Research Article

Examining construct validity of a new naturalisticobservational assessment of hand skills for preschool- andschool-age children

Chi-Wen Chien,1 Ted Brown2 and Rachael McDonald2,3

1Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane,Queensland, 2Department of Occupational Therapy, and 3Centre for Developmental Disability Health Victoria, School ofPrimary Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria,Australia

Background/aim: The Assessment of Children’s HandSkills is a new assessment that utilises a naturalisticobservational method to capture children’s real-life handskill performance when engaged at various types of dailyactivities in everyday living contexts. The Assessment ofChildren’s Hand Skills is designed for use with 2- to 12-year-old children with a range of disabilities or health con-ditions. The study aimed to investigate construct validityof the Assessment of Children’s Hand Skills in Australianchildren.Methods: Rasch analysis was used to examine internalconstruct validity of the Assessment of Children’s HandSkills in a mixed sample of 53 children with disabilities(including autism spectrum disorder, developmental/genetic disorders and physical disabilities) and 85 typi-cally developing children. External construct validity wasexamined by correlating with three questionnaires evaluat-ing daily living skills and hand skills.Results: Rasch goodness-of-fit analysis suggested that all22 activity items and 19 of 20 hand skill items in theAssessment of Children’s Hand Skills measured a single

construct. The Assessment of Children’s Hand Skills itemswere placed in a clinically meaningful hierarchy from easyto hard, and the difficulty range of the items also matchedthe majority of children with disabilities and typicallydeveloping preschool-aged children. Moderate to highcorrelations (0.59 � Spearman’s ρ coefficients � 0.89,P < 0.01) were found with the assessments of daily livingand fine motor skills.Conclusion: This study provided preliminary evidencesupporting the construct validity of the Assessment ofChildren’s Hand Skills for its clinical application inassessing children’s real-life hand skill performance inAustralian contexts.

KEY WORDS child, motor skills, rehabilitation.

Introduction

Problems or difficulties in using the hands are associ-

ated with restriction of children’s participation in daily

life (Jackman & Stagnitti, 2007; Kimmerle, Mainwaring

& Borenstein, 2003). Children with a range of health

conditions can present with hand skill difficulties and

are often referred to occupational therapy services when

they experience participation restriction (Henderson &

Pehoski, 2006; Kimmerle et al., 2003). Effective interven-

tion is critical to minimise children’s hand skill dysfunc-

tion and prevent participation restriction. Accurate

assessment of hand skills in children is essential for

planning and evaluation of such interventions (Buffart,

Roebroeck, Pesch-Batenburg, Janssen & Stam, 2006;

Greaves, Imms, Dodd & Krumlinde-Sundholm, 2010).

A number of standardised instruments are used to

assess children’s hand skills, such as the fine motor sub-

scale of the Peabody Developmental Motor Scales-

Second Edition (Folio & Fewell, 2000). However, these

assessments are usually completed in standardised test-

ing environments, they assess children’s capacity in

contrast to real-life performance (i.e. what a child can

Chi-Wen Chien PhD, MEd(Hons), BSc(OT); PostdoctoralResearch Fellow. Ted Brown AccOT, OTR, OT(C), PhD,MSc, MPA, OT(Hons), BSc; Associate Professor. RachaelMcDonald PhD, GCHE, PGDip, BAppSc(OT); Senior Lec-turer.

Correspondence: Chi-Wen Chien, Division of OccupationalTherapy, School of Health and Rehabilitation Sciences, TheUniversity of Queensland, Brisbane, Qld 4072, Australia.Email: c.chien@uq.edu.au

The study was carried out when Chi-Wen Chien was adoctoral student at Monash University.

Accepted for publication 18 January 2012.

© 2012 TheAuthorsAustralianOccupational Therapy Journal© 2012OccupationalTherapyAustralia

Australian Occupational Therapy Journal (2012) 59, 108–120 doi: 10.1111/j.1440-1630.2012.00997.x

do rather than what he/she does do with their hands;

World Health Organization, 2001). To address this issue,

assessments that reflect children’s ecologically based,

real-life hand skill performance in natural contexts have

been developed, allowing the evaluation of children’s

participation affected by hand skill difficulties. At

present, these instruments such as the Assisting Hand

Assessment (Krumlinde-Sundholm, Holmefur, Kottorp

& Eliasson, 2007) and ABILHAND-Kids (Arnould, Penta,

Renders & Thonnard, 2004) are only available for use

with children with cerebral palsy or those with unilateral

hand dysfunction. The assessments are also limited to

play or self-care domains of activities and therefore may

not be generalisable to other activity contexts.

The Assessment of Children’s Hand Skills (ACHS;

Chien, Brown & McDonald, 2010) is a newly developed

instrument designed for use with 2- to 12-year-old chil-

dren to capture real-life hand skill performance in a

range of childhood activities (e.g. play, educational and

self-care activities). The ACHS includes 20 hand skill

items that are rated by using a 6-level rating scale based

on the effectiveness of children’s hand use. These items

cover a range of representative hand skills that all chil-

dren may exhibit, such as reaching for, grasping or

manipulating objects and bimanual use. To enable eval-

uation and scoring of these hand skill items, 22 activity

items used to elicit the observation of hand skills are

also included in the ACHS. These activities are repre-

sentative of typical childhood occupations ranging

across different difficulty/ability levels and three

domains of leisure and play, school/education and

activities of daily living. Thus, the ACHS has potential

for being used to elicit hand skill performance in chil-

dren with a range of disabilities or health conditions

and at different age levels. More information about the

development, test items and rating scale of the ACHS is

detailed in the Appendix, and a research version of test

manual can be requested by direct contact with the

authors.

The ACHS uses a naturalistic observational approach

to evaluate how effective children are at using their hand

skills when engaged in some of the 22 selected activities

within real-life contexts. Thus, this assessment concept

reflects ecologically based measurement. However, it is

demanding and not necessary to observe children com-

pleting all of the activities included in the ACHS. A par-

ent- and caregiver-report questionnaire has therefore

been developed as part of the ACHS to provide family

centred input and assist in the selection of appropriate

activities for observations of individual children (Chien

et al., 2010). This questionnaire is used to obtain the

parent’s and caregiver’s perceptions regarding, which

activities are difficult for the child to perform and the

best environment(s) in which to observe selected activi-

ties. On the basis of the parent- and caregiver-report

results, occupational therapists are able to estimate the

challenging level of the activities, select at least 2–3

appropriate challenging activities out of the 22 available

activities, and observe and rate the child performing

these selected activities in real-life contexts.

The content validity of the ACHS was established

through review of the literature and existing hand skill-

related instruments, international experts’ review and

pilot field testing of six children with and without dis-

abilities (Chien et al., 2010). A reliability study was con-

ducted in a group of 54 children with and without

disabilities in Australia (Chien et al., 2010). The ACHS

test–retest reliability in a two-week interval was deemed

satisfactory at the individual item level (0.42 � j-val-ues � 0.79) and total scale level (Pearson’s r coeffi-

cient = 0.85, P < 0.01). Moderate inter-rater agreement

between the test developer and a new graduate thera-

pist was also found at the total scale level (r = 0.79,

P < 0.01). Several individual items exhibited limited

inter-rater agreement and, accordingly, the descriptions

of these items and the scope of rater training were

revised or enhanced (Chien et al., 2010). Validation of

the assessment construct (i.e. internal construct validity)

was examined by applying Rasch measurement analysis

to data from a group of Taiwanese children with and

without disabilities. Internal construct validity of the

ACHS could be achieved after removing one hand skill

item (Chien, Brown & McDonald, 2011). External con-

struct validity (e.g. concurrent, convergent and diver-

gent validity) of the ACHS has not yet been evaluated

by correlating the ACHS with other measures/vari-

ables.

The aim of this study was to investigate the construct

validity of the ACHS when used in a group of Austra-

lian children. Although the internal construct of the

ACHS has been verified in a group of Taiwanese chil-

dren, the evidence cannot be readily generalised to chil-

dren in other cultures and contexts, as cultural factors

may influence the validity of a hand skill test (Chow,

Henderson & Barnett, 2001; Henderson & Pehoski,

2006). Therefore, this study examined the internal con-

struct validity of the ACHS in a group of Australian

children with and without disabilities. Furthermore, the

correlation of the ACHS with other assessments related

to hand skills was examined as additional evidence for

its external construct validity. Further understanding of

the construct validity of the ACHS provides added evi-

dence for this new instrument before it is introduced

into occupational therapy practice.

Method

Participants

A total of 138 Australian children aged 2–12 years (mean

age = 6 years 11 months (SD = 2 years 10 months))

were recruited in this study between May and Novem-

ber 2008. Fifty-three (38.4%) of the participants were

children with disabilities (34 males, 19 females; mean

© 2012 The AuthorsAustralian Occupational Therapy Journal © 2012 Occupational Therapy Australia

ASSESSMENT OF CHILDREN’S HAND SKILLS 109

age = 8 years (SD = 2 years 3 months)), who were

recruited using convenience sampling from special

developmental schools around Melbourne if they pre-

sented with hand skill difficulties according to parents’,

caregivers’ or therapists’ reports. Diagnoses included

autism spectrum disorder (n = 19), developmental disor-

ders (e.g. developmental delay, n = 15), genetic/chromo-

some disorders (e.g. Down syndrome, n = 12) and

neuromuscular disorders (e.g. cerebral palsy or brachial

plexus birth palsy, n = 7). Eighty-five (61.6%) were typi-

cally developing children (41 males, 44 females; mean

age = 6 years 3 months (SD = 3 years)) who had no his-

tory of known disorders and were recruited from local

childcare centres and schools in the south of Greater

Melbourne. As the ACHS is conceptually based on a gen-

eric hand skill framework (Chien, Brown & McDonald,

2009) that can be applied to all children regardless of

health conditions, the combination of those children with

and without disabilities were used to examine its con-

struct validity.

Ethical approval for the study was granted by the

Monash Standing Committee on Ethics in Research

Involving Humans (2008000013-CF08/0139), the Depart-

ment of Education and Early Childhood Development

(ADD/08/6248 and SOS003803) and committees of the

participating childcare centres and schools. Written

consent was obtained from the participants’ parents and

caregivers.

Procedures

The participants’ parents and caregivers completed the

ACHS questionnaire before the observations were con-

ducted. On the basis of the obtained information, one

rater (i.e. the first author) observed each participant’s

hand skill performance, whereas undertaking appropri-

ate challenging activities (i.e. those rated as ‘difficult’ by

the parents and caregivers). The selection of these activ-

ities for the ACHS observations was also based on the

rater’s judgment on which activities could be observed

in the environment(s) that the parents and caregivers

specified as relevant. In this study, each child was

observed in performing as many appropriate activities

as possible to gather maximum information for the pur-

pose of examining the construct validity of the ACHS.

For typically developing children, age-appropriate activ-

ities were also observed if their parents and caregivers

reported no or few activities difficult for their child to

perform. These ACHS observations were conducted

within the children’s real-life environments, such as

homes, childcare centres, kindergartens or school set-

tings. The 6-level rating scale was used by the rater to

score the effectiveness of each hand skill item in the

children with and without disabilities during the ACHS

observations (see Appendix for detailed rating scale

information and scoring interpretation).

The participants’ parents and caregivers were also

invited to complete two additional questionnaires

together with the ACHS questionnaire. One was the

Personal Living Skills subscale of the Vineland Adap-

tive Behaviour Scales (VABS; Sparrow, Bella & Cicchetti,

1985), given to all participants. The other was the VABS

Fine Motor Skills subscale for children younger than six

years, or the Developmental Coordination Disorder

Questionnaire (DCDQ; Wilson, Kaplan, Crawford,

Campbell & Dewey, 2000) for children over six years.

Instrumentation

The two subscales (i.e. Personal Living Skills and Fine

Motor Skills) of the VABS and the DCDQ were included

in this study with the ACHS. These assessments sought

information about children’s hand skill use in certain

self-care, play or handwriting activities and they also

reflected the assessment of hand skill performance in

children’s real-life contexts. Therefore, these assess-

ments were expected to measure constructs similar to

the ACHS and were used to examine the external con-

struct validity of the ACHS.

The VABS Personal Living Skills subscale includes 36

items that assess the performance of children’s eating,

drinking, toileting, grooming, appearance, health care

and dressing. The Fine Motor Skills subscale contains 13

items that are related to object manipulation, drawing

and scissor use. Each item is rated on a 3-point scale, and

total raw scores range from 0 to 72 (Personal Living Skills

subscale) and 0 to 26 (Fine Motor Skills subscale). Higher

total scores indicate better personal living or fine motor

skills. The DCDQ contains 17 items that rate the degree of

children’s coordination in movement control, gross

motor/planning and fine motor/handwriting on a 4-

point scale. The possible total score ranges from 5 to 85

and, additionally, a factor score (ranging from 5 to 20)

obtained from the four items related to fine motor/hand-

writing can be calculated. Both the VABS and DCDQ have

been reported as being valid and reliable (Rosenbaum, Sa-

igal, Szatmari & Hoult, 1995; Sparrow et al., 1985; Wilson

et al., 2000). In this study, the raw scores for both the two

VABS subscales and DCDQwere used for analysis.

Statistical analysis

Internal construct validity of the ACHS was assessed

using Rasch measurement analysis, which expects that

easy items are easy for all children and that more able

children are more apt to receive higher test scores than

are less able children (Bond & Fox, 2007). Rasch analy-

sis provides unique examination of different aspects of

a test’s internal construct validity, particularly unidi-

mensionality (i.e. the extent to which items in a test

measure a single construct; Bond & Fox, 2007; Lim,

Rodger & Brown, 2009). The person response validity

(i.e. the extent to which the responses of participants

demonstrate logical hierarchical ordering) can be also

examined (Fisher, Bryze & Atchison, 2000). Rasch analy-

sis has been increasingly used to evaluate the integrity

of existing children’s hand skill-related outcome

© 2012 The AuthorsAustralian Occupational Therapy Journal © 2012 Occupational Therapy Australia

110 C.-W. CHIEN ET AL.

measures in rehabilitation and healthcare fields (Arnould

et al., 2004; Chien & Bond, 2009; Krumlinde-Sundholm

et al., 2007; Wallen, Bundy, Pont & Ziviani, 2009).

In this study, data were analysed with the Many-

Faceted Rasch model using the FACETS software (Lina-

cre, 2009). The Many-Faceted Rasch model allows the

effects of additional factors, known as facets, to be

accounted for in the estimate of person ability and item

difficulty (Bond & Fox, 2007). In the ACHS, a child’s

observational assessments involve several of the 22

activities, presenting with different challenge levels. The

challenge levels of the activity items were considered as

an important facet as they may affect the measurement

estimation when children performed the activities with

different challenging demands. In other words, a child

may demonstrate distinct effectiveness levels of hand

skills when folding paper into an airplane (perhaps a

more challenging activity) or just drinking water from a

cup. Therefore, the Many-Faceted Rasch model was used

for analysis of the ACHS data, in which one facet (chal-

lenge levels of activity items) was considered besides the

facets of children’s abilities and difficulty levels of hand

skill items. Furthermore, the ACHS is a rater-based

assessment. Although this study included only one rater,

the Many-Faceted Rasch model will also be used to

investigate rater severity when more raters are involved

in the ACHS observations in future research.

Rasch analysis of the ACHS was begun with the eval-

uation of its unidimensionality and person response

validity by goodness-of-fit statistics. The goodness-of-fit

statistics represented how well the participating chil-

dren as well as the ACHS activity items and hand skill

items fit with the Rasch model’s expectations. Items

were deemed to fit the model if the infit and outfit

mean of squared residuals (MnSq) were < 1.4 and their

standardised Z-values (Zstd) were < 2.0 for both ACHS

items and participating children. These criteria have

been suggested as acceptable and have been commonly

used for clinical observational assessments in published

literature (Bond & Fox, 2007; Krumlinde-Sundholm

et al., 2007). Person response validity can be established

when data from 95% of children exhibit acceptable

goodness-of-fit and, similarly, unidimensionality is indi-

cated when 95% of activity and hand skill items demon-

strate acceptable fit (Fisher et al., 2000). Items or

children presenting with infit and outfit MnSq > 1.4 as

well as Zstd > 2.0 were considered as misfitting and

removed from subsequent analyses.

The remaining acceptable fit activity and hand skill

items were placed along a hierarchical order according

to their difficulty calibrations (expressed in logits, also

known as log-odds probability units) that were gener-

ated by Rasch analysis. Whether the Rasch-generated

item-difficulty ordering in the ACHS conformed to clini-

cal reasoning was then examined to provide additional

evidence for internal construct validity. In addition, the

researchers examined how well the ACHS activity/

hand skill items targeted (or encompassed) the ability

range of the participating children with mixed disabili-

ties and health conditions, by inspecting the Rasch-

generated item-person map. In this map, children and

ACHS activity or hand skill items are displayed along

the same linear continuum, allowing the investigation

of the extent to which items are of appropriate difficulty

for the sample.

The external construct validity of the ACHS was

assessed through correlation analyses with the DCDQ

and VABS Personal Living Skills and Fine Motor Skills

subscales. The Rasch-transformed children’s ability esti-

mates (i.e. the logit scores) on the ACHS were used to

correlate with the raw scores of these VABS and DCDQ

assessment results. Spearman’s ρ correlation coefficients

were used with the interpretations: � 0.75, high rela-

tionship; range from 0.50 to 0.74, moderate relationship;

and � 0.49, weak relationship (Portney & Watkins,

2000). To examine whether there was consistency in the

correlation results across the children with different

characteristics, three correlation analyses were per-

formed. One was conducted with all the participating

children (typically developing and disability groups

combined), another with the typically developing group

only, and the other with the disability group only.

Results

A total of 764 observational assessments were obtained

from the group of 138 participating children. The obser-

vational assessments were spread relatively evenly

among three activity domains of leisure and play

(31.3%), school/education (40.6%) and activities of daily

living (28.1%). Approximately two-thirds (60.0%) of the

assessments were with regard to typically developing

children and half (53.6%) were from boys. Each activity

category comprised at least 20 observational assess-

ments (mean = 34.7; SD = 13.6) for analysis.

Internal construct validity: Rasch analysisresults

The results of Rasch goodness-of-fit analysis initially

found that overall response patterns of 12 (8.7%) partici-

pating children (five typically developing children and

seven with known disabilities) were identified as misfit

to the Rasch model’s expectations. Given that this rate

was higher than expected, a detailed investigation was

conducted to examine the overall percentage of all the

misfitting responses on the ACHS. A total of 642 out of

11262 responses were identified as unexpected, and the

misfitting response rate (5.7%) remained slightly higher

than the acceptable rate of 5%. Therefore, a decision was

made to eliminate four misfitting children who demon-

strated extreme misfit by the criteria of infit and outfit

MnSq > 2.0 with Zstd > 2.0. The extreme misfit indi-

cated that the four children exhibited double the magni-

tude of unexpected responses as the Rasch analysis

© 2012 The AuthorsAustralian Occupational Therapy Journal © 2012 Occupational Therapy Australia

ASSESSMENT OF CHILDREN’S HAND SKILLS 111

predicted (Bond & Fox, 2007). Particularly, three were

children with disabilities who exhibited a total number

of 55 unexpected responses (ranging from 14 to 24 for

each child), and the other one was a typically develop-

ing child, but she also exhibited as high as 10 unex-

pected responses. The four extremely misfitting children

were thus removed due to their potential threat for the

ACHS item fit analysis. The reduced group of 134 chil-

dren, 94% of whom demonstrated acceptable fit, was

used in the subsequent Rasch analyses.

With regard to the Rasch analysis results of the

ACHS items, all of the 22 activity items were found to

demonstrate acceptable goodness-of-fit (Table 1). How-

ever, 2 (10%) of the 20 hand skill items (i.e. Catch and

Manual gesture) exhibited misfit to the Rasch model’s

expectations (Table 2). Considering that the Catch hand

skill item had the worst misfit, this item was removed

from the ACHS and Rasch analysis was repeated. The

Manual gesture item still failed to fit the model’s expec-

tation, but all the activity items continued to fit after

removing the Catch skill item. This resulted in the

reduced ACHS having 19 hand skill items, of which

94.7% of the hand skill items overall had acceptable fit,

and the 22 activity items demonstrated acceptable

fit. These data provide evidence for unidimensionality

of the ACHS, and the 19 hand skill items and 22 activity

items were used for subsequent analyses.

A logical hierarchical ordering was found for the

activity and hand skill items of the reduced ACHS

TABLE 1: Measures and fit statistics for the 22 activity items

of the Assessment of Children’s Hand Skills

Activity

items Measure SE

Infit

MnSq

Infit

Zstd

Outfit

MnSq

Outfit

Zstd

Leisure and play domain

Block �0.36 0.10 0.9 �1.2 0.9 �0.7

Puzzle �0.35 0.09 0.9 �0.9 1.0 �0.4

Bead �0.20 0.11 0.8 �2.4 0.8 �2.2

Ball �0.20 0.07 1.2 3.9 1.2 2.2

Card 0.77 0.11 1.1 1.3 1.3 2.4

Clay �0.28 0.10 0.8 �2.9 0.8 �3.0

Fold paper 1.23 0.10 0.9 �1.5 0.8 �2.1

Handle

money

0.52 0.09 0.9 �0.9 1.0 0.1

School/education domain

Turn book �1.22 0.10 1.2 2.2 1.3 3.2

Draw 0 0.06 0.9 �1.7 0.9 �1.3

Write 0 0.09 1.0 �0.3 0.9 �1.1

Cut paper 0.83 0.07 1.0 �0.5 1.0 �0.1

Paste 0.53 0.09 0.7 �4.1 0.7 �3.2

Computer 0.55 0.11 1.0 0.4 0.9 �0.7

Ruler use 0.93 0.12 1.2 2.1 1.0 0.2

Put on

backpack

�0.51 0.11 1.1 1.4 1.1 1.3

Activities of daily living domain

Drink �1.55 0.09 1.0 0 1.0 �0.4

Eat �0.46 0.07 1.0 �0.4 0.9 �1.2

Dress 0.12 0.09 1.2 1.7 1.0 0.2

Put on

shoes

0.12 0.11 1.3 3.8 1.2 1.7

Wash

hands

�0.85 0.08 0.8 �2.4 0.7 �3.0

Brush

teeth

0.38 0.12 1.1 1.4 1.1 1.3

SE, standard error of the mean; MnSq, mean of squared

residuals; Zstd, standardised Z.

TABLE 2: Hierarchical ordering, measures and fit statistics for

the 20 hand skill items of the Assessment of Children’s Hand

Skills

Hand skill

items† Measure SE

Infit

MnSq

Infit

Zstd

Outfit

MnSq

Outfit

Zstd

Hold �2.37 0.09 0.9 �2.3 0.8 �1.9

Reach �2.05 0.08 0.7 �6.7 0.6 �4.4

Release �1.56 0.08 0.9 �2.6 0.9 �1.0

Manual gesture �1.28 0.16 1.5 4.0 1.6 3.4

Grasp �1.12 0.08 0.9 �1.6 0.9 �1.3

Carry �1.09 0.08 0.8 �4.3 0.7 �3.6

Body contact

hand skills

�0.85 0.14 1.1 0.6 1.1 0.4

Transfer �0.63 0.09 0.7 �4.9 0.7 �3.6

Turn �0.40 0.07 0.9 �2.6 0.9 �2.3

Pace �0.24 0.07 1.1 2.2 1.2 2.5

Use both hands

simultaneously

�0.19 0.10 1.1 1.0 1.1 0.6

Stabilise �0.13 0.08 1.2 3.7 1.2 2.3

Isolated finger

movement

�0.12 0.07 1.1 1.3 1.1 1.6

Accuracy 0.12 0.07 1.2 3.1 1.2 3.6

Move 0.78 0.08 1.2 2.4 1.2 2.8

Use both hands

cooperatively

1.19 0.08 1.1 1.0 1.1 0.8

In-hand

manipulate

1.65 0.09 1.3 3.2 1.2 2.8

Movement

quality

1.73 0.07 0.8 �3.0 0.9 �1.6

Throw 2.05 0.22 1.3 1.6 1.5 2.2

Catch 4.51 0.22 2.7 6.1 2.8 6.2

Note: The misfitting items were highlighted in bold.

†The items are arranged in a hierarchical order from

easy (i.e. minus values) to difficult (i.e. positive values).

SE, standard error of the mean; MnSq, mean of squared

residuals; Zstd, standardised Z.

© 2012 The AuthorsAustralian Occupational Therapy Journal © 2012 Occupational Therapy Australia

112 C.-W. CHIEN ET AL.

based on Rasch-generated difficulty levels (Fig. 1). Fold

paper and Ruler use were the two most difficult activi-

ties that required more complex use of the hands than

the easier activities (e.g. Turn book, Wash hands and

Drink activities). Likewise, the four most advanced

hand skills (e.g. Throw, In-hand manipulate, Movement

quality and Use both hands cooperatively) were

expected to be harder to complete than the Hold,

Release and Reach skills in children’s developmental

trajectories. Thus, both the activity and hand skill item-

difficulty hierarchies were deemed correspondent with

clinical experience.

The inspection of the item-person map (via Fig. 1)

revealed a wide distribution of the participating chil-

dren’s ability measures from �7.2 to 11.3 logits (a range

of 18.5 logits), but a narrower difficulty range for the

activity items (2.9 logits, from �1.6 to 1.3) and the hand

skill items (4.5 logits, from �2.2 to 2.3). No activities for

hand skill items existed, which presented suitable diffi-

culty for highly capable children on the top of Figure 1

(i.e. the typically developing and school-age children).

However, the ACHS’s item-difficulty coverage (particu-

larly for hand skill items) was found to be sufficient for

the majority of the children diagnosed with disabilities

or at preschool age (see Fig. 1).

External construct validity: Correlation withother measures

The correlations of the ACHS with the two VABS sub-

scales and the DCDQ are summarised in Table 3. Signif-

icantly high or moderate correlations (0.58 � ρ � 0.89,

P < 0.01) were found consistently between most assess-

ments on children with and/or without disabilities.

There were only weak correlations between the ACHS

and DCDQ for the typically developing children

(ρ � 0.49). Furthermore, the ACHS results of the chil-

dren with disabilities did not correlate with their chro-

nological ages (Pearson’s r coefficient = 0.09), but were

highly correlated with age in the typically developing

group of children (r = 0.96, P < 0.01).

Discussion

This study used Rasch measurement analysis to examine

internal construct validity of the ACHS with a group of

Australian children who are typically developing or

present with disabilities. The rate of the participating

children’s hand skill response patterns that fit with Ras-

ch model was marginally below expected. This provides

preliminary support for person response validity of the

ACHS. However, the high number of children (n = 12)

whose data were misfitting detracted from evidence for

the validity of the ACHS. Particularly, 5 (41.6%) of these

12 children had a clinical diagnosis of autism spectrum

disorder. A high proportion (28.2%) of unexpected

responses among participating children was related to

this diagnosis group. These children with autism spec-

trum disorder were found to have large numbers of

misfitting ratings (� 15) on hand skill items assessing

general quality (i.e. Pace and Accuracy) and easier activ-

ity items (e.g. Eat, Wash hands and Turn book). It is pos-

sible that children in this diagnostic group may perform

FIGURE 1: Item-person map for difficulty calibration of 22 activity items and 19 hand skill items with ability measures of 134 children.

Higher measures indicate higher item difficulty and higher child’s ability. Underlined child labels indicate typically developing preschool-

age children and highlighted labels indicate children with disabilities. The remaining are typically developing school-age children.

© 2012 The AuthorsAustralian Occupational Therapy Journal © 2012 Occupational Therapy Australia

ASSESSMENT OF CHILDREN’S HAND SKILLS 113

unexpectedly poorly on those easier activities because of

their stereotypical or inefficient hand use (e.g. with inac-

curacy or slow pace). Further research is needed to

determine if this kind of diagnosis-specific response pat-

tern exists in children with autism spectrum disorder,

since the present study cannot confirm the pattern due

to a small group of these children.

The goodness-of-fit analysis of the ACHS identified

no misfitting activity items, but two misfitting skill

items, Catch and Manual gesture. A previous study

(Chien et al., 2011) also found that the Catch item,

when completed by Taiwanese children, did not fit the

Rasch model. Although conceptually related to hand

use (i.e. using the arms and hands to stop a moving

ball and hold it), evaluation of the Catch skill item

could be affected by the children’s fear or inexperience

in catching balls. Moreover, the raters may have had

difficulty in gauging whether children’s unsuccessful

catches were contributed to playmates who threw the

balls with too much force. Thus, it was decided that

the Catch skill item be removed from the ACHS when

the data of Australian children were analysed. How-

ever, this skill item may be included (but not scored)

in the ACHS observations given that examining chil-

dren’s catching skills is of clinical importance. In con-

trast, the Manual gesture item was retained in analysis

of the ACHS data because the 95% acceptable fit rate

of the ACHS skill items was approximated and the

item did not exhibit misfit in the previous study with

Taiwanese children (Chien et al., 2011). It was also con-

sidered important that a considerable proportion

(13.8%) of children with autism spectrum disorder

were included in this Australian sample. The stereo-

typed hand/finger movements associated with this

diagnostic group may be falsely rated as ineffective

manual gesturing during the ACHS observations, even

though the children’s other hand skills were accept-

able. Therefore, a conservative decision to retain the

Manual gesture item was made.

The activity and hand skill items of the ACHS were

found to exhibit a difficulty hierarchy in agreement

with general clinical expectations. According to Brown

(2010) and Lim et al. (2009), this logical hierarchy could

be viewed as evidence for the internal construct validity

of the ACHS. The item-difficulty hierarchical structures

hold further promise for clinicians to use when analy-

sing children’s hand skill patterns or targeting interven-

tion to achieve hand skills at higher levels on the

hierarchy. However, Rasch analysis revealed a narrow

range of ACHS item difficulty and inadequate targeting

of items to assess more capable children. The problem

may be partially related to the removal of the most dif-

ficult hand skill item in the ACHS (i.e. the Catch item

in Table 2). Future studies could consider the addition

of new and more challenging activities/hand skills to

enable the ACHS to be used with typically developing,

school-age children and discriminate them from those

who present with mild hand skill problems. In the

meantime, it is suggested that the current version of the

ACHS remains sufficient for use with Australian pre-

school-aged children and those presenting with disabili-

ties.

Preliminary evidence of the external construct validity

of the ACHS was demonstrated by the associations with

other hand skills and daily functional assessments. Con-

sistent results were also evident in the combined or sepa-

rated analyses of the typically developing and disability

groups of children. The only exception was the weak cor-

relation between the ACHS and the DCDQ in typically

developing children. This is possibly because the DCDQ

TABLE 3: Correlation of the Assessment of Children’s Hand Skills with the Vineland Adaptive Behaviour Scales and the Developmental

Coordination Disorder Questionnaire, presented as Spearman’s ρ coefficients

Instruments†

Assessment of Children’s Hand Skills

Total sample

Typically developing

group Disability group

VABS

Personal Living Skills subscale 0.87* (n = 127) 0.89* (n = 79) 0.77* (n = 48)

Fine Motor Skills subscale 0.64* (n = 62) 0.59* (n = 46) 0.66* (n = 16)

DCDQ

Total score 0.79* (n = 54) 0.49* (n = 29) 0.62* (n = 25)

Fine motor/handwriting factor‡ 0.76* (n = 54) 0.27 (n = 29) 0.58* (n = 25)

*Indicates significance at P < 0.01.

†The raw scores of both the Vineland Adaptive Behaviour Scales (VABS) and the Developmental Coordination Dis-

order Questionnaire (DCDQ) were used in the correlation analysis.

‡The fine motor/handwriting factor score of the DCDQ was also used for this analysis, as the score provided spe-

cific information related to hand skills.

© 2012 The AuthorsAustralian Occupational Therapy Journal © 2012 Occupational Therapy Australia

114 C.-W. CHIEN ET AL.

is a screening questionnaire and the included activities

would therefore be easy for children who do not have dif-

ficulty using their hands. In addition, the weak correla-

tion between hand skill performance and age of the

children with disabilities was found in this study. This

accorded with previous findings (Krumlinde-Sundholm

et al., 2007) that age may not be an important factor in

assessing the hand skill performance of children diag-

nosed with disability and could be used as additional evi-

dence for external construct validity (particularly the

divergent validity) of the ACHS.

Implications for occupational therapypractice

Given current and previous evidence for construct

validity, the ACHS presents a new option for occupa-

tional therapists who want to assess children’s real-life

hand skill performance. The ACHS, being a naturalistic

observation tool, can be carried out in children’s homes

or schools when they are engaged in certain everyday

activities contained in the ACHS. The results obtained

from the ACHS provide criterion-referenced, descriptive

information about the children’s current hand skills. For

example, in the block playing activity, a child with an

intellectual disability may reach for and grasp the

LEGO blocks effectively (rated as level 5), but demon-

strate slightly ineffective in-hand manipulation (e.g.

rotating the blocks in the hand, rated as level 3) and

ineffective cooperative two-hand use (e.g. assembling

the blocks together, rated as level 2). This information is

useful for occupational therapists to analyse children’s

hand skill problems, approach assessment results and

guide treatment planning. For instance, the information

generated by the ACHS may assist in selecting further

instruments that specifically assess the identified prob-

lematic hand skill components. Furthermore, therapists

could use the ACHS results (i.e. those hand skills rated

as slightly inefficient or lower) as a basis to design

appropriate interventions and/or environmental adapta-

tions that promote children’s hand skill use, whereas

engaging in specific activities.

Study limitations

There are several limitations of this study. First, a con-

venient sample was recruited, in which fewer children

with disabilities were included. Second, the sample size

was also relatively small in several portions of the cor-

relation analyses. These may limit the generalisability of

the study’s results. Future studies that involve a larger

group of children with and without disabilities are

needed to confirm the construct validity of the ACHS,

particularly whether the Catch skill item is consistently

identified as misfit. In addition, the misfitting Manual

gesture item was not removed when generating the

ACHS scores, but more replication studies are needed

to explore the impact of retention of this item on the

internal structure of the ACHS.

Future directions for the ACHS

The ACHS is currently under re-investigation and

refinement. A study to explore the feasibility of video-

recoding ACHS observations for clinical and research

purposes and to investigate inter-rater and test–retestreliability is underway. The ACHS will also be exam-

ined in a larger group of children with disabilities to

generate evidence for validity in specific disabilities and

the cut-off values that can be used to identify children

with poor hand skill use. In addition, commercial publi-

cation of the ACHS will be sought to promote its clini-

cal use. The proposed ACHS test manual will include

digital video discs (DVDs) for training in administration

and scoring protocols, so that prospective users could

learn how to use the ACHS without the need to attend

formal training sessions. An online database will be also

developed to assist users of the ACHS to transform raw

scores into Rasch-based logit scores that characterise

children’s overall hand skill performance. The Rasch-

transformed scores could be further used in document-

ing and monitoring children’s hand skill improvements

as a result of intervention, however, establishing the

sensitivity to change and minimal detectable change for

the ACHS Rasch-transformed scores is needed in future

studies. Given that publication of an assessment tool is

a long process, therapists or researchers who are inter-

ested in using the ACHS before it is formally released

can contact the authors for a copy of the research

version.

Conclusion

This study provides preliminary evidence for the

internal and external construct validity of the newly

developed, naturalistic observational ACHS in Austra-

lian children. Rasch analysis confirmed the unidimen-

sionality of the ACHS after removing one item. The

internal construct validity of the ACHS is also

supported by demonstrating reasonable children’s

response validity, meaningful item-difficulty ordering

and item sufficiency for use among typically develop-

ing children of preschool-aged as well as most chil-

dren with a range of disabilities. External construct

validity of the ACHS was demonstrated by high to

moderate correlations with the children’s daily living

skills and hand skills obtained from similar tests.

Taken together, our results suggest that clinicians are

able to use the ACHS, through naturalistic observa-

tion, to assess children’s hand skill performance,

whereas engaging in a variety of predetermined activi-

ties in real-life contexts.

References

Arnould, C., Penta, M., Renders, A. & Thonnard, J. L.

(2004). ABILHAND-Kids: A measure of manual ability in

children with cerebral palsy. Neurology, 63, 1045–1052.

© 2012 The AuthorsAustralian Occupational Therapy Journal © 2012 Occupational Therapy Australia

ASSESSMENT OF CHILDREN’S HAND SKILLS 115

Bond, T. G. & Fox, C. M. (2007). Applying the Rasch model:

Fundamental measurement in the human sciences (2nd ed.).

Mahwah, NJ: Lawrence Erlbaum Associates.

Brown, T. (2010). Construct validity: A unitary concept for

occupational therapy assessment and measurement. Hong

Kong Journal of Occupational Therapy, 20, 30–42.Buffart, L. M., Roebroeck, M. E., Pesch-Batenburg, J. M.,

Janssen, W. G. & Stam, H. J. (2006). Assessment of arm/

hand functioning in children with a congenital transverse

or longitudinal reduction deficiency of the upper limb.

Disability and Rehabilitation, 28, 85–95.Chien, C. W. & Bond, T. G. (2009). Measurement properties

of fine motor scale of Peabody Developmental Motor

Scales-Second Edition: A Rasch analysis. American Journal

of Physical Medicine and Rehabilitation, 88, 376–386.Chien, C. W., Brown, T. & McDonald, R. (2009). A frame-

work of children’s hand skills for assessment and

intervention. Child: Care, Health and Development, 35, 873–884.

Chien, C. W., Brown, T. & McDonald, R. (2010). Examining

content validity and reliability of the Assessment of

Children’s Hand Skills (ACHS): A preliminary study.

American Journal of Occupational Therapy, 64, 756–767.Chien, C. W., Brown, T. & McDonald, R. (2011). Rasch

analysis of the Assessment of Children’s Hand Skills in

children with and without disabilities. Research in Devel-

opmental Disabilities, 32, 253–261.Chow, S. M., Henderson, S. E. & Barnett, A. L. (2001). The

Movement Assessment Battery for Children: A compari-

son of 4-year-old to 6-year-old children from Hong Kong

and the United States. American Journal of Occupational

Therapy, 55, 55–61.Fisher, A. G., Bryze, K. & Atchison, B. T. (2000). Naturalis-

tic assessment of functional performance in school set-

tings: Reliability and validity of the School AMPS scales.

Journal of Outcome Measurement, 4, 491–512.Folio, M. R. & Fewell, R. R. (2000). Peabody Developmental

Motor Scales: Examiner’s manual (2nd ed.). Austin, TX:

PRO-ED.

Greaves, S., Imms, C., Dodd, K. & Krumlinde-Sundholm,

L. (2010). Assessing bimanual performance in young chil-

dren with hemiplegic cerebral palsy: A systematic

review. Developmental Medicine and Child Neurology, 52,

413–421.

Henderson, A. & Pehoski, C. (Eds.). (2006). Hand function in

the child: Foundations for remediation (2nd ed.). Philadel-

phia, PA: Mosby.

Jackman, M. & Stagnitti, K. (2007). Fine motor difficulties:

The need for advocating for the role of occupational ther-

apy in schools. Australian Occupational Therapy Journal, 54,

168–173.Kimmerle, M., Mainwaring, L. & Borenstein, M. (2003). The

functional repertoire of the hand and its application to

assessment. American Journal of Occupational Therapy, 57,

489–498.Krumlinde-Sundholm, L., Holmefur, M., Kottorp, A. &

Eliasson, A. C. (2007). The Assisting Hand Assessment:

Current evidence of validity, reliability, and responsive-

ness to change. Developmental Medicine and Child Neurol-

ogy, 49, 259–264.Lim, S. M., Rodger, S. & Brown, T. (2009). Using the Rasch

analysis to establish the construct validity of rehabilita-

tion assessment tools. International Journal of Therapy and

Rehabilitation, 16, 251–260.Linacre, J. M. (2009). FACETS: Many faceted Rasch measure-

ment computer program. Chicago, IL: MESA Press.

Portney, L. G. & Watkins, M. P. (2000). Foundation of clinical

research: Application to practice (2nd ed.). Upper Saddle

River, NJ: Prentice Hall Health.

Rosenbaum, P., Saigal, S., Szatmari, P. & Hoult, L. (1995).

Vineland Adaptive Behavior Scales as a summary

of functional outcome of extremely low-birthweight

children. Developmental Medicine and Child Neurology, 37,

577–586.Sparrow, S. S., Bella, D. A. & Cicchetti, D. V. (1985). The

Vineland Adaptive Behavior Scales: Classroom edition. Circle

Pines, MN: AGS Publishing.

Wallen, M., Bundy, A., Pont, K. & Ziviani, J. (2009). Psy-

chometric properties of the Pediatric Motor Activity Log

used for children with cerebral palsy. Developmental Medi-

cine and Child Neurology, 51, 200–208.Wilson, B. N., Kaplan, B. J., Crawford, S. G., Campbell, A.

& Dewey, D. (2000). Reliability and validity of a parent

questionnaire on childhood motor skills. American Journal

of Occupational Therapy, 54, 484–493.World Health Organization (2001). International classification

of functioning, disability, and health. Geneva: World Health

Organization.

© 2012 The AuthorsAustralian Occupational Therapy Journal © 2012 Occupational Therapy Australia

116 C.-W. CHIEN ET AL.

Appendix

Summary of the Assessment of Children’s Hand Skills

Title Assessment of Children’s Hand Skills (ACHS)

Authors Chi-Wen Chien, Ted Brown, Rachael McDonald

Publication date 2010

Purpose The ACHS is designed as a descriptive, discriminative and evaluative tool. The ACHS assesses

how effective children are at using their hands when engaged in play, school-related, or

self-care activities in natural contexts so as to provide an indication of children’s real-life hand

skill performance. The information generated by the ACHS also aims to assist in selection of

further detailed assessments and treatment/intervention planning for children’s hand skill

problems or difficulties

Target population The target population includes typically developing children and, particularly, children with a

range of medical or clinical conditions. Children with known or suspected hand skill problems

or difficulties can be assessed by the ACHS

Age range for test The ACHS is applicable for children aged 2–12 years and who are able to perform specific play,

school-related, or self-care activities spontaneously regardless of their success or completion of

the activities

Potential user The ACHS has been developed for occupational therapists, but the potential users of the ACHS

may also include other child-related professionals (such as paediatricians, neurologists,

physicians in physical medicine and rehabilitation, physiotherapists, developmental

psychologists, speech therapists and educators) and relevant researchers who may be involved

in the completion of children’s hand skill assessments

Time to administer Approximately 20–30 min to complete naturalistic observations of at least two to three desired

activities (a maximum of 10 min is required for observation of each activity)

Materials/equipment

required

A test kit is not supplied as part of the ACHS, but specific, non-standardised materials and

equipment are required to complete the assessment observations. The materials and equipment

include toys (e.g. blocks, puzzles, beads, balls, card game materials, playdough or coins),

school-related materials (e.g. pencils and paper, books, crayons, scissors, glue sticks, computer,

rulers or backpacks) and self-care materials (e.g. drinking bottles, eating utensils, shoes and

socks, clothes, soap or toothbrushes) that children may use in daily activities

Method of

administration

Naturalistic observation in real-life contexts

Procedure for

administration

Before the ACHS observations are conducted, the parent and caregiver of the child being

assessed completes an ACHS questionnaire, referred to as the Children’s Hand Skills

Questionnaire (see ‘Other clinical utility’ section for its details). On the basis of the obtained

information, the examiner selects at least two to three activities that present an appropriate

challenge for the child to complete. The selection of the activities is also based on the examiner’s

judgment on which activities can be observed in the environment(s) that the parent and

caregiver specifies as relevant. The examiner contacts the parent and caregiver (if observed at

home) or the teacher (if observed at school) to arrange a suitable date/time for observing those

selected activities. During the ACHS observations, the child is motivated by the parent and

caregiver or the teacher to perform the selected activities spontaneously. The examiner sits in a

place close to the child and minimises necessary moves so as not to intrude, whereas observing

the child performing the selected activities. The examiner completes the scoring of the child’s

hand skill performance simultaneously when the child undertakes each activity or immediately

after the activity is completed

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ASSESSMENT OF CHILDREN’S HAND SKILLS 117

Appendix (Continued)

Scale construction/test structure ● Item generation/item selection:

The ACHS has two components: hand skill items and activity items. The hand

skill items were generated from the development of a hand skill framework

through the completion of an extensive literature review and input from an

expert review panel consisting of 10 international well-known researchers and

clinical experts. The activity items were selected from review of a number of

existing hand skill-related instruments, based on four selection criteria: (i) to be

representative of common childhood occupations that require hand use; (ii) to

present a specific challenge or age-appropriate level of difficulty for children

ages 2–12 years; (iii) to be easily observed naturalistically, whereas placing

minimal demands on children’s language, cognition and perception; and (iv)

to have minimal gender and/or cultural bias. A panel of 10 international

experts was invited to evaluate the suitability of the selected hand skill activities.● Number of activity items/categories:

Twenty-two activity items are divided into three domains:

(i) Leisure and Play domain includes eight activities: Block, Puzzle, Bead, Ball,

Card, Clay, Fold paper and Handle money

(ii) School/Education domain includes eight activities: Turn book, Draw,

Write, Cut paper, Paste, Computer, Ruler use and Put on backpack

(iii) Activities of daily living domain includes six activities: Drink, Eat,

Dress, Put on shoes, Wash hands and Brush teeth

● Number of hand skill items/categories:

Twenty hand skill items are grouped in six categories (as below) and detailed

definitions can be found in the test manual

(i) Manual gesture, one item

(ii) Body contact hand skills, one item

(iii) Arm-hand use includes seven items: Reach, Turn, Carry, Move, Catch,

Throw and Stabilise

Note: The Catch item will not be included when generating the ACHS scores.

(iv) Adaptive skilled hand use includes five items: Grasp, Hold, In-hand

manipulate, Release and Isolated finger movement

(v) Bimanual use includes three items: Transfer, Use both hands

simultaneously and Use both hands cooperatively

(vi) General quality of hand skills includes three items: Accuracy, Pace and

Movement quality

Scoring/response format A six-level rating scale is used for the examiner to score a child’s degree of effective

use on each hand skill item. The top three rating levels indicate that the child demonstrates

effective hand skill performance that does not disrupt the activity processing (e.g. leading

to unacceptable delay, increased efforts, activity breakdown, or the need for others’

assistance), whereas the lower three levels are rated when the child’s demonstrated hand

skill performance disrupts activity processing. Each level of the rating scale has a general

meaning across all of hand skill items as follows, and detailed guidelines/examples

for the rating scale across hand skill items

can be found in the test manual

6 = Very effective, indicating that the child performs the hand skill with perfect

competence and proficiency; the examiner does not see any problems when the child

performs the hand skill

5 = Effective, indicating that the child performs the hand skill with reasonable but not

perfect competence and proficiency; the examiner does not see any problems when the

child performs the hand skill

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118 C.-W. CHIEN ET AL.

Appendix (Continued)

4 = Slightly effective (or functional), indicating that the child performs the hand skill with

functional competence and proficiency that supports the activity completion; however, the

examiner sees some minor problems (e.g. atypical or irregular patterns) when the child

performs the hand skill

3 = Slightly ineffective, indicating that the examiner sees some problems in the hand skill, which

has minimally disrupted the child’s activity completion

2 = Ineffective, indicating that the examiners sees some problems in the hand skill, which has

obviously disrupted the child’s activity performance and results in the child’s ineffective use of

time or increased effort

1 = Very ineffective, indicating that the activity completion has been negatively disrupted

because the child is unable to perform the hand skill or needs others’ assistance.

Note: The scoring of each hand skill is based on the child’s effectiveness of use (e.g.

how effectively the child uses specific hand skill to complete the activity) regardless of

whether one or two hands are involved in the activity performance. For example, a typically

developing child may use right, left or both hands to reach for task objects, whereas the sound

hand may be used in the reaching performance by a child with hemiplegia. No matter

which hand(s) is used, the effectiveness of reaching performance during the child’s activity

completion is the main focus. Not all of the hand skill items need to be scored. The hand skill

items could be reported as ‘not observed’ if the child does not use them in the activity

Normative population Normative data are not applicable as the ACHS is intended to be used as a criterion-referenced

assessment. The test developers are currently conducting research to determine a

criterion-referenced cut-off value, which could assist clinicians and researchers in identifying

children who are experiencing problems impacting the effectiveness of hand skill use

Interpretability

(scores provided)

Three types of scores are proposed for scoring interpretation of the ACHS:

● Item raw score: used to indicate a child’s performance on a hand skill item,

whereas engaging in one specific activity. For example, this item raw score can

be used to know whether a child’s grasping performance in the writing activity

is effective or ineffective.● Percentage score on a particular activity item is calculated by the formula:

Percentage score ¼ ðAverage scores of the hand skill items� 1Þ5

� 100

Note: To make the percentage score ranging from 0 to 100%, the average score of

the hand skill items need to subtract 1 (as the minimum average item score is 1),

then divide by 5 (as the score range becomes 5 after subtracting 1), and lastly

multiply by 100

The percentage can be used to indicate a child’s overall hand skill performance on

a specific activity, as the child may not use all hand skills when engaging in the

activity and the total raw score has little meaning. For example, in the cutting

activity, the child may use all of the hand skills except for the throwing skills.

Thus, the percentage scores can be generated to show the effectiveness of the

child’s hand skills performed in the cutting activity on the overall basis. It can

be also used to know whether the child’s hand skill performance is more efficient

in the cutting activity than in other activities● Rasch-transformed logit score: derived from the raw scores (excluding the Catch

skill item) by Rasch analysis software; it can be used to represent a child’s

overall hand skill performance on several observed activities. Particularly, the

logit score can enable comparison of the children’s composite hand skill

performance when they perform different activities

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ASSESSMENT OF CHILDREN’S HAND SKILLS 119

Appendix (Continued)

Examiner qualifications Individuals who use the ACHS need to have general understanding of test statistics,

specific expertise in completing hand skill assessments, and knowledge of development of

children with and without disabilities. Test developers suggest that examiners should possess

tertiary level qualifications (e.g. undergraduate degree or higher) relevant to health sciences

or child development. Furthermore, the examiners should practice observing and scoring the

hand skill items in all of the 22 activity items with typically developing children and those with

known disabilities

Other clinical utility The ACHS includes the Children’s Hand Skills Questionnaire that promotes family centred

assessment. The information obtained from the questionnaire assists examiners in selecting

suitable challenging activities and appropriate environment(s) for the ACHS observations. At

first, the questionnaire obtains the parent’s and caregiver’s perceptions and input regarding

which activities are difficult for the child being observed to perform. Activities from the ACHS

that are too easy or over-challenging may not produce appropriate estimates indicating

children’s current hand skills. Therefore, the questionnaire includes a 22-item checklist that

requires the child’s parent and caregiver to report their perceptions regarding their child’s hand

skill proficiency at carrying out the 22 ACHS activities on a three level scale: ‘extremely

difficult’, ‘difficult’ or ‘not difficult’. Furthermore, activities not attempted by the child in the

last three months are not scored and are marked as ‘not applicable’. An additional question

seeks information about which environments (e.g. home, school or others) provide the most

appropriate opportunity to observe their child performing the challenging activities (i.e. those

activities that the parent and caregiver report as ‘difficult’)

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120 C.-W. CHIEN ET AL.