Jebsen Taylor Test of Hand Function (JTTHF)
Upper limb manual speed and dexterity will be measured using the JTTHF [
94]. Six timed tasks of varying complexity using everyday items requiring grasp and release ability will be performed on each UL. The dominant hand will be tested first, followed by the non-dominant hand. In accordance with previously published modifications to the administration of the JTTHF, the writing task will be omitted. The maximum allowable time to complete each item will be capped at two minutes to reduce frustration [
95‐
97]. The JTTHF is responsive to change due to UL intervention although there have been questions raised about the stability of test-retest performance in the unimpaired limb [
95‐
98]. Inter-rater reliability for each subtest is high (ICC = 0.82-1.0).
The Melbourne Assessment of Unilateral Upper Limb Function (MUUL)
Quality of UL movement will be evaluated using the MUUL [
99]. The MUUL was designed for children with neurological impairment aged 5–15 years and comprises 16 criterion-referenced items measuring movement range, accuracy, dexterity and fluency. The maximum possible raw score is 122. Raw scores will be converted and reported as percentage scores (higher scores represent greater quality of movement). Total test scores have very high levels of inter-rater (ICC = 0.95), intra-rater (ICC = 0.97), and test re-test reliability (Concordance Correlation of 0.98). Construct, content and criterion validity for the MUUL have been established [
99‐
101]. The MDC has been estimated in a number of studies ranging from 7.4 to 14 % [
99,
102,
103]. The MUUL has recently undergone revision. Rasch analysis did not support uni-dimensionality of the MUUL. The revised version comprised 14 items that are organised in four separate sub-scales [
104]. The original version of the MUUL will be used in this study as evidence for the revised version is preliminary.
Executive functioning
Executive functioning will be evaluated using a comprehensive neuropsychological test battery which was designed to assess the four domains of executive functioning in accordance with Anderson’s paediatric model of executive functioning [
13]. The four domains are attentional control, information processing, cognitive flexibility and attentional control. The neuropsychological test battery consists of subtests from the Delis-Kaplan Executive Function System (D-KEFS) [
105], Test of Everyday Attention For Children [
106], the Wechsler Intelligence Scale for Children Fourth Edition (WISC-IV) [
65], the Comprehensive Trail Making Test (CTMT) [
107] and the Tower of London – Second Edition [
108]. The Behaviour Rating Inventory of Executive Function (BRIEF) [
109], a parent-rated questionnaire will be used as a measure of behavioural manifestations of executive functioning in everyday life. All scores will be converted into scaled scores using age and gender based norms.
i)
Colour-Word Interference Test (from the D-KEFS)
The inhibition condition of the Colour-Word Interference subtest of the D-KEFS will be used as a primary measure of attentional control. The subtest measures an individual’s ability to suppress an automatic response in favour for an abstract one. Participants will be assessed on their ability to name the colour of the ink colour words that are printed across five rows (e.g. say “blue” for the word “red” that is printed in blue ink). Participants will be timed (in seconds) on how long it takes them to complete the task as well as how many mistakes they make. Raw scores are converted into scaled scores (M = 10, SD = 3) using normative data provided in the manual. The Colour-Word Interference subtest of the D-KEFS has demonstrated excellent test-retest reliability (
r = 0.90) [
105].
ii)
Comprehensive Trail Making Test (CTMT)
Trails one, two and three from the Comprehensive Trail Making test will be used to measure attentional control and trails four and five will be used to measure cognitive flexibility in children with an ABI. In trails one to three, participants will connect numbers printed on an A4 sheet in numerical order from 1–25. Distractor items are contained in trails two and three to increase the need for attentional control. In trail four, participants will draw a line in order connecting the numbers 1–20. The numbers are presented in both Arabic numerals (e.g. 1, 7) and numbers spelled out in the English language form (e.g. Nine). Lastly, for trail five, participants will be required to switch back and forth between connecting numbers in numerical order and letters in alphabetical order, also printed on an A4 sheet, from 1–13, and A – L (e.g. “1-a-2-b-3-c”). The total time (seconds) taken to complete each trail will be recorded, with a longer time indicating greater difficulty with attentional control or cognitive flexibility. Raw scores will be converted to T-scores (M = 50, SD = 10). Good internal test-retest reliability has been shown for the five trails (
r = 0.70–0.78) [
107].
iii)
Tower of London (TOL) – Second Edition
The Tower of London will be used to measure goal setting. Participants will move three coloured beads across three vertical pegs on their board varying in height to build a target tower on the examiner’s identical board, within a specified time limit. There are 10 problems of increasing difficulty. They will be instructed to use the least number of moves possible to complete the tower, that they can only move one bead at a time and that they must not put more beads on a peg than it will hold (e.g. the second peg can only hold two beads and the third peg can only hold one bead). The total move score, which is based on the total number of moves needed to build each of the 10 towers; the total correct score which is the number of towers correctly solved in the recommended moves; and the total rule violations will be used to measure goal setting abilities. The lower the total move score and total correct score, and the higher the total rule violations score indicate greater goal setting difficulties. Raw scores will be converted into standard scores (M = 100, SD = 15). The Tower of London has adequate test-retest reliability (
r = 0.28–0.75) [
108].
iv)
Digit Span (from the WISC-IV)
As explained previously, the Digit Span subtest from the WISC-IV is a verbal memory task where children are required to repeat a number of digits in the forward and backwards order. Digit Span Forward is a measure of a child’s ability to temporarily store information. The examiner will say a string of numbers increasing from two digits to nine, and the participant is required to repeat them back. Digit Span Backwards, is similar but instead of repeating the string of numbers in the same order as presented, the child is required to repeat the string of numbers in the reverse order (e.g. if “5-7-4”, the child should say “4-7-5”). Digit Span Backward is also a measure of a child’s ability to temporarily store information but they are also required to mentally manipulate in working memory too. As such, Digit Span Backwards will be used as a measure of cognitive flexibility. Children are given a score of one for every number string they repeat correctly in reverse order. This means lower overall scores for Digit Span Backwards will indicate poorer cognitive flexibility. Raw scores are converted into scaled scores (M = 10, SD = 3) using normative data provided in the manual. Internal consistency for Digit Span Backwards was good (α = 0.80) and it also has adequate test-retest reliability (
r = 0.74) [
110].
v)
Coding (from the WISC-IV)
The Coding subtest from the WISC-IV will be used as a measure of information processing. Participants will be required to match up and copy abstract geometric shapes with numbers from a key within a two minute period. Participants will be scored based on the number of correctly copied abstract geometric shapes within the time limit. Lower numbers will ultimately indicate poor information processing abilities. Raw scores will be converted into scaled scores (M = 10, SD = 3) using normative data provided in the manual. Coding has been shown to have a good internal consistency (α = 0.82) and test-retest reliability (
r = 0.81) [
110].
vi)
Symbol Search (from the WISC-IV)
The Symbol Search subtest of the WISC-IV is also used as a measure of information processing. In a two-minute time limit, participants will be required to visually scan for target symbols in groups of five symbols and indicate whether the target symbol is in the group by placing a line through the word ‘yes’ or ‘no’. Participants will be scored based on the total number of correctly identified symbols minus the total number of incorrectly identified symbols. Lower scores on Symbol Search indicate poorer information processing. Raw scores will be converted into scaled scores (M = 10, SD = 3) using normative data provided in the manual. Symbol search has adequate internal consistency (α = 0.79) and a high level of test-retest reliability (
r = 0.80) [
110].
vii)
Brief Rating Inventory of Executive Function (BRIEF)
As indicated, the BRIEF is a parent-rated questionnaire designed to assess the behavioural manifestations of executive functions in everyday life. Parents will be required to rate 85 items (e.g. “becomes upset with new situations”) on a three-point likert scale ranging from 1 (
never) to 3
(often). Raw scores will be converted into
T scores (M = 50, SD = 10) using normative data provided in the manual. The BRIEF consists of eight subscales which combine to form the Behavioural Regulation Index (BRI; Initiate, Working Memory, Plan/Organise, Organisation of Materials and Monitor subscales) and the Metacognition Index (MCI; Inhibit, Emotional Control, and Shift subscales). These inturn form the overall Global Executive Composite (GEC). Elevations on subscales and indices will be determined by a
T score of 65 and above, which is 1.5 SD above the mean. Higher
T scores indicate progressively greater levels of executive dysfunction. The BRI, MCI and GEC indices will be used as primary measures of executive function in everyday life. The BRIEF has been shown to be a valid measure of executive functioning and has good internal consistency (
α = 0.80-0.98) and high test-retest reliability on the BRI (
r = 0.92), MCI (
r = 0.88), and the GEC (
r = 0.86) [
109].
Test of Everyday Attention for Children [106]
Sustained attention will be assessed using Score!. Participants will be required to keep a count of the number of ‘scoring’ sounds they hear on a tape, as if they were keeping the score on a computer game across several trials. Due to the ceiling effect in this test, correlations are unrealistic therefore there is 76.2 % agreement within one SD for test-retest [
106].
Selective/focused attention will be assessed using Sky Search. This is a brief, timed subtest. Participants will be required to circle as many ‘target’ spaceships as possible on an A3 sheet filled with very similar distracter spaceships. In the second part of the task there are no distracters. Subtracting part two from part one gives a measure of a child’s ability to make this selection that is relatively free from the influence of motor slowness. Sky Search has high test-retest reliability (
r = 0.80 for time-per-target and
r = 0.75 for attention score) [
106].
Sustained attention will be assessed using Sky Search Dual Task (DT). This subtest combines the sustained attention task of counting ‘scoring’ sounds (Score!) with the selective/focused attention task of Sky Search. Participants will be required to circle as many ‘target’ spaceships as possible on the A3 sheet at the same time as counting the number of ‘scoring’ sounds on a tape. Sky Search DT has high test-retest reliability (
r = 0.81) [
106].
Conners 3rd Edition™ (Conners 3™)
The Conners 3™ [
111] is a thorough assessment of ADHD and its most common co-morbid problems and disorders in children and adolescents ages 6–18 years old. The Conners 3™ will be completed by the participant’s parents or guardian and consists of 110 statements and takes approximately 20 min to complete. Parents or guardians must rate each statement using a four-point scale ranging from ‘0 – Not true at all (never, seldom)’ to ‘3 – Very much true (very often, very frequently)’. The Conners 3™ measures the seven key areas of inattention, learning problems, aggression, family relations, hyperactivity/impulsivity, executive functioning and peer relations. Raw scores are converted into T scores based on a large representative normative sample based on United States of America consensus data. In addition, the Conners 3™ calculates T scores for symptom scales including ADHD Hyperactive/Impulsive, ADHD Combined, Oppositional Defiant Disorder, ADHD Inattentive and Conduct Disorder. Both internal consistency coefficients (α = 0.83–0.94) and test-retest reliability (
r = 0.52–0.94) are good for the Conners 3™ Parent version total sample age range [
111].