Research in Developmental Disabilities 35 (2014) 733–740
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Research in Developmental Disabilities
Movement Assessment Battery for Children-2: Translation, reliability, and validity for Brazilian children N.C. Valentini a, M.H. Ramalho b, M.A. Oliveira c,* a Department of Physical Education, School of Physical Education, Federal University of Rio Grande do Sul, Rua Felizardo 7500, Bairro Jardim Botaˆnico, Porto Alegre, Rio Grande do Sul, Brazil b Department of Physical Education, State University of Santa Catarina, Rua Pascoal Simone 358, Coqueiros, Floriano´polis, Santa Catarina, Brazil c School of Public Health, University of Maryland, College Park, MD, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 16 May 2012 Received in revised form 23 October 2013 Accepted 28 October 2013 Available online 27 November 2013
The Movement Assessment Battery for Children 2nd edition (MABC-2) is a wellrecognized assessment used to identify children with Developmental Coordination Disorder (DCD). Although researchers and practitioners across Brazil have used the MABC2 to identify children with motor deficits, its validation for this particular population has yet to be investigated. In this study, we translated all MABC-2 items and validated them with respect to content, construct and criteria validity. The validation process involved 13 experts in Motor Development and a total of 844 children (3–13 years old) from two different states in Brazil. A cross-cultural translation method yielded a Brazilian– Portuguese version of the battery. The expert panel confirmed language clarity and pertinence of the items. High intra- and inter-rater reliability and internal consistency for the MABC-2 was established for Brazilian children. A discriminant analysis confirmed the MABC-2 power (.80) to differentiate children with DCD and those at risk for DCD from typically developing children. Predictive validity was observed for the impairment scores and a percentile main effect was found in the repeated measures ANOVA (ICC: .93 and .73, respectively). Although our data are not representative of the entire country, this study is the first to confirm that the original standardized scores established for the MABC-2 are valid in Brazilian children. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Movement Assessment Battery for children Developmental Coordination Disorder (DCD) Construct validity Content validity
1. Introduction Children with difficulties in the execution of gross (Geuze, 2005; Missiuna, Gaines, & Soucie, 2006) and fine motor skills (Summers, Larkin, & Dewey, 2008) and lacking postural control (Summers et al., 2008) have been diagnosed with Developmental Coordination Disorder (DCD). Research has shown that DCD has adverse effects on children’s everyday life and the reported prevalence varies across countries, including USA – 6% (APA, 2000), UK – 2% (Lingam, Hunt, Golding, Jongmans, & Emond, 2009), and Greece – 19% (Tsiotra et al., 2006). There has been an increased focus on the diagnosis and assessment of this disorder as these difficulties are not due to an identifiable neurological or sensory problem (APA, 2000). Several assessment tools are used to identify children with DCD including the Bruininks–Oseretesky Test of Motor Proficiency (Bruininks, 1978), the Motor Dysfunction Index (Gillberg, Carlstrom, Rasmussen, & Waldenstrom, 1983), and the
* Corresponding author at: School of Public Health, University of Maryland, Room 2242-C, SPH Building, College Park, MD, USA. Tel.: +1 301 405 2454. E-mail addresses: [email protected] (N.C. Valentini), [email protected] (M.H. Ramalho), [email protected] (M.A. Oliveira). 0891-4222/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ridd.2013.10.028
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first edition of the Movement Assessment Battery for Children – MABC-1 (Henderson & Sugden, 1992). Overall, the MABC-1 is the most common assessment tool used to assess children with motor impairments (Geuze, Jongmans, Schoemaker, & Smith-Engelsman, 2001). The MABC-2 (Henderson, Sugden, & Barnett, 2007) has been widely adopted by clinicians and researchers in several countries (Chow & Henderson, 2003; Croce, Horvat, & McCarty, 2001; Ellinoudis et al., 2011; Engel-Yeger, Rosenblum, & Josman, 2010). One of the obstacles faced by practitioners and researchers is the absence of translated and validated versions of the MABC-1 and MABC-2 for different geographic, socioeconomic and cultural backgrounds (Engel-Yeger et al., 2010). To our knowledge, although frequently employed in Brazil, the MABC-2 has not been properly validated for this population. This is a critical problem because the diagnosis of DCD, similar to other movement disorders, depends on the use of reliable and valid instruments (Netelenbos, 2005; Wiart & Darrah, 2001; Yun & Ulrich, 2002). Although not yet validated in Brazil, there have been studies on MABC-2 validation in other countries. For example, a study conducted in Greece revealed adequate coefficients of test–retest reliability for children in Age Band I (ICC = .85) (Ellinoudis et al., 2011). Furthermore test–retest reliability was also confirmed for a group of Taiwanese children with DCD (ICC = .97; Wuang, Su, & Huang, 2012a; Wuang, Su, & Su, 2012b). These studies provided support for the reliability of MABC-2; however, they were restricted to specific ages and groups of children. Moreover, although the factorial validity of the MABC-2 has been reported in the literature (Ellinoudis et al., 2011; Wagner, Kastner, Petermann, & Bo¨s, 2011), there is a lack of studies that report discriminant validity (Brown & Lalor, 2009; Venetsanou et al., 2011; Wagner et al., 2011). Accurate and valid assessment techniques are imperative to promote global understanding and multicultural relationships of DCD. As researchers envision collaborating and developing large data sets (big data) to investigate developmental disorders, common standards must be established. Currently, researchers investigating DCD employ different assessment tools and behavioral measures, leading to differential diagnostics. In many cases, assessment tools are selected according to access, availability and psychometric properties, and used based on the assumption of universal application. However, as researchers have previously emphasized, it is unusual to find translated and validated assessment tools in which the procedures are adequately described and standardized adjustments are published (Bhui, Mohamud, Warfa, Craig, & Stansfeld, 2003; Vallerand, 1989). Yet, content validity should be strengthened in different cultures in order to trust test results (Bhui et al., 2003). Furthermore, investigations of cultural clarity, pertinence, reliability and validity are critical prior to the use of instruments for individuals with different cultural backgrounds (Cicchetti & Rourke, 2004; Cronbach, 1989; Vallerand, 1989). Unreliable assessment will inevitably lead to misdiagnoses (Yun & Ulrich, 2002), resulting in generating false alarms or failing to detect a disorder (Henderson et al., 2007). Reliable and valid assessment tools allow for international comparative studies of incidence, prevalence and individual profiles. These particular studies contribute to knowledge about the epidemiology of different disorders (Bhui et al., 2003). Yet, since the reliability and validity of a single assessment are not constant across populations of individuals the psychometric proprieties of an assessment must be investigated in order to comprise a suitable body of knowledge (Yun & Ulrich, 2002). Therefore, the aims of this study were to: (1) translate the MABC-2 into the Brazilian–Portuguese language; and (2) examine the reliability and validity of the translated MABC-2. 2. Method 2.1. Participants A total of 844 children (440 boys and 404 girls) between 3 and 13 years of age (M = 8.31, SD = 2.91) were participants in the study. Participants (59.6% white and 40.4% non-white) attended public schools and had no known history of physical and/or learning disabilities. Consent was obtained from the custodial caregivers of each child as well as from each professional participating in the study. All caregivers were informed about the test results and received a report with the participant’s motor performance scores. Information about public services was provided to those children identified with low motor scores (at or below 15% percentile). Table 1 provides detailed information about the participants. The school boards of education from 6 cities from two states in the south of Brazil (Rio Grande do Sul and Santa Catarina) approved the research procedures in 14 schools and mediated the contact between the researcher and the schools’ administrators and teachers. The objectives and relevance of this study were presented to teachers and administrators. Informed consent was sent home by classroom’ teachers. 2.2. Assessment Children were assessed using the MABC-2 (Henderson et al., 2007). The MABC-2 is designed to assess motor impairments of children in different age bands (AB) from 3 to 16 years old (AB1: 3–6 years; AB2: 7–10 years; AB3: 11–16 years). The MABC-2 comprises 8 tasks, 3 tasks measuring manual dexterity (MD) (posting coins/placing or turning pegs; threading lace/ set-up triangle; drawing), 2 tasks measuring ball skills (BS) (throwing/aiming and catching) and 3 tasks measuring balance (B) (one or two leg balance; walking lines; jumping or hopping). The entire assessment takes an average of 30 min for each child to complete. Motor impairment scores are acquired and compared to standardized norms. The norms were established on a standardization sample of 1172. An impairment score at or below the 5th percentile is the standard cut off for severe motor coordination difficulties and serves as an indication that the child has DCD. Children scoring between the 6th and 15th
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Table 1 Sample N and MABC-2 scores and categorization by age (n = 844). ABs
Age
n(%)
MABC-2 Standard scores M (SD)
AB1
AB2
AB3
3 4 5 6 7 8 9 10 11 12 13
Total
67(7.9) 52(6.2) 54(6.4) 50(5.9) 100(11.8) 100(11.8) 88(10.4) 96(11.4) 112(13.3) 76(9) 49(5.8) 844(100)
Percentile
Classification n(%)
Test
MD
BS
B
M(SD)
DCD
At risk
TD
8.7(3.5) 7.8(3.2) 8.1(2.9) 8.8(2.6) 8.0(3) 8.1(2.9) 8.1(2.8) 9.6(3.2) 8.4(2.5) 7.7(2.8) 9.1(2.0) 8.4(2.9)
7.7(3.8) 7.1(3.3) 7.1(3.8) 7.6(3) 8.5(3.3) 8.1(2.8) 8.2(2.6) 9.6(3.4) 8.8(2.7) 7.2(2.8) 8.2(2.4) 8.2(3.2)
10.9(3.8) 9.7(3.2) 9.9(2.4) 10.3(3.1) 9.1(2.8) 9.1(3) 9.1(2.7) 10(2.7) 9.5(3.2) 9.2(3.3) 9.4(2.5) 9.6(3.0)
9.1(3.4) 8.9(3.2) 9.0(2.7) 10(2.8) 8.1(3) 8.7(3.6) 8.8(3.3) 9.9(3.4) 8.8(3.2) 9.2(3.3) 10.9(2.9) 9.1(3.3)
37.8(31.8) 29.1(28) 31(27.3) 37.4(25.6) 31.5(26.8) 32.3(26.1) 33.1(25.9) 48.7(29.8) 34.2(25.5) 29.8(24.8) 39.9(22.8) 35.1(27.3)
13(19) 11(21) 12(22) 3(6) 24(24) 19(19) 17(19) 15(16) 16(14) 19(25) 2(4) 151(18)
10(15) 10(19) 5(9) 3(6) 10(10) 9(9) 8(9) 3(3) 12(11) 6(8) 3(6) 79(9)
44(66) 31(60) 37(69) 44(88) 66(66) 72(72) 63(72) 78(81) 84(75) 51(67) 44(90) 614(73)
percentile are considered at risk for DCD and performance at or above the 16th percentile is considered in the range of typical development (Geuze et al., 2001; Henderson & Sugden, 1992). Content validity was attained by an expert panel that unanimously judged the content of the MABC-2 to be representative of the motor domains as specified by the test developers. The panel also reported that the MABC-2 has adequate coverage across the age bands. Adequate face validity concerning the length of the test, attractiveness to children, levels of task- and age-appropriateness and contribution to the assessment process was reported by health-related professionals. Test–retest reliability for components scores (MD: r = .77; BS: r = .84; B: r = .73) and total test scores (r = .80) has been originally reported for the UK’s main study (Henderson et al., 2007). Henderson et al. (2007) also reported in the MABC-2 manual two studies specifically targeting AB3 provided further support for test–retest (ICC = .62–92) and inter-rater reliability (ICC = .92–1.0). A group of children were also assessed using the Test of Gross Motor Development – second edition (TGMD-2). The TGMD-2 was designed to assess the gross motor skills of children from 3 to 10 years of age. The test contains 12 motor skills organized into 2 subtests: locomotor (run, leap, gallop, hop, jump, and slide) and object control (catch, strike, bounce, over and underhand throw, and kick; Ulrich, 2000). The TGMD-2 has been recently validated for Brazilian children with appropriate indices of the confirmatory factorial validity (RMSEA = .06; CFI = .88; TLI = .83; NFI = .09; GFI = .98; AGFI = .95), test–retest (values from .83 to .91) and inter- and intra-rater (values from .86 to .94) reliability (Valentini, 2012). 2.3. Translation The Institutional Review Board (IRB) from the Federal University of Rio Grande do Sul, Brazil, approved all experimental procedures. A double-back reverse independent translation procedure was adopted (Vallerand, 1989). This procedure involved 4 bilingual certified translators (2 English and 2 Brazilian–Portuguese native-speakers) and required two independent translations from English to Brazilian–Portuguese. Two subsequent independent translations from Brazilian– Portuguese to English were completed. The translators did not have access to the original English version of the MABC-2. All translators attended a meeting in which the 4 translated versions were compared with the original version. The two Brazilian–Portuguese versions were semantically adjusted based upon unanimous agreement. A final translated and edited score sheet was developed based on the Brazilian–Portuguese version of the MABC-2. No changes on the motor items and scoring system were made. A panel of experts formed by health-related professionals was established to test content validity of the MABC-2 for Brazilian children. Three experts (Ph.D. degree in Motor Development) were asked to use the following Likert scale to independently evaluate the level of agreement of each task regarding clarity and pertinence: (5) very clear/pertinent; (4) somewhat clear/pertinent; (3) neutral; (2) not really clear/pertinent; and (1) not at all clear/pertinent). Ten health-related professionals (physical therapists, kinesiologists, physical educators, and pediatricians) participated in the face validity procedure. Each evaluator used a Likert scale (5 points) to score all motor items regarding the appropriateness to measure motor impairment: (5) strongly agree; (4) agree; (3) neutral; (2) disagree; and (1) strongly disagree. 2.4. Procedures Motor assessments of the children (N = 844) were conducted individually in the schools. A group of 168 children (Age: M = 7.54, SD = 3.10) were retested within approximately two weeks of an initial testing session (M = 17.65, SD = 4.97 days). A group of 41 children between 3 and 6 years (M = 3.85, SD = 0.8) were followed up longitudinally, assessed three times within a 6-month interval (M = 6.4 SD = .24). A group of 43 children between 6 and 11 years (M = 7.9, SD = 1.7) were also assessed using the TGMD-2 in order to assess concurrent validity of the MABC-2. Three trained health-related professionals (>3 years
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experience with the MABC-2 and TGMD-2) independently assessed all children and provided inter- and intra-rater reliability data for analysis. 2.5. Data analyses A sample size of 800 children was needed to determine the validity of the MABC-2 for Brazilian children within a 99% of confidence interval (4% of margin of error). A conservative approach was adopted and approximately 50 more children were tested. Data were computed by using the PEPI-for-Windows-version 4.0. Content validity index (CVI) (Neuendorf, 2002) and kappa concordance coefficient (Sim & Wright, 2000) were used to analyze clarity and pertinence, respectively, of the MABC-2 items. Percent agreement across different professionals was used to assess face validity. The inter-rater and intra-rater scores were analyzed using the intra-class correlation coefficient (ICC) and ANOVA oneway (Stephen, 2009). The test–retest reliability was computed using Pearson’s correlation coefficient and ICC to investigate consistency of the MABC-2 items and to provide information about the scale temporal stability (Cicchetti & Rourke, 2004). Internal consistency analysis was verified through Cronbach’s alpha index (Cronbach & Meehl, 1976). Criteria validity was investigated using predictive and concurrent validity. Predictive validity was investigated using two methodologies. Discriminant analysis was conducted to test the ability of the MABC-2 to predict group membership (Humphreys, Lubinski, & Yao, 1993; Tatsuoka, 1988) and the results from the ANOVA are reported (Cronbach & Meehl, 1976). Predictive validity of the MABC-2 was also analyzed using ICC and ANOVA with repeated measure (standard scores) and chisquare (MABC-2 classification) tests (Waltz, Strickland, & Lenz, 2010). Pearson’s correlation coefficient and dependent t-tests were used to investigate the concurrent validity. Correlation coefficient values over .60, between .30 and .60, and below .30 were considered strong, moderate and small, respectively (Hernandez-Nieto, 2002; Waltz et al., 2010). Cronbach’ alpha values over .80 and between .70 and .80 were considered excellent and good, respectively. Cronbach’ alpha value ranging from .60 and .69 are considered acceptable Cronbach & Meehl, 1976). Partial h2 (eta squared) are presented as an index of effect size (i.e., small: h2 = .01; moderate: h2 = .06; and large: h2 = .14; Breakweell, Hammond, Fife-Schaw, & Smith, 2006; Cicchetti & Rourke, 2004). Significance level was set at p .05. 3. Results 3.1. Content and face validity The results for content validity are presented on Table 2. The CVI concordance results among experts were strong. The MABC-2 items ranged from 71.8 to 93.9 for language clarity and 98.5–99.3 for pertinence. The kappa coefficients statistical test was significant (p < .001). Health-related professionals scored high values on the Likert scale for every item on the MABC-2 (98% concordance among them), indicating high face validity. 3.2. Reliability The inter-rater (ICC values from .86 to .99) and the intra-rater reliability (ICC values from .68 to .85) indicated strong and congruent results among the evaluators (Table 3). There were also no significant differences among the evaluators for standard scores (p > .05). As shown in Table 4, the test–retest reliability results using Pearson’s test detected a strong positive and significant correlation for the standard scores (r = .74; p < .0001). A similar trend was observed for the 3 subtest standard scores (MD: r = .67, p < .0001; BS: r = .52, p < .0001; B: r = .53, p < .0001). The ICC values were also high for the standard score (.85), and moderate for the subtests (MD: r = .59; BS: r = .61; B: r = .69). 3.3. Construct validity The Cronbach’s alpha coefficient (N = 844 children) analyses showed good reliability in the 3 subscales (a = .78), as well as for the standard scores on each subtest independently (MD: a = .77; BS: a = .52; B: a = .77). These findings confirm the internal consistency of the MABC-2. Table 2 Validity content index (CVI) and kappa concordance coefficient (p-values). Experts
Clarity CVI (%)
Kappa (IC 95%)
p
CVI (%)
Kappa (IC 95%)
p
123 12 13 23
71.8 93.9 78.9 74.3
– .88 (.76 to .99) .80 (.65 to.95) .76 (.59 to .93)
– .70) reported in the original edition of the MABC-2 (Henderson et al., 2007). A recent study tested young children and also reported higher values (.94) of temporal stability (Smits-Engelsman et al., 2011). High values of test–retest reliability for the MABC-1st edition were also reported when tests were separated bye one week (ICC = .92–.98; Croce et al., 2001), 2- to 3-weeks (ICC = .77; Chow & Henderson, 2003) and a full 3 weeks (ICC = 88; Hilde, Wim, Matthieu, & Smits-Engelsman, 2007). The MABC-2 showed great ability to discriminate typically developing children from those who may potentially be diagnosed with DCD. High ability to predict group membership was observed for the MABC-2 (Humphreys et al., 1993). Furthermore, children labeled as probable DCD, at risk for DCD or TD in the first assessment had the same diagnosis at the second and third assessments (6 and 12 months, respectively, after initial assessment). These results underline the predictive ability of the MABC-2 for Brazilian children. The results from the concurrent validity were satisfactory, a significant moderate and positive association was found between MABC-2 and TGMD-2 standard scores (0.30). However, we must acknowledge that concurrent validity was lower than recommended (Cronbach, 1989). Previously, low-to-moderate correlations between MABC and TGMD-2 (values from .13 to .40) have been reported for preschool children (Logan, Robinson, & Getchell, 2011). The ‘fragile’ result of the present study could be related to the specificity of each assessment. The MABC has two sections assessing manual dexterity and balance; skills more related to children every day tasks. The TGMD-2 was designed to assess children’s motor development in locomotor and ball skills that seems more related to sports skills. A limitation of our study is that the analyses of longitudinal predictive validity and concurrent validity were restricted to children from 3 to 6 and 6 to 11 years, respectively. Unfortunately, school administrators only permitted the younger group of children to be included in our longitudinal study. We hope to include a full age range in future studies. 5. Conclusions It was demonstrated for the first time that the MABC-2 is valid in Brazil. A Brazilian–Portuguese version of the MABC-2 was created and rigorously tested with respect to its reliability and face, content, criterion and construct validity.
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The MABC-2 proved to be accurate and valid for Brazilian children. In addition, several experimental procedures and statistical analyses were employed to test the internal consistency, reliability, and its predictive, concurrent and discriminative power. Although a large sample size was used in this investigation, we should consider the cultural diversity of motor experiences found in different states and regions in Brazil. As seen in several large countries, children originating from different regions certainly have a distinctive (or context-specific) motor repertoire, especially those children at the age range targeted in the MABC-2. Hence, generalization of these findings is currently limited; future research should replicate and extend our results to children from other states in Brazil. 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Research in Developmental Disabilities
Movement Assessment Battery for Children-2: Translation, reliability, and validity for Brazilian children N.C. Valentini a, M.H. Ramalho b, M.A. Oliveira c,* a Department of Physical Education, School of Physical Education, Federal University of Rio Grande do Sul, Rua Felizardo 7500, Bairro Jardim Botaˆnico, Porto Alegre, Rio Grande do Sul, Brazil b Department of Physical Education, State University of Santa Catarina, Rua Pascoal Simone 358, Coqueiros, Floriano´polis, Santa Catarina, Brazil c School of Public Health, University of Maryland, College Park, MD, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 16 May 2012 Received in revised form 23 October 2013 Accepted 28 October 2013 Available online 27 November 2013
The Movement Assessment Battery for Children 2nd edition (MABC-2) is a wellrecognized assessment used to identify children with Developmental Coordination Disorder (DCD). Although researchers and practitioners across Brazil have used the MABC2 to identify children with motor deficits, its validation for this particular population has yet to be investigated. In this study, we translated all MABC-2 items and validated them with respect to content, construct and criteria validity. The validation process involved 13 experts in Motor Development and a total of 844 children (3–13 years old) from two different states in Brazil. A cross-cultural translation method yielded a Brazilian– Portuguese version of the battery. The expert panel confirmed language clarity and pertinence of the items. High intra- and inter-rater reliability and internal consistency for the MABC-2 was established for Brazilian children. A discriminant analysis confirmed the MABC-2 power (.80) to differentiate children with DCD and those at risk for DCD from typically developing children. Predictive validity was observed for the impairment scores and a percentile main effect was found in the repeated measures ANOVA (ICC: .93 and .73, respectively). Although our data are not representative of the entire country, this study is the first to confirm that the original standardized scores established for the MABC-2 are valid in Brazilian children. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Movement Assessment Battery for children Developmental Coordination Disorder (DCD) Construct validity Content validity
1. Introduction Children with difficulties in the execution of gross (Geuze, 2005; Missiuna, Gaines, & Soucie, 2006) and fine motor skills (Summers, Larkin, & Dewey, 2008) and lacking postural control (Summers et al., 2008) have been diagnosed with Developmental Coordination Disorder (DCD). Research has shown that DCD has adverse effects on children’s everyday life and the reported prevalence varies across countries, including USA – 6% (APA, 2000), UK – 2% (Lingam, Hunt, Golding, Jongmans, & Emond, 2009), and Greece – 19% (Tsiotra et al., 2006). There has been an increased focus on the diagnosis and assessment of this disorder as these difficulties are not due to an identifiable neurological or sensory problem (APA, 2000). Several assessment tools are used to identify children with DCD including the Bruininks–Oseretesky Test of Motor Proficiency (Bruininks, 1978), the Motor Dysfunction Index (Gillberg, Carlstrom, Rasmussen, & Waldenstrom, 1983), and the
* Corresponding author at: School of Public Health, University of Maryland, Room 2242-C, SPH Building, College Park, MD, USA. Tel.: +1 301 405 2454. E-mail addresses: [email protected] (N.C. Valentini), [email protected] (M.H. Ramalho), [email protected] (M.A. Oliveira). 0891-4222/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ridd.2013.10.028
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first edition of the Movement Assessment Battery for Children – MABC-1 (Henderson & Sugden, 1992). Overall, the MABC-1 is the most common assessment tool used to assess children with motor impairments (Geuze, Jongmans, Schoemaker, & Smith-Engelsman, 2001). The MABC-2 (Henderson, Sugden, & Barnett, 2007) has been widely adopted by clinicians and researchers in several countries (Chow & Henderson, 2003; Croce, Horvat, & McCarty, 2001; Ellinoudis et al., 2011; Engel-Yeger, Rosenblum, & Josman, 2010). One of the obstacles faced by practitioners and researchers is the absence of translated and validated versions of the MABC-1 and MABC-2 for different geographic, socioeconomic and cultural backgrounds (Engel-Yeger et al., 2010). To our knowledge, although frequently employed in Brazil, the MABC-2 has not been properly validated for this population. This is a critical problem because the diagnosis of DCD, similar to other movement disorders, depends on the use of reliable and valid instruments (Netelenbos, 2005; Wiart & Darrah, 2001; Yun & Ulrich, 2002). Although not yet validated in Brazil, there have been studies on MABC-2 validation in other countries. For example, a study conducted in Greece revealed adequate coefficients of test–retest reliability for children in Age Band I (ICC = .85) (Ellinoudis et al., 2011). Furthermore test–retest reliability was also confirmed for a group of Taiwanese children with DCD (ICC = .97; Wuang, Su, & Huang, 2012a; Wuang, Su, & Su, 2012b). These studies provided support for the reliability of MABC-2; however, they were restricted to specific ages and groups of children. Moreover, although the factorial validity of the MABC-2 has been reported in the literature (Ellinoudis et al., 2011; Wagner, Kastner, Petermann, & Bo¨s, 2011), there is a lack of studies that report discriminant validity (Brown & Lalor, 2009; Venetsanou et al., 2011; Wagner et al., 2011). Accurate and valid assessment techniques are imperative to promote global understanding and multicultural relationships of DCD. As researchers envision collaborating and developing large data sets (big data) to investigate developmental disorders, common standards must be established. Currently, researchers investigating DCD employ different assessment tools and behavioral measures, leading to differential diagnostics. In many cases, assessment tools are selected according to access, availability and psychometric properties, and used based on the assumption of universal application. However, as researchers have previously emphasized, it is unusual to find translated and validated assessment tools in which the procedures are adequately described and standardized adjustments are published (Bhui, Mohamud, Warfa, Craig, & Stansfeld, 2003; Vallerand, 1989). Yet, content validity should be strengthened in different cultures in order to trust test results (Bhui et al., 2003). Furthermore, investigations of cultural clarity, pertinence, reliability and validity are critical prior to the use of instruments for individuals with different cultural backgrounds (Cicchetti & Rourke, 2004; Cronbach, 1989; Vallerand, 1989). Unreliable assessment will inevitably lead to misdiagnoses (Yun & Ulrich, 2002), resulting in generating false alarms or failing to detect a disorder (Henderson et al., 2007). Reliable and valid assessment tools allow for international comparative studies of incidence, prevalence and individual profiles. These particular studies contribute to knowledge about the epidemiology of different disorders (Bhui et al., 2003). Yet, since the reliability and validity of a single assessment are not constant across populations of individuals the psychometric proprieties of an assessment must be investigated in order to comprise a suitable body of knowledge (Yun & Ulrich, 2002). Therefore, the aims of this study were to: (1) translate the MABC-2 into the Brazilian–Portuguese language; and (2) examine the reliability and validity of the translated MABC-2. 2. Method 2.1. Participants A total of 844 children (440 boys and 404 girls) between 3 and 13 years of age (M = 8.31, SD = 2.91) were participants in the study. Participants (59.6% white and 40.4% non-white) attended public schools and had no known history of physical and/or learning disabilities. Consent was obtained from the custodial caregivers of each child as well as from each professional participating in the study. All caregivers were informed about the test results and received a report with the participant’s motor performance scores. Information about public services was provided to those children identified with low motor scores (at or below 15% percentile). Table 1 provides detailed information about the participants. The school boards of education from 6 cities from two states in the south of Brazil (Rio Grande do Sul and Santa Catarina) approved the research procedures in 14 schools and mediated the contact between the researcher and the schools’ administrators and teachers. The objectives and relevance of this study were presented to teachers and administrators. Informed consent was sent home by classroom’ teachers. 2.2. Assessment Children were assessed using the MABC-2 (Henderson et al., 2007). The MABC-2 is designed to assess motor impairments of children in different age bands (AB) from 3 to 16 years old (AB1: 3–6 years; AB2: 7–10 years; AB3: 11–16 years). The MABC-2 comprises 8 tasks, 3 tasks measuring manual dexterity (MD) (posting coins/placing or turning pegs; threading lace/ set-up triangle; drawing), 2 tasks measuring ball skills (BS) (throwing/aiming and catching) and 3 tasks measuring balance (B) (one or two leg balance; walking lines; jumping or hopping). The entire assessment takes an average of 30 min for each child to complete. Motor impairment scores are acquired and compared to standardized norms. The norms were established on a standardization sample of 1172. An impairment score at or below the 5th percentile is the standard cut off for severe motor coordination difficulties and serves as an indication that the child has DCD. Children scoring between the 6th and 15th
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Table 1 Sample N and MABC-2 scores and categorization by age (n = 844). ABs
Age
n(%)
MABC-2 Standard scores M (SD)
AB1
AB2
AB3
3 4 5 6 7 8 9 10 11 12 13
Total
67(7.9) 52(6.2) 54(6.4) 50(5.9) 100(11.8) 100(11.8) 88(10.4) 96(11.4) 112(13.3) 76(9) 49(5.8) 844(100)
Percentile
Classification n(%)
Test
MD
BS
B
M(SD)
DCD
At risk
TD
8.7(3.5) 7.8(3.2) 8.1(2.9) 8.8(2.6) 8.0(3) 8.1(2.9) 8.1(2.8) 9.6(3.2) 8.4(2.5) 7.7(2.8) 9.1(2.0) 8.4(2.9)
7.7(3.8) 7.1(3.3) 7.1(3.8) 7.6(3) 8.5(3.3) 8.1(2.8) 8.2(2.6) 9.6(3.4) 8.8(2.7) 7.2(2.8) 8.2(2.4) 8.2(3.2)
10.9(3.8) 9.7(3.2) 9.9(2.4) 10.3(3.1) 9.1(2.8) 9.1(3) 9.1(2.7) 10(2.7) 9.5(3.2) 9.2(3.3) 9.4(2.5) 9.6(3.0)
9.1(3.4) 8.9(3.2) 9.0(2.7) 10(2.8) 8.1(3) 8.7(3.6) 8.8(3.3) 9.9(3.4) 8.8(3.2) 9.2(3.3) 10.9(2.9) 9.1(3.3)
37.8(31.8) 29.1(28) 31(27.3) 37.4(25.6) 31.5(26.8) 32.3(26.1) 33.1(25.9) 48.7(29.8) 34.2(25.5) 29.8(24.8) 39.9(22.8) 35.1(27.3)
13(19) 11(21) 12(22) 3(6) 24(24) 19(19) 17(19) 15(16) 16(14) 19(25) 2(4) 151(18)
10(15) 10(19) 5(9) 3(6) 10(10) 9(9) 8(9) 3(3) 12(11) 6(8) 3(6) 79(9)
44(66) 31(60) 37(69) 44(88) 66(66) 72(72) 63(72) 78(81) 84(75) 51(67) 44(90) 614(73)
percentile are considered at risk for DCD and performance at or above the 16th percentile is considered in the range of typical development (Geuze et al., 2001; Henderson & Sugden, 1992). Content validity was attained by an expert panel that unanimously judged the content of the MABC-2 to be representative of the motor domains as specified by the test developers. The panel also reported that the MABC-2 has adequate coverage across the age bands. Adequate face validity concerning the length of the test, attractiveness to children, levels of task- and age-appropriateness and contribution to the assessment process was reported by health-related professionals. Test–retest reliability for components scores (MD: r = .77; BS: r = .84; B: r = .73) and total test scores (r = .80) has been originally reported for the UK’s main study (Henderson et al., 2007). Henderson et al. (2007) also reported in the MABC-2 manual two studies specifically targeting AB3 provided further support for test–retest (ICC = .62–92) and inter-rater reliability (ICC = .92–1.0). A group of children were also assessed using the Test of Gross Motor Development – second edition (TGMD-2). The TGMD-2 was designed to assess the gross motor skills of children from 3 to 10 years of age. The test contains 12 motor skills organized into 2 subtests: locomotor (run, leap, gallop, hop, jump, and slide) and object control (catch, strike, bounce, over and underhand throw, and kick; Ulrich, 2000). The TGMD-2 has been recently validated for Brazilian children with appropriate indices of the confirmatory factorial validity (RMSEA = .06; CFI = .88; TLI = .83; NFI = .09; GFI = .98; AGFI = .95), test–retest (values from .83 to .91) and inter- and intra-rater (values from .86 to .94) reliability (Valentini, 2012). 2.3. Translation The Institutional Review Board (IRB) from the Federal University of Rio Grande do Sul, Brazil, approved all experimental procedures. A double-back reverse independent translation procedure was adopted (Vallerand, 1989). This procedure involved 4 bilingual certified translators (2 English and 2 Brazilian–Portuguese native-speakers) and required two independent translations from English to Brazilian–Portuguese. Two subsequent independent translations from Brazilian– Portuguese to English were completed. The translators did not have access to the original English version of the MABC-2. All translators attended a meeting in which the 4 translated versions were compared with the original version. The two Brazilian–Portuguese versions were semantically adjusted based upon unanimous agreement. A final translated and edited score sheet was developed based on the Brazilian–Portuguese version of the MABC-2. No changes on the motor items and scoring system were made. A panel of experts formed by health-related professionals was established to test content validity of the MABC-2 for Brazilian children. Three experts (Ph.D. degree in Motor Development) were asked to use the following Likert scale to independently evaluate the level of agreement of each task regarding clarity and pertinence: (5) very clear/pertinent; (4) somewhat clear/pertinent; (3) neutral; (2) not really clear/pertinent; and (1) not at all clear/pertinent). Ten health-related professionals (physical therapists, kinesiologists, physical educators, and pediatricians) participated in the face validity procedure. Each evaluator used a Likert scale (5 points) to score all motor items regarding the appropriateness to measure motor impairment: (5) strongly agree; (4) agree; (3) neutral; (2) disagree; and (1) strongly disagree. 2.4. Procedures Motor assessments of the children (N = 844) were conducted individually in the schools. A group of 168 children (Age: M = 7.54, SD = 3.10) were retested within approximately two weeks of an initial testing session (M = 17.65, SD = 4.97 days). A group of 41 children between 3 and 6 years (M = 3.85, SD = 0.8) were followed up longitudinally, assessed three times within a 6-month interval (M = 6.4 SD = .24). A group of 43 children between 6 and 11 years (M = 7.9, SD = 1.7) were also assessed using the TGMD-2 in order to assess concurrent validity of the MABC-2. Three trained health-related professionals (>3 years
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experience with the MABC-2 and TGMD-2) independently assessed all children and provided inter- and intra-rater reliability data for analysis. 2.5. Data analyses A sample size of 800 children was needed to determine the validity of the MABC-2 for Brazilian children within a 99% of confidence interval (4% of margin of error). A conservative approach was adopted and approximately 50 more children were tested. Data were computed by using the PEPI-for-Windows-version 4.0. Content validity index (CVI) (Neuendorf, 2002) and kappa concordance coefficient (Sim & Wright, 2000) were used to analyze clarity and pertinence, respectively, of the MABC-2 items. Percent agreement across different professionals was used to assess face validity. The inter-rater and intra-rater scores were analyzed using the intra-class correlation coefficient (ICC) and ANOVA oneway (Stephen, 2009). The test–retest reliability was computed using Pearson’s correlation coefficient and ICC to investigate consistency of the MABC-2 items and to provide information about the scale temporal stability (Cicchetti & Rourke, 2004). Internal consistency analysis was verified through Cronbach’s alpha index (Cronbach & Meehl, 1976). Criteria validity was investigated using predictive and concurrent validity. Predictive validity was investigated using two methodologies. Discriminant analysis was conducted to test the ability of the MABC-2 to predict group membership (Humphreys, Lubinski, & Yao, 1993; Tatsuoka, 1988) and the results from the ANOVA are reported (Cronbach & Meehl, 1976). Predictive validity of the MABC-2 was also analyzed using ICC and ANOVA with repeated measure (standard scores) and chisquare (MABC-2 classification) tests (Waltz, Strickland, & Lenz, 2010). Pearson’s correlation coefficient and dependent t-tests were used to investigate the concurrent validity. Correlation coefficient values over .60, between .30 and .60, and below .30 were considered strong, moderate and small, respectively (Hernandez-Nieto, 2002; Waltz et al., 2010). Cronbach’ alpha values over .80 and between .70 and .80 were considered excellent and good, respectively. Cronbach’ alpha value ranging from .60 and .69 are considered acceptable Cronbach & Meehl, 1976). Partial h2 (eta squared) are presented as an index of effect size (i.e., small: h2 = .01; moderate: h2 = .06; and large: h2 = .14; Breakweell, Hammond, Fife-Schaw, & Smith, 2006; Cicchetti & Rourke, 2004). Significance level was set at p .05. 3. Results 3.1. Content and face validity The results for content validity are presented on Table 2. The CVI concordance results among experts were strong. The MABC-2 items ranged from 71.8 to 93.9 for language clarity and 98.5–99.3 for pertinence. The kappa coefficients statistical test was significant (p < .001). Health-related professionals scored high values on the Likert scale for every item on the MABC-2 (98% concordance among them), indicating high face validity. 3.2. Reliability The inter-rater (ICC values from .86 to .99) and the intra-rater reliability (ICC values from .68 to .85) indicated strong and congruent results among the evaluators (Table 3). There were also no significant differences among the evaluators for standard scores (p > .05). As shown in Table 4, the test–retest reliability results using Pearson’s test detected a strong positive and significant correlation for the standard scores (r = .74; p < .0001). A similar trend was observed for the 3 subtest standard scores (MD: r = .67, p < .0001; BS: r = .52, p < .0001; B: r = .53, p < .0001). The ICC values were also high for the standard score (.85), and moderate for the subtests (MD: r = .59; BS: r = .61; B: r = .69). 3.3. Construct validity The Cronbach’s alpha coefficient (N = 844 children) analyses showed good reliability in the 3 subscales (a = .78), as well as for the standard scores on each subtest independently (MD: a = .77; BS: a = .52; B: a = .77). These findings confirm the internal consistency of the MABC-2. Table 2 Validity content index (CVI) and kappa concordance coefficient (p-values). Experts
Clarity CVI (%)
Kappa (IC 95%)
p
CVI (%)
Kappa (IC 95%)
p
123 12 13 23
71.8 93.9 78.9 74.3
– .88 (.76 to .99) .80 (.65 to.95) .76 (.59 to .93)
– .70) reported in the original edition of the MABC-2 (Henderson et al., 2007). A recent study tested young children and also reported higher values (.94) of temporal stability (Smits-Engelsman et al., 2011). High values of test–retest reliability for the MABC-1st edition were also reported when tests were separated bye one week (ICC = .92–.98; Croce et al., 2001), 2- to 3-weeks (ICC = .77; Chow & Henderson, 2003) and a full 3 weeks (ICC = 88; Hilde, Wim, Matthieu, & Smits-Engelsman, 2007). The MABC-2 showed great ability to discriminate typically developing children from those who may potentially be diagnosed with DCD. High ability to predict group membership was observed for the MABC-2 (Humphreys et al., 1993). Furthermore, children labeled as probable DCD, at risk for DCD or TD in the first assessment had the same diagnosis at the second and third assessments (6 and 12 months, respectively, after initial assessment). These results underline the predictive ability of the MABC-2 for Brazilian children. The results from the concurrent validity were satisfactory, a significant moderate and positive association was found between MABC-2 and TGMD-2 standard scores (0.30). However, we must acknowledge that concurrent validity was lower than recommended (Cronbach, 1989). Previously, low-to-moderate correlations between MABC and TGMD-2 (values from .13 to .40) have been reported for preschool children (Logan, Robinson, & Getchell, 2011). The ‘fragile’ result of the present study could be related to the specificity of each assessment. The MABC has two sections assessing manual dexterity and balance; skills more related to children every day tasks. The TGMD-2 was designed to assess children’s motor development in locomotor and ball skills that seems more related to sports skills. A limitation of our study is that the analyses of longitudinal predictive validity and concurrent validity were restricted to children from 3 to 6 and 6 to 11 years, respectively. Unfortunately, school administrators only permitted the younger group of children to be included in our longitudinal study. We hope to include a full age range in future studies. 5. Conclusions It was demonstrated for the first time that the MABC-2 is valid in Brazil. A Brazilian–Portuguese version of the MABC-2 was created and rigorously tested with respect to its reliability and face, content, criterion and construct validity.
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The MABC-2 proved to be accurate and valid for Brazilian children. In addition, several experimental procedures and statistical analyses were employed to test the internal consistency, reliability, and its predictive, concurrent and discriminative power. Although a large sample size was used in this investigation, we should consider the cultural diversity of motor experiences found in different states and regions in Brazil. As seen in several large countries, children originating from different regions certainly have a distinctive (or context-specific) motor repertoire, especially those children at the age range targeted in the MABC-2. Hence, generalization of these findings is currently limited; future research should replicate and extend our results to children from other states in Brazil. 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