RESEARCH ARTICLE

Hypo-Activity Screening in School Setting; Examining Reliability and Validity of the Teacher Estimation of Activity Form (Teaf) Sara Rosenblum*† & Batya Engel-Yeger The Laboratory of Complex Human Activity and Participation (CHAP), Department of Occupational Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel

Abstract It is well established that physical activity during childhood contributes to children’s physical and psychological health. The aim of this study was to test the reliability and validity of the Hebrew version of the Teacher Estimation of Activity Form (TEAF) questionnaire as a screening tool among school-aged children in Israel. Six physical education teachers completed TEAF questionnaires of 123 children aged 5–12 years, 68 children (55%) with Typical Development (TD) and 55 children (45%) diagnosed with Developmental Coordination Disorder (DCD). The Hebrew version of the TEAF indicates a very high level of internal consistency (α = .97). There were no significant gender differences. Significant differences were found between children with and without DCD attesting to the test’s construct validity. Concurrent validity was established by finding a significant high correlation (r = .76, p < .01) between the TEAF and the Movement-ABC mean scores within the DCD group. The TEAF demonstrated acceptable reliability and validity estimates. It appears to be a promising standardized practical tool in both research and practice for describing information about school-aged children’s involvement in physical activity. Further research is indicated with larger samples to establish cut-off scores determining what point identifies hypo activity in striated age groups. Furthermore, the majority of the participants in this study were boys, and further research is needed to include more girls for a better understanding of the phenomena of hypo activity. Copyright © 2015 John Wiley & Sons, Ltd. Received 29 June 2014; Revised 20 January 2015; Accepted 22 January 2015

Keywords physical activity; teacher; screening *Correspondence Sara Rosenblum, The Laboratory of Complex Human Activity and Participation (CHAP), Department of Occupational Therapy, University of Haifa, Mount Carmel, Haifa 3498838, Israel. †

Email: [email protected]

Published online 9 February 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/oti.1387

Introduction Participation is a major component of the International Classification of Functioning, Disability and Health— Occup. Ther. Int. 22 (2015) 85–93 © 2015 John Wiley & Sons, Ltd.

Children and Youths Version (ICF-CY) (World Health Organization [WHO], 2007). Participation is defined as involvement and enjoyment in varied activities and 85

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life situations that are vital parts of children development (King, 2013). Participating or taking part in varied activities enables children to develop skills, competencies and self-efficacy (WHO, 2007). Occupational therapists encourage children’s participation to advance their quality of life and future life outcome (King et al., 2003; King et al., 2007). Children’s participation in physical activity during childhood is a meaningful factor related to both their physical and psychological health throughout childhood and adulthood (Hay, 1992; King et al., 2003; Strauss et al., 2001; Ziviani et al., 2004). Results of extensive research concerning the relationship between hypo-activity and higher risk for disease development among adults (e.g. Juonala et al., 2011) lead to the call to encourage physical activity participation as a preventive aid among children (Kohl et al., 2000; Loprinzi et al., 2011). However, several factors such as overweight (e.g. Loprinzi et al., 2011; Wrotniak et al., 2006), low perceptions of physical competence, low selfefficacy (Pahkala et al., 2008) and motor coordination disorders (e.g. Cairney et al., 2005; Hay and Missiuna, 1998; Hay et al., 2003) may cause reduced physical activity participation among children. Following the national health policy to promote physical activity among children and adolescents, Kohl et al., (2000) indicated the need for a practical valid, reliable self-report or observation tool for better understanding of physical activity patterns among children in large populations. The Teacher Estimation of Activity Form (TEAF) (Hay, 1992; Hay and Donnelly, 1996) questionnaire addresses the above mentioned criteria. In comparison to other available tools (e.g. Kohl et al., 2000; Trost et al., 2002) it is a short practical reliable and valid tool which is appropriate to the Israeli culture. This questionnaire was developed in Canada and includes 10 items rated on a 5-point Likert-type scale. The TEAF is designed to obtain teachers’ assessments of their students’ motor ability, participation in physical activity and generalized self-efficacy toward physical activity, based on observations made during school-based activities (Hay and Donnelly, 1996). The TEAF requires approximately 10 min per child to complete (Faught et al., 2008; Hay, 1992; Hay and Donnelly, 1996; Hay et al., 2004). The tool’s reliability and validity were previously established among school-aged children in Canada (Faught et al., 2008; Hay, 1992; Hay and Donnelly, 86

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1996; Hay et al., 2004). Significant correlation was found between hypothetical and concrete items (r = .89, p < .01) (Hay, 1992). The TEAF has high internal consistency (Cronbach’s alpha = .98) (Faught et al., 2008). It also has good concurrent validity with measures of physical activity and fitness, such as the Children’s Self-perception for Adequacy and Predilection for Physical Activity scale (Hay, 1992), which measures children’s self-perceptions of their adequacy in performance, and their desire to participate in physical activities (r = 0.45, p = .001). The TEAF also has good concurrent validity with the Participation Questionnaire (Hay, 1992; Cairney et al., 2006; Faught et al., 2008) (r = 0.25, p = .001), which asks children to report their participation levels in activities such as free-time play, seasonal recreational pursuits and school sports (Faught et al., 2008). However, previous literature indicated the importance of examining the psychometric properties of evaluation tools in different countries and cultures (Craig et al., 2003). Consequently, the aim of the current study was to test the reliability and validity of the valid translated Hebrew version of the Teacher Estimation of Activity Form (TEAF) (Hay, 1992; Hay and Donnelly, 1996) among school-aged children in Israel ages 5–12. This aim was executed within three phases, the first phase focused on examining the TEAF’s internal reliability. The second phase focused on examining the TEAF’s construct validity including three subobjectives, and the last phase focused on examining the TEAF’s concurrent validity. The TEAF’s construct’s validity was analysed by three sub-objectives. First it was tested whether factor analysis would establish the construct/s covered by the scale, based on the theoretical background. Results concerning significant gender differences found among school-aged children related to physical activity participation characteristics with the TEAF in Canada (Faught et al., 2008; Hay, 1992; Hay and Donnelly, 1996; Hay et al., 2004), as well as other worldwide studies using different scales and measures (Cooper et al., 2005; Trost et al., 2002), led to a second sub-objective, to discover whether significant gender differences will be found for the TEAF’s scores within the entire sample of children aged 5–12 years (construct validity). Our third sub-objective referred to differences in physical activity participation among children at high risk for deficient physical activity participation. Although in recent years, physical inactivity Occup. Ther. Int. 22 (2015) 85–93 © 2015 John Wiley & Sons, Ltd.

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may characterize all children, there is evidence that children with neuro-developmental disorders and especially children with Developmental Coordination Disorders (DCD) (‘clumsiness’) are at greater risk for hypo activity in comparison to typically developed (TD) children (Cairney et al., 2005; Faught et al., 2005; Hands and Larkin, 2002). DCD is the diagnostic term based on the DSM-IV for motor coordination problems that result in significant impairments to both social and academic functioning (American Psychiatric Association, 2000). The prevalence of DCD ranges from 1.4% to 19% among school aged children, depending on the definition used and the methods applied in their evaluation (Kadesjö and Gillberg, 1999; Lingam et al., 2009), and is among the most common childhood developmental disorders (Cairney et al., 2007). As a result of their motor coordination deficits, children with DCD are less involved in social events that require physical activities such as running, jumping, ball throwing and catching, as well as in activities requiring fine motor movements (Fox and Lent, 1996; Polatajko, 1999). Their reduced involvement in physical activity may increase the prevalence of body fat, together with low self-esteem and self-efficacy (Cairney et al., 2005; Hay et al., 2003). Our third research phase concerned examining concurrent validity of the TEAF with the Movement Assessment Battery for Children (MABC) (Henderson and Sugden, 1992). The MABC was developed as a clinical and research tool that provides an indication of motor functioning across fine and gross motor tasks of children aged 4 to 12 years and used extensively worldwide for identifying DCD (Crawford et al., 2001; Goyen and Lui, 2009). As both of the tools focus on motor performance, it was assumed that significant correlations would be found between the TEAF and MABC mean final scores among the group of children with DCD. Schools can provide many opportunities for young people to engage in physical activity and therefore can play an important role in motivating young people to stay active (Burgeson et al., 2001). In schools, physical education teachers are responsible for this area. They have the unique opportunity to observe children engaging in different activities and play, and consequently have an advantage uncommon to other professionals in screening children with hypo activity as a result of various causes (Faught et al., 2008). Physical education teachers can observe these children during gym classes and may have an important role in screening their Occup. Ther. Int. 22 (2015) 85–93 © 2015 John Wiley & Sons, Ltd.

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motor coordination deficits, which influence their involvement in physical activities (Faught et al., 2008). Therefore, internal reliability, construct and concurrent validity of the TEAF scale designated for physical education teachers were examined among school aged children in Israel to enable the tool’s utility in both the academic and clinical fields.

Methods Participants One hundred twenty-three children aged 5–12 years from a cohort of the Laboratory of complex human activity and participation at the University of Haifa were included in the study. Sixty-eight children (55%) were with Typical Development (TD), whereas 55 children (45%) were diagnosed as having Developmental Coordination Disorder (DCD). All participants were registered in mainstream public schools in northern Israel. Based on information from the Central Bureau of Statistics in Israel (2012) and the literature, the amount of mothers’ education years served as a measure for the participants’ familial socioeconomic status and ranged from two to 19 years. Children in the DCD and TD groups were matched based on gender, age and familial socioeconomic status. No significant differences were found between groups for these measures (see Table I). The children with DCD were diagnosed by a pediatrician/developmental neurologist according to the DSM-IV criteria, and by occupational therapists who examined the children using the Movement Assessment Battery for Children (MABC) (Henderson and Sugden, 1992). All children in the DCD group scored below the 15th percentile in the MABC, indicating that the child is at risk for motor difficulties. All children in the TD group scored above the 15th percentile on the MABC and had no developmental, physical or neurological deficits based on their parents report. Exclusion criteria for both groups were positive neurological findings, chronic diseases and syndromes, visual impairment or being under treatment with medication that affects the nervous system functioning. Instruments Demographic questionnaire This questionnaire was designed by the authors and included data on family socio-demographic status, 87

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Table I. Participants’ socio-demographic data

Variable Gender Child’s mean age Hand dominance Mother’s education years

Number of boys Number of girls Range: 5–12 years Right Left Range: 2–19 years

Children with TD (n = 68) M (SD)

Children with DCD (n = 55) M (SD)

49 19 9.0 (0.13) 63 5 12.68 (3.32)

44 11 9.5 (0.12) 53 2 11.53 (3.23)

child’s health status, medications, treatments and health professions therapy.

require teachers rating of the student in a number of hypothetical situations dealing with physical activity.

Movement Assessment Battery for Children (MABC) (Henderson and Sugden, 1992)

Procedure

The MABC was developed as a clinical and research tool that provides an indication of motor functioning across fine and gross motor tasks for children aged 4 to 12 years. There are four age-related item sets, which measure manual dexterity, ball skills, static balance and dynamic balance. Each set consists of eight items and scores range from 0 to 5 on each item, resulting in a total score between 0 and 40 per set. The total scores can be transformed into percentile scores. According to the Dutch standardization of the MABC, the American norms are valid for the Dutch population (Smits-Engelsman, 1998). Moreover, the MABC has acceptable validity and reliability (e.g. Crawford et al., 2001; Van Waelvelde et al., 2007).

Ethical approval for this study was provided by the Israeli Ministry of Education and Helsinki approval was obtained for participants with DCD diagnosed by pediatricians. All parents signed a consent form allowing their children to participate and then completed the demographic questionnaire. A meeting was arranged with all children who fulfilled the inclusion criteria at their school, home or at the medical developmental center. All evaluations were administered individually in a quiet room. Their physical education teachers completed the TEAF. A year later, these children’s data compiled a large anonymous database at the laboratory of complex human activity and participation in the University of Haifa. Data analysis

The Teacher Estimation of Activity Form (TEAF) (Hay, 1992; Hay et al., 2004) As mentioned in the introduction, this standardized tool includes 10 items rated on a 5-point Likert-type scale scored by the child’s physical education teacher based on his or her impression of the child’s activity. Each item response includes: (1) well below average, (2) somewhat below average, (3) average, (4) somewhat above average and (5) well above average. Teachers are asked to rate children relative to others of the same age and gender. The first six items focus on personal observations of the student during physical education classes, intramural sports, interschool sports, lunch periods and recess. The remaining four questions 88

Data analysis was conducted via SPSS 13 software. Descriptive statistics were used to describe the sample and the main variables. Factor analysis was conducted to find the TEAF main factors, and their internal reliability was analysed with Cronbach’s alpha. T-test was applied to check for group differences (males versus females and DCD versus typical) for the TEAF mean score, and MANOVA was conducted across the TEAF items. The correlations between the TEAF and MABC mean scores were examined by Pearson correlation test among the children with DCD. Discriminant analysis was applied to test whether the TEAF mean score differentiated between children with TD and those with DCD. Occup. Ther. Int. 22 (2015) 85–93 © 2015 John Wiley & Sons, Ltd.

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Results

2C: The TEAF construct validity—TD versus DCD

The TEAF internal consistency

A significant difference was found between the groups (TD versus DCD) in the TEAF mean final score (TD: M = 3.5 ± .84; DCD: M = 2.46 ± .75, t(121) = 7.15 p < .0001). In order to obtain more information regarding the differences, MANOVA was conducted for all the 10 TEAF items (F(10,112) = 5.98 p < .0001 η2 = .348). As expected, significant differences were found between the groups for those 10 items, as presented in Table III. Tukey’s post-hoc analysis indicated that the differences were significant for each of the 10 items.

As presented in Table II, a very high level of internal consistency was presented by the TEAF as constitutes a single factor (α = .975). Examining the TEAF construct validity 2: Through Factor analysis Factor analysis results revealed one factor with Eigen values >1. This factor accounted for 82.5% of the variance. Table II provides details of the factor loading for the 10 TEAF items, together with their initial Eigen value and the high internal reliability, presented as alpha value. 2B: The TEAF construct validity—Gender A preliminary chi-square analysis indicated no significant differences for the percent of children with and without DCD among the groups based on gender. No significant differences were found for the TEAF mean final score between males and females in the entire sample (Males: M = 3.04 ± .95 Females: M = 3.02 ± .98, t(121) = .103 p = N.S)

2D: Group differentiation (TD versus DCD)— Discriminant analysis One discriminant function was found for group classification of all participants (Wilks’ lambda = .70, p < .0001). Based on this function, 77% of the participants overall, 78% of the children with TD and 73% of the children with DCD were correctly classified (sensitivity rate); 27% were classified as TD (specificity rate). A Kappa value of .62 (p < .001) was calculated, demonstrating that the group classification did not occur by chance. Hence, the TEAF sensitivity is 73% and specificity is 27%.

Table II. Factor loading for each of the 10 items of the TEAF questionnaire Number 1 2 3 4 5 6 7 8

9

10

TEAF items

Factor 1

In terms of physical ability (strength, agility, endurance) In terms of physical skill (how well they can play. To what extent does this student participate in physically active games? To what extent does this student become involved in house league or intramural sports and inter-school sports? This student’s enjoyment in being involved in physically active games and sports. This child’s confidence in his or her ability to participate in physically active games and sports. If this student had to complete an obstacle course that required substantial strength and endurance, would you expect this student to complete the course in a time? If you were to teach this student a new sport skill that required a great deal of agility and coordination, compared to his/her peers, how quickly would you expect this child to learn and master that skill? If you were placed in charge of developing your school’s teams for a variety of inter-school sports competitions, over the course of the year, would you expect this child to try out for your school teams? During recess or lunch period if you saw a group of students this child’s age and gender playing a very active game outside, how likely would it be that this child would be among those involved?

.92 .92 .89 .92

Eigen value % of variance Internal consistency (α)

.81 .93 .90 .91

.92

.91

8.20 82.5 .975

Note—the table provides an abbreviated version of the items

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Table III. Mean and standard deviation of each of the 10 TEAF items and F and significance values of the comparison between groups (TD versus DCD)

TEAF item

Typical development M (SD)

1 2 3 4 5 6 7 8 9 10 Note:

3.50 3.55 3.54 3.42 3.70 3.52 3.39 3.44 3.45 3.50 ***

(.81) (.79) (.99) (.86) (.84) (.93) (.94) (.92) (1.08) (1.04)

DCD M (SD) 2.58 2.49 2.58 2.30 2.81 2.50 2.36 2.25 2.18 2.52

(.85) (.92) (.99) (.98) (.96) (.87) (.86) (.84) (.94) (.83)

F ***

36.75 *** 47.40 *** 28.33 *** 44.87 *** 29.49 *** 38.04 *** 38.90 *** 54.41 47.00*** 37.44***

p < .0001

The TEAF concurrent validity Significant high correlation (r = .76 p < .01) was found between the TEAF mean score and the M-ABC mean score among the DCD group, showing that the worse the motor performance according to M-ABC, the lower was the child’s activity level, as measured by the TEAF.

Discussion The aim of the current study was to examine reliability and validity of the Hebrew version of the Teacher Estimation of Activity Form (TEAF) questionnaire as a screening tool among school-aged children in Israel. The high construct validity was supported first by the factor analysis. Similar to previous results, high loading levels of the items were found in a single factor (Faught et al., 2008). Based on these 10 items, the teacher not only provides information about the child’s activity level (the first six items) but also how the child behaves in hypothetical situations (the last four items) (Hay, 1992). The very high internal consistency that relates to item homogeneity, which was found for this single factor, indicates that the TEAF items jointly measure the same construct (Cronbach and Shavelson, 2004; Henson, 2001). These results support TEAF’s high internal reliability (.98) mentioned in previous reports (Faught et al., 2008; Hay, 1992). When evaluating additional aspects of construct validity in the present study, no significant differences were found between males and females in the TEAF mean score. Results regarding gender differences 90

observed from the TEAF scores are contradictive based on studies carried out among Canadian children. On the one hand, Hay (1992) reported that teachers who were instructed to evaluate children relative to their peers, of the same age and gender, found significant gender differences in the TEAF mean score among children aged 9 to 16 (Hay, 1992) . On the other hand, in another study conducted among children aged 9 to 11 years, TEAF scores were found to be almost identical for boys and girls (Faught et al., 2008) thus supporting the results of the present study. Further studies are required to determine whether gender differences in TEAF scores derive from gender biases in elementary school teachers’ evaluation (Hay and Donnelly, 1996) or due to other reasons such as age group or cultural differences. Further support for the TEAF high construct validity was achieved by comparison between children with DCD and those with typical development. The TEAF showed good discrimination between children in these two groups. Significant group differences were found for the TEAF mean score as well as for each of TEAF’s items. These results are not surprising based on previous literature indicating that children with DCD are significantly less likely than their peers to be physically active (Hands and Larkin, 2002). They participate less in organized activities such as team sports as well as in free play activities, e.g. active play at recess (Cairney et al., 2005; Fitzpatrick and Watkinson, 2003). Furthermore, they are less likely to participate in physical activity, especially in structured play opportunities such as organized sport, because they fear embarrassment and ridicule when being with their peers. Another explanation is their low perceived competence or self-efficacy regarding their physical abilities (Cairney et al., 2005). It is important to mention that the TEAF items’ content not only provides information about how the physical education teacher perceives the physical ability and physical skills of children with DCD (strength, agility and endurance) but also emphasizes the teacher’s ability to report these children’s restricted participation and involvement in physically active games at school and after school hours. In addition, the TEAF reflects the low enjoyment level and reduced confidence related to physical activities among children with DCD. For example, the teacher has lower expectations regarding the ability of children with DCD to complete a course that requires substantial strength and endurance, to have great agility and coordination Occup. Ther. Int. 22 (2015) 85–93 © 2015 John Wiley & Sons, Ltd.

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and to be part of a school team or part of a group that plays a very active game outside. Thus, if the teacher perceives children with DCD as having lower physical activity abilities, it is not surprising that this is how the children perceive themselves. This point is supported by previous studies. For example, a significant correlation was found between the TEAF scores and Children’s Self-Perception of Adequacy in Predilection for Physical Activity (CASPPA) (Hay and Missiuna, 1998, Hay et al., 2004). Engel-Yeger and Hanna Kasis (2010) also found that children with DCD scored significantly lower in self-efficacy as was measured by the Perceived Efficacy and Goal Setting (PEGS) (Missiuna et al., 2004). The present study emphasizes the benefits of the TEAF including the ability of the TEAF’s mean score to be sensitive in identifying children with DCD (73% sensitivity and 23% specificity according to discriminant analysis). It may be that the 27% of children found to be included in the DCD group but who were not actually diagnosed as DCD were those with hypoactivity but did not necessarily fulfill the criteria for being DCD. Yet, it highlights the importance of the remark made by Cairney et al. that hypoactivity in children has become a major public health concern (Cairney et al., 2007). The results of the current and previous studies (Cairney et al., 2005; Faught et al., 2008) show that the TEAF may be suitable as a quick and practical tool for such identification. Although the MABC is the most respected motor test worldwide for establishing the diagnosis of DCD (Sugden, 2012), it is both time consuming and expensive, and therefore it is not always applicable to be used within educational systems. As previously concluded, questionnaire-based assessments may be more practical for screening purposes (Cairney et al., 2007; Schoemaker et al., 2003). The high correlation (.75) that was found between the TEAF and the MABC scores among the DCD group provides further support for the TEAF’s suitability for screening children with DCD. It seems that a survey-based instrument may help teachers to reflect what they see in a more focused and standardized way (Larkin and Rose, 2005). Results of three previous studies, which focused on the MABC teacher checklist to screen for coordination problems/DCD, show that finding such a tool that supplies good sensitivity and specificity is not a trivial task (see Junaid et al., 2000; Schoemaker et al., 2003 and Wright and Sugden, 1996 for more details). Occup. Ther. Int. 22 (2015) 85–93 © 2015 John Wiley & Sons, Ltd.

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The results of the present study highlight the TEAF’s ability to serve as an assessment tool for DCD and to be used by teachers. Yet, it is important to provide teachers with an explanation of the rationale behind each of TEAF’s items and TEAF’s meaning for evaluation. This may serve as a reinforcement process for teachers as identifiers of meaningful deficit among their students (Armour and Yelling, 2004). Giving meaning to physical education teachers in observing children with DCD or hypoactivity may enhance their awareness of the problem, which may lead them to encourage the children’s active participation in school settings. As mentioned in the introduction, identifying children with DCD and hypoactivity in school may prevent the negative cycle with associated consequences such as inactivity, increased body weight and poor fitness and a possible risk for cardiovascular diseases when they reach adulthood (Cairney et al., 2005). In conclusion, as mentioned above, finding a practical tool for screening children with hypoactivity/ coordination disorders/DCD is not a trivial task (Junaid et al., 2000; Schoemaker et al., 2003; Wright and Sugden, 1996). The TEAF results indicated good reliability and validity in comparison to cited benchmarks for reliability and validity for other scales (e.g. Lucey, 2005). The TEAF also indicated reasonable values of sensitivity and specificity among school-aged children in Israel. These results, together with previous reports such as those conducted in Canada, highlight that the TEAF is a practical tool and that its use should be encouraged among school sports teachers. Evaluation of hypo-activity/coordination disorders/ DCD on time may reduce negative consequences related to hypoactivity and DCD. Several limitations may be considered and thus lead to further studies. First, due to the small sample, future studies with larger samples are required for finding cutoff scores which will determine what point identifies hypo activity in each age group. Furthermore, the majority of the participants were boys, and samples including more girls are required for better understanding of the phenomena of hypoacidity of this group. Thus further studies with larger samples should be performed to strengthen the TEAF’s psychometric properties.

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