C C MD 306 38 344 MD 125 18 143 MD 181 20 201 MD 183 12 195 MD 123 26 149 (70.3%) (53.5%) (69.8%) (47.4%) (70.7%) (60.6%) (65.1%) (37.5%) (79.9%) (66.7%) NMD 129 33 162 NMD 54 20 74 NMD 75 13 88 NMD 98 20 118 NMD 31 13 44 (29.7%) (46.5%) (30.2%) (52.6%) (29.3) (39.4%) (34.9%) (62.5%) (20.1%) (33.3%) Total 435 71 506 Total 179 38 217 Total 256 33 289 Total 281 32 313 Total 154 39 193 (k)-coefficient = 0.110, p = 0.005 (k)-coefficient = 0.164, p = 0.008 (k)-coefficient = 0.059, p = 0.236 (k)-coefficient = 0.126, p = 0.002 (k)-coefficient = 0.126, p = 0.079 Effect size (r) = 0.125 (small) Effect size (r) = 0.180 (small) Effect size (r) = 0.070 (small) Effect size (r) = 0.173 (small) Effect size (r) = 0.126 (small) Caucasian boys Caucasian girls Black boys Black girls MABC-2 TEST MABC-2 TEST MABC-2 TEST MABC-2 TEST MABC- MD NMD Total MABC- MD NMD Total MABC- MD NMD Total MABC- MD NMD Total C C C C MD 79 5 84 MD 104 7 111 MD 46 13 59 MD 77 (77%) 13 90 (63.2%) (27.8%) (66.7%) (50%) (85.2%) (65%) (68.4%) NMD 46 13 59 NMD 52 7 59 NMD 8 7 15 NMD 23 6 29 (36.8%) (72.2%) (50%) (14.8%) (35.0%) (23%) (31.6%) Total 125 18 143 Total 156 14 170 Total 54 20 74 Total 100 19 119 (k)-coefficient = 0.179, p = 0.004 (k)-coefficient = 0.068, p = 0.210 (k)-coefficient = 0.219, p = 0.050 (k)-coefficient = 0.071, p = 0.425 Effect size (r) = 0.239 (medium) Effect size (r) = 0.096 (small) Effect size (r) = 0.223 (small) Effect size (r) = 0.073 (small) Abbreviations: MD = Motor difficulties; NMD = No Motor difficulties 108 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom Specificity and Sensitivity of the MABC-2 Test and the Teacher-completed MABC- C According to Ellinoudis, Kyparisis, Gitsas and Kourtesis (2009), specificity refers to the ability of the teachers using the MABC-C to correctly identify children with no motor difficulties (green zone) as identified by the MABC-2 Test. Sensitivity refers to the ability of the teachers using the MABC-C to correctly identify children with motor difficulties (Ellinoudis et al., 2009) as identified by the MABC-2 Test. As shown in Table 5.1, the specificity between the MABC-2 Test and the teacher- completed MABC-C is 70.3% (306/435) for the total group. It is interesting to note that almost one third (29.7%) of these children were incorrectly identified by the MABC-C as children with motor difficulties. The sensitivity for the motor difficulties group was 46.5% (33/71) for the total group, indicating that the teachers could not identify the learners with motor difficulties, or that the instrument is not sensitive enough. Although the specificity for boys (69.8%, 125/179) and girls (70.7%, 181/256) was high, the sensitivity (52.6%, 20/38) for boys was higher than for their female counterparts (39.4%, 13/33). As far as race was concerned, the specificity was high, although somewhat lower for Caucasian learners (65.1%, 183/281) than for the Black learners (79.9%, 123/154), even though the reverse was true for sensitivity (Caucasian learners: 62.5%, 20/32, Black learners: 33.3%, 13/39. The same trend is evident when comparing Caucasian and Black learners by gender. Convergent Validity of the MABC-2 Test and the Teacher-completed MABC-C The agreement was also investigated by calculating the percentage of convergent validity between the MABC-2 Test and the MABC-C in classifying children as those with motor impairment and those without motor impairment, and by calculating the sensitivity and the specificity of the two measuring instruments. Cohen’s kappa was calculated to evaluate the proportion of convergent validities. The calculated k-coefficient for the various groups that were investigated, namely the total group (11% convergent validity), boys (16.4% convergent validity), girls, Caucasian 109 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom learners and Black learners (12.6%), Black boys, Caucasian girls as well as Black girls, was on the 1%-level and provides a small effect size, which means that the findings are of insignificant practical importance. The k-coefficient indicates that there was only an 11.0% convergent validity between the two measuring instruments after adjusting for the proportion of convergent validities that take place by chance (Cohen, 1960). For Caucasian boys, the results indicate a k-coefficient of 0.179 and provide a medium effect size, which means that the findings are of average practical importance. In this case the k-coefficient indicates that there is an 18.0% convergent validity between the two measuring instruments after correcting for chance. DISCUSSION The aim of the study was to examine the convergent validity of the classification of motor difficulties by trained Kinderkineticists using the MABC-2 Test and the classification of motor difficulties by the teachers of the participants using the MABC-C, in order to determine if teachers possess the competency to identify Grade 1-learners with DCD in the classroom. The results of the MABC-2 Test were compared to the MABC-C to determine the convergent validity of the two instruments. Limited studies have been conducted in South Africa (Lombard and Pienaar, 2003) to compare the specificity and sensitivity between the teacher-completed MABC-C and the MABC-2 Test by Kinderkineticists in order to determine convergent validity of the identification of DCD among different race groups (Caucasian and Black) as well as with regard to gender. For this reason, no comparisons could be made to previous research. Although the design of this study made use of the revised MABC-C, previous findings on the original MABC-C will also be discussed, but are limited to the findings for the total group. 110 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom Specificity of the MABC-2 Test and the Teacher-completed MABC-C for the Total Group The study succeeded in showing that the teachers could identify a large percentage of children without motor difficulties, specificity of 70.3% (306/435), when using the age- related cut-off scores. The current study correlates with the findings of Green et al. (2005), who reported an even higher specificity of 75%. However, several authors have proposed higher specificity on the original MABC-C. Reported specificity using either the original or revised MABC, ranged between 80-90% (Ellinoudis et al. (2009), Schoemaker et al. (2003 Schoemaker et al. (2012).. From the results of the current study, it is clear that the teachers were able to identify a large percentage of children without motor difficulties correctly using the revised MABC-C. The relativelower specificity amongst South African teachers might be due to the fact that the majority of the teachers who participated in this study have not been trained in the field of P.E. Sensitivity of the MABC-2 Test and the Teacher-completed MABC-C for the Total Group This study found that teachers could not identify a large percentage of learners with motor difficulties, with a sensitivity of 46.5% (33/71). The findings of several authors using the original MABC-C correlate well with the findings of the current study. Henderson and Sugden (1992) found a sensitivity of 43.8%. Green et al. (2005) reported a sensitivity of 44% and Shoemaker et al. (2012), using the revised MABC-C, found a low sensitivity of 41%, similar to the current study. Some researchers, using the original MABC-C reported even lower sensitivity levels, ranging from 14-27% (References With the exception of Schoemaker et al. (2003), who reported a sensitivity of 80% using the revised MABC-C, the literature clearly indicates that the majority of researchers found a low sensitivity when using the MABC-C. This may represent an inherent characteristic of this instrument, rather than the skills of the persons using them. 111 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom Convergent Validity of the MABC-2 Test and the Teacher-completed MABC-C for the Total Group An overall analysis of the convergent validity between the MABC-2 Test and the MABC- C indicates that the MABC-C completed by the teachers had a convergent validity of 11% (k-coefficient of 0.110) with the MABC-2 Test in identifying learners with motor difficulties, and therefore the convergent validity was low (small effect) for the total group. With reference to the original MABC-C similar results were found. These results correlate well with Green et al. (2005), as well as Ellinoudis et al. (2009), who also reported low convergent validities with a k-coefficient of 0.14. In a recent study by Schoemaker et al. (2012) on the revised MABC-C the researchers also established that the convergent validity was low, with a k-coefficient of 0.28. However, several authors have found an average convergent validity when using the original MABC-C. Piek and Edwards (1997) found a 50% convergent validity where severe motor difficulties could be identified by the classroom teachers (7/14), compared to PE teachers who could only identify 36% (5/14). In addition, Junaid (1998) also reported an average convergent validity of 51%. With reference to the revised MABC-C, Schoemaker et al. (2012) found the highest convergent validity (80%), in marked contrast to the current study. However, Shoemaker et al. (2012) also reported that low rates for either sensitivity or specificity are a common finding in population-based samples, irrespective of which questionnaire measuring functional motor impairment is used and irrespective of whether teachers or parents are asked to rate motor performance. Reasons for the low convergent validity in South Africa might be that some of the items on the MABC-C were inappropriate for this population due to the lack of facilitations and apparatus including playgrounds. With regard to classroom activities some of the children used a scissors for the first time when they entered school. In addition, some schools do not have balls, bats or bicycles for recreational activities, nor climbing apparatus for children to develop their gross motor abilities. Furthermore, not all schools 112 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom provide opportunities for sport activities because children have to go home immediately after school for transport reasons. It can be concluded that, using the MABC-C, teachers are better at identifying children who do not have DCD, than those who do have in Grade 1-learners. It might be due to the fact that one fifth of the teachers in South Africa are presently not appropriately qualified for the classes they are responsible for (Pienaar, 2004). Furthermore, the norms of the MABC-C might have to be adapted in order to make provision for the diversity in cultures amongst various countries (Pienaar (2004). From the results of this study it cannot be recommended that the MABC-C is used by teachers to identify learners with DCD. This finding contributes to the dialogue regarding the fact that children are not identified in a timely manner so that earlier intervention can be initiated in order to help these learners overcome their motor difficulties. Further research should be conducted to explore the value of other DCD screening questionnaires in an attempt to identify those whereby children with motor difficulties would be easier identified by the teachers. CONCLUSION To our knowledge, this is the second study in South Africa to assess the competency of teachers to use the MABC-C to correctly identify children with motor difficulties. This study showed only an 11% convergent validity between the MABC-2 Test and the MABC-C as completed by the teachers. Therefore the ability of teachers in the Bloemfontein area, Free State province, South Africa to use the MABC-C to correctly identify children with motor difficulties was found to be low. Thus, the MABC-C is useful to screen children without DCD, although the purpose of a screening tool is to identify children with a specific condition. Wilson et al. (2009) state that the degree of accuracy in identifying children with possible DCD (sensitivity) must be compared to the accuracy in correctly identifying children who do not have the condition (specificity). This “trade-off” is common to all diagnostic tests, because when one of these predictive values increases, the other 113 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom decreases. The current study demonstrates the need for further research in identifying efficient and effective assessment screening tools for teachers to help professionals in the early identification of motor difficulties. It is clear from the research that a screening tool alone will rarely identify all children with DCD and that the MABC-C may not be the best screening tool for identifying DCD in primary school children in South Africa. LIMITATIONS OF STUDY This study had some limitations. The teachers who took part in the current study were not formally trained to observe and rate motor development according to the MABC-C criteria. The large number of teachers may have affected the reliability of the scores according to the MABC-C. Furthermore, since this was a population-based sample, criterion B of the diagnostic criteria for DCD, which states that the academic performance of the children should also be considered (American Psychiatric Association, 2013), was not used. It should also be recognized that the current study recruited children from the Bloemfontein metropolitan area only. One should note that two different groups of people were used with two different measuring instruments. Furthermore, the Kinderkineticists and teachers are all from different backgrounds and experiences. This can influence the results due to the fact that some of the teachers have years of experience with regard to developing children. It is recommended that the Kinderkineticist should have done the testing with the MABC-2 Tests well as the MABC- C, in order to have the same background and experience to determine if the results would have been different. Hence, a replication of this study in different provinces and regions in South Africa is recommended to provide more generalized and robust results. RECOMMENDATIONS FOR FUTURE RESEARCH As indicated in the current study, the MABC-C demonstrated a low sensitivity and is therefore not a valid screening tool in a South African sample. The multifactorial nature of motor capacity required the measurement of a large number of skills to assess a heterogeneous condition such as DCD. We therefore conclude that caution should be taken when the MABC-C is used as a single indicator of DCD in young learners. Results with regard to sensitivity differ between various authors, thus the independent use of 114 Article 3 – The ability of South African teachers to identify Grade 1-learners with DCD in the classroom screening tools will not aid professionals in the early identification of motor difficulties in young children. It is therefore recommended that more research should be conducted on this topic. 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Journal of Child Psychology and Psychiatry, 46(8), 804–823. doi: 10.1111/j.1469-7610.2005.01409.x WRIGHT, H.C., & SUGDEN, D.A. (1996). A two-step procedure for the identification of children with developmental co-ordination disorder in Singapore. Developmental Medicine & Child Neurology, 38(12), 1099–1105. doi: 10.1111/j.1469- 8749.1996.tb15073.x WRIGHT, H.C., & SUGDEN, D.A. (1998). A school based intervention programme for children with developmental coordination disorder. European Journal of Physical Education, 3(1), 35–50. doi: 10.1080/1740898980030104 122 CHAPTER 6 Article 4: The prevalence and effect of developmental coordination disorder on learning related skills in grade 1 children in South Africa Prepared for publication: South African Journal for Research in Sport, Physical Education and Recreation The prevalence and effect of developmental coordination disorder on learning related skills in grade 1 children in South Africa MONIQUE DE MILANDER, FREDERIK F. COETZEE AND ANDRÈ VENTER Department of Exercise and Sport Sciences, University of the Free State, P.O. Box 339, Bloemfontein 9300, South Africa. E-mail: demilanderm@ufs.ac.za (Received: 16 March 2015) 123 Article 4: The prevalence and effect of DCD on learning-related skills in grade 1 children in South Africa, Bloemfontein ABSTRACT Physically awkward children face a host of difficulties, but rarely receive attention. It is therefore important to identify developmental coordination disorder (DCD) early in a child’s life to allow for proper and timely intervention and support, reducing the negative secondary consequences associated with this condition. The objective of the study was to determine the prevalence of DCD and examine the effect of the degree of motor difficulties on learning-related skills. This comparative study made use of quantitative data. The Movement Assessment Battery for Children-2 (MABC-2 Test) was used to identify DCD. In addition, each participant was evaluated with the Aptitude Test for School Beginners (ASB), conducted and interpreted by qualified teachers. Learning-related skills of children with DCD were compared to those of children without DCD. The prevalence of DCD (severe motor difficulties) amongst grade 1 learners was 6% and the at risk group constituted another 6%. Of the children tested, 88% had no motor difficulties. Motor difficulties had a significant effect on five of the eight learning-related subtypes, namely reasoning, numerical skills, gestalt, coordination and memory. The degrees of motor difficulties (at risk/severe motor difficulties) have significant effects on the learning skills of grade 1 children. Keywords: Developmental coordination disorder (DCD); Movement Assessment Battery for Children-2 (MABC-2 Test); Learning-Related skills; Aptitude Test for School Beginners (ASB) questionnaire. 124 Article 4: The prevalence and effect of DCD on learning-related skills in grade 1 children in South Africa, Bloemfontein The Prevalence and Effect of Developmental Coordination Disorder on Learning-Related Skills in Grade 1 Children in South Africa, Bloemfontein INTRODUCTION Children with DCD experience considerable difficulties in motor learning as well as in the performance of functional motor tasks that are critical for success in the school environment (American Psychiatric Association [APA]; 2013). These children demonstrate poor motor performance that is not accounted for by their age, intellect or neurological disorders, and the impact can be found in both their daily living activities and academic performance (APA, 2013). Research indicates that DCD affects 5%–6% of school-age children (APA, 2013; Gaines & Missiuna, 2007). According to Hamilton, (2002) as well as Wilmut et al. (2007) the prevalence of DCD might be even higher (5%–15%) and the research indicates that a large percentage of school-aged children have coordination difficulties serious enough to interfere with social integration as well as academic performance. In South-Africa (Bloemfontein province) the results indicated that 15% of children have moderate to severe motor difficulties (De Milander et al. 2014). Alarmingly, different studies reported significantly higher prevalences of DCD in the North West province of South Africa of 61.2% (Pienaar, 2004) and 52% (Wessels et al. 2008) respectively. This clearly indicates that South African children appear to have more motor difficulties than children in other parts of the world. Pienaar (2004) concluded that the norms of the Movement Assessment Battery for Children should be adjusted for South African children. Furthermore, the real prevalence of DCD among children might even be higher, since medical as well as educational systems frequently fail to identify this disorder in young children (Hamilton, 2002; Missiuna, 2003; Miyahara et al. 2008). A gender difference also occurs with regard to DCD. The literature indicates that boys experience more problems than girls with a boy:girl ratio of 2:1 (Wright & 125 Article 4: The prevalence and effect of DCD on learning-related skills in grade 1 children in South Africa, Bloemfontein Sugden, 1996). According to Rivard et al. (2007) it has been estimated that the gender difference could even be as high as 3–4:1. These findings are supported by Hoare and Larkin (1991) who stated that more boys than girls are attending remedial programs (9:1). South African researchers have found boy:girl ratios of 2– 3:1 (Wessels et al. 2008) as well as 1.6:1 (De Milander et al. 2014). Major concerns relating to DCD according to Schoemaker et al. (2003) as well as Sugden and Wright (2005) are the considerable harmful effects associated with this disorder. Developmental coordination disorder influences children’s daily activities at home (self-care tasks), normal play (running, riding a bike, swimming and ball games) and school activities (writing and cutting activities). A problem found amongst children with DCD is that they are often not formally diagnosed, but rather described by their teachers as lazy or awkward (Zwicker et al. 2012). These children are not diagnosed due to the lack of awareness of the disorder (Wilmut et al. 2007; Zwicker et al. 2012). Children with DCD share a common feature, namely experiencing difficulty in executing motor skills necessary for progress in the formal and informal learning in a school environment (Sugden and Chambers, 2003). The impaired ability to control functional movements often continues throughout the school years, with evidence showing that children do not outgrow this disorder (Henderson and Henderson, 2002; Sugden and Chambers, 2003). Thus, without early identification and intervention, the difficulties experienced in the school environment will persist into later life (Losse et al. 1991). Secondary problems associated with DCD are physical health issues such as obesity and lower aerobic capacity due to lower activity levels (Cantell et al., 2003; Tsiotra et al. 2009), social problems, along with emotional problems, due to withdrawal or exclusion from peers, as well as academic problems related to aspects such as tracing, writing and learning difficulties (Piek and Edwards, 1997; 126 Article 4: The prevalence and effect of DCD on learning-related skills in grade 1 children in South Africa, Bloemfontein Hamilton, 2002; Cantell et al. 2003). Other co-occurring problems linked to DCD are speech and language disorders (Missiuna, 2003; Wilmut, 2007), visual-motor deficits (Hamilton, 2002) and attention deficit hyperactivity disorder (ADHD) (Watemberg et al. 2007; Wessels et al. 2008). It is clear from the literature that the DCD child experiences countless problems associated with the learning process. Limited research findings were available with reference to the relationship between DCD and learning-related skills amongst children in South Africa (Wessels et al. 2008), thus the purpose of this study was to determine the prevalence of DCD as well as the relationship between DCD and learning-related skills amongst grade 1 children in the Bloemfontein area, Free State province, South Africa. METHODOLOGY Participants Initially 13 mainstream schools in the Bloemfontein area, Free State province, South Africa were targeted to take part in the research project, but only seven schools eventually agreed to participate. All of these schools are classified as quintile 5 schools, indicating a high socio economic status. From these seven schools, only four made use of the Aptitude Test for School Beginners (ASB). Scores on the Movement Assessment Battery for Children-2 (MABC-2 Test) and the ASB were obtained for a total of three hundred and forty seven (N = 347) grade 1 children. The children who took part in this study were between the ages of five and eight years. There were n = 190 girls and n = 157 boys. The mean age of the children was six years and seven months with a standard deviation of 0.4. The minimum age was five years and eight months and the maximum age was eight years. All children in the participating primary schools were considered for inclusion in the study. Exclusion criteria included a child in the age group outside the expected range of five to eight years, parental permission not obtained or the informed consent not completed fully, or parents indicating that they would be relocating during the study. Additionally the Diagnostic and Statistical Manual of 127 Article 4: The prevalence and effect of DCD on learning-related skills in grade 1 children in South Africa, Bloemfontein Mental Disorders, fifth edition, (DSM-5) (APA, 2013) was used to exclude children who had associated symptoms according to the criteria for DCD as stated in the DSM-5. Children with motor difficulties should meet criterion C (disturbance is not due to a general medical condition, for example, cerebral palsy, hemiplegia, or muscular dystrophy, and does not meet criteria for a pervasive developmental disorder). or criterion D (if mental retardation is present, the motor difficulties are in excess of those usually associated with it). None of the children met the criteria and therefore all of them were included for further data analysis. Ethical consideration The Department of Education of the Free State province as well as the principals of each school gave permission for the research to be conducted on the school premises during the Life Orientation periods. Approval had been obtained from the Ethics Committee of the Faculty of Health Sciences, University of the Free State (ECUFS57/2012). The participants were treated in accordance with the ethical guidelines outlined by the Ethics Committee of the Faculty of Health Sciences. The parents of the participants completed an informed consent form for each child participating in this study. In addition, the children signed an assent form. Recruitment was targeted at children with and without DCD via the four participating schools. Measuring instruments Movement Assessment Battery for Children-2 (MABC-2 Test). The MABC-2 Test requires children to perform a series of motor tasks in a specified manner (Henderson and Sugden, 2007). In addition to age-related norms, the test also provides qualitative information on how children should approach and perform the tasks. The MABC-2 Test is used to assess the subject’s motor proficiency levels and to diagnose DCD in children. The first assessment component of this test battery contains 24 items organized into three sets of eight tasks. Each set is designed for use with children of a different age band. For the current study age 128 Article 4: The prevalence and effect of DCD on learning-related skills in grade 1 children in South Africa, Bloemfontein band 1 and age band 2 were used. The eight tasks are grouped under three headings, namely manual dexterity (MD), balance (B) as well as aiming and catching (AC). Age-adjusted standard scores and percentiles are provided, as well as a total test score for each of the three components of the test. The total test score can be interpreted in terms of a “traffic light” system. The green zone indicates performance in a normal range (> 15th percentile), while the amber zone indicates that a child is at risk and needs to be carefully monitored (5th–15th percentile). The red zone is an indication of definite motor impairment (≤ 5th percentile). Thus, high standard scores on the MABC-2 Test represent good performance. The MABC-2 Test is a valid and reliable tool to use with a reliability coefficient for the total test scores of 0.80 (Henderson and Sugden, 2007). The Aptitude Test for School Beginners (ASB). The ASB was administered by qualified teachers to all participating children in the first two months of the school year. A requirement of the ASB is that it must be presented and completed in a child’s mother tongue. The ASB is a norm-based instrument and consists of eight sub-items, which include perception, spatial skills, reasoning, numerical skills, gestalt, coordination, memory and verbal comprehension (Olivier and Swart, 1996; Van Zyl, 2004). Each sub-item is evaluated by means of a standard score out of five. An evaluation score of 1 is regarded as below average and an evaluation score of 5 as above average. The aim of the ASB is to obtain a differentiated picture of certain aptitudes of grade 1 children. The ASB is a valid and reliable tool to use with a reliability coefficient for the total test of 0.80 (Olivier and Swart, 1996). Procedure This comparative study made use of quantitative data. The study involved one testing procedure by means of the MABC-2 Test in order to identify DCD among grade 1 children. The participants were tested at their schools during the Life Orientation periods by Kinderkineticists-in-training who were trained in the use of the measuring instrument. Each Kinderkineticst-in-training was responsible for one 129 Article 4: The prevalence and effect of DCD on learning-related skills in grade 1 children in South Africa, Bloemfontein subtest in order to have consistency across the study. In addition, each participant was evaluated with the ASB, conducted and interpreted by qualified teachers. Learning-related skills (determined with the ASB) of children with DCD (as identified by the MABC-2 Test) were compared to the learning-related skills of children without DCD. Statistical analysis of data Data from the MABC-2 Test as well as the ASB were captured electronically by the principle researcher using Microsoft Excel. Data analysis was performed by a statistician using the Statistical Package for the Social Sciences (SPSS) for Windows (SPSS version 16.0, SPSS Inc., Chicago, IL). Descriptive statistics, namely frequencies and percentages, were calculated for categorical data. Medians and percentiles were calculated for numerical data. Median differences were tested by calculating p-values using the signed-rank test. The chi-squared statistics were used to test for proportion differences. A probability level of 0.05 or less was taken to indicate statistical significance. RESULTS The distribution of the children in terms of the traffic light system (degree of motor difficulty) according to the MABC-2 Test is illustrated in Figure 6.1. 6% 6% 88% No motor difficulties Moderate motor difficulties Severe motor difficulties Figure 6.1: Prevalence of DCD in Grade 1 Children 130 Article 4: The prevalence and effect of DCD on learning-related skills in grade 1 children in South Africa, Bloemfontein Figure 6.1 presents the percentages in terms of the traffic light system (degree of motor difficulty). Green indicates no motor difficulties (88%), amber indicates moderate motor difficulties (6%) and the red zone indicates severe motor difficulties or DCD (6%) amongst children in Bloemfontein, Free State province, South Africa. It is interesting to note that more children are experiencing motor difficulties than previously indicated in the literature. The distribution of the girls and boys in terms of the traffic light system (degree of motor difficulty) according to the MABC-2 test is shown in Figures 6.2 and 6.3. 4% 5% 9% 7% 91% 84% No motor difficulties No motor difficulties Moderate motor difficulties Moderate motor difficulties Severe motor difficulties Severe motor difficulties Figure 6.2: Traffic Light Categories for Figure 6.3: Traffic Light Categories for Girls. Boys. As expected, Figures 6.2 and 6.3 indicate that 91% of the girls fell in the green zone compared to 84% of the boys. With reference to the amber zone, 4% of the girls had moderate motor difficulties in contrast to 9% of the boys. The red zone indicates that 5% of the girls had severe motor difficulties compared to 7% of the boys. However, there was no significant difference (p = 0.1150) between the genders. 131 Article 4: The prevalence and effect of DCD on learning-related skills in grade 1 children in South Africa, Bloemfontein Perception Spatial skills Reasoning Numerical skills Score 1 & 2 Score 3 Score 4 &5 Score 1 & 2 Score 3 Score 4 &5 Score 1 & 2 Score 3 Score 4 &5 Score 1 & 2 Score 3 Score 4 &5 94 95 57 85 69 81 60 55 64 414 1 55 353 5 32 30 36 30 25 30 18 23 11 10 0.140 9 10 0.393 13 14 15 6 0.004 0.000 1 4 5 5 6 0 8 0 0 1 NMD AR SMD P-Value NMD AR SMD P-Value NMD AR SMD P-Value NMD AR SMD P-Value Gestalt Coordination Memory Verbal Score 1 & 2 Score 3 Score 4 &5 Score 1 & 2 Score 3 Score 4 &5 Score 1 & 2 Score 3 Score 4 &5 comprehension 68 85 Score 1 & 2 Score 3 Score 4 &5 78 73 70 47 50 45 41 40 47 50 36 38 40 303 0 41 32 26 34 23 27 19 20 15 18 15 15 6 10 0.022 0.0745 6 9 10 0.0001 0 0.0001 4 1 NMD AR SMD P-Value NMD AR SMD P-Value NMD AR SMD P-Value NMD AR SMD P-Value Figure 6.4: Learning-Related Skill Scores of the ASB Expressed as a Percentage by Degree of Motor Difficulty Abbreviations: NMD – no motor difficulties; AR – at risk; SMD – severe motor difficulties; Score 1 & 2 = below average; Score 3 = average; Score 4 & 5 = above average. 132 Article 4: The prevalence and effect of DCD on learning-related skills in grade 1 children in South Africa, Bloemfontein Figure 6.4 indicates the results of the various learning-related skills according to the ASB in the different categories of degree of motor difficulty (at risk and severe) and no motor difficulties. From Figure 4 it can be observed that for three of the eight learning-related skills, namely perception (p = 0.1408), spatial skills (p = 0.3930) as well as comprehension (p = 0.0741), there was no significant difference. Furthermore, Figure 4 illustrates that, of the remaining learning-related skills, significant differences were indicated for reasoning (p = 0.0040) and memory (p = 0.024). It is interesting to note that there were highly significant differences between the children with different degrees of motor difficulty and those with no motor difficulties for numerical skills (p = 0.0001), gestalt (p = 0.0001) and coordination (p = 0.0001). In summary, it would appear that children at risk for motor difficulties as well as those with severe motor difficulties may struggle more with the domains of reasoning, numerical skills, gestalt, coordination and memory, as illustrated by the sub-tests of the ASB. DISCUSSION The research set out to determine the prevalence of DCD in Bloemfontein, Free State province, South Africa. In addition, the study aimed to provide possible answers regarding the effect of DCD on specific learning-related skills amongst children aged five to eight years. Literature clearly indicates that DCD affects children all over the world, but the prevalence differs considerably between various countries (Lingam et al. 2009; Prado et al. 2009). The results of the current study indicated that at least 12% of the sample had moderate to severe motor difficulties. These results are in contrast to various findings reported in the literature where the researchers state that DCD affects more or less 5%–6% of school-age children (APA, 2013; Prado et al. 2009). Researchers on the prevalence of DCD in the United Kingdom estimate that 4%–5% of children struggle with motor difficulties (Lingam et al. 2009), which is much lower than the 12% found in the present study. The findings of research conducted on Canadian children correlate the best with the findings of the current study. These researchers found approximately 8%–15% of Canadian children to have some form of coordination problems (Junaid et al. 2000). Studies in America and Europe found an even higher prevalence of DCD, estimated at 5%–19% (Miller et al. 2001). 133 Article 4: The prevalence and effect of DCD on learning-related skills in grade 1 children in South Africa, Bloemfontein The current study found that boys did not exhibit significantly (p = 0.1150) more moderate to severe motor difficulties than girls, with a boy:girl ratio of 1.6:1. However, this ratio is smaller than the ratio found in other research. The literature indicates that boys experience more problems than girls, with reported boy:girl ratios of 2–3: (Wessels et al. 2008) and 3– 4:1 (Wright and Sugden; 1996). Although gender differences do occur, researchers need to take into consideration that gender differences are a normal phenomenon in the attainment of motor skills among children. Literature indicates that girls perform better in fine motor skills, whilst boys are better at gross motor skills (Gallahue and Ozmun, 2006). Furthermore, research reported that girls outperformed the boys with regard to the manual dexterity items of the MABC and the boys were superior with regard to the ball skills items (Junaid et al. 2006). No differences were established between the boys’ and girls’ balancing skills and the researchers argue that these differences are due to the disparity in the acquisition of motor skills between boys and girls (Junaid et al. 2006). Limited research reported on the effect of DCD on specific learning-related skills such as reasoning, numerical skills, gestalt, coordination, memory perception, spatial skills and comprehension amongst children. The results of the current study indicate that the different degrees of motor difficulty do have a significant differential negative effect on the subtypes of specific learning-related skills such as reasoning, numerical skills, gestalt, coordination and memory. This may be due to the fact that children who are at risk as well as children with severe motor difficulties could have deficits due to their diagnosis that may influence these different domains negatively. Children with DCD struggle to organize tasks, since the DCD child need to plan the movement over and over. This could influence their gestalt and reasoning abilities. The findings of the current study correlate with a number of other studies indicating that children with DCD struggle with academic skills such as writing and tracing, which forms part of gestalt, numerical and coordination abilities (Hamilton, 2002; Missiuna, 2003; Tsiotra et al. 2009). Since children with DCD struggle with coordination activities in general, it is obvious that they will experience significant difficulties with regard to the coordination domain of the ASB. This result correlates with a previous study done in Potchefstroom, North West province, South Africa, where the researchers established that boys with DCD struggled more with the coordination domain of the ASB (Wessels et al. 2008). In contrast to the current study, the same researchers did not find any significant correlation between 134 Article 4: The prevalence and effect of DCD on learning-related skills in grade 1 children in South Africa, Bloemfontein learning-related skills and DCD with regard to the remaining 7 domains in 52 children with DCD (Wessels et al. 2008). There were no significant differences between the different categories of motor difficulties for the domains of perception, spatial skills and verbal comprehension. The results of this study indicated that being at risk for or having severe motor difficulties did have an effect on learning-related skills. Similar to the results of this study, the majority of research reported that there is a strong correlation between DCD and learning-related skills and that many children with DCD experience difficulties with learning and academic performance (Hamilton, 2002; Henderson and Henderson, 2002; Rivard et al. 2007; Wilmut et al. 2007; Tsiotra et al. 2009). The research done showed that children who are at risk for or who have severe motor difficulties are potentially at risk of struggling more with specific learning-related skills. These findings of this research can be used to evaluate, manage and possibly improve the specific domains of weakness for the degrees of motor difficulty in order to improve these children’s prognosis for their learning-related skills. CONCLUSIONS The results of this study are important for teachers who work with young children, as children who start formal school with a motor deficit may also have problems with a variety of learning-related skills necessary for school success. Thus, the teachers can take these limitations in consideration and address these problems by means of new preventative strategies. It would also be necessary to present motor programs by professionals who are familiar with motor development, to attend to the motor difficulties experienced by children with DCD. It is important to view development in a holistic manner,24 thus motor difficulties as well as difficulties with learning-related skills should be addressed in order to minimize problems associated with academic performance. LIMITATIONS This study had some limitations. It should be recognized that the current study only recruited children from the Bloemfontein metropolitan area, while excluding children from the rural regions. Furthermore, since this was a population-based sample, criterion B of the diagnostic criteria for DCD, which states that the academic performance of the children 135 Article 4: The prevalence and effect of DCD on learning-related skills in grade 1 children in South Africa, Bloemfontein should also be considered (APA, 2013), was not used. Hence, a replication of this study in different provinces and regions in South Africa is recommended to provide more generalized and robust results. IMPLICATIONS FOR SCHOOL HEALTH As indicated in the current study, children with DCD in a Bloemfontein, Free State province, South African sample struggle more with learning-related skills than children without motor difficulties. The researchers therefore conclude that it is critical that early identification of DCD should take place by means of parent and teacher questionnaires, since these children do not outgrow their motor difficulties. Appropriate interventions by professionals at an early age are crucial. Results with regard to the learning-related skills can give teachers a better understanding of difficulties experienced by children with DCD. Thus, the researchers propose that teachers should take these difficulties in consideration in order to help children excel in their academic performance. ACKNOWLEDGEMENTS Thank you to the principals, staff members and children at the primary schools where the study was conducted. 136 Article 4: The prevalence and effect of DCD on learning-related skills in grade 1 children in South Africa, Bloemfontein REFERENCES AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and Statistical Manual of Mental Disorders (5thed.). Arlington, VA: American Psychiatric Association; 2013. CANTELL, M.H., SMYTH, M.M., & AHONEN, T.P. (2003). Two distinct pathways for developmental coordination disorder: persistence and resolution. Human Movement Science, 22(4-5):413-431. 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European Journal of Paediatric Neurology, 16(6):573-581 140 CHAPTER 7 ARTICLE 5: Perceptual-motor intervention for developmental coordination disorder in grade 1 children Accepted for publication: South African Journal for Research in Sport, Physical Education and Recreation, Volume 37(2), March 2015, pp. in press Perceptual-motor intervention for developmental coordination disorder in grade 1 children MONIQUE DE MILANDER, FREDERIK F. COETZEE AND ANDRÈ VENTER Department of Exercise and Sport Sciences, University of the Free State, P.O. Box 339, Bloemfontein 9300, South Africa. E-mail: demilanderm@ufs.ac.za 141 Article 5: Perceptual-motor intervention for DCD in grade 1 children ABSTRACT Although different approaches, such as the bottom-up and the top-down approach have been used as interventions to treat developmental coordination disorder (DCD), there is controversy about the effectiveness of these approaches as interventions for improving the motor skills of children with DCD. Thus, the purpose of this study was to determine if a perceptual-motor intervention would improve the symptoms associated with DCD. Seventy- six children with DCD between the ages of five and eight years participated in this study The study had a pre-test/post-test experimental design (n = 36) with a control group (n = 40). The Movement Assessment Battery for Children-2 was used to assess the motor proficiency levels of the children. The intervention comprised a 10-week programme of two 30-minute sessions per week. The dependent variables were all measurable on an interval scale with the Mann-Whitney U-test was used. No significant differences (p ≥ 0.05) occurred between the two groups prior to the intervention. After the intervention one subtest, balance, showed a significant difference (p = 0.050), while manual dexterity (p = 0.797) and aiming and catching (p = 0.252) showed no significant differences. These three components contributed to the total test score, which revealed no significant difference (p = 0.068) in the overall motor proficiency levels of the experimental group and the control group. It is concluded that a perceptual-motor intervention only improved balance. However, participation in physical education classes presented by teachers also proved to be beneficial. Keywords: Perceptual-motor; Motor proficiency; Developmental coordination disorder; Intervention; Movement Assessment Battery for Children-2 142 Article 5: Perceptual-motor intervention for DCD in grade 1 children Perceptual-motor intervention for developmental coordination disorder in grade 1 children INTRODUCTION Developmental coordination disorder (DCD) is recognised as one of the most common developmental dysfunctions during childhood (Ellinoudis et al., 2009) and a large number of children are identified with DCD between five and eleven years of age (APA, 2013). Literature indicates wide debate with regard to the prevalence of DCD (Giagazoglou et al., 2011) and varies according to the diagnostic criteria that are used (Carslaw, 2011). According to Gaines and Missiuna (2007), as well as Prado et al. (2009), DCD affects 5%- 6% of school-age children, while Wilmut et al. (2007) indicated the prevalence of DCD to be between 5%-10%. However, it is estimated that 5%-19% of children in America and Europe are struggling with DCD (Miller et al., 2001; Henderson & Henderson, 2002). In South-Africa (Bloemfontein, Free State province) the prevalence was also high, with 15% of children having moderate to severe motor difficulties (De Milander et al., 2014). According to Henderson and Henderson (2002), children will not outgrow this disorder, as was previously believed; however, children can be assisted by means of the five-step assessment process (Barnett, 2008). This process entails firstly the use of questionnaires for screening and identification of children with motor difficulties. The second step is the use of norm-referenced tests for measuring the child’s motor performance. These tests are administered by professionals. The third step of this motor assessment process entails making a formal diagnosis of DCD. This is done by measuring the qualitative and quantitative performance in motor tasks. The fourth step focuses on understanding the nature of the condition. Finally, the fifth step is the planning of an intervention programme. It follows that intervention programmes are a vital element of the assessment process for improving DCD. Sugden and Chambers (1998) proposed that most interventions are successful with a good number of children diagnosed with DCD. Researchers conventionally made use of a process-orientated approach by means of sensory integration and perceptual 143 Article 5: Perceptual-motor intervention for DCD in grade 1 children motor training in children with DCD (Bernie & Rodger, 2004; Sugden et al., 2008). The process-orientated approach is also known as the bottom-up or developmental approach. The aim of this approach is to improve the underlying process which is not developed fully for the child’s age. This includes sensory functions, attention and planning, considered prerequisite for the attainment of motor skills. This approach can therefore be considered to eliminate motor deficiencies (Sugden & Chambers, 2003; Bernie & Rodger, 2004). According to Auxter et al. (2005), the underlying principle of this approach is to ensure that the supporting building blocks and integration processes are functioning optimally in order to facilitate skill development. This approach aimed to improve children’s processing abilities or performance components and are still being practiced as an intervention by many therapists (Missiuna et al., 2006; Sugden et al., 2008). According to Hamilton (2002), the most frequently used interventions were sensory-integration therapy, kinesthetic training as well as perceptual-motor therapy, and all of these produced positive results more often than not. Johnstone and Ramon (2011) state that perceptual-motor skills permit sensory information to be successfully obtained and understood with appropriate reaction. Thus, “perceptual” refers to obtaining information and “motor” deals with the outcome of the movement (Gallahue & Ozmun, 2006). According to Gallahue and Ozmun (2006), perceptual-motor activities require children to use cognitive functions (memory, attention and awareness) and the body together in order to accomplish tasks. Johnstone and Ramon (2011) also state that meeting children’s gross motor needs will improve their academic readiness, as well as their overall behaviour. Neural pathways are built by means of physical activity. This process refers to the connections by which information travels through the brain. A child with more neural pathways will be able to learn more easily, thus early intervention is very important in order to develop perceptual-motor skills. A perceptual-motor intervention targets components such as laterality (unilateral, bilateral and cross-lateral activities), balance, body image, tracking, spatial relations (body, spatial, directional and temporal awareness), locomotor as well as manipulative skills (Gallahue & Ozmun, 2006; Johnstone & Ramon (2011). Taking part in perceptual-motor activities enables children to develop greater levels of body control and encourages greater effort in 144 Article 5: Perceptual-motor intervention for DCD in grade 1 children all areas of the school curriculum. Children with sufficient perceptual-motor skills enjoy better coordination, greater body awareness, stronger intellectual skills and a more positive self- image (Johnstone & Ramon, 2011). Due to a lack of support for the bottom-up approach, new approaches emerged known as the cognitive or top-down approach (Bernie & Rodger; 2004). More researchers are in favour of this approach (Sugden et al., 2008). These new approaches were based on theoretical concepts of motor learning and cognition. Motor learning is based on a conscious understanding of the processes involved when a motor problem needs to be solved. Thus, the interaction between the task and environment, as well as the child needs to be taken into consideration (Perry, 1998). Cognitive approaches use direct skill teaching, but differ in the sense of the unique problem-solving framework, attempting to help children generalise from the learning of one skill to the next (Missiuna et al., 2006). According to Missiuna et al. (2006) and Sugden et al. (2008), although the task-specific approach aims at increasing various participations for children, it is preferable to consider how children can perform a specific task in a variety of real-life situations, rather than in one specific setting. Consequently, one should consider how to modify the task or to adapt the environment in order for children to participate and improve their learning capabilities. It is clear that controversies exist between these different approaches and there is still not enough evidence to substantiate that one specific intervention approach is superior to another (Miller et al., 2001; Miyahara et al., 2008). It is thus proposed that these two approaches (bottom-up and top-down) should be merged in order to care for children with DCD (Peters & Wright, 1999; Davidson & Williams, 2000). The aim of study was to determine the efficacy of a perceptual-motor intervention for improving the motor proficiency levels of children classified with DCD. 145 Article 5: Perceptual-motor intervention for DCD in grade 1 children METHODOLOGY Study design A pre-test/post-test quasi-experimental design with a control group was applied as an empirical study which made use of quantitative and qualitative data. The study involved one testing procedure by means of the Movement Assessment Battery for Children-2 (MABC-2 Test) in order to identify DCD among grade 1 children. The participants were tested at their schools during the physical education periods by Kinderkineticists-in-training who were trained in the use of the instrument. Each Kinderkineticst-in-training was responsible for one subtest in order to have consistency across the study. The cut-off scores used in this study were based on the recommendations of Henderson et al. (2007), which are as follows: performance at or below the 5th percentile is classified as severe motor difficulties, performance from the 5th to the 15th percentile is classified as moderate motor difficulties and performance above the 15th percentile is classified as no motor difficulties. All the children took part in some form of intervention for 30 minutes two times a week over a period of 10 weeks. The control group followed a school programme (Physical Education classes) presented by personnel from the school. The personnel made use of the Curriculum Assessment Policy Statements (CAPS) according to the Department of Basic Education. The CAPS document with regard to Physical Education states that they should develop children’s gross- and fine motor skills in addition to perceptual development (Department of Basic Education, 2011). The personnel focused on perceptual activities which include aspects such as locomotor, rhythm, balance and laterality. The experimental group followed a specific perceptual-motor intervention implemented by a Kinderkineticist familiar with the motor development of young children. The perceptual-motor intervention was divided into four categories namely unilateral-, bilateral-, contralateral- and combined activities. These categories consisted of a variety of aspects such as spatial awareness; eye-hand- as well as eye-foot coordination; body awareness; gross motor coordination; motor planning; directionality and dynamic balance in order to improve DCD. It can be concluded that both interventions include activities for perceptual-motor development, thus both groups followed 146 Article 5: Perceptual-motor intervention for DCD in grade 1 children a bottom-up approach. A post-test using the same procedure as the pre-test took place after the intervention process in order to observe any improvement. Participants Initially 13 schools in the Bloemfontein area were targeted to take part in the research project, but only seven schools eventually agreed to participate. The Department of Education of the Free State province as well as the principal of each school gave permission for the research to be conducted on the school premises during the Physical Education periods. Approval had been obtained from the Ethics Committee of the Faculty of Health Sciences, University of the Free State (ECUFS57/2012). The participants were treated in accordance with the ethical guidelines outlined by the Ethics Committee of the Faculty of Health Sciences. The parents/legal guardians of the participants completed an informed consent form for each child participating in this study. In addition, the children signed an assent form. Recruitment was targeted at children with DCD via the 7 participating schools who had permission to take part in the study (inclusion criteria). Exclusion criteria included a child in the age group outside the expected range (younger than five and older than eight), parental permission not obtained, the informed consent form not fully completed, or parents indicating that they would be relocating during the study. Children who were absent during the testing procedure were also excluded due to incomplete testing. Additionally, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, (DSM-5) (APA, 2013) was used to exclude children if they had associated symptoms according to the criteria for DCD as stated in the DSM-5. Children with motor difficulties should not meet criterion C (disturbance is not due to a general medical condition, for example, cerebral palsy, hemiplegia, or muscular dystrophy and does not meet criteria for a pervasive developmental disorder) or criterion D (if mental retardation is present, the motor difficulties are in excess of those usually associated with it). None of the children met the criteria and therefore all of them were included for further data analysis. 147 Article 5: Perceptual-motor intervention for DCD in grade 1 children Measuring instruments According to Henderson et al. (2007), the Movement Assessment Battery for Children-2 (MABC-2 Test) requires children to perform a series of motor tasks in a specified manner. In addition to age-related norms, the test also provides qualitative information on how children should approach and perform the tasks. The MABC-2 Test is used to assess the subject’s motor proficiency levels and to diagnose DCD in children. The first assessment component of this test battery contains 24 items organised into three sets of eight tasks. Each set is designed to use with children of a different age band. For the current study age band 1 and age band 2 were used. The eight tasks are grouped under three headings, namely manual dexterity (MD), balance (B) and aiming and catching (AC) (Henderson et al., 2007). Age- adjusted standard scores and percentiles are provided, as well as a total test score for each of the three components of the test. The total test score can be interpreted in terms of a “traffic light” system. The green zone indicates performance in a normal range (> 15th percentile), while the amber zone indicates that a child is at risk and needs to be carefully monitored (5th-15th percentile). The red zone is an indication of definite motor impairment (≤ 5th percentile). Thus, high standard scores on the MABC-2 Test represent good performance. The MABC-2 Test is a valid and reliable tool to use with a reliability coefficient for the total test scores of 0.80 (Henderson et al., 2007). Statistical analysis of data The principal researcher used Microsoft Excel to electronically capture data from the MABC- 2 Test. Data analysis was performed by a statistician using the Statistical Package for the Social Sciences (SPSS) for Windows (SPSS version 16.0, SPSS Inc., Chicago, IL). Regarding the size of the subgroups (see Table 7.2), a non-parametric statistical technique was used to explore the objective stated. This was due to the small sample size used, which could cause doubt regarding the assumptions of normality and homogeneity of variances. A bigger sample size could, however, not be obtained in order for the central limit-setting to be implemented. The dependent variables are all measurable on an interval scale and therefore the Mann 148 Article 5: Perceptual-motor intervention for DCD in grade 1 children Whitney U-test (Howell, 2012) – which is a counterpart of the t-test for independent variables – has been considered. The two groups’ pre-recordings on the four dependent variables with the use of the Mann-Whitney U-test to compare, where after it has been recorded for the post-recordings. A probability level of 0.05 or less was taken to indicate statistical significance. RESULTS Table 7.1 shows that the group of 76 children was made up of more boys (55.3%) than girls (42.1%). With regard to race, there were more Black children (57.9%) than Caucasian children (42.1%). TABLE 7.1: FREQUENCY DISTRIBUTION FOR THE PARTICIPANTS ACCORDING TO GENDER AND RACE Gender Race Total Caucasian Black Boys 18 (56.3%) 24 (54.6%) 42 (55.3%) Girls 14 (43.7%) 20 (45.4%) 34 (44.7%) Total 32 (42.1%) 44 (57.9%) 76 (100%) As indicated in Table 7.2, the group consisted of 76 children, 36 of whom formed the experimental group and the remaining 40 the control group. With regard to gender, the control group consisted of 14 girls (18.4%) and 26 boys (34.2%) compared to the 20 girls (26.3%) and 16 boys (21.1%) in the experimental group. 149 Article 5: Perceptual-motor intervention for DCD in grade 1 children TABLE 7.2: FREQUENCY DISTRIBUTION FOR THE PARTICIPANTS ACCORDING TO GENDER AND RACE FOR THE EXPERIMENTAL AND CONTROL GROUPS Group Caucasian Caucasian Black Black Total boys girls boys girls Experimental 6 (33.3%) 10 (71.4%) 10 (41.7%) 10 (50%) 36 (47.4%) Control 12 (66.7%) 4 (28.6%) 14 (58.3%) 10 (50%) 40 (52.6%) Total 18 (23.7%) 14 (18.4%) 24 (31.6%) 20 (26.3%) 76 (100%) It is clear from Table 7.3 that there was no significant difference between the control group and the experimental group for the pre-test, done before the intervention commenced, with regard to the various subtests, namely manual dexterity (p = 0.737), aiming and catching (p = 0.527), and balance (p = 0.582), as well as the total test score (p = 0.372). Manual dexterity involves the coordinated use of the hands, guided by the visual system, within time limits (Henderson et al., 2007). For this subtest the post-test average scores for the experimental group as well as the control group improved in the total group, Caucasian children and Black children, as well as for the girls and boys. As can be seen in Table 7.3, the results for the total group indicate that, although there was no significant difference (p = 0.068) between the two groups after the intervention, the average scores for both groups did increase. The increase was found with regard to the total group and for boys, girls, Caucasian children and Black children independently. Furthermore, although both groups improved on their average scores, the improvement was found to be greater in the experimental group than in the control group. Aiming and catching entails coordinating body movements when receiving moving objects, as well as performing throwing tasks accurately (Henderson et al., 2007). Similar to the results of the subtest for manual dexterity, the post-test average scores for this subtest increased in both the control and the experimental group. The increase was also obtained in all the categories researched and again the improvement was found to be greater in the experimental group. It is interesting to note that the boys had a higher average pre-test score 150 Article 5: Perceptual-motor intervention for DCD in grade 1 children ( X = 9.31) than their female counterparts ( X = 8.45). These results emphasise the fact that boys have better ball skills than girls. The balance subtest involves static and dynamic balance, where the child has to keep the body upright against gravity while standing on one leg and performing hopping and jumping movements (Henderson et al., 2007). Balance is the only subtest indicating a significant difference between the pre-test (p = 0.582) and the post-test (p = 0.050) for the total group. From Table 7.3 it is clear that the experimental group ( X = 8.86) had a significantly higher average score than the control group ( X = 7.80) in the post-test. Similar findings were obtained for the Caucasian children, the experimental group ( X = 9.31) achieving a significantly higher average score than the control group ( X = 7.31), indicating that their balancing skills improved significantly (p = 0.035). In addition, the girls also improved on their average score, the experimental group ( X = 9.15) performing better than the control group ( X = 7.29), resulting in a significant difference (p = 0.043) between the two groups. This indicates that the perceptual-motor intervention did aid in the improvement of the balancing skills of some of the children. However, no significant differences were observed for the Black learners or the boys. The sum of the three categories of the MABC-2 Test produced the total test score. Although the average total test score improved in all the categories, the only significant difference was found in the Caucasian children. The results in Table 7.3 indicate that the experimental group ( X = 9.00) had a significantly higher total test score than the control group ( X = 7.19) in the post-test. Thus a significant difference (p = 0.050) was observed. The results indicate that the perceptual-motor intervention did improve the overall motor proficiency of Caucasian children. 151 Article 5: Perceptual-motor intervention for DCD in grade 1 children TABLE 7.3: DESCRIPTIVE STATISTICS REGARDING THE PRE- AND POST- TEST SCORES FOR THE TOTAL GROUP, BOYS, GIRLS, CAUCASIAN CHILDREN AND BLACK CHILDREN IN THE EXPERIMENTAL AND CONTROL GROUPS Total Group Boys Girls Variable Test Gr. M ss SD U p Mss SD U p Mss SD U p Pre Exp 4.14 1.48 688.5 0.737 3.75 1.34 196.0 0.751 4.45 1.54 121.5 0.522 Con 3.99 1.51 3.90 1.45 4.14 1.66 MD Post Exp 6.42 2.43 611.0 0.252 5.87 2.36 205.0 0.937 6.85 2.46 100.5 0.169 Con 5.75 2.42 5.77 2.60 5.71 2.13 Pre Exp 8.83 1.95 660.5 0.527 9.31 2.41 205.5 0.947 8.45 1.43 126.5 0.641 Con 9.05 2.06 9.42 1.65 8.36 2.59 AC Post Exp 10.64 2.49 695.5 0.797 11.25 2.79 187.0 0.581 10.15 2.16 132.0 0.796 Con 10.33 2.79 10.54 2.98 9.93 2.43 Pre Exp 7.25 1.34 668.0 0.582 7.13 1.36 186.5 0.570 7.35 1.35 135.0 0.877 Con 7.17 1.88 6.96 1.68 7.57 2.21 B Post Exp 8.86 2.73 533.0 0.050 8.50 2.78 177.0 0.416 9.15 2.72 82.0* 0.043 Con 7.80 2.97 8.08 3.12 7.29 2.70 Pre Exp 5.42 0.77 642.0 0.372 5.25 0.93 203.5 0.899 5.55 0.61 117.0 0.436 Con 5.25 0.84 5.27 0.78 5.21 0.98 TTS Post Exp 7.97 2.72 546.0 0.068 7.69 2.36 172.0 0.348 8.20 3.02 89.5 0.077 Con 6.82 2.71 7.00 3.01 6.50 2.14 Total Group Caucasian children Black children Variable Test Gr. M ss SD U p M ss SD U p Mss SD U p Pre Exp 4.14 1.48 688.5 0.737 5.06 1.53 107.0 0.445 3.40 0.94 223.5 0.685 Con 3.99 1.51 4.44 1.50 3.69 1.47 MD Post Exp 6.42 2.43 611.0 0.252 7.63 1.78 99.5 0.287 5.45 2.48 234.5 0.896 Con 5.75 2.42 6.75 2.52 5.09 2.16 Pre Exp 8.83 1.95 660.5 0.527 8.56 2.39 95.5 0.224 9.05 1.54 225.0 0.716 Con 9.05 2.06 9.38 2.19 8.83 1.99 AC Post Exp 10.64 2.49 695.5 0.797 10.94 2.57 125.5 0.926 10.40 2.46 234.0 0.886 Con 10.33 2.79 10.69 2.55 10.08 2.96 Pre Exp 7.25 1.34 668.0 0.582 6.81 1.38 87.0 0.128 7.60 1.23 219.5 0.622 Con 7.17 1.88 6.06 1.18 7.92 1.91 B Post Exp 8.86 2.73 533.0 0.050 9.31 2.92 72.0 0.035 8.50 2.58 215.0 0.552 Con 7.80 2.97 7.31 2.41 8.13 3.30 Pre Exp 5.42 0.77 642.0 0.372 5.63 0.50 81.0 0.080 5.25 0.91 223.5 0.668 Con 5.25 0.84 5.06 0.85 5.38 0.82 TTS Post Exp 7.97 2.72 546.0 0.068 9.00 2.78 76.5 0.050 7.15 2.43 206.0 0.419 Con 6.82 2.71 7.19 2.37 6.58 2.94 Gr= Group; Mss= Mean standard score; SD= Standard deviation; p≤0.05; Exp=Experimental Gr.; Con= Control Gr.MD= Manual dexterity; AC= Aiming and catching; B= Balance; TTS= Total test score 152 Article 5: Perceptual-motor intervention for DCD in grade 1 children The distribution of the children according to the traffic light system (degree of motor difficulty) before and after the perceptual-motor intervention is shown in Figures 7.1 and 7.2. Note that only children classified as borderline or with severe motor impairment took part in the intervention. Pre-Test by group Post-Test by group Control group Experimental group Control group Experimental group 21 24 20 19 13 18 18 7 6 6 Amber Red Green Amber Red FIGURE 7.1: Pre-Test placements using FIGURE 7.2:Post-Test placement using the traffic light system by group the traffic light system by group As stated previously, the total test score is derived from the three subtests and can be interpreted in terms of a traffic light system. The green zone indicates performance in a normal range, the amber zone indicates a child as being at risk and the red zone is an indication of definite motor impairment. After the pre- and post-tests, the total test scores of the 76 children were interpreted and placed according to the traffic light system. Figure 7.1 indicates the placement in terms of the traffic light system prior to the intervention. The results clearly indicate that all the participants had some form of motor problems prior to the intervention. Of the control group, 21 children fell in the amber zone and 19 children in 153 Article 5: Perceptual-motor intervention for DCD in grade 1 children the red zone. Of the experimental group, 18 children fell in the amber zone and another 18 in the red zone. In addition, Figure 7.2 indicates that, subsequent to the intervention, the experimental group performed better than the control group. The distribution according to the traffic light system was as follows: the majority of the children in the control group improved, with 20 children placed in the green zone (no motor difficulties). Similar results can be observed for the experimental group, in which 24 children improved after the intervention and were placed in the category for no motor difficulty. Furthermore, the results show that seven children from the control group and six of the experimental group remained in the amber zone. Finally, of the 19 children in the control group who were initially in the red zone, 13 remained after the intervention. This confirms that children will not outgrow their motor problems. Of the intervention group, only 6 children remained in the red zone. The findings of this study indicate that the motor proficiency levels of children with DCD improved not only due to their participation in a perceptual-motor intervention, but also by taking part in physical education classes presented by their teachers. DISCUSSION There has been an abundance of published research concerning various interventions for children with DCD. According to Smits-Engelsman et al. (2013), interventions in general have proved to be beneficial for children with DCD, implying that any intervention is better than no intervention at all. It must be mentioned that literature available with regard to the bottom-up approach has become somewhat outdated. This might be due to the criticism towards this approach (Bernie & Rodger, 2004), since more researchers are in favour of the top-down approach (Sugden et al., 2008). A combined systematic review and meta-analysis was conducted by Smits-Engelsman et al. (2013), reviewing studies published between 1995 and 2011 on various interventions for children with DCD. The researchers concluded their study indicating that the comparison between various interventions showed strong effects for the task-oriented intervention (dw = 0.89), in addition to physical and occupational therapies (dw = 0.83), whereas the process-oriented intervention was weak (dw = 0.12). 154 Article 5: Perceptual-motor intervention for DCD in grade 1 children The results with regard to manual dexterity indicated no significant difference (p = 0.252) between the two groups after the intervention was completed. This is similar to a study conducted by Pienaar and Lennox (2006), who determined that the fine motor skills of children between five and eight years from two farm schools did improve, but not significantly. Furthermore, Peens et al., (2008) also found no improvement after a motor intervention. In the current study, the perceptual-motor intervention did not focus on fine motor development; however, both groups did improve. This might be due to the exposure in the classroom, where children take part in writing and cutting activities as well as beading. With reference to aiming and catching, it is interesting to note that the control group had a higher average score during the pre-test, although the difference was not significant (p = 0.527). Both groups improved with regard to aiming and catching. Although the intervention group improved more based on the average score, the results do not indicate a significant difference (p = 0.797) between the pre- and post-tests of the two groups. The findings of Pienaar and Lennox (2006) were of a similar nature. In contrast, Peens et al. (2008) used a motor-based intervention and found a significant improvement. Another reason for improvement in both groups might be the fact that these children participate in a variety of object manipulative skills at school and in sports. The results for balance indicate a significant difference (p = 0.050) between the two groups after the intervention was completed. The improvement of the intervention group correlates with the findings of Pienaar and Lennox (2006) as well as Peens et al. (2008), who found that a motor intervention improved the balance sub-test of the Movement Assessment Battery for Children. The results of this study indicate that the perceptual-motor intervention contributed to the improvement of balance. Although there was an improvement in the average score of the total test score, there was no significant difference (p = 0.068) between the groups after the intervention. It was also apparent that the participants of the current study were a heterogeneous group and it is necessary to address the individual needs of each child; this statement is also confirmed by Missiuna et al. (2006). Based on the current study, a perceptual-motor intervention did not 155 Article 5: Perceptual-motor intervention for DCD in grade 1 children lead to a significant improvement with regard to overall motor proficiency. This correlates with Pienaar and Lennox (2006), who also found no significant difference in motor performance after conducting a motor intervention with 32 children between five and eight years of age. In contrast, Peens et al. (2008) found that a motor-based intervention did improve the total test score of 20 children between seven and nine years. The results of the current study show that the children who followed the perceptual-motor intervention, conducted by a Kinderkineticist-in-training familiar with the development of children, had a 67% improvement (24/36). Furthermore, the results indicate that the physical education classes conducted by the teachers also improved the motor proficiency of the children in the control group by 50% (20/40). This indicates that a majority of the children in both groups achieved scores above the 15th percentile during the post-test. The improvement illustrates that interventions conducted by other people, such as teachers, can also be helpful. This statement is supported by findings from Sugden and Chambers (2003), observing that interventions done by parents and teachers can also be successful. The researchers found that a seven-week intervention (task-orientated approach) conducted by parents and teachers helped a majority of children to obtain scores above the 15th percentile. Miyahara et al. (2008) made use of university students in a clinical setting to apply a task-orientated approach and found that 40% of the participants improved beyond the cut-off scores. Intervention by means of a combination of the bottom-up and top-down approaches through intense physical activity, conducted by Watemberg et al. (2007), concluded that 50% of the participants with DCD scored above the cut-off scores (> 15 percentile) after a four-week intervention. The implications of the results indicate that although both groups improved in general with regard to the average scores, the experimental group improved more compared to the control group. Therefore, the results indicate that a perceptual-motor intervention can be used as an appropriate intervention for children identified with DCD. 156 Article 5: Perceptual-motor intervention for DCD in grade 1 children CONCLUSIONS When children are identified with DCD, it is important to implement intervention programmes. Intervention programmes have proven to enhance the motor proficiency of these children (Peens et al., 2008). The results suggest that a perceptual-motor intervention did not improve the motor proficiency levels of children with DCD. From the point of view of a therapist, no two children are the same, especially children identified with DCD, since they are not a homogeneous group. LIMITATIONS One of the major limitations was the fact that the control group was exposed to physical education classes. This could have contributed to the improvement of their motor proficiency levels and influenced the results. Since this was a population-based sample, criterion B of the diagnostic criteria for DCD, which states that the academic performance of the children should also be considered (APA, 2013), was not used. It should also be recognized that the current study recruited children from the Bloemfontein metropolitan area only. Hence, a replication of this study in different provinces and regions in South Africa is recommended to provide more generalized and robust results. Another limitation of the study was the fact that the children were tested on age band 1 (age six) during the pre-test. The majority of the children turned seven during the intervention, and therefore had to be tested on age band 2, implying that they had to perform more difficult activities than for age band 1. ACKNOWLEDGEMENTS We thank the principals, staff members and children at the primary schools where the study was conducted. 157 Article 5: Perceptual-motor intervention for DCD in grade 1 children REFERENCES APA (AMERICAN PSYCHIATRIC ASSOCIATION). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. AUXTER, D.; PYFER, J. & HUETTIG, C. (2005). Principles and methods of adapted physical education and recreation (10thed.). Boston, MA: McGraw-Hill. BARNETT, A.L. 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Disability and Rehabilitation, 29(1): 47-55. 161 Article 6: Sport stacking intervention programme for children with DCD CHAPTER 8 ARTICLE 6: Sport stacking intervention programme for children with developmental coordination disorder Accepted for publication: South African Journal for Research in Sport, Physical Education and Recreation, Volume 36(3), September 2014, pp. 51-60 Sport stacking intervention programmefor children with developmental coordination disorder MONIQUE DE MILANDER, JALè DU PLESSIS AND ANELDA DU RANDT Department of Exercise and Sport Sciences, University of the Free State, P.O. Box 339, Bloemfontein 9300, South Africa. E-mail: demilanderm@ufs.ac.za 162 Article 6: Sport stacking motor intervention for children with DCD ABSTRACT The purpose of this study was to explore sport stacking as an alternative intervention approach with typically developing children and in addition to improve DCD. Sport stacking consists of participants stacking and unstacking 12 specially designed plastic cups in predetermined sequences in as little time as possible. Eighteen children (6 girls and 12 boys) classified with DCD, between the ages of 6 and 7 years, participated. A pre-test/post-test quasi-experimental design with a control group was applied. The Movement Assessment Battery for Children-2 (MABC-2) was used to assess the motor proficiency levels of the children and to classify DCD. The sport stacking intervention consisted of an 8-week programme of 3 sessions per week, 30 minutes per session. During the intervention the children learned the various sport stacking sequences, as well as how to apply them to a variety of physical activities. The results indicate that prior to the intervention no significant differences occurred between the 2 groups. After the intervention, manual dexterity and balance showed a significant difference, while aiming and catching, showed no significant difference. The total test score revealed a significant difference in the overall motor proficiency levels of the experimental group. The results suggest that sport stacking can be used as an effective intervention programme for children with DCD. Key words: Sport stacking; Motor proficiency; Developmental coordination disorder; Intervention; Movement Assessment Battery for Children-2. 163 Article 6: Sport stacking motor intervention for children with DCD Sport Stacking Motor Intervention Programme for Children with Developmental Coordination Disorder INTRODUCTION Developmental coordination disorder (DCD) is a neuro-developmental disorder, causing marked impairment in the maturation of motor coordination (Polatajko & Cantin, 2006). According to Missiuna et al. (2006), children with DCD experience significant difficulties in motor learning and in the execution of functional motor tasks that are pivotal for success in their everyday lives. A large number of school-aged children have been identified with motor proficiency problems. These problems have substantial negative effects on their ability to participate fully in daily activities at home, school and in normal play (Polatajko & Cantin, 2006). Even though children will not outgrow this disorder as previously believed (Henderson & Henderson, 2002), children can be facilitated by means of Barnett’s V- step assessment process for the identification of children with motor problems (Barnett, 2008). The first step focus on the use of questionnaires for the screening and identification of children with motor problems. The second entails the use of norm-referenced tests for measuring the motor performance of the child. The third step of this motor assessment process entails the making of a formal diagnosis of DCD. This is served by measuring the qualitative and quantitative performance in motor tasks. The fourth step focus on understanding the nature of the condition. Finally, the fifth step is the planning of an intervention programme. It follows that intervention programmes are a vital element of the assessment process in order to improve DCD. Researchers conventionally made use of bottom- up approaches by means of sensory integration and perceptual motor training in children with DCD (Bernie & Rodger, 2004; Sugden et al., 2008). These approaches aim to improve children’s processing abilities or performance components and are still being practised as an intervention by many therapists (Missiuna et al., 2006; Sugden et al., 2008). According to Hamilton (2002), the most frequently used approaches are perceptual-motor therapy, sensory-integration therapy and kinesthetic training. All of these more often produced positive results than not. 164 Article 6: Sport stacking motor intervention for children with DCD Due to a lack of support for the bottom-up approach, new approaches emerged known as the cognitive or top-down approach (Bernie & Rodger; 2004). More researchers are in favour of this approach (Sugden et al., 2008). These new approaches were based on theoretical concepts of motor learning and cognition. Motor learning is based on a conscious understanding of the processes involved when a motor problem needs to be solved. Thus, the interaction between the task and environment, as well as the child needs to be taken into consideration (Perry, 1998). Cognitive approaches use direct skill teaching, but differ in the sense of the unique problem-solving framework, attempting to help children generalise from the learning of one skill to the next (Missiuna et al., 2006). According to Missiuna et al. (2006) and Sugden et al. (2008), although the task- specific approach aims at increasing various participations for children, it is preferable to consider how children can perform a specific task in a variety of real-life situations, rather than in one specific setting. Consequently, one should consider how to modify the task or to adapt the environment in order for children to participate and improve their learning capabilities. Sugden and Chambers (1998) proposed that most interventions are successful with a good number of children diagnosed with DCD. This statement was supported by findings from the same authors (Sugden & Chambers, 2003), observing that interventions done by parents and teachers can also be successful. The researchers found that a 7-week intervention (task-orientated approach), conducted by parents and teachers helped the majority of children to obtain scores above the 15th percentile. Miyahara et al. (2008) made use of university students in a clinical setting to apply a task-orientated approach and found that 40% of the participants improved beyond the cut-off scores. Intervention by means of a combination of the bottom-up and top-down approaches through intense physical activity conducted by Watemberg et al. (2007), concluded that 50% of the participants with DCD scored above the cut-off scores (>15th percentile) after a 4-week intervention. It is clear that controversies exist between these different approaches and there is still not enough evidence to substantiate that one specific intervention approach is superior to another (Miller et al., 2001; Miyahara et al., 2008). It is thus proposed that 165 Article 6: Sport stacking motor intervention for children with DCD these two approaches (bottom-up and top-down) should be merged in order to care for children with DCD (Peters & Wright, 1999; Davidson & Williams, 2000). Sport stacking was launched in a South African setting in January 2009. Sport stacking is already recognised as a sport by more than 18 nations, including Australia and Germany in addition to South Africa (Krog, 2008). According to the World Sport Stacking Association (2009), sport stacking is defined as a sport where 12 specialised cups are used to build formations. A participant is called a stacker. Stackers must stack cups in predetermined sequences, competing against the clock or another player (Gibbons et al., 2007). Sport stacking can, therefore, be used as an innovative and exciting way of improving motor proficiency, such as hand-eye coordination, ambidexterity, speed and concentration while having fun (Udermann et al., 2004; Krog, 2008). RESEARCH PROBLEM The aim of this study was to explore the effectiveness of sport stacking as an alternative intervention approach for typically developing children and in addition to improve DCD in children. According to Aparo (2009:ii): “Sport stacking seems to improve, in a fun and challenging way, several rudimentary fine motor skills, such as hand-eye coordination, which is assessed in this study, and others such as bimanual coordination, ambidexterity, reaction time, concentration and quickness”. This study explores the efficacy of a cup stacking intervention for children classified with DCD in order to improve their motor proficiency levels. MATERIAL AND METHODS Study design A pre-test/post-test quasi-experimental design with a control group was applied as an empirical study, which made use of quantitative data. The study involved a pre- test in order to identify the children with motor difficulties, in other words DCD. The children were tested at their school by Kinderkineticists in-training who were familiar 166 Article 6: Sport stacking motor intervention for children with DCD with the testing procedures of the relevant instrument. Each Kinderkineticist in- training was responsible for one subtest in order to have consistency across the study. The children classified with DCD were divided into 2 groups. The experimental group took part in an 8-week intervention programme (sport stacking) comprising 30- minute group sessions 3 times a week. The reason for the 8-week intervention instead of the prescribed 12-week intervention is due to the fact that a school term consists of only 10 consecutive weeks. The Kinderkineticists were trained by professionals from a Speed Stacking company in order to execute the intervention programme accordingly. The speed stacking intervention was combined with various fundamental movements, such as locomotor-, manipulation-, as well as stability skills. A post-test, using the same procedure as the pre-test, took place after the intervention process in order to observe any improvement. Participants The participants were selected from a primary school in Bloemfontein, Free State province, South Africa, and therefore, constitute a convenient sample. Eighteen children between the ages of 6 and 7 years took part in this study. The group consisted of girls (n=6) and boys (n=12) classified with DCD. Ethical considerations The Department of Education, as well as the principal of the school granted permission for the research to be conducted on the school premises during the Life Orientation class periods. Approval had been obtained from the Ethics Committee of the Faculty of Health Sciences (ECUFS57/2012) of the University of the Free State. The parents of the participants completed an informed consent form for each child participating in this study. All children in the identified classes were considered for inclusion in the study. Exclusion criteria included a child in the age group outside the expected range of 6 to 7 years, where parental permission was not obtained or the informed consent form had not been completed fully or where parents had indicated that they would be relocating during the study. 167 Article 6: Sport stacking motor intervention for children with DCD Measuring instrument The Movement Assessment Battery for Children-2 (Movement ABC-2) is a standardised test and requires children to perform a series of motor tasks in a specified manner. In addition to age-related norms, the test also provides qualitative information on how children approach and perform the tasks. The Movement ABC-2 assesses the subject’s motor proficiency levels and classifies children with DCD. The first assessment component of this test battery contains a total of 24 items organised into 3 sets of 8 tasks. Each set is designed for use with children of a different age band. The 8 tasks are grouped under 3 categories, namely manual dexterity (MD), balance (B) and aiming and catching (AC) (Henderson et al., 2007). Age-adjusted standard scores and percentiles are provided, as well as a total score based on each of the 3 components of the test. The total test score can be interpreted in terms of a ‘traffic light’ system. The green zone indicates performance in a normal range (>15th percentile), while the amber zone indicates a child as being at risk and needing to be carefully monitored (5th to 15th percentile). The red zone is an indication of definite motor impairment (≤5th percentile). Analysis of data Analysis of the data was completed by a Bio-statistician using Statistical Analysis Software Version 9.1.3. Descriptive statistics, namely frequencies and percentages, were calculated for categorical data. Medians and percentiles were calculated for numerical data. Median differences were tested by calculating p-values using the signed-rank test. The chi-square was used to test for proportional differences. A significance level of 0.05 was accepted for all aspects of the study. RESULTS The sample consisted of 18 children, of which 8 formed the control group and 10 the intervention group. With regard to gender the control group consisted of 2 girls (25%) and 6 boys (75%) and the intervention group consisted of 4 girls (40%) and 6 (60%) boys. There was no significant difference, (p=0.6380) between the 2 groups at the start. Table 8.1 presents the numerical data to compare the 2 groups regarding the pre-test median results of the various subtests of the Movement ABC-2 168 Article 6: Sport stacking motor intervention for children with DCD TABLE 8.1. Median results of two groups: comparison of pre- and post-test Control group Experimental p-Value group Variables n Pre- Post- Pre- Post- Pre- Post- test test test test test test MD 18 1.5 1.0 1.5 5.0 0.7832 0.0191 AC 18 25.0 50.0 25.0 69.0 0.6732 0.0734 B 18 20.5 7.0 37.0 20.5 0.2595 0.0472 TTS 18 5.0 2.0 9.0 12.5 0.1784 0.0018 Abbreviations: MD= Manual Dexterity, AC= Aiming and Catching, B= Balance, TTS= Total Test Score It is clear from median results for the pre-test of the control and intervention groups that there was no significant difference between the 2 groups before the intervention commenced with regard to the various subtests, namely manual dexterity (p=0.7832), aiming and catching (p=0.6732), balance (p=0.2595) and the total test score (p=0.1784). Manual dexterity involves the coordinated use of the hands, guided by the visual system, within time limits (Henderson et al., 2007). The pre-test median for the control group was 1.5 and the post-test showed a slight decrease to 1.0. For the intervention group, the pre-test was 1.5 and increased to 5.0. A significant difference (p=0.0191) was found between the 2 groups after the intervention was completed. Aiming and catching entails coordinating body movements when receiving moving objects, as well as performing throwing tasks accurately (Henderson et al., 2007). The pre-test median score for the control group was 25.0 and this improved to 50.0 in the post-test. With regard to the intervention group, the median score was also 25.0 and increased to 69.0. Both groups improved in this category and there was no 169 Article 6: Sport stacking motor intervention for children with DCD significant difference (p<0.0734) between the pre- and post-test median scores of the 2 groups in respect of aiming and catching. The balance subtest involves static and dynamic balance where the child has to keep the body upright against gravity while standing on 1 leg and performing hopping and jumping movements (Henderson et al., 2007). The median value of the pre-test for the control group was 20.5 and for the post-test the median score decreased to 7.0. The intervention group scores for balance resulted in a median score of 37.0, which decreased to 20.5 at the post-test. While there was a decrease in performance for both groups between pre- and post-test scores, there was a significant difference (p<0.0472) with reference to balance between the 2 groups. The 3 categories of the MABC-2 produced the total test score. At the pre-test, the median score for the control group was 5.0 and in the post-test it decreased to 2.0. The pre-test median score for the intervention group was 9.0 and increased to 12.5 in the post-test. These results indicate a significant difference (p=0.0018) between the 2 groups in respect of the total test score. The results indicate that the control group performed poorer in the post-test with regard to manual dexterity, balance and the total test score compared to the intervention group. It is interesting to note that both groups scored poorer in the post- test with reference to the balance subtest. After the intervention period there was a significant difference between the 2 groups with regard to manual dexterity (p=0.0191), balance (p=0.0472) and the total test score (p=0.0018). The distribution of the children, according to the traffic light system (degree of motor difficulty) before and after the intervention programme is shown in Figures 8.1 and 8.2. Note that only the children classified as borderline or severe motor proficiency impairment took part in the intervention. 170 Article 6: Sport stacking motor intervention for children with DCD Pre Test by group PostTest by group Control Group Experimental group Control Group 6 6 Experimental group 7 4 5 2 3 2 1 0 Amber Red Green Amber Red FIGURE 8.1. Pre-test placements using FIGURE 8.2. Post-test placement using the traffic light system by group the traffic light system by group As stated previously, the total test score is derived from the 3 subtests and can be interpreted in terms of a ‘traffic light’ system. The green zone indicates performance in a normal range, the amber zone indicates a child as being at risk and the red zone is an indication of definite motor impairment. After the pre- and post-tests the total test scores of the 18 children were interpreted and placed according to the traffic light system. Figure 8.1 indicates the placement with regard to the traffic light system prior to the intervention. The results clearly indicate that all the participants had some form of motor proficiency problems prior to the intervention. With reference to the control group, 2 children fell in the amber zone and 6 children in the red zone. With regard to the intervention group, 6 children fell in the amber zone while 4 children were in the red zone. In addition, Figure 8.2 indicates that subsequent to the intervention, the intervention group performed better in contrast to the control group. The distribution according to the traffic light system was as follows: observing the control group none of the children improved and, therefore, no children were in the green zone (no motor difficulties). In contrast, 5 children from the intervention group improved after the intervention and landed in the no motor difficulty category. Furthermore, the results 171 Article 6: Sport stacking motor intervention for children with DCD shows that only 1 child from the control group remained in the amber zone, in contrast to 3 of the intervention group. Finally, 7 children of the control group were in the red zone whereas there were 6 initially. This confirms that children will not outgrow their motor problems. With regard to the intervention group, only 2 children remained in the red zone. The findings of this study indicate that the motor proficiency levels of children with DCD improved to a great extent due to their participation in a sport stacking intervention. DISCUSSION OF RESULTS With regard to manual dexterity, the results indicate a significant difference (p=0.0191) between the 2 groups after the intervention was completed. This is similar to a study conducted by Aparo (2009) who determined the influence of a sport stacking intervention on hand-eye coordination in children. According to the Saskatchewan Physical Education Association (2008), children using both sides of their bodies should improve their bilateral abilities. These statements support the finding of the current study. The children had ample opportunity to use both hands in a coordinated fashion during the speed stacking intervention; therefore, their manual dexterity (ability to use the 2 hands together) did improve significantly compared to the control group. With reference to aiming and catching, it is interesting to note that both groups had a median score of 25.0, indicating a good standard of aiming and catching ability. Both groups improved with regard to aiming and catching. Although the intervention group improved more based on the median score, the results do not indicate a significant difference (p<0.0734) between the pre- and post-test median scores of the 2 groups. The improvement of the intervention group correlates with the findings of Udermann et al. (2004), who found that sport stacking intervention improves hand-eye coordination and reaction time, which are both important components when executing aiming and catching skills successfully. The findings of Aparo (2009) were of a similar nature. The improvement in both groups can be attributed to the fact that they had good skills prior to the intervention, thus it is harder to improve on these skills. Another reason for improvement in both groups might be due to the fact that these children participate in a variety of manipulative skills at school. 172 Article 6: Sport stacking motor intervention for children with DCD Even though both groups decreased in performance with reference to the balance subtest there was a significant difference (p<0.0472) between the 2 groups after the intervention. The decline in performance could be due to the fact that the majority of the children had to be tested on age band 2 during the post-test, indicating that the balancing activities were more difficult to execute. This may also indicate the need for the intervention to include more balancing activities. With reference to the total test score, a significant difference (p=0.0018) was observed between the groups after the intervention. The results, therefore, suggest that children would not outgrow their motor difficulties without appropriate interventions (Henderson & Henderson, 2002; Sugden & Chambers, 2003). It was also apparent that the participants of the current study were a heterogeneous group and it is necessary to address the individual needs of each child. Based on the current study, speed stacking led to a significant improvement with regard to overall motor proficiency. This correlates with Aparo (2009), who also found a significant increase in motor performance after using a speed stacks intervention programme with 20 children between 7 and 11 years of age. LIMITATIONS Although the aim of this study was to determine if a sport stacking intervention might improve the motor proficiency levels of children with DCD, the population sample used in this study was obtained from a single institution and province and can, therefore, not be generalised to the larger population of 6 and 7 year old children. It is recommended that the effect of a Sport stacking intervention on children with DCD should be explored further by means of larger samples. In addition, the long-term effects of a sport stacking intervention should be researched. Another limitation to the study was that the children were tested on age band 1 (age 6) during the pre- test. A majority of the children turned 7 during the intervention, and therefore, had to be tested on age band 2, indicating that they had to perform more difficult activities compared to age band 1. CONCLUSION The aim of this study was to determine if a sport stacking intervention resulted in an improvement of motor proficiency levels of children with DCD. When children are 173 Article 6: Sport stacking motor intervention for children with DCD diagnosed with DCD, it is important to implement motor intervention programmes. Intervention programmes have proven to enhance the motor proficiency of these children (Peens et al., 2008). The results suggest that a sport stacking intervention improved the motor proficiency levels of children with DCD. From the point of view of a therapist, no two children are the same, especially children identified with DCD, since they are not a homogeneous group. The findings of this research contribute to the field of study by providing an alternative intervention approach, namely sport stacking, for Kinderkineticists to utilise with the purpose of improving the motor proficiency levels of children with DCD. ACKNOWLEDGEMENT Thank you to the principal, staff and children at the primary school where the study was conducted. To Linley Myburg and Rikus van Dyk for their contribution of a pilot study for this research. 174 Article 6: Sport stacking motor intervention for children with DCD REFERENCES APARO, L. (2009). “Influence of Sport Stacking on hand-eye coordination in children aged 7-11.” Hyperlink: [http://www.speedstacks.com/groups/benefits/thesis_luca_aparo.pdf]. Retrieved on 12 March 2010. BARNETT, A.L. (2008). Motor assessment in developmental coordination disorder: From identification to intervention. International Journal of Disability, Development and Education, 55(2): 113-129. BERNIE, C. & RODGER, S. (2004). Cognitive strategy use in school-aged children with developmental coordination disorder. Physical and Occupational Therapy in Peadiatrics, 24(4): 23-45. DAVIDSON, T. & WILLIAMS, B. (2000). Occupational therapy for children with developmental coordination disorder: A study of the effectiveness of a combined sensory integration and perceptual-motor intervention. British Journal of Occupational Therapy, 63(10): 495-499. GIBBONS, E.; HENDRICK, J.L. & BAUER, J. (2007). “Distribution of practice on cup stacking performance.” Hyperlink: [http://facultyweb.cortland.edu/henrdrick/aahperdposter%20-%20S07.pdf]. Retrieved on 12 March 2010. HAMILTON, S.S. (2002). Evaluation of clumsiness in children. American Family Physician, 66(8): 1435-1440. HENDERSON, S.E. & HENDERSON, L. (2002). Toward an understanding of developmental coordination disorder. Adapted Physical Activity Quarterly, 19: 12-31. HENDERSON, S.E.; SUGDEN, D.A. & BARNETT, A.L. (2007). Movement Assessment Battery for Children-2 (2nd ed.). London: Harcourt Assessment. KROG, S. (2008). “Sport stacking on motor skills development.” Hyperlink: [http://www.speedstacks.co.za/benefits]. Retrieved on 11 September 2012. 175 Article 6: Sport stacking motor intervention for children with DCD MILLER, L.T.; POLATAJOKO, H.J.; MISSIUNA, C.; MANDICH, A.D. & MACNAB, J.J. (2001). A pilot trial of a cognitive treatment for children with developmental coordination disorder. Human Movement Science, 20(1-2): 183-210. MISSIUNA, C.; RIVARD, L. & BARTLETT, D. (2006). Exploring assessment tools and the target of intervention for children with developmental coordination disorder. Physical and Occupational Therapy in Pediatrics, 26(1/2): 71-89. MIYAHARA, M.; YAMAGUCHI, M. & GREEN, C. (2008). A review of 326 children with developmental and physical disabilities, consecutively taught at the Movement Development Clinic: Prevalence and intervention outcomes of children with DCD. Journal of Development and Physical Disability, 20(4): 353-363. PEENS, A.; PIENAAR, A.E. & NIENABER, A.W. (2008). The effect of different intervention programmes on the self-concept and motor proficiency of 7- to 9-year- old children with DCD. Child Care, Health and Development, 34(3): 316-328. PERRY, S.B. (1998). Clinical implications of a dynamic systems theory. Neurology Report, 22(1): 4-10. PETERS, J.M. & WRIGHT, A.M. (1999). Development and evaluation of a group physical activity programme for children with developmental co-ordination disorder: An interdisciplinary approach. Physiotherapy Theory and Practice, 15(4): 203-216. POLATAJKO, H.J. & CANTIN, N. (2006). Developmental coordination disorder (dyspraxia): An overview of the state of the art. Seminars in Pediatric Neurology, 12(4): 250-258. SASKATCHEWAN PHYSICAL EDUCATION ASSOCIATION (2008). Hyperlink: [http://speaonline.ca/speed.html]. Retrieved on 3 April 2010. SUGDEN, D.A. & CHAMBERS, M.E. (1998). Intervention approaches and children with developmental coordination disorder. Pediatric Rehabilitation, 2(4): 139-147. SUGDEN, D.A. & CHAMBERS, M.E. (2003). Intervention in children with developmental coordination disorder: The role of parents and teachers. British Journal of Education Psychology, 73: 545-561. 176 Article 6: Sport stacking motor intervention for children with DCD SUGDEN, D.A.; KIRBY, A. & DUNFORD, C. (2008). Issues surrounding children with developmental coordination disorder. International Journal of Disability, Development and Education, 55(2): 173-187. UDERMANN, B.E.; MAYER, J.M.; MURRAY, S.R. & SAGENDORF, K. (2004). Influence of cup stacking on hand-eye coordination and reaction time of second- grade students. Perceptual and Motor Skills, 98: 409-414. WATEMBERG, N.; WAISERBERG, N.; ZUK, L. & LERMAN-SAGIE, T. (2007). Developmental coordination disorder in children with attention-deficit-hyperactivity disorder and physical therapy intervention. Developmental Medicine and Child Neurology, 49(12): 920-925. WORLD SPORT STACKING ASSOCIATION (2009). “Official Rule Book version 5.0.” Hyperlink: [http://www.worldsportstackingassociation.org/pdf/WSSARuleBookv4.0.pdf]. Retrieved on 3 April 2010. 177 Chapter 9 – Summary, conclusions and recommendations CHAPTER 9 Summary, conclusions and recommendations 9.1 Summary…...………………………………………………………………........ 178 9.2 Conclusions……………………………………………………………………. 185 9.2.1 Research question 1……………………………………………………………. 185 9.2.2 Research question 2……………………………………………………………. 186 9.2.3 Research question 3……………………………………………………………. 186 9.2.4 Research question 4……………………………………………………………. 187 9.2.5 Research question 5……………………………………………………………. 187 9.2.6 Research question 6..………………………………………………………….. 188 9.3 Recommendations and limitations ………………….…………………….. 188 9.5 References……………………………………………………………………… 191 9.1 Summary The research questions addressed in this study were the following: Firstly, to determine the prevalence of developmental coordination disorder (DCD) amongst Grade 1- learnersin Bloemfontein. Secondly, to determine if parents have the competency to identify DCD in Grade 1-learnersat home. Thirdly, to determine if teachers have the competency to identify DCD in Grade 1-learnersin the classroom. Fourthly, to determine if DCD influence the learning related skills of Grade 1 children. In addition, determine if the application of a perceptual-motor intervention programme (research 178 Chapter 9 – Summary, conclusions and recommendations question 5) as well as the application of a sport stacking intervention programme (research question 6) will improve the status of Grade 1-learnersclassified with DCD. Chapter 1 provided a brief introduction and outline of the problem statement that underlies the research questions and aims that form the basis of this study. The thesis is submitted in article format, as approved by the senate of the University of the Free State (Bloemfontein Campus), and therefore includes a literature review (Chapter 2) and six research articles (Chapter 3,4,5,6,7, and 8 respectively) which all have been presented to accredited peer reviewed journals. In order to answer the aims of this study, the current literature on DCD was investigated in Chapter 2. Firstly the definition and terminologies used for DCD were discussed, together with the prevalence of DCD as well as the characteristics of comorbidity. Furthermore, the etiology of DCD was discussed and an overview on the basic principles of neurophysiology was provided as well as the major psychomotor problems related to the nervous system. The importance of diagnoses and various assessments required to identify children with DCD were discussed in detail and included the psychometric properties, reliability, validity, sensitivity and specificity of each assessment used in this study. The assessments included the Developmental Coordination Disorder Questionnaire ’07 (DCDQ’07), Movement Assessment Battery for children-2 Checklist (MABC-2 C), as well as the Movement Assessment Battery for children-2 Performance Test (MABC-2 Test). Interventions for children with DCD were also discussed in Chapter 2, with emphasis on the process orientated approach, specifically for perceptual-motor skills. The reason for using a process orientated approach is because the current study made use of a perceptual-motor intervention in addition to speed stacking. In conclusion, the reviewed literature indicated that the prevalence of DCD differs between various countries and was found to be as low as 5% in the United Kingdom and as high as 15% in Europe. Furthermore, the literature states that the prevalence might even be higher since medical as well as educational systems frequently fail to 179 Chapter 9 – Summary, conclusions and recommendations identify DCD in young children. Thus, it is important to use screening tools, for parents and teachers, to identify children with possible motor delays due to DCD in order to be tested by professionals on the Movement ABC-2 Test. After assessments, interventions should follow. The literature clearly indicates that a variety of intervention approaches are available for therapists to utilize in order to improve the symptoms associated with DCD, since children will not outgrow this disorder. However, controversies exist between these different approaches and there is still not enough evidence to prove that one specific intervention approach is superior to another. It is therefore recommended that these two approaches (bottom-up and top-down) should be combined in order to treat children with DCD. In Chapter 3, the research article entitled “Developmental Coordination Disorder in grade 1 learners” by De Milander, M., Coetzee, F.F. and Venter, A. was accepted for publication in the African Journal for Physical, Health Education, Recreation and Dance (AJPHERD) Volume 20(3:1), September 2014, pp. 1075-1085. The purpose of the study was; to determine the prevalence of DCD amongst Grade 1 learners, to establish the boy-girl ratio regarding DCD and the prevalence of DCD amongst various ethnic groups. Five-hundred and fifty nine learners between the ages of 6 and 8 years took part in this study. There were n=321 girls (57%) and n=238 boys (43%) of various ethnical groups, which consisted of 57.4% Caucasian, 39.7% Black, 2.50% Mixed-race, 0.3% Hispanic and 0.1% Indian children. The Movement ABC-2 was used to determine DCD. Analysis of the data was done using Statistical Analysis Software Version 9.1.3. Descriptive statistics, namely frequencies and percentages, were calculated for categorical data. Medians and percentiles were calculated for numerical data. Median differences were tested by calculating p-values using the signed-rank test. The Chi- square statistics were used to test for proportion differences. Probability level of 0.05 or less was taken to indicate statistical significance. The results indicated that 85% participants had no motor difficulties (green zone), 8% of children in the group were identified with moderate motor difficulties (amber zone), while 7% were identified with severe motor difficulties (red zone). With regard to the boy-girl ratio, 9% of boys had moderate difficulties and 10% severe difficulties in contrast to 7% moderate difficulties 180 Chapter 9 – Summary, conclusions and recommendations and 5% severe difficulties amongst the girls. With reference to ethnical groups, 5.3% of Caucasian learners fell in the amber zone and 5.3% in the red zone, 10.6% of Black learners fell in the amber zone and 9.7% in the red zone, 14.2% Mixed-race learners fell in the amber zone and 21.4% in the red zone. The conclusions drawn from the results suggest that the prevalence of DCD amongst Grade 1 learners in Bloemfontein is estimated to be 15%. The results also indicate that boys have a significantly higher (p=0.0507) prevalence of DCD, although marginally when compared to their female counterparts. In Chapter 4, the second research article entitled “The competency of parents to identify Grade 1-learnerswith Developmental Coordination Disorder at home” by De Milander, M., Coetzee, F.F. and Venter, A. was presented for publication in the South African Journal for Research in Sport, Physical Education and Recreation and accepted for publication, 2015, 37(3): in press. The corresponding author is still waiting for the results. The aim of the study was to examine the convergent validity of the classification of motor difficulties by Kinderkineticists-in-training using the MABC-2 Test and the classification of motor difficulties by the parents of the participants using the DCDQ’07, in order to determine if parents possess the competency to identify Grade 1- learnerswith DCD at home. Four hundred and ten (N = 410) Grade 1-learnersbetween the ages of five and eight years took part in this study. There were n = 226 girls (55%) and n = 184 boys (45%). The ethnic groups that took part consisted of 67% Caucasian and 33% Black children. Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) for Windows (SPSS version 16.0, SPSS Inc., Chicago, IL). In order to determine the convergent validity of the classification of motor problems (no motor difficulties or motor difficulties) using the MABC-2 Test and the classification of motor difficulties (no motor difficulties or motor difficulties) by the parents of the participants using the DCDQ’07, the kappa (k-) coefficient was used. This coefficient supplies information with regard to the convergent validity between the two measuring instruments. The results indicated 91% specificity for the DCDQ’07. In contrast, the sensitivity was only 23%. The kappa coefficient of 0.151 indicated a 15% convergent 181 Chapter 9 – Summary, conclusions and recommendations validity between the two assessment tools. Therefore, it can be argued that parents using the DCDQ’07 could not identify children with DCD at home. Article 3 in Chapter 5 is entitled “The ability of South African teachers in identifying Grade 1 learners with developmental coordination disorder in the classroom” by De Milander, M., Coetzee, F.F. and Venter, A. was presented for publication in the Adapted Physical Activity Quarterly (MS APAQ.2014-0209.R1.). The corresponding author is still waiting for the results. The aim of the study was to examine the convergent validity of the classification of motor difficulties by trained Kinderkineticists using the MABC-2 Test and the classification of motor difficulties by the teachers of the participants using the MABC-C, in order to determine if teachers possess the competency to identify Grade 1- learnerswith DCD in the classroom. Five hundred and six (n = 506) Grade 1-learnersin South Africa between the ages of five and eight years took part in this study. There were n = 289 girls and n = 217 boys. The ethnic groups that took part consisted of 313 Caucasian and 193 Black learners. Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) for Windows (SPSS version 16.0, SPSS Inc., Chicago, IL). In order to achieve the aim of this study, namely to examine the convergent validity of the classification of motor problems (no motor difficulties/motor difficulties) using the MABC-2 Test and the classification of motor difficulties (no motor difficulties/motor difficulties) by the teachers of the participants using the MABC-C, the kappa (k-) coefficient was used. This coefficient supplies information with regard to the convergent validity between the two measuring instruments. The higher the coefficient (whether it is a negative or a positive value), the greater the convergent validity between the two measuring instruments. The practical importance of the results was also investigated. As standard of practical significance, the effect size was calculated. The following guideline values need to be used when the effect size is interpreted (Steyn, 1999): r = 0.1: small effect; r = 0.3: medium effect and r = 0.5: large effect. A probability level of 0.05 or less was taken to indicate statistical significance. The MABC-C demonstrated a specificity of 70.3% and a sensitivity of 46.5%. The convergent validity between the two assessment tools when completed by teachers indicated a kappa coefficient of 0.110 (11%), and thus had a small effect size (r = 0.125). Therefore, it can 182 Chapter 9 – Summary, conclusions and recommendations be argued that teachers using the MABC-C could not identify children with DCD in the classroom. In Chapter 6, the fourth research article entitled “The Prevalence and Effect of Developmental Coordination Disorder on Learning Related Skills in Grade 1-learnersin South Africa” by De Milander, M., Coetzee, F.F. and Venter, A. was presented for publication in the South African Journal for Research in Sport, Physical Education and Recreation (MS1115). The corresponding author is still waiting for the results. The objective of the study was to determine the prevalence of DCD additionally to examine the effect of the degree of motor difficulties on learning related skills. This comparative study made use of quantitative data. The study involved one testing procedure by means of the MABC-2 Test in order to identify DCD. In addition, each participant was evaluated on the Aptitude Test for School Beginners (ASB) conducted and interpreted by qualified teachers. Learning related skills of children who were identified by the MABC-2 Test with DCD was compared to children without DCD. Data analysis was performed by a Statistician using the Statistical Package for the Social Sciences (SPSS) for Windows (SPSS version 16.0, SPSS Inc., Chicago, IL. Descriptive statistics, namely frequencies and percentages, were calculated for categorical data. Medians and percentiles were calculated for numerical data. Median differences were tested by calculating p-values using the signed-rank test. The chi-square statistics were used to test for proportion differences. Probability level of 0.05 or less was taken to indicate statistical significance. The prevalence of DCD amongst Grade 1 learners was 6% for at risk for motor difficulties as well as severe motor difficulties. Eighty eight percent (88%) of the children had no motor difficulties. The degrees of motor difficulties had a significant effect on five of the eight specific learning related subtypes namely; reasoning, numerical, gestalt, coordination and memory. The different degrees of motor difficulties, namely at risk and severe motor difficulties have significant different effects on learning of Grade 1 children. Article 5 in Chapter 7 is entitled “Perceptual-motor intervention for developmental coordination disorder in grade 1 children” by De Milander, M., Coetzee, F.F. and Venter, 183 Chapter 9 – Summary, conclusions and recommendations A. was presented for publication in the South African Journal for Research in Sport, Physical Education and Recreation and accepted for publication, 2015, 37(2): in press. The corresponding author is still waiting for the results. The purpose of this study was to determine if a perceptual-motor intervention will improve the symptoms associated with DCD. Seventy six children between the ages of 5 and 8 years took part in this study. The group consisted of girls (n=34) and boys (n=42) classified with DCD. The study had a pre-test/post-test experimental design (n=36) with a control group (n=40). The Movement Assessment Battery for Children-2 (MABC-2 Test) was used to assess the motor proficiency levels of the children and to classify DCD. The perceptual-motor intervention consisted of a 10-week programme of 2 sessions per week, 30 minutes per session. The dependent variables were all measurable on an interval scale and therefore the Mann-Whitney-U test was used. The results indicate that prior to the intervention, no significant differences (p≥0.05) existed between the two groups. However, after the intervention one subtest, namely balance showed a significant difference, (p=0.050) whiles the remaining components, manual dexterity (p=0.797) as well as aiming and catching (p=0.252), showed no significant difference. The three components contribute to the total test score, which revealed no significant difference (p=0.068) in the overall motor proficiency levels of the experimental group compared to the control group. The conclusion drawn from the results suggests that a perceptual- motor intervention only improved balance. However, children taking part in physical education classes presented by the teachers also proved to be beneficial. In Chapter 8, the sixth research article entitled “The Prevalence and Effect of Developmental Coordination Disorder on Learning Related Skills in Grade 1-learnersin South Africa” by De Milander, M., Du Plessis, J. and Du Randt, A. was accepted for publication in the South African Journal for Research in Sport, Physical Education and Recreation, 2014, 36(3): 51-60, ISBN: 0379-9069. The purpose of this study was to explore sport stacking as an alternative intervention approach with typically developing children and in addition to improve DCD. Sport stacking consists of participants stacking and un-stacking 12 specially designed plastic cups in predetermined sequences in as little time as possible. Eighteen children (6 girls and 12 boys) classified with DCD, 184 Chapter 9 – Summary, conclusions and recommendations between the ages of 6 and 7 years, participated. A pre-test/post-test quasi-experimental design with a control group was applied. The MABC-2 was used to assess the motor proficiency levels of the children and to classify DCD. The sport stacking intervention consisted of an 8-week programme of 3 sessions per week, 30 minutes per session. During the intervention the children learned the various sport stacking sequences, as well as how to apply them to a variety of physical activities. Analysis of the data was done using Statistical Analysis Software Version 9.1.3. Descriptive statistics, namely frequencies and percentages, were calculated for categorical data. Medians and percentiles were calculated for numerical data. Median differences were tested by calculating p-values using the signed-rank test. The chi-square was used to test for proportional differences. A significance level of 0.05 was accepted for all aspects of the study. The results indicated that prior to the intervention no significant differences occurred between the 2 groups. After the intervention, manual dexterity and balance showed a significant difference, while aiming and catching, showed no significant difference. The total test score revealed a significant difference in the overall motor proficiency levels of the experimental group. The results suggest that sport stacking can be used as an effective intervention programme for children with DCD. 9.2 Conclusions The conclusions that are drawn from this research are presented in accordance with the research questions set in Chapter 1, (p. 5-6). Research question 1: What is the prevalence of developmental coordination disorder amongst Grade 1 learners in Bloemfontein? The conclusions drawn from the results suggest that the prevalence of DCD amongst Grade 1 learners in Bloemfontein is estimated to be 15%. The results also indicate that boys have a higher prevalence of DCD when compared to their female counterparts. Although there was a statistically significant difference, it was only marginal. The 185 Chapter 9 – Summary, conclusions and recommendations research indicated a trend towards a higher prevalence in black learners with a suggestion of even a higher prevalence in learners of mixed race. Research question 2: Do parents have the competency to identify developmental coordination disorder in Grade 1-learnersat home? The results indicated that parents could identify 324 out of the 356 Grade 1 learners without motor difficulties indicating a 91% specificity by means of the DCDQ’07. In contrast the parents were able to identify 12 children with motor difficulties only, compared to 52 children identified by the MABC-2 Test, indicating a sensitivity of 23%. The (k)-coefficient of 0.151 indicated a 15.1% agreement between the two assessment tools after correcting for chance and show that the agreement of the two assessments is not high when completed by parents. The results suggest that parents possess the ability to identify children without motor difficulties, but not those where motor difficulties exist. Research question 3: Do teachers have the competency to identify developmental coordination disorder in Grade 1-learnersin the classroom? The results indicated that the teachers had 70.3% (306/435) specificity by means of the MABC-C. In contrast the teachers were only able to achieve a 46.5% (33/71) sensitivity for the total group. The calculated (k)-coefficient of 0.110 was on the 1%-level and provides a small effect size which means that the findings are of insignificant practical importance. The (k)-coefficient of 0.110 indicates that there was only a 11.0% agreement between the two measuring instruments after correcting for chance, which implies that the agreement of the two assessments was not high when questionnaires were completed by the teachers. Thus, the results suggest that the teachers could not accurately identify the learners with motor difficulties in the classroom. 186 Chapter 9 – Summary, conclusions and recommendations Research question 4: Does developmental coordination disorder influence the learning related skills of Grade 1 learners? The results indicated that the prevalence of DCD amongst children was 88% for those with no motor difficulties and 6% were at risk for motor difficulties as well as severe motor difficulties. The degree of motor difficulties had an effect on five of the eight specific learning related subtypes that were assessed namely; reasoning, numerical, gestalt, coordination and memory. The conclusion can be drawn that the different degrees of motor difficulties, namely at risk and severe motor difficulties, have significant different effects on learning of Grade 1 children. Research question 5: Will the application of a perceptual-motor intervention programme improve the status of Grade 1 learners diagnosed with developmental coordination disorder? The results indicate that prior to the intervention, no significant differences occurred between the two groups. However, after the intervention one subtest, namely balance showed a significant difference, while the remaining components, manual dexterity as well as aiming and catching, showed no significant differences. The three components contribute to the total test score, which revealed no significant difference in the overall motor proficiency levels of the experimental group compared to the control group. The conclusion drawn from the results suggests that a perceptual-motor intervention did not improve the motor proficiency levels of children with DCD significantly. However, the children who followed the perceptual-motor intervention had a 67% improvement (24/36), and the children who followed the Physical Education classes also improved by 50% (20/40). This indicates that a majority of children in both groups achieved scores above the 15th percentile during the post-test. 187 Chapter 9 – Summary, conclusions and recommendations Research question 6: Will the application of a sport stacking intervention programme improve the status of Grade 1 learners classified with DCD? The results indicate that prior to the intervention, no significant differences existed between the two groups. However, after the intervention two subtests, namely manual dexterity and balance each showed a significant difference, while the remaining component, aiming and catching, showed no significant difference. The three components contribute to the total test score, which revealed a significant difference in the overall motor proficiency levels of the experimental group compared to the control group. The conclusion drawn from the results suggests that sport stacking can be used as an effective intervention programme for children with DCD. 9.3 Recommendations and Limitations The results and recommendations made in this thesis will be disseminated to health professionals through publications in peer-reviewed research journals as indicated earlier in this chapter and presentations of papers at the following national conferences during 2014: Life Through Movement Conference (LTM), Developmental Coordination Disorder in grade 1 learners, Stellenbosch, September 2014. South African Sport and Recreation Conference (SASReCon), The competency of parents to identify Grade 1-learnerswith Developmental Coordination Disorder at home, Potchefstroom, November 2014. The following recommendations are proposed for each article presented in this study: The results of this thesis indicated that the prevalence of DCD amongst Grade 1 learners in Bloemfontein is estimated to be 15%. The results also indicate that boys 188 Chapter 9 – Summary, conclusions and recommendations have a significantly higher (p=0.0507) prevalence, although marginally, of DCD when compared to their female counterparts. In addition there was a statistically significant difference (p=0.0192) in DCD between the various ethnic groups. It is clear that the prevalence of DCD is higher in South-Africa compared to other parts of the world. It is therefore recommended that specific norms should be established for South African children. Additionally, establish a measuring instrument specifically for the South African population. It would also be necessary to present intervention programs by professionals who are familiar with motor development, to attend to the motor difficulties experienced by children with DCD. The results of this thesis with regard to the competency of parents to identify Grade 1- learnerswith DCD at home indicated a 15% convergent validity between the DCDQ’07 and the MABC-2 Test. In addition, to determine the ability of South African teachers in identifying Grade 1-learnerswith DCD in the classroom. The convergent validity between the two assessment tools was 11%, Therefore, it can be argued that parents using the DCDQ’07 at home as well as teachers using the MABC-C in the classroom could not identify children with DCD. Therefore the researchers recommend that caution should be taken when the DCDQ’07 and the MABC-C is used as a single indicator of DCD in young children. Results with regard to sensitivity differ between various authors, thus the independent use of screening tools will not aid professionals in the early identification of motor difficulties in young children. It is therefore recommended that more research should be conducted on this topic. In addition, the researchers propose that the norms of the MABC-C might be adapted in order to address each country’s specific needs. Furthermore, adapt the DCDQ’07 to the South African context, since the use of Canadian norms and Canadian item development, includes specific sports, which may not be applicable to South African children. With reference to the results for the Prevalence and effect of DCD on learning-related skills in Grade 1-learnersin South Africa, the prevalence of DCD (severe motor difficulties) amongst grade 1 learners was 6% and the at risk group constituted another 6%. Of the children tested, 88% had no motor difficulties. Motor difficulties had a 189 Chapter 9 – Summary, conclusions and recommendations significant effect on five of the eight learning-related subtypes, namely reasoning, numerical skills, gestalt, coordination and memory. It is recommended that the knowledge generated from this article should be used to inform teachers in order to address these problems by means of new preventative strategies. Thus, the researchers propose that teachers should take these difficulties in consideration in order to help children excel in their academic performance. It would also be necessary to present motor programs by professionals who are familiar with motor development, to attend to the motor difficulties experienced by children with DCD. With regard to the final two articles focusing on interventions for children with DCD the results were as follows. With regard to the perceptual-motor intervention for DCD in grade 1 children, the results indicated that only the balance sub-test improved. Interesting to note that the children taking part in Physical Education classes presented by the teachers also prove to be beneficial. In contrast, the sport stacking motor intervention programme for children with DCD showed an improvement in manual dexterity, balance as well as the total tests score. From the point of view of a therapist, no two children are the same, especially children identified with DCD, since they are not a homogeneous group. It is therefore recommended that individualized programmes should be established to address the specific need(s) for each child. The findings of this research contribute to the field of study by providing evidence that the bottom-up approach and the top-down approach should be combined with the purpose of improving the motor proficiency levels of children with DCD. The study demonstrated several limitations on various areas, which could be overcome in future research. The limitations include the following: The results of the study were based on data obtained from the Bloemfontein metropolitan only; therefore the results cannot be generalized to the larger population in the country, as certain discrepancies may occur. It is recommended that future studies should be conducted to incorporate all the provinces of South Africa including urban- and rural areas. 190 Chapter 9 – Summary, conclusions and recommendations A comparison between the DCDQ’07 and the MABC-2 Checklist, which can also be completed by the parents, could have been conducted to determine which screening questionnaire yielded the best results. Furthermore, the parents who took part in the current study were not specifically taught how to complete the DCDQ’07. Furthermore the teachers who took part in the current study were also not formally trained to observe and rate motor development according to the MABC-C criteria. The large number of parents and teachers may have affected the reliability of the scores according to the DCDQ’07 and the MABC-C. Additionally, since this was a population-based sample, criterion B of the diagnostic criteria for DCD, which states that the academic performance of the children should also be considered (APA, 2013), was not used. One of the major limitations with regard to the perceptual-motor intervention article was the fact that the control group was exposed to Physical Education classes. Thus, this could have contributed to the improvement of their motor proficiency levels and influenced the results. Another limitation to the study with regard to both interventions was that the children were tested on age band 1 (age 6) during the pre-test. A majority of the children turned 7 during the intervention, and therefore, had to be tested on age band 2, indicating that they had to perform more difficult activities compared to age band 1. Furthermore, the long-term effects/benefits of the perceptual-motor intervention as well as the sport stacking intervention should be researched. 9.4 References APA (AMERICAN PSYCHIATRIC ASSOCIATION). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. STEYN, H.S. (1999). Praktiese beduidendheid: die gebruik van effek groottes. Wetenskaplike Bydraes, Reeks B: Natuurwetenskappe nr. 117. Potchefstroom: Publikasiebeheerkomitee, PU vir CHO. 191 Appendix A APPENDIX A Premission from Department of Education 192 Appendix A 205 Nelson Mandela ave. / rl. Park West, Bloemfontein 9301 P.O. Box / Posbus 339 Bloemfontein 9300 South Africa / Suid Afrika T: +27(0)51 401 3000 F: +27(0)51 447 5211 www.ufs.ac.za 16 April 2012 MR. R.S. MALOPE Head of Department of Education Department of Education BLOEMFONTEIN 9301 Dear Mr. R.S. Malope RESEARCH TITLE: DEVELOPMENTAL COORDINATION DISORDER IN PRIMARY SCHOOL CHILDREN AGED 6-7 YEARS Hereby I (Monique de Milander) would like permission to conduct research at seven primary schools in Bloemfontein. The purpose of the research project will be to determine how many children in Bloemfontein suffer from Developmental Coordination Disorder. Furthermore, the impact of this disorders on children's school performance will be investigated as well as the ability of parents and teachers in the early identification of possible coordination problems. Finally, recommendations are made regarding intervention to improve this deviation. No research indicates whether South African parents and teachers have the ability in the early identification of possible coordination problems could be found. Data will be collected through the help of parents, teachers and Kinderkineticists. Parents will complete two questionnaires. The first questionnaire is the DCDQ-07 as well as the Movement Assessment Battery for Children-2 Checklist (Movement ABC- 2) about parents' perceptions of their child's motor abilities. Teachers will also complete the Movement ABC-2 Checklist, one month after school commenced. Questionnaires will take parents and teachers approximately 20 minutes to complete. 193 Appendix A In addition, Kinderkineticists will determine children's motor abilities using a standardized measuring instrument. All the learners participating in the research project will receive an intervention programme to improve potential developmental delays and to prevent future problems from occurring. The study will be executed over an eight week period. Three schools will form the control group with one intervention session per week. The other four schools will form the experimental group with three intervention sessions per week. The intervention will take place during the Life-Orientation period. Feedback will be provided to parents regarding their children's motor skills and school readiness. There is no cost associated with testing and feedback of results. The principals of each school in Bloemfontein, granted permission for the participation of their learners in this project and will receive a parental informed consent form to be completed by their legal guardians and each learner will receive a minor’s consent form to be completed. There are no risks involved in participation in this study. I trust that my application will meet your approval. …………………………. …………………………. MONIQUE DE MILANDER DR. F.F. COETZEE (RESEARCHER) (PROMOTOR) 194 Appendix B APPENDIX B Feedback from the Department of Education 195 Appendix B 196 Appendix C APPENDIX C Informed consent form 197 Appendix C 205 Nelson Mandela ave. / rl. Park West, Bloemfontein 9301 P.O. Box / Posbus 339 Bloemfontein 9300 South Africa / Suid Afrika T: +27(0)51 401 3000 F: +27(0)51 447 5211 www.ufs.ac.za 9 January 2012 INFORMATION DOCUMENT DEVELOPMENTAL COORDINATION DISORDER IN PRIMARY SCHOOL CHILDREN AGED 6-7 YEARS Studies in America and Europe have shown that 5-6% of children encounter motor difficulties with a boy to girl ratio of 2:1. Developmental Co-ordination Disorder (DCD) affects children's performance of functional motor tasks necessary for success in children's daily lives, in activities at home, free play and school. Children do not out grow this disorder, and to take preventive and rehabilitative action, specialized intervention programs are implemented. Negative influences associated with this disorder are, for example, physical health problems such as obesity, leading to the withdrawal from activities, which further leads to social, emotional and academic problems. Other contributing problems associated with DCD are Attention Deficit Hyperactivity Disorder (ADHD), speech and language impairments, and visual-motor problems. The purpose of the research project will be to determine how many children in Bloemfontein suffer from DCD. Furthermore, the impact of these disorders on children's school performance will be investigated as well as the role that parents and teachers may play in the early identification of possible coordination problems. Finally, recommendations are made regarding intervention to improve this deviation. No research showing whether South African parents and teachers have a role to play in the early identification of possible coordination problems could be found. Data will be collected through the help of parents, teachers and Kinderkineticists. Parents will complete two questionnaires. The first questionnaire is the DCDQ-07 as well as the Movement Assessment Battery for Children-2 198 Appendix C Checklist (Movement ABC-2) about parents' perceptions of their child's motor abilities. Teachers will also complete the Movement ABC-2 Checklist, one month after school commenced. Questionnaires will take parents and teachers approximately 20 minutes to complete. In addition, Kinderkineticists will determine children's motor abilities using a standardized measuring instrument. All the learners participating in the research project will receive an intervention programme to improve potential developmental delays and to prevent future problems from occurring. The study will be executed over an eight week period. Three schools will form the control group with one intervention session per week. The other four schools will form the experimental group with three intervention sessions per week. The intervention will take place during the Life-Orientation period. Feedback will be provided to parents regarding their children's motor skills and school readiness. There is no cost associated with testing and feedback of results. This information is vital in order to determine whether parents and teachers have a role to play in the early identification of coordination problems. Kinderkineticists involved in the development of the young child will be able to evaluate the results to help make the correct recommendations regarding intervention and the awareness of this disorder among parents and teachers. Your participation in this research project is greatly appreciated, but remains voluntary. The researcher undertakes to keep all personal information confidential. The results of this research study will be used for presentations at national and international conferences and for publication of articles in medical journals. Contact details of the researcher: ................................. Monique de Milander 051 401 9342 199 Appendix C CONSENT FORM TO PARTICIPATE IN RESEARCH PROJECT Please return all relevant forms back to school no later than Monday 22 of January 2012, whether completed or not. DEVELOPMENTAL COORDINATION DISORDER IN PRIMARY SCHOOL CHILDREN AGED 6-7 YEARS I, ____________________________________________, parent / guardian of ____________________________________________ (child's full name and surname) ______________________ (date of birth), give permission that he / she may participate in the research project. I am aware that the information supplied by completing the questionnaires, will be analysed to determine parents' perceptions of their child's motor skills and the ability of parents' in the early identification of motor problems. The researcher will take precautions to ensure that the identities of participants remain anonymous and that all information is kept confidential. ____________________ ____________________ Parent / Guardian Date ____________________ ____________________ Researcher's Signature Date 200 Appendix D APPENDIX D Child Assent Form 201 Appendix D 205 Nelson Mandela ave. / rl. Park West, Bloemfontein 9301 P.O. Box / Posbus 339 Bloemfontein 9300 South Africa / Suid Afrika T: +27(0)51 401 3000 F: +27(0)51 447 5211 www.ufs.ac.za 9 January 2012 CHILD ASSENT FORM You are being asked to take part in a research study being done by the University of the Free State. In this study, we are interested to know more about your motor proficiency. We have asked your parent or caregiver whether it is OK for you to participate, but now we want to see if it is OK with you. If you decide to take part in this study, you will be asked to perform a variety of physical activities such as catching a ball, jumping and throwing activities. This will take about 30 minutes to do. Also, we would like to ask your parents about your motor abilities. All the information we collect will be kept secret. We will not use your name so everything will remain private. By signing this you are showing that you understand what is going to be happening and have asked any questions you may have about the research. You can also ask questions later if you cannot think of them now. Signing this form does not mean that you have to finish the study- you can pull out from the study at any time without explaining why. _______________________________ ______________ Child’s signature Date Time 202 Appendix E APPENDIX E Summary of intervention programmes 203 Appendix E PERCEPTUAL-MOTOR INTERVENTION Week 1: Unilateral activities Skills developed Equipment Setup Activity Skill check Laterality; motor- One tumbling mat; four Place cones in a straight Do a unilateral crawl The child should raise planning; gross motor cones; active learning line 0.6 meter apart on from cone to cone by his or her torso so that coordination. cards (colors and the mat. using your right hand the weight is supported shapes). and right leg at the by the hands and knees same time and then without the stomach your left hand and left touching the floor; leg at the same time. As movement should be you pass each cone, continual; the relevant say what is shown on hand and knee should the card for that cone. move forward Once you reach the last simultaneously. cone, do a backward unilateral crawl to your original starting point by using your left hand and left leg at the same time and then your right hand and right leg at the same time. Skills developed Equipment Setup Activity Skill check Laterality; locomotor Hopscotch mat; active Hop through the mat The student should hop skills; spatial learning cards (colors using only your left foot. on only one foot in each awareness; motor and shapes). With each hop, say what square, thus isolating planning. is shown on the card for that side of the body. the square you are Make sure that the landing in. Repeat the student uses proper activity using only your hopping form: right foot. Continue in Swing your non-weight- this way-hopping bearing leg like a 204 Appendix E through the mat on your pendulum to produce left foot, then hopping power; on landing, keep through on your right the foot of your non- foot, then back to the weight-bearing leg left, and so on. behind your body; bend arms and swing forward to produce power. Skills developed Equipment Setup Activity Skill check Spatial awareness; eye- One hoop for each Crawl around the Make sure the student hand coordination; body student; one 22- outside of the hoop uses proper crawling awareness; gross motor centimeter playground while rolling the ball form: coordination. ball for each student. around inside the hoop Raise your torso so that with the fingertips of one your weight is supported hand; repeat the activity by your hands and using the elbow; reverse knees without your the direction of the stomach touching the crawl, using the other floor; movement should side. be continual; right side of the body and left side should move forward simultaneously. Skills developed Equipment Setup Activity Skill check Laterality; locomotor Agility rings (round ring), Place the rings on the Hop forward three rings, Make sure the student skills, motor planning. active learning cards floor so that they are saying the letter shown uses proper hopping (uppercase letters with touching one another. on the card for each ring form: Swing your non- pictures). Place an active learning as you land in it. Then weight-bearing leg like a card in each ring. hop to the next ring and pendulum to produce say what is shown in the power; on landing, keep picture on the card. the foot of your non- Continue on to the next weight-bearing leg letter-picture sequence. behind your body; bend arms and swing forward 205 Appendix E to produce power. Week 2: Bilateral activities Skills developed Equipment Setup Activity Skill check Locomotor skills; motor Ten cones with clear Scatter the cones 1.2 Frog-jump randomly Remind student to slow planning, spatial sleeves; active learning meters apart. from cone to cone. down and focus on awareness. cards (numbers 1-10). When you get to each using the correct form cone, touch it and say for a frog jump: start in a the color and number squat position; place shown on its card. your hand on the floor between your legs; move your hands to a position on the floor a short distance in front of your body; keeping your feet together and your hands on the floor, jump and let your feet land near your hands. Skills developed Equipment Setup Activity Skill check Locomotor skills; motor Foo-Foo wands (two per Touch your body parts Make sure the child planning, spatial child). with your wands and uses the wands awareness. name the different parts. properly, should be to identify body parts. Skills developed Equipment Setup Activity Skill check Laterality, motor One stomp board for Stop on the stomp Make sure that the planning, gross motor each child; one beanbag board with feet at once student uses both feet coordination. for each child. to project the beanbag while stomping. Remind into the air. Catch the the student to slow beanbag with two hands down and focus on and say the color of the using the correct form beanbag. Try five times. for a bird’s nest catch Repeat the activity, clap (two-hand catch with 206 Appendix E once and catch the palms up): prepare by beanbag with two extending your hands in hands. Try five times. front of your body with your elbows bent; reach for the beanbag with your palms up as the beanbag approaches; catch the beanbag with your hands only; keep eyes on the beanbag while catching. Skills developed Equipment Setup Activity Skill check Spatial awareness, Eight hoops, the color of Place hoop in a circle Starting at the first hoop, The ball should contact gross motor the hoop should match (about 1 meter) apart. say the shape and color the surface in front of coordination. that of the active Put an active learning shown on the card in the the student; keep your learning card; one 22- card inside each hoop. hoop. Then use a two- eyes up; use your finger centimeter playground handed dribble to pads – not your ball for each child; dribble the ball in the fingertips; for good active learning cards hoop five times, control, dribble at waist (shapes). counting from 1 to 5 as level or lower; student you dribble. Move to the should maintain control next hoop and repeat. of the ball for at least four consecutive bounces. Week 3: Cross-lateral activities Skills developed Equipment Setup Activity Skill check Locomotor skills, motor Six cones; active Place six cones 1 meter Crawl from cone to Make sure child use planning, spatial learning cards apart in a straight line. cone. Along the way proper crawling form: awareness. (numbers). touch each cone and raise your torso and say the number shown support your weight on on the card for that your hands and knees cone. with your stomach off 207 Appendix E the floor; move without stopping; your right hand and left knee should move forward simultaneously; make sure child correctly identifies the numbers on the cards Skills developed Equipment Setup Activity Skill check Cross-laterality, 22-centimeter Use the floor tape to Hold the ball and walk Make sure that the child directionality, balance, playground ball; floor mark an 2.4 meter line. forward on the line using uses proper form for eye-hand coordination; tape. a crossover step: On dribbling: keep your midline crossing. each step with your right eyes up; use your finger foot, step to the left of pads – not your the line; do the same fingertips; for good with the opposite foot; control, dribble at waist continue this pattern to level or lower. Make the end of the line. After sure that child use each step, bounce the proper form for the ball with either hand. crossover step: midline crossing. Skills developed Equipment Setup Activity Skill check Eye-hand coordination, One stomp board for Stop on the stomp Make sure that the gross motor each child; one beanbag board with right foot to student uses proper development. for each child. project the beanbag into form for cross-lateral the air. Catch the stomping: face the beanbag with the left board with feet slightly hand and count. Try ten apart and adjacent to times. Repeat the each other; step quickly activity, with the on the stomp board with opposite foot. minimum force; if Progression, clap once stomping with right foot 208 Appendix E and catch the beanbag. catch with left hand and Try ten times; repeat the opposite. Make sure opposite side. child uses proper form for catching: prepare by extending your hands in front of your body with your elbows bent; reach for the beanbag with your palms up as the beanbag approaches; catch the beanbag with your left or right hand only; keep eyes on the beanbag while catching. Skills developed Equipment Setup Activity Skill check Dynamic balance, Floor beam; hoop with Walk forward on the Watch for balance spatial awareness. stand; two cones with beam from one end to problems and provide hurdle. the other. Along the support when needed, if way, step over the child have trouble let hurdle and through the them walk on floor; hoop. make sure that the child uses dynamic balance to maintain equilibrium while in motion; child should do the task smoothly, without falling or having to hold on to an object. Week 4: Combined activities Skills developed Equipment Setup Activity Skill check Laterality; locomotor Jump box (30- Place the hurdle 30- Step onto the box; jump Make sure only one skills; motor planning. centimeter high); one centimeter in front of the from the box over the child is on the course at 209 Appendix E foam hurdle (made from jump box. Place the first hurdle and into hoop a time; make sure the pool noodle on two hoop 30-centimeter in one; from one to two child prepare to jump cones); three hoops front of the hurdle and and step through the with movement that (two on the ground, on the second hoop 30- last hoop. includes bending both of in a stand). centimeters in front of their knees and the first hoop. Set up the extending their arms third hoop in the stand behind the body. and place it 1 meter in front of the second hoop. Skills developed Equipment Setup Activity Skill check Locomotor skills, motor Mini trampoline; scooter Place the scooter board Jump on the mini Emphasize safety: on planning, eye-hand board; 2 meter jumping 1.2 meter in front of the trampoline for five times; the scooter board, coordination. rope; hoop; 22- mini trampoline. Place lie facing forward on our trampoline etc. Remind centimeter ball. the jump rope 1.5 tummy on the scooter the child to slow down meters in front of the board and use both and focus on using the scooter board and the arms together to propel correct form for a hoop and ball 1.2 meter yourself forward to the standing long jump; in front of the jump rope. rope; jump over the rope bend both knees with from front to back and your arms extended then back to front five behind your body before times; walk to the hoop take-off; when jumping, and bounce the ball in thrust your arms the hoop five times with forcefully forward and both hands together. upward (above your head); take off and land with both feet; move arms downward on landing; child should use both hands to push the ball to the ground. 210 Appendix E Skills developed Equipment Setup Activity Skill check Cross-lateral Ladder mat; three Place the hoops in a Walk on the rungs of the Make sure that the child awareness; dynamic hoops; stomp board; row 1.2 meters away ladder; leap into and uses proper form for balance; eye-hand one beanbag. from the ladder mat with then out of each hoop; leaping: move coordination. 30-centimeters in stomp on the board with continuously without between each one. The your right foot to launch hesitation before the stomp board should be the beanbag, the catch leap; take off on one- placed 1.2 meters away it with your left hand; foot and land on the from the last hoop. opposite side as well. other; use a long stride in which both feet are off the ground during each leap; for each leap reach in front of your body with the opposite arm. Skills developed Equipment Setup Activity Skill check Cross-lateral Scooter board; 3 meter Lie on your tummy on Stress scooter board awareness; dynamic tunnel; three cones; two the scooter board; use safety; make sure that balance; eye-hand noodles or long jump alternating hands to the student uses only coordination. ropes (4 meters). propel yourself forward one hand at a time in through the tunnel; propelling the scooter kneel on the scooter board. board and use alternate hands to weave through the cones; sit on the scooter board and use alternating feet to propel yourself backward through the space between the noodles or ropes. 211 Appendix E Week 5: Unilateral activities Skills developed Equipment Setup Activity Skill check Laterality; locomotor Hopscotch mat; active Hop sideways through Child should hop only skills; motor planning; learning cards (lower the mat using only your on one foot in each spatial awareness. case with pictures). left foot. With each hop, squared; make sure say what is shown on child uses proper the card for the square hopping form: swing you are landing in. non-weight-bearing leg Repeat with right foot. like a pendulum to produce power; on landing, keep the foot of your non-weight-bearing leg behind your body; bend your arms and swing them forward to produce power. Skills developed Equipment Setup Activity Skill check Laterality; motor One scooter board for Attach the rope to the Lie on your torso on the Safety is important; planning; gross motor each child; jump rope of base of the volleyball scooter board and use make sure child isolates coordination. 3 meters long; and extend in on the the rope to pull yourself one side of the body by volleyball. floor; position the forward with only your using only one hand to scooter at the free end right hand; repeat using pull. of the rope. left hand; sit on the scooter board and pull with right and then left hand. Skills developed Equipment Setup Activity Skill check Laterality; eye-foot Five white and black Arrange to rows of Walk between the two Make sure that the coordination. foam bricks. bricks-the right one rows of bricks, kicking student kicks each brick containing whit bricks the black ones over with with proper foot. and the left one black your left foot and kicking bricks; in each row, the the white ones over with 212 Appendix E bricks should be 0.6 your right foot. meters apart; stagger the spacing go the rows. Skills developed Equipment Setup Activity Skill check Laterality; motor One hula hoop for each Place the hoops on the Toss the disc into the Make sure child isolates planning; coordination. child; Frisbee; floor floor against a wall; the target using your right one side of the body; tape. hoops should be in a hand and stepping with make sure that the child row about 1 meter apart your right foot, do the use proper form for from each other; use the same with your left hand tossing the disc: turn floor tape to mark a line and foot. your throwing hand so approximately 1.5 the palms faces up; hold meters away from the the Frisbee with your hoops. index finger on the outside rim, your other three fingers on the bottom side, and your thumb on the top side; keep your palm up and the elbow of your throwing arm in toward your body; face the target and step toward it with the foot on the same side as throwing hand, then toss; snap wrist and fingers on the follow-through; keep palm up throughout the throw. 213 Appendix E Week 6: Bilateral activities Skills developed Equipment Setup Activity Skill check Laterality; locomotor Leap; hop and jump Start at the pointed end Encourage child to skills; motor planning. mat; active learning of the mat; jump across speak loudly when cards (uppercase this first section of the saying the numbers as letters). mat with both feet and he/she jumps; remind say the number shown child to slow shown and on the card for that focus on correct form for sections; move to the standing long jump; next section to the right bend both knees with and jump across every your arms extended remaining sections until behind your body before you reach the end. Don’t take-off; when jumping, need to make the thrust your arms distance. forcefully forward and upward above head; take off and land with both feet; move arms downward on landing. Skills developed Equipment Setup Activity Skill check Motor planning; gross Ten giant shapes Scatter the giant shapes Do frog jumps from one During sideways motor coordination; (circles). on the floor; 30- shape to another; after jumping, make sure that locomotor skills. centimeters apart. each jump and starting the child jumps with feet with A, work your way facing forward; remind through the alphabet, child of proper form for start again if you get to frog jump: start in a the end; repeat by squat position; place jumping sideways. your hand on the floor between your legs; move your hands to a position on the floor a short distance in front of 214 Appendix E your body; keeping your feet together and your hands on the floor, jump and let your feet land near your hands. Skills developed Equipment Setup Activity Skill check Eye-hand coordination; One 22-centimeter Use floor tape to mark Sit facing the and roll Make sure child tracking skills. playground ball for each out a line parallel to a the ball to the wall with performs activity with child. wall at a distance of 2 two hands, after each both hands. meters. roll, say the alphabet, roll as many times as possible in the allotted time; stand on line and toss the ball with two hand against the wall, let it bounce one time after hitting the wall, catch with two hand, repeat the toss but catch without the bounce. Skills developed Equipment Setup Activity Skill check Locomotor skills; motor Floor tape. Use tape to mark four Jump over the line on Remind the student to planning; spatial lines, approximately 3 the floor with both feet; slow down and focus on awareness. meter long and 3 meters with hand on your hips, using the correct form apart on the floor for jump over the line slowly for a standing long each station. for five times and the jump: bend both knees quickly; jump across the with your arms extended line high, then turn behind your body before around and jump across take-off; when jumping, the line, repeat and thrust your arms 215 Appendix E jump low; repeat the forcefully forward and activities and recite the upward (above your alphabet while jumping. head); take off and land with both feet; move arms downward on landing. Week 7: Cross-lateral activities Skills developed Equipment Setup Activity Skill check Cross-lateral 22-centimeter Position two cones 1.5 Taking a 3-meter Make sure the child awareness. playground ball; foam meters apart; use the approach, run up to the uses proper kicking brick; two cones; floor floor tape to mark a line ball without slowing and form: a fast and nonstop tape. 3 meters from where use your right foot to approach to the ball; just child will be kicking the kick the ball at the brick prior to kicking the ball, ball. between the cones; take a long stride; place when kicking with your your non-kicking foot right foot, extend your even with or slightly left arm forward; repeat behind the ball; kick the with your left foot and ball with instep or toe of right arms; repeat five preferred foot; follow times. through by landing on your kicking foot. Skills developed Equipment Setup Activity Skill check Laterality; motor One scooter board for Position the cones a half Lie on your tummy on Safety first; watch for planning; gross motor each child; four cones; meter apart in a straight the scooter board and cross-laterality; make coordination. active learning cards line. push yourself from cone sure child says aloud (lowercase letters). to cone, alternate side in what is shown on the pushing, as you pass card. each cone, say what is shown on the card; repeat the activity by sitting on the scoot board. 216 Appendix E Skills developed Equipment Setup Activity Skill check Laterality; motor Four buckets and four Crawl from beanbag t Make sure child does planning; gross motor beanbags in primary beanbag, putting each not switch hands; make coordination. colors. one in the bucket with sure child uses correct the matching color; crawling form: the child when picking up a should raise his or her beanbag from the floor, torso so that the weight use whichever hand is is supported by the closest to it and use that hands and knees same hand to put the without the stomach beanbag in the bucket. touching the floor; movement should be continual; the relevant hand and knee should move forward simultaneously. Skills developed Equipment Setup Activity Skill check Cross-lateral Leap; hop and jump Start at a line 3 meters Make sure child uses awareness; dynamic mat; floor tape; active from the mat and leap proper form for leaping: balance. learning cards (lower across the mat; start at move continuously case). the narrow end and without hesitation before work your way to the the leap; take off on one wide end; emphasize foot and land on the using good leaping other; use a long stride form; on landing say in which both feet are off what is shown on the the ground during each card for the section. leap; for each leap, reach in front of your body with the arm on the opposite side from your landing foot. 217 Appendix E Week 8: Combination activities Skills developed Equipment Setup Activity Skill check Eye-hand coordination; Giant shapes; 22- Place the shapes 1.2 Hop from shape to Make sure child use one unilateral awareness. centimeter playground meters apart to allow shape, at each shape hand to bounce; make ball. space for child to hop to bounce the ball in the sure child uses proper the next shape. shape five times with form for dribbling: keep your right hand and then your eyes up; use your the left hand; while finger pads – not your bouncing the ball say fingertips; for good the shape and color. control, dribble at waist level or lower. Make sure that child use proper form for the crossover step: midline crossing; make sure child use proper hooping form: Swing your non-weight-bearing leg like a pendulum to produce power; on landing, keep the foot of your non-weight-bearing leg behind your body; bend arms and swing forward to produce power. Skills developed Equipment Setup Activity Skill check Eye-hand coordination; Eight hula hoop; floor Set each hoop close Hop five times in each If child have trouble motor planning; dynamic beam; 22-centimeter enough to the floor hoop; get on the beam walking on the beam, balance. playground ball. beam so the students and slide sideways to walk on the floor; make can bounce the ball in the right to the end of sure child uses proper the hoop as the slide the beam, as you go hopping form (as 218 Appendix E down the beam. bounce ball once in indicated previously); each hoop with right proper sliding form; turn hand, repeat with the body sideways with your left hand. leading foot, the slide your trailing foot to meet it; move with a rhythmic continual motion; make use of proper dribbling (as indicated previously). Skills developed Equipment Setup Activity Skill check Bilateral awareness; Three hoops; scooter Place the hoops in a line Jumping from hoop to Remind child to use eye-hand coordination; board; beanbag; floor so that they are hoop by taking off and proper form for standing motor planning. tape. touching each other; landing with both feet long jump and catching use the floor tape to simultaneously; lie on (as indicated mark an X about half a your tummy on the previously); as well as meter away from the board and use both tossing: use both hands hoops and place the hand at the same time together to make the scooter board there; to propel yourself toss; make your tosses place the beanbag 2 forward to the beanbag; equally high; keep your meters away from the toss and catch the eyes focused at the scooter board. beanbag five times with peak of the toss; keep both hands. your elbows close to your body; stand straight without leaning. Skills developed Equipment Setup Activity Skill check Cross-lateral Incline mat; step box 30- Place one hoop on the Crawl up the incline mat Make sure child uses awareness; motor centimeters high; hoop floor 30-centimeters in onto the step box; jump proper crawling: raise planning. on stand; hurdle on two front of the incline mat, off the box into the hoop your torso so that your cones. the vertical hoop should on the floor; step weight is supported by be set up 1.2 meters through the vertical your hands and knees away from the hoop on hoop and say “through”; without your stomach 219 Appendix E the floor; place the crawl under the hurdle touching the floor; hurdle 1.2 meters away and say “under”. movement should be from the vertical hoop. continual; right side of the body and left side should move forward simultaneously. and standing long jump (as indicated previously). Week 9: Unilateral activities Skills developed Equipment Setup Activity Skill check Locomotor skills; motor Six cones; six cone Place six cones 1.2 Hop from cone to cone, Make sure child uses planning. collars; active learning meter apart in a straight at each cone, say the proper hopping form: cards (uppercase letters line, place matching letter or picture shown Swing your non-weight- with pictures). letter and picture cards on the card for that c bearing leg like a in the cones, alternating one. Repeat activity pendulum to produce with each cone using your other foot. power; on landing, keep example, letter A, apple, the foot of your non- letter B, ball picture. weight-bearing leg behind your body; bend arms and swing forward to produce power. Skills developed Equipment Setup Activity Skill check Spatial awareness; 65-centimeter exercise Post a letter card and a Roll the ball to the wall Make sure child uses gross otor coordination. ball; active learning picture card side by side with your dominant proper form for cards (uppercase with on the wall against hand; be sure you step unilateral rolling: face pictures); floor tape. which students will roll forward with the same your target; step toward the ball, the name of foot as the hand you the target with the foot whatever is shown on used to roll the ball, on the same side as the picture card should while it rebounds off the your rolling arm; use a start with the letter wall, say the letter pendulum motion with shown on the letter shown on the card your arm to roll the ball card. Use the floor tape posted on the wall, (as in bowling); bend 220 Appendix E to mark a line 2 meters catch the ball on the your knees to lower your from the wall so that the rebound, repeat with body and release the child will know where to non-dominant hand. ball close to the ground; stand to roll the ball. follow through with your rolling hand toward the sky. Skills developed Equipment Setup Activity Skill check Laterality; eye-hand Juggling scarves. Toss the scarf up into Make sure child toss coordination. the air with your right and catch with the same hand, then catch it with hand; make sure child your right hand using uses proper form for the lion’s claw catch; as lion’s claw hand: you toss the scarf, say prepare by extending “toss up” and catch your hand in front of “catch down”; repeat your body with your with the left hand until elbows bent; palms music stops. facing outward; reach for the scarf with your palms downward with palm facing down; catch the scarf with your hand only; keep eyes on the scarf while catching. Skills developed Equipment Setup Activity Skill check Balance. 22-centimeter Put your belly on the Child should try to playground ball ball and try to balance achieve static balance, yourself without encourage to make no touching the floor; with movement if possible. belly on ball, lift right arm and right leg and try to balance, repeat with 221 Appendix E left side. Week 10: Bilateral activities Skills developed Equipment Setup Activity Skill check Laterality; locomotor Five hoops. Place five hoops in a Jump forward from hoop Remind child to slow skills; motor planning. straight line 15- to hoop while saying down and focus on centimeters apart. one letter in alphabetical correct form for standing order after each jump; long jump: bend both repeat activity knees with your arms backwards. extended behind your body before take-off; when jumping, thrust your arms forcefully forward and upward (above your head); take off and land with both feet; move arms downward on landing. Skills developed Equipment Setup Activity Skill check Laterality, dynamic Floor beam – best if 2 Hold a noodle horizontal Make sure child uses balance. meters long and no in both hands with proper form for walking: more than 15- palms up at chest level stand tall by keeping centimeters off the floor; and walk forward for the your body erect; you long noodle 1 meter length of the beam; should be able to draw a long. carry a noodle over your straight line from ear to head with both hands shoulders; align your and walk forward for the hips, knees and ankles; length of the beam. you head should be level and looking forward, and your chin should be parallel to the ground; shoulders should be relaxed and 222 Appendix E arms bent; walk heel to toe; should do task smoothly, without falling or holding on to an object; if they experience difficulty let them walk on the floor. Skills developed Equipment Setup Activity Skill check Eye-hand coordination; Four cones; active Use floor tape to mark a While standing, place Make sure child spatial awareness; learning cards 2 meter line away from the ball on the floor performs each activity coordination. (lowercase letters and each cone. between your legs and with both hands. spelling words); floor roll it ( with both hand tape; 22-centimeter together) at a cone, say playground ball. the letter on the cone, retrieve the ball and repeat until you have rolled the ball five times; turn and face away from the cone, roll the ball backward between your legs at the cone. Skills developed Equipment Setup Activity Skill check Directionality; locomotor Jump box; incline mat; Activity may be done Make sure child lands skills hoop. without the incline mat, on two feet and thrusts use a mat to crawl up to his or her arms the jump box; get on the downward on landing; jump box and assume remind to slow down proper jumping position, and focus on correct with knees bent and form for a standing long your arms extended jump: bend both knees behind your body, jump with your arms extended into the hoop, making a behind your body before 223 Appendix E quarter-turn to the right, take-off; when jumping, repeat it to the left. thrust your arms forcefully forward and upward; take off and land with both feet; move arms downward on landing. Adapted from Johnstone and Ramon (2011) 224 Appendix E SPORT STACKING INTERVENTION During week 1 and week 10 the children underwent the pre-test and post-test. During week 2 to week 5 the children took part in the intervention that was repeated in order to complete an 8 week intervention period. Week 2: Programme 1 Equipment: Speed-Stacks; four trampolines; four beacons; twelve beanbags; twelve ropes; 30 hula hoops. Activity 1 Build-up and break down the 3 tower Activity 2 Run and jump 20 jumps on the trampoline Then jump double legs and build the 3 tower Run back Activity 3 Walk on a line Balancing a beanbag on your head Build and break down the 3 tower Activity 4 Jump from hula to hula (hula’s in a snake shape) each 3rd hula build and break down the 3 tower Week 2: Programme 2 Equipment: Speed-Stacks; different colour shapes; big beacons; small beacons; wooden planks; all the hula’s; 12 Hockey beacons. Activity 1 Build-up and Break down the 3 Tower Activity 2 Robot Game Each child stands on a shape Jump on left/right leg Build the colour you are standing on (3 tower) Activity 3 Obstacle course 2 Teams 4 beacons with planks on (going over and under) Build and break down 3 tower 225 Appendix E Run back running backwards Activity 4 Hula snake Climbing through each hula as fast as you can Build and break down the 3 tower Week 2: Programme 3 Equipment: Speed-Stacks; 12 beanbags; 12 Stump-boards; 12 Hula’s; 12 Hockey beacons. Activity 1 Build-up and Break down the 3 Tower Activity 2 Race 2 Children in a team Throw and catch beanbag (5 times without falling; both hands) Run to the middle Build and break down 3 stacks of the 3 tower Run back and sit down (first team to sit wins) Activity 3 Individual race Stump-board, catch 5 times (both hands/left/right) Run and build 3 stacks of 3 tower Run back (first one to sit wins) Activity 4 3 Teams- Race Each team stands in the corner of the hall in a colour hoola-hoop Jump on one leg (left/right) Collecting your colour speed-stacks(one by one) Build your 3 tower and sit (first team sitting down wins) Week 3: Programme 4 Equipment: Speed-Stacks; 12 hockey beacons; 12 hula’s; beads and laces; bouncey ear balls. Activity 1 Build-up and Break down the 6 Tower Activity 2 Race Hop on right leg 226 Appendix E Build and break down 6 Tower Hop back on left leg Activity 3 Start at the beacon Run to the Hula Thread all the beads Run to the speed-stacks Build a 6 tower and run back (tag your friend to go next) Activity 4 Bouncing Race Bounce on the Ear Ball Build and break down the 6 tower Bounce back (tag your friend to go next) Week 3: Programme 5 Equipment: Speed-Stacks; purple worms; 12 hockey beacons; 12 elephant feet; 12 shapes. Activity 1 Build-up and Break down the 6 tower Activity 2 Crawl through purple worm Jump hop-scotch on shapes Build and break down 6 tower Activity 3 Race on elephant feet Build and break down 6 tower Race back on elephant feet Activity 4 2 teams! Competition Building the BIGGEST and HIGHEST tower Week 3: Programme 6 Equipment: Speed-Stacks;12 hula hoops; 12 blue balance boards; 15 hockey. beacons Activity 1 Build-up and break down the 6 tower Activity 2 Building circle Standing in a circle each child gets a number to remember 227 Appendix E When your number is called run to the middle Build and break down 6 tower and run back (you call the next number) Activity 3 Clock-building Speed-Stacks Building your Speed-Stacks – CLOCK-WISE Breaking down your Speed-Stacks – CLOCK-WISE Activity 4 Balancing on blue balance boards When whistle blow run and build a 6 tower Run back and start balancing When whistle blow run and break down a 6 tower Week 4: Programme 7 Equipment: Speed-Stacks; 12 big picture balls. Activity 1 Build-up and break down the 10 tower Activity 2 Bounce and catch the ball After 10 bounces build a 10 tower and break down Activity 3 Competition TIME! Building and breaking down 10 tower competition! Week 4: Programme 7 Equipment: Speed-Stacks; 12 big picture balls. Activity 1 Build-up and break down the 10 tower Activity 2 Bounce and catch the ball After 10 bounces build a 10 tower and break down Activity 3 Competition TIME! Building and breaking down 10 tower competition! Week 4: Programme 8 Equipment: Speed-Stacks; 12 hula hoops; 12 beanbags; beads and lace; 12 hockey beacons. Activity 1 Build-up and break down the 10 tower 228 Appendix E Activity 2 Stand at the beacon Aim for a hula-hoop throw your beanbag into a hula Run and build a 10 tower Activity 3 Animal walk RACE (crab, frog ,baboon) Build and break down a 10 tower Activity 4 Start at the beacon Run to the Hula Thread all the beads Run to the speed-stacks Build a 10 tower and run back (tag your friend to go next) Week 4: Programme 9 Equipment: Speed-Stacks; 12 hula hoops; ladders (speed and agility); 12 hockey beacons; 12 big picture balls; 12 small hand balls. Activity 1 Build-up and Break down the 10 Tower Activity 2 RACE (speeds-stacks spread out all over) Run and fetch 10 cups Only one cup at a time (picking the cups up with your left hand only) Build a 10 tower and sit down (first one to sit wins) Activity 3 Ladder Race (Speed and Agility) Build and break down a 10 tower Activity 4 Teams (2 Children in a team) Bounce / throw / roll (10 times) Run and build a 10 tower Week 5: Programme 10 Equipment: Speed-Stacks; 12 hockey beacons; purple worms. Activity 1 Build-up and break down the 3 and 6 tower Activity 2 Build-up and break down 10 tower Activity 3 RACE 229 Appendix E Build 3 ,6,10 tower Break down 10,6,3 tower Activity 4 Build and break down 3 tower Crawl through purple worm Build and break down 6 tower Run back and tag a friend Week 5: Programme 11 Equipment: Speed-Stacks; 12 hockey beacons; 4 trampolines; 4 small hand balls; 1 bib. Activity 1 Build-up and Break down the 3,6,10 tower Activity 2 SQUARE Building and breaking down each other’s towers Moving forward in square formation Building and breaking down 3,6,10 towers Activity 3 Jump on trampoline 10 times Hold ball under your chin Stop and build a 6 tower stop and build a 10 tower Run back and tag a friend Activity 4 Build-touchers One is the “tagger” When tagged run to speed-stacks and start stacking Week 5: Programme 12 Equipment: Speed-Stacks; 12 hockey beacons; 12 beanbags; 12 balloons. Activity 1 Build-up and break down the 3, 6,10 tower Activity 2 Teams (2 in a team) Beanbag race- (holding beanbag with hands/backs/heads/bums) Then build a 6 tower Activity 3 Obstacle course Walk with beanbag between knees Wheel-barrow race 230 Appendix E Both build a 10 tower Wheel-barrow race back (first team to sit wins) Activity 4 balloon game Keeping your balloon in the air (both hands/right/left) When whistle blow, run and build a 6 tower Run back and start keeping your balloon in the air again. Created by du Plessis and du Randt (2013) 231 Appendix F APPENDIX F Guidelines for authors: The African Journal for Physical, Health Education, Recreation and Dance 232 Appendix F GUIDELINES FOR AUTHORS The African Journal for Physical, Health Education, Recreation and Dance (AJPHERD) is a peer-reviewed journal established to: i) provide a forum for physical educators, health educators, specialists in human movement studies and dance, as well as other sport-related professionals in Africa, the opportunity to report their research findings based on African settings and experiences, and also to exchange ideas among themselves. ii) afford the professionals and other interested individuals in these disciplines the opportunity to learn more about the practice of the disciplines in different parts of the continent. iii) create an awareness in the rest of the world about the professional practice in the disciplines in Africa. GENERAL POLICY AJPHERD publishes research papers that contribute to knowledge and practice, and also develops theory either as new information, reviews, confirmation of previous findings, application of new teaching/coaching techniques and research notes. Letters to the editor relating to the materials previously published in AJPHERD could be submitted within 3 months after publication of the article in question. Such letter will be referred to the corresponding author and both the letter and response will be published concurrently in a subsequent issue of the journal. Manuscripts are considered for publication in AJPHERD based on the understanding that they have not been published or submitted for publication in any other journal. In submitting papers for publication, corresponding authors should make such declarations. Where part of a paper has been published or presented at congresses, seminars or symposia, reference to that publication should be made in the acknowledgement section of the manuscript. AJPHERD is published quarterly, i.e. in March, June, September and December. Supplements/Special editions are also published periodically. SUBMISSION OF MANUSCRIPT Three copies of original manuscript and all correspondence should be addressed to the Editor-In-Chief: 233 Appendix F Professor L. O. Amusa Tel: +27 15 9628076 Centre for Biokinetics, Recreation Fax: +27 15 9628076/9628035 and Sport Science, University of Venda for E-mail: amusalbw@yahoo.com Science and Technology, P. Bag X5050, Thohoyandou 0950 Republic of South Africa Articles can also be submitted electronically, i.e. via e-mail attachment. However, the corresponding author should ensure that such articles are virus free. AJPHERD reviewing process normally takes 4-6 weeks and authors will be advised about the decision on submitted manuscripts within 60 days. In order to ensure anonymity during the reviewing process authors are requested to avoid self-referencing or keep it to the barest minimum. PREPARATION OF MANUSCRIPT Manuscripts should be type written in fluent English (using 12-point Times New Roman font and 1½ line-spacing) on one side of whiteA4-sized paper justified fully with 3cm margin on all sides. Guidelines for Authors 317 234 Appendix F In preparing manuscripts, MS-Word, Office 98 or Office 2000 for Windows should be used. Length of manuscripts should not normally exceed 12 printed pages (including tables, figures, references, etc.). For articles exceeding 10 typed pages US$ 10.0 is charged per every extra page. Longer manuscripts may be accepted for publication as supplements or special research reviews. Authors will be requested to pay a publication charge of US$ 350.0 to defray the very high cost of publication. The pages of manuscripts must be numbered sequentially beginning with the title page. The presentation format should be consistent with the guidelines in the publication format of the American Psychological Association (APA) (4th edition). Title page: The title page of the manuscript should contain the following information: Concise and informative title. Author(s’) name(s) with first and middle initials. Authors’ highest qualifications and main area of research specialisation should be provided. Author(s’) institutional addresses, including telephone and fax numbers. Corresponding author’s contact details, including e-mail address. A short running title of not more than 6 words. Abstract An abstract of 200-250 words is required with up to a maximum of 5 words provided below the abstract. Abstract must be typed on a separate page using single line spacing, with the purpose of the study, methods, major results and conclusions concisely presented. Abbreviations should either be defined or excluded. Text Text should carry the following designated headings: Introduction, materials and methods, results, discussion, acknowledgement, references and appendices (if appropriate). Introduction The introduction should start on a new page and in addition to comprehensively giving the background of the study should clearly state the problem and purpose of 235 Appendix F the study. Authors should cite relevant references to support the basis of the study. A concise but informative and critical literature review is required. Materials and Methods This section should provide sufficient and relevant information regarding study participants, instrumentation, research design, validity and reliability estimates, data collection procedures, statistical methods and data analysis techniques used. Qualitative research techniques are also acceptable. Results Findings should be presented precisely and clearly. Tables and figures must be presented separately or at the end of the manuscript and their appropriate locations in the text indicated. The results section should not contain materials that are appropriate for presentation under the discussion section. Formulas, units and quantities should be expressed in the systeme 318 Guidelines for Authors 236 Appendix F internationale (SI) units. Colour printing of figures and tables is expensive and could be done upon request authors’ expense. Discussion The discussion section should reflect only important aspects of the study and its major conclusions. Information presented in the results section should not be repeated under the discussion. Relevant references should be cited in order to justify the findings of the study. Overall, the discussion should be critical and tactfully written. References The American Psychological Association (APA) format should be used for referencing. Only references cited in the text should be alphabetically listed in the reference section at the end of the article. References should not be numbered either in the text or in the reference list. Authors are advised to consider the following examples in referencing: Examples of citations in body of the text:- For one or two authors; Kruger (2003) and Travill and Lloyd (1998). These references should be cited as follows when indicated at the end of a statement: (Kruger, 2003); (Travill & Lloyd, 1998). For three or more authors cited for the first time in the text; Monyeki, Brits, Mantsena and Toriola (2002) or when cited at the end of a statement as in the preceding example; (Monyeki, Brits, Mantsena & Toriola, 2002). For subsequent citations of the same reference it suffices to cite this particular reference as: Monyeki et al. (2002). Multiple references when cited in the body of the text should be listed chronologically in ascending order, i.e. starting with the oldest reference. These should be separated with semi colons. For example, (Tom, 1982; McDaniels & Jooste, 1990; van Heerden, 2001; de Ridder at al., 2003). 237 Appendix F Reference List In compiling the reference list at the end of the text the following examples for journal references, chapter from a book, book publication and electronic citations should be considered: Examples of journal references: Journal references should include the surname and initials of the author(s), year of publication, title of paper, name of the journal in which the paper has been published, volume and number of journal issue and page numbers. For one author: McDonald, A.K. (1999). Youth sports in Africa: A review of programmes in selected countries. International Journal of Youth Sports, 1(4), 102- 117. For two authors: Johnson, A.G. & O’Kefee, L.M. (2003). Analysis of performance factors in provincial table tennis players. Journal of Sport Performance, 2(3), 12-31. For multiple authors: Kemper, G.A., McPherson, A.B., Toledo, I. & Abdullah, I.I. (1996). Kinematic analysis of forehand smash in badminton. Science of Racket Sports, 24(2), 99-112. Examples of book references: Guidelines for Authors 319 238 Appendix F Book references should specify the surname and initials of the author(s), year of publication of the book, title, edition, page numbers written in brackets, city where book was published and name of publishers. Chapter references should include the name(s) of the editor(s) and other specific information provided in the third example below: For authored references: Amusa, L.O. & Toriola, A.L. (2003). Foundations of Sport Science (1st ed.) (pp. 39-45). Mokopane, South Africa: Dynasty Printers. For edited references: Amusa, L.O. and Toriola, A.L. (Eds.) (2003). Contemporary Issues in Physical Education and Sports (2nd ed.) (pp. 20-24). Mokopane, South Africa: Dynasty Printers. For chapter references in a book: Adams, L.L. & Neveling, I.A. (2004). Body fat characteristics of sumo wrestlers. In J.K. Manny and F.O. Boyd (Eds.), Advances in Kinanthropometry (pp. 21-29). Johannesburg, South Africa: The Publishers Company Ltd. Example of electronic references: Electronic sources should be easily accessible. Details of Internet website links should also be provided fully. Consider the following example: Wilson, G.A. (1997). Does sport sponsorship have a direct effect on product sales? The Cyber-Journal of Sport Marketing (online), October, 1(4), at http://www.cad.gu.au/cjsm/wilson.html. February 1997. PROOFREADING Manuscript accepted for publication may be returned to the author(s) for final correction and proofreading. Corrected proofs should be returned to the Editor-In- Chief within one week of receipt. Minor editorial corrections are handled by AJPHERD. COPYRIGHT AGREEMENT The Africa Association for Health, Physical Education, Recreation, Sport and Dance (LAM Publications Ltd) holds the copyright for AJPHERD. In keeping with copyright laws, authors will be required to assign copyright of accepted manuscripts to LAM Publications Ltd. This ensures that both the publishers and the authors are protected from misuse of copyright information. Requests for permission to use copyright materials should be addressed to the Editor-in-Chief. 239 Appendix F COMPLIMENTARY COPY OF AJPHERD AND REPRINTS Principal authors will receive three (3) complimentary copies of the journal. In case of two or more joint authors the principal author distributes the copies to the co-authors. Reprints of published papers and additional copies of the journal may be ordered from: Leach Printers & Signs, 16 Rissik Street, P. O. Box 143, Makhado 0920, South Africa. Tel: +27 15 516 5221; Fax: +27 15 516 1210. E-mail: info@leachprinters.co.za; website: www.leachprinters.co.za 240 Appendix G APPENDIX G: Guidelines for authors: South African Journal for Research in Sport, Physical Education and Recreation 241 Appendix G INFORMATION FOR AUTHORS The South African Journal for Research in Sport, Physical Education and Recreation is published by the Stellenbosch University. Contributions from the fields of Sport Science, Movement Education, Recreation/Leisure Studies, Exercise Science and Dance Studies will be considered for publication. The articles submitted will be administered by the appropriate Subject Review Editor and evaluated by two or more referees. The decision as to whether a particular article is to be published or not, rests with the Editorial Board. SUBMISSION Manuscripts should be typed with one and a half spacing in 12-point Times New Roman letter size and printed on A4-size white paper in laser quality. The original manuscript (clearly indicated) and three copies of the manuscript must be submitted. Length must not exceed 20 pages (tables, figures, references, etc. included). Original manuscripts may be submitted in English or Afrikaans and should be sent to: The Editor Editorial Office South African Journal for Research in Sport, Tel: 021-808 4915 / 4724 Physical Education and Recreation Fax: 021-808 4817 Department of Sport Science E-mail: floris@sun.ac.za Private Bag X1 7602 Matieland, STELLENBOSCH Republic of South Africa NB. Articles can also be submitted by e-mail. CONDITIONS A signed declaration in respect of the originality must accompany each manuscript. On submission of the manuscript, the author shall present a written statement that the article has not been published or is not being presented for publication elsewhere. We discourage the practice of parts of one study in different journals. Authors who submit a manuscript from a study, some of these data which has been or will be published elsewhere, must provide a strong justification in an 242 Appendix G accompanying letter to the editor. The justification for not publishing all the data together in one paper or as multiple papers in a single issue of the South African Journal for Research in Sport, Physical Education and Recreation must also be covered in the covering letter. Should the article be taken from a Master’s thesis or Doctoral dissertation, academic ethic requires that the student will be the first author. The author should also ensure that the LANGUAGE of the manuscript has been thoroughly edited at the time of submission (in British English). The name, address and telephone number of the person who has done the language editing must be provided. On receiving a written notification from the Managing Editor that the article has been accepted, a final hard copy of the manuscript and a diskette (virus checked) should be submitted using MS WORD as a DOC-file (see figures). It can also be send per e-mail as an attached file. PREPARATION OF MANUSCRIPT Title page The first page of each manuscript should indicate the title in English and Afrikaans (will be translated for foreign authors), the names (title, first name in full and other initials, surname) of the author(s), the telephone numbers (work & home), facsimile number, e-mail address (if available) and the field of study. The mailing address of the first named author and the institution where the work was conducted should be provided in full. A short title of not more than 45 characters, including the spaces, should be provided for use as a running head. Abstract Each manuscript must be accompanied by an abstract of approximately 150-200 words in English and should be set on a separate page as a SINGLE paragraph (one and a half spacing). A list of three to seven key words in English is required for indexing purposes and should be typed below the abstract. Articles in Afrikaans must include an additional extended summary (500-1000 words) in English. This summary must start on a new page (following the list of sources) providing the English title of the article at the beginning. 243 Appendix G Text Start the text on a new page with the title of the article (centred and without the names of the authors). Follow the style of the most recent issue of the journal regarding the use of headings and subheadings. Use only one space after a sentence. Tables and figures Tables and figures should be numbered in Arabic numerals (1, 2, etc.). Tables require a heading at the top and figures a legend below and separate from the figure. Note: Use the decimal POINT (not the decimal comma). References In the text the Harvard method must be adopted by providing the author's surname and the date placed in parentheses. For example: Daly (1970); King and Loathes (1985); (Botha & Sonn, 2002); McGuines et al. (1986) or (Daly, 1970: 80) when Daly is not part of the sentence. More than one reference must be arranged chronologically. Note that et al. is used in the body of the text when there are more than two authors, but never in the list of references. List of references Only the references cited in the text should be listed alphabetically according to surname (last name) of authors (capitals) after the body of text under the heading, References (capitals) starting on a new page. In the case of articles published in JOURNALS, references listed should include the surnames and initials (capitals) of all authors, the date of the publication in parentheses, the full title of the article, the full title of the journal (italics), the volume number, the serial number in parentheses (omitted only if the said journal does not use issue numbers), followed by a colon and the first and last page numbers separated by a hyphen. Example: VAN WYK, G.J. & AMOORE, J.N. (1995). A practical solution for calculating instantaneous values of tension in the extensor muscles of the knee joint during extension and flexion. South African Journal for Research in Sport, Physical Education and Recreation, 18(1): 77-97. 244 Appendix G If the reference is a BOOK, the surname (last name) and initials of the author or editor (Ed.) must be given, followed by the date of publication in parentheses, the title of the book (italics) as given on the title page, the number of the edition (ed.) in parentheses, the city (and abbreviation for the state in the case of the USA) where published, followed by a colon and the name of the publisher. Example: JEWETT, A.E.; BAIN, L.L. & ENNIS, C.E. (1995). The curriculum process in Physical Education (2nd ed.). Madison, WI: WCB Brown & Benchmark. For a CHAPTER from a book, the page numbers of the chapter cited must be provided in parentheses (not italics) after the title of the book. For further details, authors should consult the most recent publication of this Journal for other examples. Example: DE RIDDER, J.H. (1999). Kinanthropometry in exercise and sport. In L.O. Amusa; A.L. Toriola & I.U. Onyewadume (Eds.), Physical Education and sport in Africa (235-263). Ibadan (Nigeria): LAP Publications. If the reference is a THESIS or DISSERTATION, no italics is used as it is an unpublished work. Example: CRAVEN, D.H. (1978). The evolution of major games. Unpublished PhD dissertation. Stellenbosch: Stellenbosch University. For ELECTRONIC SOURCES all references start with the same information that would be provided for a printed source (if available). The web page information follows the reference. It will usually contain the name of the author(s) (if known), year of publication or last revision, title of complete work in inverted commas, title of web page in italics, Uniform Resource Locater (URL) or access path in text brackets (do not end the path statement with a fullstop) and date of access. See "How to cite information from the internet and the world wide web" at http://www.apa.org/journals/webref.html for specific examples. When citing a web 245 Appendix G site in the text, merely give the author and date (in this case: Ackermann, 1996). Example of Web Page: ACKERMANN, E. (1996). "Writing your own Web Pages." Creating Web Pages. Hyperlink [http://www.mwc.edu/ernie/writeweb/writeweb.html]. Retrieved 22 October 1999. ADMINISTRATlON If authors honour the rules and specifications for the submission of manuscripts, unnecessary delays will be avoided. A manuscript that does not meet the requirements as set out above, will be returned to the author without being evaluated. Requesting copying rights concerning figures or photographs is the responsibility of the authors. The corresponding author will receive a complimentary copy of the journal and five reprints of the article. The original manuscripts and illustrations will be discarded one month after publication unless a request is received to return the original to the first-named author. Page charges of R80 per page are payable on receipt of an account issued by the editor. 246 Appendix H APPENDIX H: Guidelines for authors: Adapted Physical Activity Quarterly 247 Appendix H Submission Guidelines for APAQ Manuscript Type As outlined in the Adapted Physical Activity Quarterly (APAQ) Editorial Mission page, the journal accepts four major types of papers: Viewpoint, Literature Review, Empirical Research and Application. APAQ will publish well informed viewpoints relevant to the field and excellent literature reviews integrating the body of knowledge in a relevant area. Potential contributors of empirical papers must carefully consider both the assumptions and theoretical foundations of their work, as well as its methodology. Indicate relevance of your work by referring to theories, paradigms, or conceptual frameworks and by briefly reviewing the existing knowledge base. All empirical papers must be based on research methods and designs appropriate to the question(s) addressed, conforming to whatever standards of excellence are expected with the approach(es) adopted. Bearing in mind this condition, qualitative and quantitative methods are thus equally welcome. APAQ also welcomes knowledge translation studies, or the presentation of new and promising intervention, in its application section. Manuscript Submission Submit manuscripts electronically to Manuscript Central: mc.manuscriptcentral.com/hk_apaq. Do not submit the manuscript to another journal at the same time. Authors are advised to check the typing of the final copy, particularly the accuracy of references, and to retain a duplicate copy to guard against loss. Authors of manuscripts accepted for publication must transfer copyright to Human Kinetics, Inc. Please direct general correspondence to the editorial assistant (Christina Johnson) at ChristinaJ@hkusa.com. Preparing Manuscripts Style. In preparing manuscripts for publication in APAQ, authors should adhere to the guidelines in the Publication Manual of the American Psychological Association (PMAPA, 6th edition, 2010, 3rd printing or later). Copies of PMAPA are available in most university libraries or obtained through the American Psychological Association (APA) Order Department, P.O. Box 92984, Washington, DC 20090-2984 248 Appendix H (www.apa.org/books). Tel: 800-374-2721. Contributors from U.K., Europe, Africa, and the Middle East may obtain copies from APA, 3 Henrietta Street, Covent Garden, London, WC2E 8LU England. Using the PMAPA as a guide, pay attention to all the facets related to manuscript preparation. Format papers with a 1-in. (2.5 cm) margin, 12-point font, and double spacing, including quotes. Papers should not exceed 30 pages including tables and figures. Check format against APA sample paper (pp. 41-59). Note that Method is singular, and the heading, Participants, is preferred over Subjects. Insert line numbers 1-27 in the left margin of each page, beginning with the abstract page. This facilitates providing line-by-line feedback. All manuscripts must include a single paragraph abstract of 100-150 words and three to five keywords chosen from terms not used in the title. Language. Use person-first, non-sexist language in your writing, according to PMAPA standards (pp. 70-76). Pay particular attention to section 3.15. Refer to disabled citizens as individuals with disabilities. Avoid using characteristic and attribute. Instead, use demographic data, diagnostic criteria met, behaviors, or indicators. Do not assume commonalities; base language on individual assessment. Ethics approval. For studies involving humans, the participants section must include a statement certifying that the study received institutional approval and that the participants’ informed consent was obtained. Preparation of figures and tables. In figures, use black and white only, no shading or color. Resolution of digital images should be 300 dpi at full size for photos and 600 dpi for line art; color images cannot be accepted. Figures or photos should be in .jpeg or .tif files. Tables must be formatted using Microsoft Word’s table-building functions, and not by using tab keystrokes and line breaks. Keeping Documents Anonymous APAQ employs a double-blind process in the review of submitted manuscripts. The manuscript should contain no clues as to author identity, such as acknowledgments, institutional information, and mention of specific city. Thus information that might 249 Appendix H identify the author(s) should be omitted or highlighted in black. If you revise or resubmit a manuscript, please include a response to the reviewers and do not insert in your response information that may lead to your identification. Word Processor Manuscripts must be prepared using Microsoft Word. Review Process Most manuscripts are read by at least two external reviewers, one Associate Editor, and the Editor. Typically, the review process takes from 10 to 12 weeks. Manuscripts are evaluated through blind review. There are no page charges to contributors. Artwork Instructions Preparation of figures and tables: In figures, use black and white only, no shading or color. Resolution of digital images should be 300 dpi at full size for photos and 600 dpi for line art; color images cannot be accepted. Figures or photos should be in .jpeg or .tif files. Format tables using the “Table” function of your word processing program rather than aligning columns in text with tabs and spaces or using text boxes. Submitting a Manuscript Submit manuscripts electronically to ManuscriptCentral. Do not submit the manuscript to another journal at the same time. Authors are advised to check the typing of the final copy, particularly the accuracy of references, and to retain a duplicate copy to guard against loss. Authors of manuscripts accepted for publication must transfer copyright to Human Kinetics, Inc. Address general correspondence to the editorial assistant (Christina Johnson) at ChristinaJ@hkusa.com. Authorship Guidelines 250 Appendix H The Journals Division at Human Kinetics adheres to the criteria for authorship as outlined by the International Committee of Medical Journal Editors*: Each author should have participated sufficiently in the work to take public responsibility for the content. Authorship credit should be based only on substantial contributions to: a. Conception and design, or analysis and interpretation of data; and b. Drafting the article or revising it critically for important intellectual content; and c. Final approval of the version to be published. Conditions a, b, and c must all be met. Individuals who do not meet the above criteria may be listed in the acknowledgements section of the manuscript. *Uniform requirements for manuscripts submitted to biomedical journals. New England Journal of Medicine, 1991, 324, 424–428. Open Access Human Kinetics is pleased to allow our authors the option of having their articles published Open Access within APAQ. In order for an article to be published Open Access, authors must complete and return the Request for Open Access form (below) and provide payment for this option, which is currently $2,000 (US). 251 Appendix I APPENDIX I: Proof of Language Editing 252 Appendix I 253 Appendix I 254 Appendix I 255 Appendix I 256 Appendix I 257 Appendix I 258