Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by repetitive and stereotyped behaviors, as well as difficulties in communication and delays in motor development. This study aims to assess the reliability and objectivity of an instrument composed of motor tests to evaluate motor coordination in children with ASD. Using the Motor Coordination Assessment Battery for Children with Autism (BACMA) The study involved the production-construction, validation, and evaluation of the instruments, including the measurement of intra- and inter-rater errors as a methodological parameter. An Evaluation Sample Group was formed by 31 children with ASD, aged between 7 and 10 years. The results indicated that BACMA demonstrated high reliability (r = 0.94; p < 0.0001) and objectivity (r = 0.91; p < 0.0001), proving to be a precise and consistent tool for evaluating motor coordination in children with ASD. The general coordination index (ICG) established by the quartiles allowed classifying the motor performance of the children as Very Good, Good, Regular, or Insufficient. It is concluded that the BACMA is a valuable tool for improving the accuracy and effectiveness of motor performance assessment in children with ASD. Furthermore, it is expected that this battery of tests will promote qualitative changes in the analysis of motor coordination in these individuals, being an important tool for professionals in the field of human motricity. This research contributes to the development of more appropriate and personalized intervention strategies aimed at improving motor coordination and overall development of children with ASD.
Research Article
Evaluating Motor Coordination in Children With Autism Spectrum Disorder: Validation of a Motor Test Instrument
https://doi.org/10.21203/rs.3.rs-5246510/v1
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Autism Spectrum Disorder
Motor Coordination
Fidelity
Objectivity
Autism Spectrum Disorder (ASD) is characterized by difficulties in social construction and relationships, deficits in communication, and presentation of repetitive and stereotyped behavior, in addition to restricted interests [1]. These difficulties are the result of the neurobiological development of the individual, meaning that each person within the spectrum will have their own characteristics. Therefore, there are no two autistic individuals identical regarding their disorder conditions [2].
Epidemiological statistics highlight a significant increase in diagnoses over the years. According to Zeidan et al. [3], it is estimated that for every 100 people in the world, one is diagnosed with ASD. Additionally, a study by the Centers for Disease Control and Prevention [4] in the United States revealed that 1 in 36 people has ASD. In the Brazilian context, the Brazilian Institute of Geography and Statistics (IBGE) has not yet provided specific data on the number of people diagnosed. However, based on information from other mentioned studies, it is estimated that approximately 4.7 million Brazilians have ASD.
Therefore, individuals with autism require ongoing treatment to support their vulnerabilities, which may vary in terms of social, motor, affective, and cognitive skills. These support needs may vary according to each individual, and it is essential to adapt the treatment according to the specificity of the conduct to be designated [5]. Considering that motor dysfunctions, such as delayed motor development that occurs with advancing age and difficulties in performing fundamental motor skills, are frequent characteristics in individuals with ASD [6], it is important to highlight that about 79 to 83% of these individuals present impairments in motor skills appropriate for their age groups, affecting their daily life activities [7].
Monteiro et al. [8] conducted a study with the aim of developing a Motor Assessment Battery for Children with Autism (BACMA), using the Delphi method. After the answers of 23 health science professionals, the results indicated high content and appearance a possible validity of the battery of tests. Additionally, the analysis of the Cronbach's alpha coefficient revealed a value of 0.99, evidencing statistically high reliability of the answers. These findings suggested the consistency of BACMA as an effective tool for assessing motor coordination in children with autism.
Currently, no studies analyzed the motor coordination global index (GI) for children with Autism, being a gap in the literature. In this sense, to meet the demand and the real need for a specific analysis of the motor coordination of these children, this study aimed to evaluate the fidelity and objectivity of an instrument consisting of motor tests, aimed at assessing motor coordination in children with ASD. This instrument, also known as the Motor Coordination Assessment Battery for Children with Autism – BACMA [8], was specifically created for this purpose.
This is a research characterized by verifying scientific methods involving the production-construction, validation, and assessment aimed at creating instruments using the application of BACMA. The measurement of intra- and inter-rater errors as a methodological is a parameter in this research [9].
Participants
The sample selection was carried out according to the procedures described by Fontelles et al. [10], using a convenience sampling criterion, which is applied in unlimited populations through a random selection. Furthermore, to ensure the objectivity and reliability of the sample, it is recommended to use at least 31 individuals in studies of this type. Therefore, in this study, the sample was composed of a total of 31 children with ASD, aged between 7 and 10 years, available at the Olympic Villages in the Rio de Janeiro city.
For the study, inclusion and exclusion criteria were established. Participating children should have a diagnosis of ASD and be between the ages of 7 and 10 years. Additionally, it was necessary for the guardian to sign the Free and Informed Consent Form (TCLE) and the children to sign the Free and Informed Assent Form (TALE), which was presented in image format to facilitate understanding.
On the other hand, children who initially could not understand the performance of the tests or could not complete all the tests of the battery were excluded from the study. These criteria were established to ensure adequate participation and the obtaining of reliable results.
This study received approval from the Ethics and Research Committee (CEP) of the Federal University of the State of Rio de Janeiro (UNIRIO), with a favorable opinion. Approval was granted due to compliance with all ethical principles established in resolutions 674/2022, as well as Circular Letter No. 1/2021-CONEP/SECNS/MS [11] and the Helsinki Resolution [12].
Procedures and Materials
In the development of the BACMA protocol, it was established that it would be composed of four tests: balance, locomotion, manipulation, and jumping. Each of these tests follows specific procedures, and this comprehensive approach allows for the assessment of different aspects of fundamental motor skills in children with autism [13].
In this context, the BACMA assessment protocol [8] was presented to the evaluators. In this sense, the Test Battery was presented to the evaluators, these composed by the main evaluator and secondary evaluator, where each individually applied the tests to the children using the BACMA, with the main evaluator conducting it twice at an interval of one week, consequently investigating the Fidelity (intra-evaluator error). Right after this assessment, it was applied with the same group of children, however, the secondary evaluator distinct from the previous one to assess the Objectivity (inter-evaluator error). Thus, the analysis of the intra and intervalidity errors achieved was determined.
The estimated time for applying the test varied between 20 and 30 minutes depending on the level of support needed to understand the application of BACMA, besides, the space provided varied according to the location provided. This was due to the low number of children in a single Olympic village, necessitating going to other Olympic villages to complete the stipulated sample in the study.
Statistical Analysis
The statistical software used for the data analysis procedures was IBM SPSS Statistics 25.0 for Windows, with the aim of outlining the objective of the study. Thus, the data presented are in the form of descriptive and inferential statistics. In compliance with the study, the normality and homogeneity of variance of the sample data were verified through the Shapiro-Wilk and Levene tests, respectively. For statistical analysis of the fidelity and objectivity of BACMA, the data treatment involved expressing the correlation in fidelity using the correlation coefficient, which ranges from 0.00 to 1.00, the closer to 1.00, the smaller the error. This was also done to correlate objectivity. Furthermore, the Pearson linear correlation test for intra-evaluator (fidelity) and inter-evaluator (objectivity) was established, with p < 0.05.
The evaluation sample group was constituted of 31 children with ASD, aged between 07 and 10 years, as characterized in table 1. The descriptive characteristics of the moments found in the BACMA tests of balance, locomotion, manipulation, and jump are shown in table 2, presented for each moment conducted by evaluator 1 and 2.
Table 1. Characterization of the study participants.
|
N |
Age |
Male |
Female |
|
31 |
7,93 ± 0,92 |
26 |
5 |
Table 2. Descriptive characteristics (arithmetic mean ± standard deviation) of the sample, for the data of the three testing moments.
|
VARIABLES |
MOMENTS |
||
|
Evaluator 1 Moment 1 |
Evaluator 1 Moment 2 |
Evaluator 2 Moment 3 |
|
|
Balance |
4,45 ± 2,13 |
4,32 ± 2,01 |
4,77 ± 1,59 |
|
Locomotion |
6,70 ± 1,54 |
6,71 ± 1,41 |
6,81 ± 1,69 |
|
Manipulation |
1,52 ± 1,61 |
1,42 ± 1,77 |
1,90 ± 2,15 |
|
Jump |
0,74 ± 0,38 |
0,75 ± 0,35 |
0,78 ± 0,35 |
It can be observed that the arithmetic mean between the two measures of the evaluators was obtained within the 31 volunteers. That is, the measure made in the first, second, and third moments of the evaluators, for a given variable, being summed and divided by 31 volunteers, generating the mean of the variable and the intended standard deviation.
In table 3, the degrees of fidelity and objectivity for the variables of balance, locomotion, manipulation, jump, and general coordination index are presented.
Table 3. Correlation indices of intra-evaluator (fidelity) and inter-evaluator (objectivity) through the Pearson correlation coefficient for the studied variables.
|
Variables |
Fidelity |
Objectivity |
||
|
R |
P |
R |
P |
|
|
Balance |
0,97 |
<0,001* |
0,69 |
<0,001* |
|
Locomotion |
0,92 |
<0,001* |
0,80 |
<0,001* |
|
Manipulation |
0,91 |
<0,001* |
0,83 |
<0,001* |
|
Jump |
0,94 |
<0,001* |
0,87 |
<0,001* |
As can be seen in table 4, high correlation was verified between the tests of evaluator 1 and between the test of evaluator 1 and 2, suggesting a high degree of fidelity and objectivity of the proposed battery.
For fidelity, an r of 0.94 was observed, indicating a strong and positive correlation, showing that with the increase of the first test, there was an increase in the second test (p<0.001*).
For objectivity, an r of 0.91 was observed, indicating a very strong and positive correlation, showing that with the increase of the first test, there was an increase in the third test (p<0.001*).
The BACMA (Motor Coordination Assessment Battery for Children with Autism) was developed to meet the need for a specific assessment of motor coordination in children with ASD. The formula for BACMA was elaborated considering the need to avoid the predominance of one category over the others, in addition to incorporating relative weights for the importance of each category.
The weights assigned to each category were defined as follows: Balance (E) - 1.5; Locomotion (L) - 1.0; Manipulation (M) - 4.4; and Jump (S) - 16.8. Thus, the general coordination index is calculated by the weighted arithmetic mean, according to the formula below:
These weights reflect the relative importance of each category in the context of the assessment of motor coordination. After assigning weights to the different categories, aiming to reflect the relative importance of each in the assessment of motor coordination, the weighted mean was applied.
This procedure is fundamental to avoid that discrepant or extreme values distort the general index. The weighted mean considers not only the individual values of each category but also the proportional influence of the weights associated with each of them. In this way, the resulting index offers a balanced and fair representation of overall performance, providing a more accurate and robust view of the assessment of motor coordination.
This approach contributes to ensuring that no category exerts a disproportionate impact on the final index, promoting a more equitable assessment aligned with the relevance attributed to each component of the assessment instrument.
Below, table 4 represents the results of the IGC that were found through the calculation performed.
Table 4. Descriptive characteristics (arithmetic mean ± standard deviation) of the sample, for the data of the three testing moments and Correlation indices of intra-evaluator (fidelity) and inter-evaluator (objectivity) through the Pearson correlation coefficient for the studied variables.
|
VARIABLES |
MOMENTS |
||
|
General Motor Coordination Index |
Evaluator 1 Moment 1 |
Evaluator 1 Moment |
Evaluator 2 Moment 3 |
|
8,10 ± 3,30 |
8,01 ± 3,29 |
8,85 ± 3,49 |
|
|
Fideliy |
Objectivity |
||
|
R |
P |
R P |
|
|
0,94 |
<0,001* |
0,91 <0,0001* |
|
After the analysis of the results, the classification parameters of each test used in the BACMA were determined, in addition to the General Motor Coordination Index of the BACMA, these represented in table 5, using the quartiles through Very Good (M), Good (B), Regular (R), and Insufficient (I). These quartiles are a statistical procedure established from the worst to the best result obtained, through measures of central tendency and their variability, finding the mean, the first, and the third quartile, obtaining the necessary quartiles at the end.
Table 5. Classification of the Quartiles of the BACMA Tests and General Motor.
|
Test |
Quartil |
Classification |
Result |
|
Balance |
First |
Very Good |
> 6 steps |
|
Second |
Good |
4,46 to 6 steps |
|
|
Third |
Regular |
3 – 4,45 steps |
|
|
Fourth |
Insufficient |
< 3 passos |
|
|
Locomotion |
First |
Very Good |
< 5,82 seconds |
|
Second |
Good |
> 5,83 to 6,70 seconds |
|
|
Third |
Regular |
>6,71 a 7,37 seconds |
|
|
Fourth |
Insufficient |
>7,37 seconds |
|
|
Manipulation |
First |
Very Good |
> 3 hits on the target |
|
Second |
Good |
1,53 - hits on the target |
|
|
Third |
Regular |
0,1 – 1,52 hits on the target |
|
|
Fourth |
Insufficient |
0 hits on the target |
|
|
Jump |
First |
Very Good |
>1,06 cm |
|
Second |
Good |
>0,75 to 1,05 cm |
|
|
Third |
Regular |
>0,39 to 0,74 cm |
|
|
Fourth |
Insufficient |
<0,38 cm |
|
|
Global Index |
First |
Very Good |
>11,36 (100%) |
|
Second |
Good |
>8,11 a 11,36 (50%) |
|
|
Third |
Regular |
|
|
|
Fourth |
Insufficient |
<5,46 (25%) |
The present study aimed to verify the fidelity and evaluate the objectivity of an assessment battery for motor coordination in children with autism, determined as BACMA, na instrument created in the study by Monteiro et al. [8]. The main results demonstrated remarkable fidelity (r = 0.94; p < 0.0001) and objectivity (r = 0.91; p < 0.0001) of the BACMA application, validating their effectiveness. In addition, the results obtained in the present study also indicate that BACMA can be a valuable tool for a more specific analysis of motor performance in autistic children between 7 and 10 years, especially considering the global coordination index established by the quartilhes.
Some studies point to the importance of assessing fundamental motor skills, in order to show the need for interventions in physical aptitudes early in children with ASD, as low motor performance directly influences social, cognitive, and affective skills in their routines [7, 13, 14]. In accordance with the Thomas et al. [15], who highlight the importance of using a valid, reliable, and objective instrument, evaluated for intra- and inter-rater assessment erros, the relationship between the assessment error and the reduction of errors throughout the study is fundamental to ensure the quality of the research [16]. The scheduled conduct follows methodological guidelines by Thomas et al. [15], seeking to establish the validity of the proposed instrument, i.e., the interpretation of the data obtained in the test is crucial for a meaningful measure. Being that fidelity, which refers to the consistency and reliability of the measure, is an integral part of validity. When the same results are obtained by the same evaluators, objectivity is considered, which is also a form of fidelity between evaluators.
The study by Monteiro et al. [17] conducted a systematic review with the aim of analyzing the efficacy of physical activity practice on motor coordination in children with ASD. From the initially found 1771 articles, 4 articles were selected according to inclusion and exclusion criteria, resulting in 5 experimental randomized studies for the meta-analysis. The study involved 56 children with ASD who participated in physical activity interventions, compared with 53 children in the control group. Despite the results indicated that physical activity had no significant effects on the motor coordination of this population, the effect size indicated an important clinical relevance, demonstrating the importance of assessing motor coordination in children with ASD and considering exercise programs directed to address the issue [18]. The complexity of assessing motor coordination in children with ASD is one of the obstacles presented in the literature [19]. Such difficulty reveals the existence of a gaps to be filled. In this context, BACMA is configured as a relevant tool in the treatment follow-up [8].
Furthermore, for the refinement of the validity and objectivity of motor test instruments, the scientific evidence regarding the use of correlation to recognize intra and inter-evaluator data is considered conclusive. Some studies using motor tests as a basis, such as Soares et al. [20], Gonçalves et al. [21] and Santos et al. [22], also ensured this correlation about the quality of fidelity and objectivity. Thus, Kiss [23] presents validity, fidelity, and objectivity as important tools in the validation of instruments. In the presente study, fidelity is a component of validity, ensuring the consistency and repeatability of the measure. The fidelity coefficient is used to measure the ratio between the variances of the true score and the observed score, while objectivity refers to the degree to which evaluators can differentiate and obtain the same scores from the same subjects [15].
The absence of studies regarding the global index for children with Autism is a gap to be filled, which makes it difficult to factor in comparison with other opportunities to discuss validation in this population, however, this is a preponderant factor in this study that considers having the first tool to be used as an intervention on motor coordination.
This study highlights the usefulness of BACMA for professionals and researchers in the field, providing a robust and reliable evaluation of motor coordination in children with ASD. The implementation of BACMA has proven to be a valuable tool for improving the precision and effectiveness of motor performance assessment, contributing significantly to research and practice in this area.
Author Contribution
“This manuscript represents original work carried out by the authors who worked equally on the study development. All authors read and approved the final manuscript"
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No competing interests reported.