Sub-themes within each free-text question.

When asked to reflect on the benefits of the MABC-2 for DCD diagnosis, the most common themes were the ease of administration (n = 6), its ability to simply identify each child’s motor difficulties (n = 4), and the extent to which it can aid formal diagnosis (n = 4). When asked to reflect on the challenges of using the MABC-2 for DCD diagnosis, the most common theme was that scores are often not reflective of motor difficulties due to its non-holistic approach (n = 11). Another common theme was that the tasks included in the MABC-2 were not functional and thus not representative of the tasks children face daily (n = 6). When asked how the MABC-2 can be improved, the common themes included the inclusion of functional tasks (n = 8), improvements to the scoring system (n = 3), a wider range of age intervals (n = 3), and improvements to the administrative guidance (n = 3). When specifically asked about the effectiveness of the scoring system, common themes indicated that the score is often not reflective of motor difficulties (n = 5), that subjective interpretation could influence results (n = 2), and that the scoring system is easy to understand (n = 4). When asked whether children can improve their MABC-2 score, a common theme indicated that children can improve their scores after targeted interventions (n = 10). However, another common theme indicated that scores could be improved, but as the tasks depend on splinter skills, their development would be redundant for activities of daily living (n = 4). When asked to elaborate on how the examiner can influence performance on the MABC-2, a common theme related to the lack of clear administrative guidance on how to instruct and interact with each child (n = 15, e.g., demonstrating, over-explaining, reassuring, motivating). Another common theme related to the subjective interpretation of performance, which can vary between and within examiners (n = 4). When asked to elaborate on how the parents can influence a child’s performance, a common theme suggested that parents can often negatively interfere with a child’s performance (n = 15), whilst another theme indicated that parents can provide positive reassurance (n = 2). Finally, when asked to elaborate on whether they had received enough training, a common theme indicated that many respondents had received no formal training (n = 11), and that formal training would be beneficial (n = 4).

Main themes.

Following the analysis, two main themes were identified and were labelled “Strengths of the MABC-2” and “Weaknesses, concerns and challenges of the MABC-2”. The following section provides descriptions and supporting quotations from the respondents to illustrate the themes more broadly within the context of the literature base.

Score is not always reflective of motor difficulties.

Despite the potential benefits of a test that is simple to administer and interpret, many respondents highlighted some fundamental issues that may question its validity for the diagnosis of DCD. Many respondents felt that the achieved MABC-2 score can fail to reflect the observed and subjectively reported motor difficulties. For example, the non-holistic approach of the MABC-2 was thought to overlook daily variations in a child’s physical and mental state:

“I feel that a child’s performance is dependent on many factors on the day. For example, their attention and concentration, their emotional wellbeing, their fatigue and their change in routine as they will have often missed school…”.

[OT2]

This response aligns with evidence that individuals with DCD are highly susceptible to cognitive [22] and physical [23] fatigue. There is also a high prevalence of co-occurrence between DCD and attentional deficit hyperactivity disorder (ADHD), with as many as 50% of children with ADHD being diagnosed with DCD [24]. This raises the possibility that the outcome of assessment might be influenced by daily variations in a child’s hyperactivity-impulsivity and/or inattention during testing—a factor that is of particular concern if only conducted on a single occasion.

It was also highlighted that scores on the MABC-2 fail to capture the quality of movement:

“…The quality of movement is so important and does not get taken into account at all…”.

[PT2]

Indeed, research has shown that children with DCD can display fundamental differences in their movement patterns (e.g., greater variability in kinematics) in tasks such as walking [25] and stair climbing [26], despite no differences in task failures (i.e., trips and falls). Interestingly, it has been suggested that increased coordinative variability in children with DCD may reflect individualised coordination solutions depending on the specific constraints placed upon their neuromuscular system [27]. Placing emphasis on crude outcome measures of task performance may therefore overlook the possibility that performance outcomes were achieved with fundamentally greater coordinative variability, which may provide a more subtle indication that motor difficulties are present.

The role of the distracting parent.

Perhaps surprisingly, most respondents indicated that parents have a negative impact upon the MABC-2 assessment. Whilst the presence of a parent or guardian generally holds emotional and ethical value, some respondents indicated that their enthusiasm to aid their child can interfere with the child’s performance:

“…Parents may invertedly put their child off or may make them perform better than they usually would”

[OT7]

“…Parents can give clues, even if instructed not to”

[OT9]

“…Some children look to their parent for reassurance which sometimes seems to interrupt the child’s performance”

[OT14]

These findings indicate that parents who intend to support the MABC-2 process might detract from the quality of assessment by altering the challenge of the task. For example, providing additional instructions to guide performance might give a child a performance advantage over a child who does not receive such support. By contrast, if parental support is distracting, it could unintentionally impair performance by drawing attention away from the task itself. Interestingly, several respondents also reported that parents can negatively impact the assessment by adding a degree of performance pressure:

“Some children feel under pressure to please parents–whether this be by achieving a really good score or a really low score in order to achieve a referral to community paediatrics for diagnosis”

[PT1]

“…I also know parents get frustrated or emotional that the child cannot complete a simple task…”

[OT2]

“Sometimes parents encourage children to hurry up or stay focused…parents get emotional which will impact the child’s success”

[OT6]

The possibility that parents can increase performance pressure is of particular concern given that pressure induced anxiety can directly influence the way we move [28]. Indeed, there is evidence that individuals with DCD experience higher levels of anxiety [29], and that motor control is related to task-specific anxiety in children with DCD [26]. Performance pressure from a parent could therefore impede some aspects of performance during the MABC-2 or simultaneously facilitate compensation in ways that ensure safe and effective movement completion [28]. Further work is needed to elucidate the influence of parental pressure on child performance during the MABC-2 so that recommendations for best practice can be developed.

MABC-2 tasks lack functional relevance.

When asked about the challenges of using the MABC-2 and how the tool can be improved, a common concern was that tasks generally lack functional relevance and are limited in their variation and complexity. For example:

“It does not give you a true diagnosis and you need to consider other elements such as their routines, adverse childhood events, opportunities they have, scores don’t tell a picture or give an accurate diagnosis“

[OT8]

Indeed, criterion two of the DSM-5 states that motor difficulties must significantly and persistently interfere with activities of daily living or academic achievement. Another respondent suggested it would be more advantageous to:

“…base it on observational assessments seen within a child’s real life context (e.g., handwriting, PE, cycling)”.

[OT7]

It could be argued that the isolated nature of each MABC-2 task lacks contextual complexity and thus fails to expose each child to aspects of executive functioning required for everyday life (e.g., working memory, inhibitory control, and cognitive flexibility). For example, children will often be faced with performing these tasks whilst holding conversations, monitoring aspects of the environment, or whilst performing a secondary motor task (e.g., whilst walking). Despite growing evidence that executive function deficits are at the heart of the difficulties faced by individuals with DCD in these dual-task environments [30], it is perhaps surprising that no components of the MABC-2 are designed to expose them. Although the MABC-2 checklist is commonly used to subjectively assess motor difficulties in everyday scenarios, concerns have been raised regarding the tool’s validity, sensitivity, and inter-rater reliability [31]. To obtain more comprehensive and accurate insights into these difficulties, it might be necessary to include additional functional and complex motor tasks as part of the physical assessment. Such tasks could provide a more direct and complementary evaluation of the child’s motor ability d help identify areas that require further attention or intervention.

Children can improve their scores with practice.

Most respondents agreed that children can display improvements in the MABC-2 scores with practice. For example:

“All children can improve a skill practising the individual activities”

[OT4]

“We know that practice helps children and children with DCD can receive strategies to work on their goals. This leads to an improvement in functional skills”.

[OT2]

These perceptions align with empirical evidence that children with DCD can improve fundamental motor skills, such as throwing, catching, and balance. Whilst these findings may not be immediately surprising, it highlights the limitations of relying on motor skills for the assessment of DCD. For example, it is possible that opportunities and encouragement to engage in motor skills throughout development could enhance motor proficiency and thus mask motor difficulties in the simpler environment imposed by the MABC-2.

The role of the examiner.

Most respondents indicated that the examiners can, to some extent, influence the child’s performance independent of their motor difficulties. Many respondents suggested that the lack of clear administrative guidance could lead to within and between examiner differences in instructional and motivational styles (e.g., demonstrating, over-explaining, reassuring). For example:

“…even though we have a manual, there is no script and we have been known as a team to have different approaches to delivering assessment and communicating with a child”

[OT2]

“Sometimes it is hard not to give extra instructions. Also deciding on a fail can be quite subjective”.

[OT1]

The impact of differing styles was reinforced by those who stated:

“Your demeanour, approach, explanation and demonstration will impact performance”

[OT13]

“Children with DCD often have low self-esteem. A supportive examiner can ensure children demonstrate their optimum level of performance”.

[PH1]

“…the manual is very clear in terms of instructions for delivering and scoring and interpreting, but I think implementing requires good child centred communication skills…which can vary between therapists”.

[OT14]

Given the clear impact that examiner style can have, it is interesting to note that most respondents reported having never received any formal training:

“I learned on the job (I have many years of experience now!). I have shared my experience with other members of staff, but I’m not aware of any formal training people can access to help them administer and, more importantly, interpret findings. This is a gap.”

[OT3]

“I didn’t have any training it has only been through experience that I have developed my own skills and knowledge”

[OT8]

It is therefore perhaps unsurprising that styles appear to vary across examiners. The lack of training could also be problematic as the MABC-2 includes a subjective assessment component that requires examiners to have sufficient training and knowledge about movement disorders. Indeed, it has been shown that a lack of training can cause deficits in the ability of PE teachers to assess fundamental movement skills and lower teacher confidence in delivering assessments [32]. Specialist, professional training may therefore be required to overcome inter- and intra-variability in examination styles and improve the robustness of assessment outcomes. That said, it should again be reinforced that the validity and reliability of the MABC-2 for discriminating between specific motor abilities has received extensive support [8, 9]. The disparity between these findings and the perceptions of stakeholders identified from our study is therefore unclear and should be addressed in future research.

Study limitations.

Several limitations should be acknowledged from the present study. For example, we relied upon a non-validated questionnaire to provide preliminary and exploratory insights to how physiotherapists and occupational therapists perceive the MABC-2. Whilst the content of our questionnaire was developed with the guidance of a senior occupational therapist and a senior physiotherapist, technical expertise on the structure of the questionnaire was not obtained. The use of a non-validated questionnaire in this manner could therefore question the validity and reliability of our findings, and lead to potential biases and inaccuracies in our data. There are also serious limitations in utilising an anonymous online questionnaire. For example, we cannot guarantee that participants met the inclusion criteria or that participants only answered once. We also limited the depth of personal information we gathered from participants such as their experience (band of practice), gender, or country of residence. Our findings should, therefore, be generalised with caution until future research attempts to tease out these factors. That said, it should be recognised that there are many advantages of adopting online questionnaires that prioritise anonymity. For example, Braun et al. [33] indicate that anonymity can encourage participants to be more honest and open in their responses and can reduce the tendency for participants to provide responses that they believe are socially desirable rather than their true beliefs (i.e., social desirability bias). This can be particularly important when researching potentially sensitive topics and is well suited to preliminary investigations like ours. Finally, our sample was heavily skewed towards occupational therapists, questioning the reliability of generalising our findings to physiotherapists.