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Brief Assessment of Motor Function: Content Validity and Reliability of the Fine Motor Scale
Rebecca Parks, MS, OTR/L, BCP, FAOTA, Holly Lea Cintas, PhD, PT, PCS, Maisie Chou Chaffin, MA, and Lynn Gerber, MD Rehabilitation Medicine Department (R.P., H.L.C., L.G.), Mark O. Hatfield Clinical Research Center, National Institutes of Health, Bethesda, Maryland; Ferkauf Graduate School of Psychology (M.C.C.), Yeshiva University, Bronx, New York; Bellevue Hospital Center (M.C.C.), New York, New York; and Center for Chronic Illness and Disability (L.G.), George Mason University, Fairfax, Virginia Purpose: The Brief Assessment of Motor Function Fine Motor Scale (FMS) allows rapid assessment, independent of age. This study was done to establish content validity of the FMS and to demonstrate FMS reliability. Methods: A standard questionnaire (Disagree to Agree, 1 4) was emailed to 28 expert panel members. Ten children with diagnoses including Proteus, Sheldon-Freeman, Smith-Lemli-Opitz, and Smith-Magenis syndromes were videotaped for reliability trials. Results: Expert panel members agreed that all 28 items should be included (means, 3.433.89); were functionally relevant (means, 2.933.82), were clearly worded (means, 2.71 3.61), and were easily discriminated (means, 3.32 4.0). Kappa values for interrater and intrarater reliability were 0.978 and 0.993, respectively. Conclusions: Feedback from an expert Panel supported content validity of the Brief Assessment of Motor Function FMS. Kappa values for interrater and intrarater reliability suggest this is a reliable instrument for rapid, objective fine motor assessment. (Pediatr Phys Ther 2007;19:315325) Key words: child development, childhood disability, content validity, motor performance, motor skills, rehabilitation, reliability INTRODUCTION The development of normal fine motor function follows a specific sequence,1 which has been documented extensively in the literature. From birth to two years, the development of fundamental hand skills occurs, including grasp, release, and bimanual skills.2 A child typically learns to button between ages three and four years3 and to snap between ages three and a half and four years. During the preschool years (ages four to six years), precision handling and manual dexterity develop1 such that in-hand manipulation,4,5 lacing and tying,3 tool use, visuomotor, and self-care skills1 are refined.
0898-5669/107/1904-0315 Pediatric Physical Therapy Copyright 2007 Lippincott Williams & Wilkins and Section on Pediatrics of the American Physical Therapy Association.

Address correspondence to: Rebecca Parks, MS, OTR/L, BCP, FAOTA, Bldg. 10-CRC, Room 1-1469, 10 Center Drive, MSC 1604, Bethesda, MD 20892-1604. E-mail: rparks@nih.gov The opinions presented in this article reflect the views of the authors and not necessarily those of the National Institutes of Health or the US Public Health Service. As we are US federal employees, this article fits the description of a US Government Work and cannot be copyrighted (Copyright Revision Act, 1976). It is available for publication and there are no restrictions on its use, now or subsequently. DOI: 10.1097/PEP.0b013e3181588616

Development of any of these skills can be directly affected by delays1 resulting from a variety of causes, including developmental disabilities, such as cerebral palsy.6 Even low birth weight can affect fine motor outcomes later in life.7,8 In both children and adults, musculoskeletal and neuromuscular disorders such as inflammatory joint disease9,10 and Wilsons disease11 may affect fine motor skills, as can stroke12 and head injury,13,14 as well as HIV/AIDS.15 Substance-induced declines in fine motor function have also been documented in populations, including acutely psychotic patients.16 Finally, studies have shown that even the normal aging process is associated with a decline in fine motor function: evidence of a critical decline in hand movements in geriatric populations suggests that there may be an identifiable point in midlife when fine motor decline either begins or significantly worsens.1719 Others have emphasized the heterogeneous nature of fine motor decline in geriatric populations, suggesting that the observed decline may not be simply age-dependent.20 Instruments commonly used to assess fine motor skills in children include the Fine Motor Scales (FMSs) of the Peabody Developmental Motor Scales (PDMS-II),21 the original PDMS,22 and the Bruininks-Oseretsky Test of Motor Proficiency.23 For children and adults, hand function is
Validity and Reliability of the BAMF Fine Motor Scale 315

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often evaluated using the Jebsen Hand Function Test.24 Additional measures used to assess fine motor function among adults include the Nine-Hole Peg Test,25 the Motor Assessment Scale,26 the Purdue Pegboard,27 and the Smith Hand Function Evaluation.28 Through wide application, many of these tests have become gold standards in their respective domains. The validity and reliability of these instruments has generally been supported6,29 35; however, results of standardized tests designed to identify developmental stage or rate skills with limited direct applicability to daily life may not be appreciated as reflective of true functional ability, and as a result, the tests may not be used routinely in clinical practice to demonstrate treatment response.36 Many assessments are considered valuable for their ability to generate normative comparison scores, although the scores may not clearly describe what an individual actually can do with respect to motor performance.37 Comparisons to normal scores may not be useful for an individual with a disability; for example, they may not be relevant to tracking performance changes of children who have functional limitations associated with neuromuscular or musculoskeletal impairments.9 In a study generally supporting the interrater reliability of the PDMS FMSs, Stokes et al34 found greater agreement between raters for a group of children who were not delayed than for a group of children with motor delay. An additional consideration is the fact that normal values may not be relevant across cultures.38 Brief Assessment of Motor Function The Brief Assessment of Motor Function (BAMF) consists of five hierarchically ordered motor scales for gross, fine, and oral motor domains.37 Designed to be used independent of age, each BAMF scale is organized to allow very rapid identification of motor skill level. The authors designed the BAMF Scales to assess observable, unequivocal, adaptive functional behaviors.37 While the BAMF FMS (see Appendix) grew out of a need for rapid assessment of fine motor skill in infants and children with disabilities, behaviors selected for inclusion in all five of the scales represent observed performance capabilities, rather than disabilityimposed limitations. The BAMF was developed from the observation that a brief assessment represents a valid and clinically useful first step in some circumstances. This is underscored by the fact that a BAMF score corresponds to a specific motor performance level, allowing the examiner to rapidly determine, and subsequently recall, an individuals level of function. Used together, the five scales of the BAMF provide a complete profile of an individuals motor functioning in five different domains in as little as 10 minutes. Ease of BAMF administration makes it a useful tool for tracking an individuals progress over time. Although a single assessment on which to base initial referrals may be useful, a need clearly exists for screening over multiple time points and across domains.39 The BAMF can be used by professionals and students of various disciplines in numerous contexts, including clinical research and educational set316 Parks et al

tings. Among the BAMF scales, the Lower Extremity Gross Motor Scale37 has been shown to demonstrate good interrater and intrarater reliability for children with various diagnoses, as well as good concurrent validity with standard measures of gross motor performance used in children with osteogenesis imperfecta. Brief Assessment of Motor Function Fine Motor Scale The BAMF FMS can be used to rapidly assess fine motor skill. Based on observable functional behaviors, and requiring a dichotomous choice of present or absent, the BAMF FMS is a 0 to 10 scale, and the score given is equivalent to the highest, most challenging observed item completed on the scale, regardless of whether items lower on the scale were performed (Figure 1). From the universe of possibilities, the BAMF FMS was made up of skills with functional salience, organized developmentally, and has

Fig. 1. (A) Child performs BAMF FMS Level 4. (B) Child performs BAMF FMS Level 9. Pediatric Physical Therapy

some value in documenting change (gain or loss) over time. In testing a child, emphasis is placed on seeing the highest skill level (0 10) possible, so instructions are made as clearly as possible, repeated as necessary, and time is given to allow the child to demonstrate the presence or absence of the skill being tested. Although every task below the observed best performance could be assessed, this is not consistent with the intent of the BAMF FMS scale, and other assessments already exist for this purpose. Measures like the BAMF FMS that incorporate a range of levels, in this case from essentially no isolated fine motor skill to a highly coordinated skill like writing, also minimize the floor effect on scores, which sometimes makes it difficult to detect change in performance over time.40 Physical performance measures like the BAMF FMS are useful not only because they document observable and reproducible behaviors, but also because they can capture meaningful changes in functional ability and reflect distinctions between an individuals usual function and the maximum level possible.41 The BAMF FMS is both a screening instrument and follow-up tool, offering a functionally meaningful and concise way to assess the outcome of specific interventions and track subsequent changes in function (see Appendix). METHODOLOGY Participants and Procedures Content Validity. Content validity is frequently the initial step in the process of instrument development,42 and

establishing content validity is encouraged by the tests and measurements standards of the American Psychological Association43 and American Physical Therapy Association.44 Content validity has been defined as the degree to which test items represent the performance domain the test is intended to measure.45(p. 154) One common way to assess the validity of an instrument is to have it evaluated by a panel of expert judges.42,45 The present study employed one of the methods described by Dunn,45 in which an expert panel is provided with both test items and a list of test objectives. Quantitative and or qualitative feedback provided by the panel is then used to modify individual items and overall test content. Other studies have used similar approaches to establish content validity.46 48 The expert panel for the BAMF FMS consisted of 28 experts in fine motor assessment, all occupational therapy clinicians and researchers with doctoral degrees (PhD, DSc, ScD). Selected for their terminal degrees and recommended to us by colleagues, they came from widely diverse locations around the United States and Canada. More than 90% of the panel had 20 years or more experience in their field, which is indicative of their collective expertise (Table 1). Questionnaire. Following an email invitation to participate and individuals consent to do so, a standard questionnaire was emailed to each prospective panel member. None of the panel had used the BAMF FMS before participating in the study, and they were asked to assess the BAMF FMS items on the basis of six standard questions for each skill level (0 10).

TABLE 1
Expert Panel Composition for Determining Content Validity of the BAMF FMS Expert No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Discipline Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Occupational therapist Education ScD PhD PhD DSc DSc PhD PhD PhD PhD PhD PhD PhD PhD PhD PhD PhD PhD PhD DSc PhD DSc PhD DSc PhD PhD PhD PhD PhD Experience (yr) 2025 1520 25 25 25 25 25 25 2025 25 2025 25 25 1520 25 25 2025 1520 25 2025 25 25 25 25 25 25 25 25 Employment Setting University, private practice University University Hospital, university, research facility University University University University University University University Hospital, university, research facility University University University University Other University, research facility University, private practice University Other University, private practice Education facility Other University University Education facility other than university University Location United States United States United States United States United States United States United States United States United States United States United States United States United States United States United States United States United States United States United States United States United States United States United States United States United States Canada United States United States

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Validity and Reliability of the BAMF Fine Motor Scale 317

Respondents were included as expert panel members only if they agreed to participate before receiving the questionnaire, and completed and returned the questionnaire. The standard six questions for each BAMF item are as follows: (1) This item should be included; (2) This item is clearly worded; (3) Item should be reordered higher on scale; (4) Item should be reordered lower on scale; (5) This is a functionally relevant motor behavior; and (6) This behavior is easily discriminated from others on the scale. Respondents were asked to respond to each question using a four-point scale, ranging from 1 Disagree to 4 Agree. This scale allowed clear expression (no neutral rating) of judgment, with some room to express intensity or strength of agreement or disagreement (4 vs 3, 1 vs 2). Reliability. A convenience sample of 10 children (ages seven months to 15 years; three boys, seven girls) with a range of diagnoses including osteogenesis imperfecta, Proteus, Sheldon-Freeman, Smith-Lemli-Opitz, and Smith-Magenis syndromes, was selected to represent a broad range of skill levels; no children who were typically developing were included in the sample (Table 2). Following parental informed consent (and child assent where possible), the children were videotaped performing specific upper extremity fine motor skills, items 0 to 10 on the BAMF FMS. High quality videotaped segments of the childrens performances were then randomly ordered on a single videotape. Ten children were selected as the maximum permitted under the Departments IRB-approved Screening Protocol, which allows data collection on small numbers (10 or fewer) in pilot studies, for cases such as instrument development. In the reliability study, five raters were used; all were employed in the Rehabilitation Medicine Department of the National Institutes of Health and had varying skill levels and training; among the group were a board certified pediatric specialist, a newly graduated therapist, and a therapist having more than 20 years of experience mainly with adults with mental health disorders. Five raters were chosen, so as to generate robust results for data analysis. Before viewing the composite videotape, the group was prepared with training consisting of an overview and brief explanation of each item 0 to 10 and the descriptive criteria. The same three occupational therapists and two physical therapists viewed the videotape together and silently rated the childrens performances on the BAMF FMS (with revisions incorTABLE 2
Reliability Trial Subjects No. 1 2 3 4 5 6 7 8 9 10 DOB 7/6/1996 11/1/1999 2/3/2002 9/29/1996 2/22/1999 4/22/1997 3/24/2004 11/3/2002 9/14/1999 Age at Time of Taping Gender 4 yr 4 mo 3 yr 9 mo 19 mo 7 yr 1 mo 5 yr 6 yr 11 mo 7 mo 1 yr 11 mo 5 yr 3 mo M F F F F F M F F M Diagnosis Proteus syndrome Smith Magenis syndrome Sheldon-Freeman syndrome Smith Lemli Opitz syndrome Smith Lemli Opitz syndrome Smith Magenis syndrome Osteogenesis Imperfecta Osteogenesis Imperfecta Infantile Neuronal Ceroid Lipofuscinosis Osteogenesis Imperfecta

porated from expert panel suggestions) on three occasions: at baseline, after 24 hours, and three weeks after the original viewing. The same tape was used on all three rating occasions; if raters needed to see specific taped segments over, they could ask for a rewind or repeat play. Data Analyses Content Validity Questionnaire. Descriptive statistics were used to determine central tendency and range of responses. Range, median, and mean were calculated for responses to each of the six questions for each of the 10 BAMF FMS items (Table 3). The percentage of responses assigned ratings of 1 through 4 was also calculated for items 0 through 10 (Table 4). Although not required to do so, many expert panel members provided item-specific commentary (we received 84 separate comments), which were used in addition to the quantitative feedback to further refine individual items on the BAMF FMS. After systematic analysis of qualitative feedback in the form of comments on the items, several items were modified and several descriptive criteria for scoring items were rewritten. To evaluate the applicability of the qualitative feedback and ultimately the decision to modify specific items, written comments provided by the panel were examined based on these criteria: (1) Does the comment appear more than once? (2) Is the comment useful for clarifying the description of an item? and (3) Is the comment useful with respect to reordering an item? Items revisions were incorporated into the scale used by raters during the reliability trials. Reliability. The kappa statistic was calculated as a quantitative measure of the magnitude of agreement between observers: K P o Pc 1 Pc

where po equals the amount of observed or actual agreement and pe equals the amount of expected agreement or that attributed to chance alone.49 RESULTS Content Validity Table 3 and Figure 2 provide and illustrate the mean response values for each of the BAMF task items. Table 4 displays the percentage of responses allocated to ratings of 1, 2, 3, or 4 for all items; Table 4 also shows the median and mode of responses for all items. For items 0 to 5, 9, and 10, some expert panel members did not provide a rating for every criterion. When this occurred, it was typically accompanied by a written response. Rated on a scale from 1 to 4, the expert panel members generally agreed that all items should be included: means ranged from 3.43 to 3.89 (Table 3). Depending on the BAMF task item, 57.1% to 92.9% of panel members gave This item should be included a rating of 4 (Table 4). There was also general agreement that the items could easily be discriminated from others on the scale (means 3.32
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TABLE 3
Responses of Expert Panel Members 1. This item should be included # Resp Item 0 Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item 10 28 28 28 28 28 28 28 28 28 28 28 Range 2.004.00 1.004.00 1.004.00 1.004.00 2.004.00 1.004.00 2.004.00 2.004.00 1.004.00 1.004.00 1.004.00 Median 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 Mean 3.89 3.50 3.71 3.43 3.43 3.61 3.82 3.68 3.71 3.57 3.64 Item 0 Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item10 2. The item is clearly worded # Resp 28 28 28 28 28 28 28 28 28 28 28 Range 1.004.00 1.004.00 1.004.00 1.004.00 1.004.00 1.004.00 2.004.00 1.004.00 2.004.00 1.004.00 1.004.00 Median 2.50 3.00 3.00 3.00 3.00 4.00 4.00 4.00 4.00 4.00 4.00 Mean 2.71 3.00 2.89 2.75 2.96 3.29 3.46 3.36 3.61 3.21 3.14 Item 0 Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item10 3. Should be reordered higher # Resp 28 27 26 26 25 27 28 28 28 26 25 Range 1.004.00 1.004.00 1.004.00 1.004.00 1.004.00 1.004.00 1.004.00 1.004.00 1.004.00 1.004.00 1.003.00 Median 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Mean 1.14 1.48 1.58 1.42 1.60 1.37 1.61 1.39 1.32 1.31 1.16

4. Should be reordered lower Item 0 Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item 10 27 27 28 26 26 26 28 28 28 26 26 1.004.00 1.004.00 1.004.00 1.004.00 1.004.00 1.003.00 1.004.00 1.004.00 1.004.00 1.002.00 1.003.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.33 1.26 1.43 1.88 1.62 1.31 1.36 1.50 1.36 1.08 1.12 Item 0 Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item10

5. Functionally relevant behavior 28 28 28 28 28 28 28 28 28 28 28 1.004.00 1.004.00 1.004.00 1.004.00 1.004.00 1.004.00 2.004.00 2.004.00 1.004.00 2.004.00 2.004.00 3.00 3.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 2.93 3.07 3.50 3.57 3.39 3.64 3.75 3.82 3.71 3.75 3.64 Item 0 Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item10

6. Behavior is easily discriminated 28 28 28 27 27 28 28 28 28 28 28 1.004.00 1.004.00 1.004.00 1.004.00 1.004.00 3.004.00 3.004.00 4.004.00 2.004.00 3.004.00 3.004.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 3.50 3.32 3.57 3.74 3.52 3.86 3.93 4.00 3.89 3.89 3.96

4.00). This behavior is easily discriminated from others on the scale was given a rating of 4 by 60.7% to 100% of panel members, depending on the BAMF task item. The panel also found the rank order of the items appropriate. In response to the statement This item should be reordered higher on scale, means ranged from 1.14 to 1.61 (Table 3), indicating strong agreement that the order of BAMF task items should not be changed. Depending on the task item, 67.9% to 92.9% of panel members assigned a rating of 1, indicating they did not recommend reordering the items (Table 4). Similarly, for This item should be reordered lower on scale, means ranged from 1.08 to 1.88 (Table 3), and, depending on the item, 61.5% to 92.3% of panel members assigned a rating of 1, again not recommending a change in order (Table 4). Although less, considerable agreement existed overall on the clear wording of the items: means ranged from 2.71 to 3.61, and 50.0% to 89.3% of panel members assigned the criterion The item is clearly worded a rating of 3 or 4. It merits mention that almost all of the written comments on the questionnaire related to changes in wording to describe the criterion behavior more clearly. For the criterion This is a functionally relevant motor behavior, means ranged from 2.93 to 3.82 (Table 3), and 60.7% to 96.5% of panel members assigned a rating of 3 or 4 (Table 4). In addition to completing the questionnaire, 18 respondents also provided 84 written comments on the questionnaire. Items 1, 2, and 10 elicited the greatest number of comments: 10, 12, and 13 comments, respectively. Table 5 provides specific examples of feedback from panel members. Item 3, Reaches while supine or sitting, had its criterion description modified to clarify that the seated posiPediatric Physical Therapy

tion was at a 90-degree trunk angle with support, if an erect trunk position required it. Item 10, Writes 10 words or characters legibly, was modified as was its criterion description, because many comments pointed out that requiring a dynamic tripod grasp in the original item hierarchy ignored the fact that not all typical children and adults use this type of grasp.50 The rewritten criterion, Using a mature grasp, acknowledges the widely recognized finding that there are acceptable variants of the dynamic tripod grasp, which are used by adults who are successful, including medical students.51 Item 10 itself, Writes 10 words or characters legibly, was rewritten from the original, Uses pencil with dynamic tripod grasp, to decrease cultural bias (eg, many Asian languages use characters, rather than words); clarify the emphasis on motor output (written or copied product); and set a specific number (10 words or figures) of units to be written or copied accurately. Some expert panel members questioned the functional relevance of isolated dynamic digital extension. The authors thought that the ability to isolate dynamic digital extension represents a specific and higher level of function that can only be developed through movement which is not dominated by reflexive or mass finger flexion patterns. Reliability Robust coefficients of reliability demonstrate success in achieving the objective of refining the clarity of the items, so that scoring remained stable when the instrument was put to use by the raters on a series of occasions (Table 6). Kappa values were 0.978 for interrater reliability, and 0.993 for intrarater reliability.
Validity and Reliability of the BAMF Fine Motor Scale 319

TABLE 4
Percentages of Responses to Validity Questionnaire Disagree 1 0: No evidence of isolated, dynamic digital isolation This item should be included This item is clearly worded Item should be reordered higher on the scale Item should be reordered lower on the scale This is a functionally relevant motor behavior This behavior is easily discriminated from others on the scale 1: Digital isolation and full finger extension This item should be included This item is clearly worded Item should be reordered higher on the scale Item should be reordered lower on the scale This is a functionally relevant motor behavior This behavior is easily discriminated from others on the scale 2: Spontaneous palmar grasp and release This item should be included This item is clearly worded Item should be reordered higher on the scale Item should be reordered lower on the scale This is a functionally relevant motor behavior This behavior is easily discriminated from others on the scale 3: Reaches while supine or sitting This item should be included This item is clearly worded Item should be reordered higher on the scale Item should be reordered lower on the scale This is a functionally relevant motor behavior This behavior is easily discriminated from others on the scale 4: Rakes object to body This item should be included This item is clearly worded Item should be reordered higher on the scale Item should be reordered lower on the scale This is a functionally relevant motor behavior This behavior is easily discriminated from others on the scale 5: Bimanual manipulation of objects This item should be included This item is clearly worded Item should be reordered higher on the scale Item should be reordered lower on the scale This is a functionally relevant motor behavior This behavior is easily discriminated from others on the scale 6: Uses superior or tip pincer grasp to pick up an object This item should be included This item is clearly worded Item should be reordered higher on the scale Item should be reordered lower on the scale This is a functionally relevant motor behavior This behavior is easily discriminated from others on the scale 7: Eating utensil in mouth This item should be included This item is clearly worded Item should be reordered higher on the scale Item should be reordered lower on the scale This is a functionally relevant motor behavior This behavior is easily discriminated from others on the scale 8: Unscrews cap This item should be included This item is clearly worded Item should be reordered higher on the scale Item should be reordered lower on the scale This is a functionally relevant motor behavior This behavior is easily discriminated from others on the scale 17.9 92.9 85.2 14.3 7.1 3.6 10.7 74.1 88.9 10.7 10.7 3.6 10.7 73.1 78.6 3.6 7.1 3.6 17.9 76.9 61.5 3.6 3.7 14.3 72.0 65.4 3.6 7.4 3.6 3.6 74.1 76.9 3.6 67.9 78.6 3.6 82.1 71.4 3.6 82.1 78.6 3.6 2 3.6 32.1 3.6 3.7 25.0 10.7 10.7 14.3 11.1 3.7 17.9 7.1 3.6 28.6 3.8 7.1 10.7 3.6 17.9 28.6 11.5 11.5 14.3 7.4 14.3 21.4 8.0 15.4 14.3 3.7 10.7 25.0 18.5 15.4 10.7 7.1 17.9 17.9 14.3 10.7 10.7 17.9 7.1 14.3 7.1 3.6 10.7 10.7 14.3 3.6 3.6 3 3.6 10.7 3.7 14.3 7.1 17.9 39.3 7.4 25.0 21.4 10.7 21.4 15.4 7.1 17.9 14.3 10.7 14.3 3.8 3.8 3.6 28.6 17.9 8.0 11.5 21.4 18.5 7.1 10.7 3.7 7.7 3.6 14.3 3.6 17.9 3.6 7.1 10.7 17.9 7.1 3.6 10.7 17.9 10.7 3.6 Agree 4 92.9 39.3 3.6 7.4 46.4 75.0 67.9 35.7 7.4 7.4 46.4 60.7 82.1 39.3 7.7 7.1 67.9 75.0 67.9 39.3 7.7 23.1 78.6 88.9 57.1 46.4 12.0 7.7 60.7 70.4 78.6 60.7 3.7 82.1 85.7 89.3 64.3 14.3 7.1 85.7 92.9 78.6 60.7 10.7 7.1 89.3 100.0 82.1 71.4 7.1 7.1 82.1 92.9 Median 4.0 3.0 1.0 1.0 4.0 4.0 4.0 3.0 1.0 1.0 3.0 4.0 4.0 3.0 1.0 1.0 4.0 4.0 4.0 2.0 1.0 1.0 4.0 4.0 4.0 3.0 1.0 1.0 4.0 4.0 4.0 4.0 1.0 1.0 4.0 4.0 4.0 4.0 1.0 1.0 4.0 4.0 4.0 4.0 1.0 1.0 4.0 4.0 4.0 4.0 1.0 1.0 4.0 4.0 Mode 4.0 4.0 1.0 1.0 4.0 4.0 4.0 3.0 1.0 1.0 4.0 4.0 4.0 4.0 1.0 1.0 4.0 4.0 4.0 4.0 1.0 1.0 4.0 4.0 4.0 4.0 1.0 1.0 4.0 4.0 4.0 4.0 1.0 1.0 4.0 4.0 4.0 4.0 1.0 1.0 4.0 4.0 4.0 4.0 1.0 1.0 4.0 4.0 4.0 4.0 1.0 1.0 4.0 4.0 (Continued)

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TABLE 4
Continued Disagree 1 9: Secures button or snap This item should be included This item is clearly worded Item should be reordered higher on the scale Item should be reordered lower on the scale This is a functionally relevant motor behavior This behavior is easily discriminated from others on the scale 10: Uses pencil with dynamic tripod grasp This item should be included This item is clearly worded Item should be reordered higher on the scale Item should be reordered lower on the scale This is a functionally relevant motor behavior This behavior is easily discriminated from others on the scale 3.6 7.1 84.6 92.3 3.6 10.7 92.0 92.3 2 7.1 21.4 7.7 7.7 3.6 3.6 17.9 3.8 10.7 3 17.9 14.3 17.9 10.7 17.9 17.9 8.0 3.8 14.3 3.6 Agree 4 71.4 57.1 7.7 78.6 89.3 75.0 53.6 75.0 96.4 Median 4.0 4.0 1.0 1.0 4.0 4.0 4.0 3.0 1.0 1.0 4.0 4.0 Mode 4.0 4.0 1.0 1.0 4.0 4.0 4.0 4.0 1.0 1.0 4.0 4.0

DISCUSSION The language of an instrument is of primary importance; an instrument is only as good as its ability to reflect recognizable, meaningful behavior, and its ability to provide stable scores from one administration to the next. From the standpoint of language, the first of the studys two objectives was to develop an instrument in which the language would reflect increasing developmental skill, such that scores would stand for representative, readily observable behaviors easily staged in a clinical or research situation. The second objective was to make the language so clear that raters would score consistently, agreeing with each other when assigning a specific score, and making interrater and intrarater reliability acceptably high. Some may criticize the items for their potential lack of stability or their lack of ability to be sensitive to small changes. The BAMF FMS was developed out of a need in our clinical research setting for a clearly differentiated, straightforward, clear-cut, and reliable assessment to quickly verify what children can do, based on a standard pertinent to the broadest possible variety of ages and disabilities. According to statistical analyses of their responses, the expert panel thought the instrument was functionally relevant with items easily discriminated from each other. They also thought, in general, that items were properly ordered, not requiring movement either up or down the hierarchy; given the tools objective of establishing baseline and monitoring change over time, appropriateness of item order is imperative. Our experience using the BAMF FMS for clinical and research purposes has shown us that childrens functional abilities can be identified and improved through actual interventions based on BAMF FMS scores. We developed the BAMF FMS to be used solo or in conjunction with more comprehensive assessments (eg, PDMS-II or BruininksOseretsky Test of Motor Proficiency, Second Edition); the two types of assessments play complementary roles for children who are followed over a long period of time. Functionally relevant information can be obtained longitudinally with the BAMF FMS, while more detailed information across a range of skills is available with conventional
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motor assessments: the BAMF FMS identifies a childs best skill in its domain at each monitoring session, while the other assessments provide norm-based, comprehensive information across a range of skills. Several potential limitations of the study should be mentioned. The expert panel was comprised of occupational therapists, a majority of whom come from academia, and whose perspective may be different from that of a panel comprised of full-time clinicians. Using a 1 to 4, Disagree to Agree scale (with no descriptors for ratings of 2 or 3) for items examined by the expert panel may have had an effect on our results: positively, it forces a clear decision on one side or the other; negatively, it may not have offered the panel members sufficient range of ratings from which to choose. During reliability trials, a single videotape with randomly ordered samples of childrens performance was used; this could have caused an ordering effect, as well as recall bias, which may result in inflated Kappa values. An additional potential effect on Kappa values was the use of videotape, rather than live performances: use of videotape allows greater convenience in carrying out reliability trials, but it also limits the degree to which the trials approximate real life. Conceivably, in real life children may perform differently at 24 hours and three weeks later than baseline. Although the instrument has been used most often with children up to now, there is a proposal to incorporate its use into the care of adults with closed head injury. To further refine its psychometric properties, there is a plan to examine the quality of the rating scale and its structure using a Rasch-measurement approach. The instrument is currently included in five research protocols, which use other gold standards like the PDMS-II; it is projected that concurrent validity studies will be undertaken in the future. CONCLUSIONS Through their responses to a standard content validity questionnaire, an expert panel agreed that the BAMF FMS is a valid hierarchical scale of fine motor performance. Changes were made to the BAMF FMS based on expert panel members quantitative feedback and 84 qualitative responses. Kappa
Validity and Reliability of the BAMF Fine Motor Scale 321

Fig. 2. Responses of expert members: mean response values for each of the BAMF task items.

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TABLE 5
Comments Provided by Expert Panel Members Item 0 1 Frequency of Comments 7 10 Frequency of Similar Comment 5 Examples Rephrase as All fingers move as one unit Purposeful or voluntary? Which finger? Isolated movement, extension or poking? Combines two behaviors Spontaneous or volitional? Why 50%? also, may be difficult to observe With or without support? Why midline; what defines midline? Small or large objects may require different skills; raking or swiping? Should be for less than 60 seconds; children may not maintain attention Grasp needs to be more clearly defined and perhaps reworded Be clear that this is more than mouthing an object Different culturally appropriate eating utensils may require different skills to operate What if they start but dont get all the way? Button or snap: different skills involved May be more a test of exposure than fine motor skill Is the emphasis on dynamic tripod grasp or functional outcome?

2 3 4 5 6 7 8 9 10

12 9 6 9 3 5 2 8 13 Total:84

3 2 3 4 3

7 13

TABLE 6
BAMF FM Reliability Raw Scores* Child Number 1 Rater Trial 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 2 2 2 2 1 1 2 2 2 2 2 2 2 2 2 2 4 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 6 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 7 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 9 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10

* Reliability coefficients: Interrater 0.978, Intrarater 0.993. Trial 2: Second videotape rating at 24 hours from first. Trial 3: Third videotape rating at 16 days from first. Each childs performance was scored 3 times by the same five raters.

values for interrater and intrarater reliability suggest this is a highly reliable instrument for baseline and screening purposes when rapid motor performance assessment is desired. The BAMF FMS expands the array of fine motor assessment options available to clinicians and researchers. Particularly for those who seek to quickly and easily document baseline fine motor skills and track subsequent progress, the BAMF FMS provides a useful solution. ACKNOWLEDGMENTS The authors acknowledge the computer graphics expertise and invaluable advice provided by Gloria Furst, OTR/L,
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MPH, Rehabilitation Medicine Department, National Institutes of Health. They also thank the parents and their children who participated in the reliability study, and the Occupational Therapists who shared their time and expertise to complete the content validity study. REFERENCES
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3. Henderson A. Self-care and hand skill. In: Henderson A, Pehoski C, ed. Hand Function in the Child. St. Louis, MO: Mosby; 1995: 164 183. 4. Pehoski C, Henderson A, Tickle-Degnen L. In-hand manipulation in young children: translation movements. Am J Occup Ther. 1997;51:719728. 5. Exner CE. In-hand manipulation skills in normal young children. Occup Ther Pract. 1990;1:6372. 6. Russell DJ, Ward M, Law M. Test-retest reliability of the Fine Motor Scale of the Peabody Developmental Motor Scales in children with cerebral-palsy. Occup Ther J Res. 1994;14:178 182. 7. Hemgren E, Persson K. Motor performance and behaviour in preterm and full-term 3- year-old children. Child Care Health Dev. 2002;28: 219 226. 8. Goyen TA, Lui K. Longitudinal motor development of apparently normal high-risk infants at 18 months, 3 and 5 years. Early Hum Dev. 2002;70:103115. 9. Singh G, Athreya BH, Fries JF, et al. Measurement of health-status in children with juvenile rheumatoid-arthritis. Arthritis Rheum. 1994; 37:17611769. 10. Stamm TA, Machold KP, Eberl G, et al. Using Moberg Picking-Up Test to measure fine motor hand function in patients with inflammatory joint disease. Arthritis Rheum. 2000;43:1963. 11. Hermann W, Caca K, Eggers B, et al. Genotype correlation with fine motor symptoms in patients with Wilsons disease. Eur Neurol. 2002; 48:97101. 12. Hermsdorfer J, Hagl E, Nowak DA, et al. Grip force control during object manipulation in cerebral stroke. Clin Neurophysiol. 2003;114: 915929. 13. Binder LM, Kelly MP, Villanueva MR, et al. Motivation and neuropsychological test performance following mild head injury. J Clin Exp Neuropsychol. 2003;25:420 430. 14. Johnk K, Kuhtz-Buschbeck JP, Stolze H, et al. Assessment of sensorimotor functions after traumatic brain injury (TBI) in childhood methodological aspects. Restor Neurol Neurosci. 1999;14:143152. 15. Wachtel RC, McGrath C, Houck DL, et al. Fine motor testing in childrennot fine. Pediatr AIDS HIV Infect: Fetus Adolesc. 1994;5:86 88. 16. Merlo MCG, Hofer H, Gekle W, et al. Risperidone, 2 mg/day vs. 4 mg/day, in first-episode, acutely psychotic patients: treatment efficacy and effects on fine motor functioning. J Clin Psychiatry. 2002; 63:885 891. 17. Contreras-Vidal JL, Teulings HL, Stelmach GE. Elderly subjects are impaired in spatial coordination in fine motor control. Acta Psychol. 1998;100:2535. 18. Desrosiers J, Hebert R, Bravo G, et al. The Purdue Pegboard Test normative data for people aged 60 and over. Disabil Rehabil. 1995;17: 217224. 19. Smith CD, Umberger GH, Manning EL, et al. Critical decline in fine motor hand movements in human aging. Neurology. 1999;53:1458 1461. 20. Krampe RT. Aging, expertise and fine motor movement. Neurosci Biobehav Rev. 2002;26:769 776. 21. Folio MR, Fewell RR. Peabody Developmental Motor Scales [manual]. 2nd ed. Austin, TX: Pro-Ed; 2000. 22. Folio MR, Fewell RR. Peabody Developmental Motor Scales and Activity Cards [manual]. Hingham, MA: Teaching Resources; 1983. 23. Bruininks RH. Bruininks-Oseretsky Test of Motor Proficiency. Circle Pines, MN: American Guidance Service; 1978. 24. Jebsen RH, Taylor N, Trieschmann RB, et al. An objective and standardized test of hand function. Arch Phys Med Rehabil. 1969;50:311319. 25. Mathiowetz V, Weber K, Kashman N, et al. Adult norms for the 9-hole Peg Test of finger dexterity. Occup Ther J Res. 1985;5: 24 38. 26. Carr JH, Shepherd RB, Nordholm L, et al. Investigation of a new motor-assessment scale for stroke patients. Phys Ther. 1985;65: 175180.

27. Tiffin J. Purdue Pegboard Examiner Manual. Chicago, IL: Science Research Associates; 1968. 28. Smith HB. Smith hand function evaluation. Am J Occup Ther. 1973; 27:244 251. 29. Gallus J, Mathiowetz V. Test-retest reliability of the Purdue Pegboard for persons with multiple sclerosis. Am J Occup Ther. 2003;57:108 111. 30. Gebhard AR, Ottenbacher KJ, Lane SJ. Interrater reliability of the Peabody Developmental Motor ScalesFine Motor Scale. Am J Occup Ther. 1994;48:976 981. 31. Hassan MM. Validity and reliability for the Bruininks-Oseretsky Test of Motor Proficiency-Short Form as applied in the United Arab Emirates culture. Percept Mot Skills. 2001;92:157166. 32. Poole JL, Whitney SL. Motor-assessment scale for stroke patients concurrent validity and interrater reliability. Arch Phys Med Rehabil. 1988;69:195197. 33. Smith YA, Hong ES, Presson C. Normative and validation studies of the Nine-hole Peg Test with children. Percept Mot Skills. 2000;90: 823 843. 34. Stokes NA, Deitz JL, Crowe TK. The Peabody Developmental Fine Motor Scalean interrater reliability study. Am J Occup Ther. 1990; 44:334 340. 35. Vlieland TPMV, vanderWijk TP, Jolie IMM, et al. Determinants of hand function in patients with rheumatoid arthritis. J Rheumatol. 1996;23:835 840. 36. Hardin M. Assessment of hand function and fine motor coordination in the geriatric population. Top Geriatr Rehabil. 2002;18:18 27. 37. Cintas HL, Siegel KL, Furst GP, et al. Brief assessment of motor functionreliability and concurrent validity of the Gross Motor Scale. Am J Phys Med Rehabil. 2003;82:33 41. 38. Cintas HL. Cross cultural similarities and differences in development and the impact of parental expectations on motor behavior. Pediatr Phys Ther. 1995;7:101111. 39. Darrah J, Hodge M, Magill-Evans J, et al. Stability of serial assessments of motor and communication abilities in typically developing infantsimplications for screening. Early Hum Dev. 2003;72: 97110. 40. Reuben DB, Siu AL. An objective measure of physical function of elderly outpatients. J Am Geriatr Soc. 1990;38:11051112. 41. Binder EF, Miller JP, Ball LJ. Development of a test of physical performance for the nursing home setting. Gerontologist. 2001;41:671 679. 42. Benson J, Clark F. A guide for instrument development and validation. Am J Occup Ther. 1982;36:789 800. 43. American Psychological Association. Standards for Educational and Psychological Testing. Washington, DC: American Psychological Association; 1985. 44. American Physical Therapy Association. Standards for Tests and Measurements in Physical Therapy Practice. Alexandria, VA: American Physical Therapy Association; 1991. 45. Dunn WW. Validity. Phys Occup Ther Pediatr. 1989;9:149 168. 46. Exner CE. Content validity of the in-hand manipulation test. Am J Occup Ther. 1993;47:505513. 47. Haley SM, Coster WJ, Faas RM. A content validity study of the pediatric evaluation of disability inventory. Pediatr Phys Ther. 1991;3: 177184. 48. Harris SR, Daniels LE. Content validity of the Harris infant neuromotor test. Phys Ther. 1996;76:727737. 49. Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas. 1960;20:37 46. 50. Dennis JL, Swinth Y. Pencil grasp and childrens handwriting legibility during different-length writing tasks. Am J Occup Ther. 2001;55:175 183. 51. Bergmann KP. Incidence of atypical pencil grasps among nondysfunctional adults. Am J Occup Ther. 1990;44:736 740.

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APPENDIX

Brief Assessment of Motor Function (BAMF) Fine Motor Scale

Rebecca Parks MS, OTR/L, Holly Cintas PT, PhD, Lynn Gerber MD Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD Scoring: Score = highest observed item completed on the scale Example: Child can rake object to body, but cannot reach: Score=4 (Rakes Object to Body) Example: Child can press a snap closed, but cannot unscrew and remove cap of container: Score=9 (Secures Button or Snap) Behavior Criterion Hands consistently fisted or open; digital mass patterns 0: No evidence of isolated, dynamic digital extension 1: Digital isolation and full finger extension 2: Spontaneous palmar grasp and release 3: Reaches while supine or sitting Independent finger movement: at least one finger fully extends Evidence of grasp with palmar contact and spontaneous release In supine, or seated at a 90 degree trunk angle, with support if needed to maintain an erect trunk position, extends an arm toward a midline object at least 50% of the potential trajectory Seated at a 90 degree trunk angle, with support if needed to maintain an erect trunk position, rakes an object toward the midline of the body Uses both hands simultaneously to manipulate an object smaller than 4 inches for at least 30 seconds Grasps raisin/pellet/cheerio between thumb and finger tip and elevates it from the surface Picks up conventional teaspoon or other culturally appropriate eating utensil and places it in the mouth as if to transport food While stabilizing object with one hand, unscrews and removes cap of container with opening no larger than 1.5 inches, using other hand Using two hands, buttons a button or presses a snap closed; button or snap no larger than inch in diameter Using a mature grasp, and a conventional pencil or pen, writes or copies accurately 10 words or figures (circles, squares, triangles) August 2003

4: Rakes object to body

5: Bimanual manipulation of objects 6: Uses superior/tip pincer grasp to pick up an object 7: Eating utensil in mouth

8: Unscrews cap

9: Secures fastener

10: Writes 10 words or characters legibly

Inclusion Criteria for all BAMF Items: Gross Motor, Fine Motor and Oral Motor 1) Every task represents observed performance 2) Performance can be judged unequivocally as present or absent 3) Tasks are adaptive behaviors typically used in daily function across cultures 4) Items chosen to test behaviors are readily available in all potential test settings 5) Lowest and highest items on each scale represent, respectively, comparatively most primitive and most advanced levels of performance for that domain 6) Hierarchical progression of motor behaviors is designed to be independent of age

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Validity and Reliability of the BAMF Fine Motor Scale 325