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Guideline Summary
Guideline Title
Best evidence statement (BESt). Use of motor and self-care assessment tools for children with autism spectrum disorder (ASD).
Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Use of motor and self-care assessment tools for children with autism spectrum disorder (ASD). Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2009 Jul 7. 6 p. [19 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Autism spectrum disorder (ASD)

Guideline Category
Assessment of Therapeutic Effectiveness
Evaluation
Clinical Specialty
Family Practice
Pediatrics
Physical Medicine and Rehabilitation
Intended Users
Advanced Practice Nurses
Nurses
Occupational Therapists
Physical Therapists
Physician Assistants
Physicians
Guideline Objective(s)

To provide recommendations for assessing motor and self-care skills in children with autism spectrum disorder (ASD) for use by occupational therapists and physical therapists

Target Population

Children up to nine years of age who present with a diagnosis of autism spectrum disorder (ASD) according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria

Note: Children with a diagnosis of the following subcategories of ASD are excluded from this guideline:

  • Rett Syndrome
  • Childhood Disintegrative Disorder
Interventions and Practices Considered

Standardized testing of motor and self-care skills, using the following assessment tools:

  • Peabody Developmental Motor Scales 2 (PDMS-2)
  • Bruininks-Oseretsky Test of Motor Proficiency-2 (BOT2)
  • Pediatric Evaluation of Disability Inventory (PEDI)
Major Outcomes Considered
  • Reliability and validity of diagnostic tools
  • Standardized test scores for motor and self-care skills

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Search Strategy

  1. Databases: OVID MEDLINE, OVID EBM Reviews (Cochrane), OVID CINAHL, Other:
    • EBM Reviews Full Text - Cochrane DSR, ACP Journal Club, and DARE
    • All EBM Reviews - Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, and NHSEED
    • Cincinnati Children's Full Text Journals @ OVID
    • Websites: www.otseeker.com External Web Site Policy, www.otcats.com External Web Site Policy, www.pedro.org.au External Web Site Policy
    • Pratt Journal Portal searched the Journal of Autism and Developmental Disorders
    • Additional articles from reference lists
  2. Search Terms: Motor skills, self-care skills, BOT-2, Bruininks-Oseretsky Test of Motor Proficiency -2, Peabody Developmental Motor Scales, Pediatric Evaluation of Disability Inventory (PEDI), autism, development, pediatrics
  3. Limits and Filters: none
Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 Other: General review, expert opinion, case report, consensus report, or guideline

†a = good quality study; b = lesser quality study

Note: Full tables of evidence grades and strength of recommendations are available in separate documents (see the "Availability of Companion Documents" field).

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is a lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the Body of Evidence
  2. Safety/Harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life

Note: Full tables of evidence grades and strength of recommendations are available in separate documents (see the "Availability of Companion Documents" field).

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

Reviewed by Clinical Effectiveness

Recommendations

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a to 5) are defined at the end of the "Major Recommendations" field.

  1. It is recommended that standardized testing of motor and self-care skills be administered only when indicated (Clark, Miller-Kuhaneck, & Watling, 2004 [5]).

    Note 1: Although standardized testing of motor and self care skills is not frequently completed with children diagnosed with autism, times at which testing may be indicated include when requested by referral source (Clark, Miller-Kuhaneck, & Watling, 2004 [5]), third-party payer, or caregiver, or upon therapist judgment based on clinical observations and clinical reasoning (Local Consensus [5]).

    Note 2: "Additionally, individuals with autism have been described as distractible, demonstrating variability in skill performance, having low tolerance for incoming sensory stimuli, and impervious to the usual verbal and even tangible motivators that are used to support optimal performance during testing (Koegel, Koegel, & Smith, 1997; Cook, 1991; Rapin, 1991). Therefore, a standardized testing process does not play to the strengths of individuals with autism and, consequently, the testing process often is not well tolerated, nor does it result in an accurate reflection of the individual's abilities" (Tomchek & Case-Smith, 2009 [5]).

  2. It is recommended that if standardized testing of motor and self-care skills is warranted, one of the following assessment tools be administered during or after the initial occupational therapy (OT) evaluation:
    • 0 through 5 years of age: Peabody Developmental Motor Scales 2 (PDMS-2)
    • 4 years through 9 years: Bruininks-Oseretsky Test of Motor Proficiency-2 (BOT2)
    • 6 months through 7.5 years of age: Pediatric Evaluation of Disability Inventory (PEDI)
      (Local Consensus [5])
    • It is recommended that the assessment results be interpreted with caution as some of the tools are not standardized for children with autism spectrum disorder (ASD) (Local Consensus [5]).

      Note 1: The PDMS 2 has not been normed for children with ASD; however, many studies report the use of the Peabody with children who have ASD (Provost, Lopez, & Heimerl, 2007 [4b]; Connolly et al., 2006 [4b]; Provost et al., 2004 [4b]).

      Note 2: Although the BOT-2 is not standardized on children with ASD, data was collected showing that the BOT-2 is sensitive enough to identify motor deficits in children with high-functioning autism/Asperger's disorder (Bruininks & Bruininks, 2005 [5]).

      Note 3: One of the limitations of the PEDI for this population is the limited sample size of children with cognitive and social disabilities (Feldman, Haley, & Coryell, 1990 [4b]). The authors propose that the PEDI is most appropriate to use with children who have physical or combined physical and cognitive disabilities. The validity of using the PEDI with children who have primarily behavioral and social concerns such as autism is unknown (Haley et al., 1992 [5]).

    Definitions:

    Table of Evidence Levels

    Quality Level Definition
    1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
    2a or 2b Best study design for domain
    3a or 3b Fair study design for domain
    4a or 4b Weak study design for domain
    5 Other: General review, expert opinion, case report, consensus report, or guideline

    †a = good quality study; b = lesser quality study

    Table of Recommendation Strength

    Strength Definition
    "Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
    "Recommended" There is consensus that benefits are closely balanced with risks and burdens.
    No recommendation made There is a lack of consensus to direct development of a recommendation.
    Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
    1. Grade of the Body of Evidence
    2. Safety/Harm
    3. Health benefit to the patients (direct benefit)
    4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
    5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
    6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
    7. Impact on morbidity/mortality or quality of life

    Note: Full tables of evidence grades and strength of recommendations are available in separate documents (see the "Availability of Companion Documents" field).

    Clinical Algorithm(s)

    None provided

    Evidence Supporting the Recommendations

    References Supporting the Recommendations
    Type of Evidence Supporting the Recommendations

    The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

    Benefits/Harms of Implementing the Guideline Recommendations

    Potential Benefits

    The family will gain an understanding of where their child is functioning compared to other children his/her age.

    Potential Harms

    No studies specifically evaluating the validity of these instruments with children diagnosed with autism were identified. Therefore, test results may not be valid and need to be interpreted with caution.

    The body of evidence for the use of standardized tests with children who have a diagnosis of autism spectrum disorder (ASD) is low. In addition, the value of standardized testing is questionable with children who have ASD. Results may "bear little relationship to the children's abilities to function."* Children with ASD may perform better than their usual abilities during standardized assessments due to the highly structured test setting as opposed to the child's natural setting, which may be less structured. Performance may be below or above their usual abilities depending on the client's level of interest and/or motivation; test procedures may need to be modified to increase child's motivation and comprehension. If tests are not completed or conducted in a standardized way, the results would need to be interpreted with caution since they would no longer be standardized.

    *Clark J, Miller-Kuhaneck H, Watling R. Autism: a comprehensive OT approach. 2004.

    Qualifying Statements

    Qualifying Statements

    This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

    Implementation of the Guideline

    Description of Implementation Strategy

    An implementation strategy was not provided.

    Institute of Medicine (IOM) National Healthcare Quality Report Categories

    IOM Care Need
    Living with Illness
    IOM Domain
    Effectiveness

    Identifying Information and Availability

    Bibliographic Source(s)
    Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Use of motor and self-care assessment tools for children with autism spectrum disorder (ASD). Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2009 Jul 7. 6 p. [19 references]
    Adaptation

    Not applicable: The guideline was not adapted from another source.

    Date Released
    2009 Jul 7
    Guideline Developer(s)
    Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
    Source(s) of Funding

    Cincinnati Children's Hospital Medical Center

    Guideline Committee

    Not stated

    Composition of Group That Authored the Guideline

    Division of Occupational Therapy and Physical Therapy: Rebecca D. Reder, OTD, OTR/L, Senior Clinical Director, Occupational Therapy and Physical Therapy

    BESt Development Team: Aurora Hoobler, OTR/L, MS, Team Leader, Division of Occupational Therapy and Physical Therapy; Christa Aylward, OTR/L, Division of Occupational Therapy and Physical Therapy; Carol Burch, PT, DPT, Division of Occupational Therapy and Physical Therapy; Karen Kovacs, OTR/L, Division of Occupational Therapy and Physical Therapy; Vicki McQuiddy, OTR/L, MHS, Division of Occupational Therapy and Physical Therapy

    Reviewed By: Jamie Donovan, MOT, OTR/L, Division of Occupational Therapy and Physical Therapy; Amy Johnson, OTR/L, Division of Occupational Therapy and Physical Therapy; Kathy Krebs, OTR/L, Division of Occupational Therapy and Physical Therapy; Patricia Manning-Courtney, MD, Associate Professor of Clinical Pediatrics, University of Cincinnati College of Medicine; Pediatric Developmental Specialist; Medical Director, The Kelly O'Leary Center for Autism Spectrum Disorders, Division of Developmental Disabilities; Donna Murray, PhD, CCC-SLP, Assistant Professor of Clinical Pediatrics, University of Cincinnati College of Medicine; Director of Clinical Services, Division of Developmental and Behavioral Pediatrics; Co-Director, The Kelly O'Leary Center for Autism Spectrum Disorders, Division of Developmental Disabilities

    Division of Health Policy & Clinical Effectiveness Support: Eloise Clark, MPH, MBA, Guidelines Program Administrator; Barbarie Hill, MLS, Pratt Library

    Ohio State University: Reviewed by Alison Lane, PhD, OTR/L, Assistant Professor, School of Allied Medical Professions, College of Medicine

    Financial Disclosures/Conflicts of Interest

    All team members and clinical effectiveness support staff listed in the original guideline document have signed a conflict of interest declaration and none were found.

    Guideline Status

    This is the current release of the guideline.

    Guideline Availability

    Electronic copies: Available from the Cincinnati Children's Hospital Medical Center External Web Site Policy.

    Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

    Availability of Companion Documents

    The following are available:

    • Judging the strength of a recommendation. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2008 Jan. 1 p.
    • Grading a body of evidence to answer a clinical question. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 1 p.
    • Table of evidence levels. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2008 Feb 29. 1 p.

    Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

    Patient Resources

    None available

    NGC Status

    This NGC summary was completed by ECRI Institute on July 22, 2010.

    Copyright Statement

    This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

    Copies of this Cincinnati Children's Hospital Medical Center (CCHMC) External Web Site Policy Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:

    • Copies may be provided to anyone involved in the organization's process for developing and implementing evidence-based care. 
    • Hyperlinks to the CCHMC website may be placed on the organization's website.
    • The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents.
    • Copies may be provided to patients and the clinicians who manage their care.

    Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented, or hyperlinked by the organization is appreciated.

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    The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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