ISSN 2526-8910

Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 1, p. 168-185, 2019

https://doi.org/10.4322/2526-8910.ctoAR1856

Review Article
An integrative review of assessments used in
occupational therapy interventions for children with
cerebral palsy
Carly Petersa , Amy Changa , Abbiagail Moralesa , Karin Barnesb ,
Ana Allegrettib 
a
Program at the UT Health San Antonio, Texas, United States.
b
Occupational Therapy Department, UT Health San Antonio, Texas, United States.

Abstract: Introduction: Children with cerebral palsy (CP) experience a wide range of deficits and symptoms.
When undergoing occupational therapy (OT) interventions, it is essential that the OT select assessments that
can accurately reflect the outcome measures of the targeted domains. Objective: To identify the assessment tools
most frequently reported in research studies as measures for OT interventions when treating children with CP.
Method: Pubmed and Ovid databases were systematically searched by using key terms “cerebral palsy,” “assessments,”
and “occupational therapy”. Assessment tools were explored and extracted from articles contingent on the following
inclusion criteria: (1) children birth to 18 years diagnosed with cerebral palsy; (2) use of assessment(s) as a measure
of OT intervention; (3) published in English between 2007 and 2017. In the preliminary search, Pubmed yielded
151 records and Ovid yielded 571. Out of these, only 76 met the inclusion criteria. From the remaining 76 articles,
a total of 88 assessment tools were retrieved and included in this literature review. Results: Ten assessments were
found to be of importance based on frequency of use. The Assisting Hand Assessment (AHA) and Pediatric Evaluation
of Disability Inventory (PEDI) were the most commonly used. Conclusion: This study helps to determine which
assessments are frequently used in OT practice with children with CP. The findings of this study play an important
role in addressing the challenge of assessment selection faced by occupational therapists and provide a basis for
future research to expand on with regards to treating children with CP.
Keywords: Cerebral Palsy, Occupational Therapists, Assessments.

Revisão integrativa de avaliações utilizadas em intervenções de terapia

ocupacional para crianças com paralisia cerebral

Resumo: Introdução: Crianças com Paralisia Cerebral (PC) apresentam uma ampla gama de déficits e sintomas.
Quando submetidos a intervenções de terapia ocupacional (OT), é essencial que as avaliações utilizadas reflitam
com precisão as medidas de resultados dos domínios visados. Objetivo: Identificar os instrumentos de avaliação
mais utilizados como medidas para intervenções no TO no tratamento de crianças com PC. Método: Bancos
de dados Pubmed e Ovid foram sistematicamente pesquisados ​​usando os termos-chave “paralisia cerebral”,
“avaliações” e “terapia ocupacional”. Avaliaçoes foram exploradas e extraídas de artigos contingentes aos seguintes
critérios de inclusão: (1) crianças de até 18 anos com diagnóstico de paralisia cerebral; (2) uso da(s) avaliação
(ões) como medida de intervenção do TO; (3) publicado em inglês entre 2007 e 2017. Na pesquisa preliminar,
foram encontrados 151  artigos em Pubmed e 571 em Ovid. Destes, apenas 76 foram inlcuidos devido aos critérios
de inclusão. Dos 76 artigos restantes, um total de 89 avaliaçoes foram encontradas e incluídas nesta revisão da
literatura. Resultados: Dez avaliações foram consideradas importantes com base na frequência de uso. A “Assisting
Hand Assessment” (AHA) e o Inventário de Avaliação Pediátrica de Incapacidade (PEDI) foram os mais utilizados.

Corresponding author: Ana Allegretti, Department at UT Health San Antonio, Texas, United States, e-mail: allegrettial@uthscsa.edu
Received on Nov. 20, 2018; 1st Revision on Dec 20, 2018; Accepted on Jan. 10, 2019.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited.
 Peters, C. et al. 169

Conclusão: Os achados deste estudo desempenham um papel importante no e do desafio de seleção de avaliação
enfrentado pelos terapeutas ocupacionais e fornecem uma base para futuras pesquisas para expandir no que diz
respeito ao tratamento de crianças com PC.
Palavras-chave: Paralisia Cerebral, Terapeutas Ocupacionais, Avaliações.

1 Introduction they only provided examples of possible measures

clinicians can utilize.
Cerebral palsy (CP) is a non-progressive group Other research that has been conducted to
of developmental motor disorders that may result review the literature on assessment tools used for
in spasticity, paralysis, or abnormal posture children with CP include Wagner and Davids (2012)
(COKER‑BOLT; GARCIA; NABER, 2015). systematic review study. Using the databases Health
CP  affects motor skills, movement, and muscle and Psychosocial Instruments (HaPI), US National
tone and is the most common cause of physical Library of Medicine (PubMed), and Cumulative Index
disability in childhood with a consistent prevalence to Nursing and Allied Health Literature (CINAHL
of 3.1 to 3.6 per 1000 births for over the last 20 years Plus) databases, they found twenty-one assessment
(LOWES et al., 2014; CHRISTENSEN et al., 2014). tools and classification systems used specifically
Because CP is a lifelong condition, all aspects of for upper extremity function and performance in
an individual’s development and independence are children with CP (WAGNER; DAVIDS, 2012).
impacted (STEULTJENS et al., 2004). Occupational Furthermore, a systematic review that searched
therapy (OT) is one of many disciplines that provides MEDLINE, Embase, CINAHL, and PscyhINFO
treatment for children with CP with the goal of databases found eight assessments that were used to
optimizing functional abilities and increasing measure only activity limitation for children with
independence (STEULTJENS et al., 2004). OT  focuses CP (HARVEY  et  al., 2008). Functional motor
on skill development to perform activities of daily abilities of children with CP represented another
living, addresses cognitive and perceptual deficits, domain used to conduct a systematic literature
promotes functional independence, and utilizes review of assessment measures (KETELAAR;
a wide variety of interventions and approaches VERMEER; HELDERS, 1998). The study searched
during treatment (STEULTJENS  et  al., 2004). MEDLINE, Sportdisk, and PsychLIT databases
The American Occupational Therapy Association’s and yielded seventeen instruments used in pediatric
centennial vision has caused a rising demand for rehabilitation to evaluate functional motor abilities
practitioners to provide evidence-based treatment of children with CP (KETELAAR; VERMEER;
in order to maximize effectiveness of client care HELDERS, 1998).
(AMERICAN…, 2017; SALEH  et  al., 2009). Overall, these studies showed the types of
A major challenge in basing OT interventions on assessments being used to measure specific domains
evidence-based practice is choosing the most appropriate (DIAS  et  al., 2017). However, there remains a
assessment for individual clients (SALEH  et  al., lack of evidence on what assessments are currently
2009). Specifically, OTs report that standardized being used to measure outcomes specifically for OT
assessment, which are essential to OT practice, interventions for children with CP. In order to develop
benefit clients and the OT profession as opposed to a toolbox of assessments utilized for children with
non-standardized assessments (PIERNIK-YODER; CP, it is necessary to gain a cohesive understanding
BECK, 2012). Considering the specific and complex of the current assessments in use. The purpose of
deficits and needs of children with CP, it is essential this study was to perform an integrative review of
that standardized assessments utilized to measure the literature to identify what assessments are being
the unique skills and behaviors of this population used to measure outcomes of OT interventions for
accurately align with and reflect targeted outcomes children with CP.
when undergoing OT interventions. According to
Wright and Majnemer (2014), if all clinicians in the 2 Method
rehabilitative community chose assessments from
the same toolbox when treating children with CP, The study aimed to obtain a frequency count of
then a universal approach of measuring outcomes can each assessment used with the children with CP
be developed. While Wright and Majnemer (2014) as reported the literature. An integrative review
discussed concepts that should be considered when was performed and followed Arksey and O’Malley
choosing assessments to use with children with CP, (2005) stages of methodological framework, which

Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 1, p. 168-185, 2019

170 An integrative review of assessments used in occupational therapy interventions for children with cerebral palsy

include identifying the research question, identifying reviews were not included in the frequency count to
relevant studies, selecting studies, charting the eliminate the possibility of duplicates. With the use
data, and summarizing and reporting the results of these post hoc criteria 76 articles were included
(Figure 1). The research team included three student for the analysis in this integrative review.
investigators and a supervising professor. Pubmed
and Ovid databases were systematically searched in 3 Results
January 2018 using the key terms “cerebral palsy”,
“assessment” and “occupational therapy”. The following The search yielded 76 articles that were synthesized
inclusion criteria were used: (1) children birth to and analyzed. In table 1, the list of the 76 articles
18 years old diagnosed with cerebral palsy; (2) use and the assessments reported in each article are
of assessment(s); (3) published in English between presented. The researchers found that there are
2007 and 2017. Using these criteria, our search 88 different assessments presented in these studies,
yielded a total of 383 articles that were imported Of the 88 assessments, the ten most frequently
to Ref Works. After eliminating duplicate articles, reported in the studies are in descending order,
307 articles remained and were allocated between including the Assisting Hand Assessment (AHA),
three student researchers to be further reviewed Pediatric Evaluation of Disability Inventory
by abstract and title. Based off the content found, (PEDI), Gross Motor Function Classification Scale
further exclusion criteria were developed post hoc (GMFCS), Canadian Occupational Performance
and included (1) articles lacking OT intervention; Measure (COPM), Goal Attainment Scale (GAS),
(2) systematic reviews. Assessments used in systematic Manual Ability Classification System (MACS),

Figure 1. Flow chart of search process.

Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 1, p. 168-185, 2019

 Peters, C. et al. 171

Table 1. Assessments Used for Children with CP as Found in Literature.

Author, Year Assessments
Aarts et al. (2007) VOAA
https://doi.org/10.1002/oti.229
Aarts et al. (2012) AHA, ABILITHAND-Kids, COPM, GAS,
https://doi.org/10.1002/oti.321 VOAA, Melbourne
Auld et al. (2012) Disk-Criminator, Exteroception, Klingel’s
https://doi.org/10.3109/01942638.2011.572150 method, SIPT, SWMs, NSMDA
Bailes, Greve and Schmitt (2010) GMFM-66, PEDI
https://doi.org/10.1097/PEP.0b013e3181cbf224
Bailes et al. (2011) GMFM-66, PEDI
https://doi.org/10.1097/PEP.0b013e318218ef58
Barroso et al. (2011) JTTHF, Digital image acquisition system for
https://doi.org/10.1016/j.clinbiomech.2011.05.006 range of motion
Berge et al. (2012) GAS, House classification, MACS, VAS
https://doi.org/10.1177/0269215511411936
Bleyenheuft et al. (2015) ABILIHAND-Kids, ABILICO-kids, AHA, BBT,
https://doi.org/10.1177/1545968314562109 PEDI, LIFE-H, 6MWT, Pinch
Bleyenheuft et al. (2017) ABILIHAND-Kids
https://doi.org/10.1111/dmcn.13338
Brandão, Gordon and Mancini (2012) COPM, PEDI
https://doi.org/10.5014/ajot.2012.004622
Brandao et al. (2010) JTTHF, PEDI
https://doi.org/10.1177%2F0269215510367974
Buccino et al. (2012) Melbourne
https://doi.org/10.1111/j.1469-8749.2012.04334.x
Cameron et al. (2017) COPM, PQRS
https://doi.org/10.1080/01942638.2016.1185500
Case-Smith et al. (2012) AHA, QUEST, PMAL
10.5014/ajot.2012.002386
Chen et al. (2014) PDMS-2, PMAL, WeeFIM
https://doi.org/10.5014/ajot.2014.009860
Cohen-Holzer et al. (2016) AHA, JTTHF
https://doi.org/10.3109/01942638.2014.990549
Coker-Bolt et al. (2015) CHUEQ, MA2, PEDI
10.5014/ajot.2016.70S1-PO5115
Note: [6MWT = Six-Minute Walk Test; AHA = Assisting Hand Assessment; AIMS = Alberta Infant Motor Scale;
AMPS = Assessment of Motor and Process Skills; APCP = Assessment of Preschool Children’s Participation; BBT = Box
and Block Test; BFMF = Bimanual Fine Motor Function scale; BOT = Bruininks–Oseretsky Test of Motor Proficiency;
CAPE = Children’s Assessment of Participation and Enjoyment; CBC = Child Behavior Checklist; CFUS = Caregiver
Functional Use Survey; CHEQ; Children’s Hand-Use Experience Questionnaire; CHQ = Australian Authorised Adaptation of
the Child Health Questionnaire; CHUEQ = Children’s Hand-Use Experience Questionaire; COPM = Canadian Occupational
Performance Meausure; CPQOL-Child = Cerebral Palsy Quality of Life Questionnaire for Children; ENNAS = Einstein Neonatal
Neurobehavioral Assessment Scale; ETCH = Evaluation Tool of Children’s Handwriting; FES Family Empowerment Scale;
fTORT = functional Tactile Object Recognition Test; GAS = Goal Attainment Scale; GMA = General Movements Assessment;
GMFCS = Gross Motor Function Classification System; GMFM = Gross Motor Function Measure; GMFM- 66 = Gross Motor
Function Measure – 66; GMFM-88 = Gross Motor Function Measure – 88; ICFI = International Classification of Functioning
Interview; JTTHF = Jebsen-Taylor Hand Function Test; LIFE-H = Assessment of Life Habits; MA2 = Melbourne Assessment 2;
MACS = Manual Ability Classification System; MAS = Modified Ashworth Scale; Melbourne = Melbourne Assessment
of Unilateral Upper Limb Function; MHA = Minnesota Handwriting Assessment; NHDC = Neurological Hand Deformity
Classification; NSMDA = Neurosensory Motor Developmental Assessment; PAC = Preferences for Activity of Children;
PAFT = Pediatric Arm Function Test; PDMS-2 = Peabody Developmental Motor Scales II; PEDI = Pediatric Evaluation of
Disability Inventory; PedsQL = Pediatric Quality of Life Inventory; PGMS = Peabody Gross Motor Scale; PMAL = Pediatric
Motor Activity Log; PQRS = Performance Quality Rating Scale; PRT = Pediatric Reach Test; PSI-Short form = Parenting Stress
Index-Short Form; QUEST = Quality of Upper Extremity Skills Test; ROM = Range of Motion; SAS = Sitting Assessment
Scale; SIPT = Sensory Integration and Praxis Test; SPPC = Harter Self-Perception Profile; SSC = Sense and Self-Regulation
Checklist; SWMs = Semmes Weinstein Monofilaments; TAUT = Toddler Arm Use Test; TCMS = Trunk Control Measurement
Scale; THS-R = Test of Handwriting Skills–Revised; TIMP = Test of Infant Motor Performance; TIS = Trunk Impairment Scale;
TVPS3 = Test of Visual Perceptual Skill -non-motor; VAS = Visual Analogue Scale; VMI = Beery–Buktenica Developmental
Test of Visual–Motor Integration; VOAA = Video Observations Aarts and Aarts].

Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 1, p. 168-185, 2019

172 An integrative review of assessments used in occupational therapy interventions for children with cerebral palsy

Table 1. Continued...
Author, Year Assessments
DeLuca et al. (2012) AHA, QUEST, PMAL Shriners Hospital
https://doi.org/10.3233/PRM-2012-0206
Ferre et al. (2017) AHA, BBT, COPM
https://doi.org/10.1111/dmcn.13330
Gelkop et al. (2015) AHA, QUEST
https://doi.org/10.3109/01942638.2014.925027
Georgiades et al. (2014) NHDC
https://doi.org/10.1111/1440-1630.12150
Golomb et al. (2010) BOT, JTTHF, Dynamometer, Pinch
https://doi.org/10.1016/j.apmr.2009.08.153
Gordon et al. (2007) AHA, Accelerometry, BOT, CFUS, JTTHF
https://doi.org/10.1111/j.1469-8749.2007.00830.x
Hamil, Washington and White (2007) GMFCS, GMFM, SAS
https://doi.org/10.1080/J006v27n04_03
Hansen et al. (2012) CBC, GMFM-66, ICFI
https://doi.org/10.1177%2F2156587211430833
Hoare et al. (2013) AHA, COPM, GAS, QUEST, PEDI
https://doi.org/10.1111/dmcn.12054
Hoare et al. (2010) AHA, COPM, GAS, QUEST, PEDI, MAS,
https://doi.org/10.1186/1471-2377-10-58 Modified Tardieu Scale, PMAL
Houwink et al. (2013) VOAA
https://doi.org/10.1111/j.1469-8749.2012.04442.x
Howcroft et al. (2011) AHA
https://doi.org/10.1111/j.1469-8749.2011.04078.x
Huang et al. (2014) PEDI
https://doi.org/10.1097/PEP.0000000000000001
Imms et al. (2017) CAPE, PAC
https://doi.org/10.1111/dmcn.13302
James et al. (2015a) AHA, AMPS, COPM, JTTHF, Melbourne, TVPS-
https://doi.org/10.1111/dmcn.12705 3
James et al. (2015b) AMPS
https://doi.org/10.3109/01942638.2015.1076555
Kara et al. (2015) BOT, BFMF, GMFM, GMFCS, MACS, WeeFIM
https://doi.org/10.1111/dmcn.12583
Note: [6MWT = Six-Minute Walk Test; AHA = Assisting Hand Assessment; AIMS = Alberta Infant Motor Scale;
AMPS = Assessment of Motor and Process Skills; APCP = Assessment of Preschool Children’s Participation; BBT = Box
and Block Test; BFMF = Bimanual Fine Motor Function scale; BOT = Bruininks–Oseretsky Test of Motor Proficiency;
CAPE = Children’s Assessment of Participation and Enjoyment; CBC = Child Behavior Checklist; CFUS = Caregiver
Functional Use Survey; CHEQ; Children’s Hand-Use Experience Questionnaire; CHQ = Australian Authorised Adaptation of
the Child Health Questionnaire; CHUEQ = Children’s Hand-Use Experience Questionaire; COPM = Canadian Occupational
Performance Meausure; CPQOL-Child = Cerebral Palsy Quality of Life Questionnaire for Children; ENNAS = Einstein Neonatal
Neurobehavioral Assessment Scale; ETCH = Evaluation Tool of Children’s Handwriting; FES Family Empowerment Scale;
fTORT = functional Tactile Object Recognition Test; GAS = Goal Attainment Scale; GMA = General Movements Assessment;
GMFCS = Gross Motor Function Classification System; GMFM = Gross Motor Function Measure; GMFM- 66 = Gross Motor
Function Measure – 66; GMFM-88 = Gross Motor Function Measure – 88; ICFI = International Classification of Functioning
Interview; JTTHF = Jebsen-Taylor Hand Function Test; LIFE-H = Assessment of Life Habits; MA2 = Melbourne Assessment 2;
MACS = Manual Ability Classification System; MAS = Modified Ashworth Scale; Melbourne = Melbourne Assessment
of Unilateral Upper Limb Function; MHA = Minnesota Handwriting Assessment; NHDC = Neurological Hand Deformity
Classification; NSMDA = Neurosensory Motor Developmental Assessment; PAC = Preferences for Activity of Children;
PAFT = Pediatric Arm Function Test; PDMS-2 = Peabody Developmental Motor Scales II; PEDI = Pediatric Evaluation of
Disability Inventory; PedsQL = Pediatric Quality of Life Inventory; PGMS = Peabody Gross Motor Scale; PMAL = Pediatric
Motor Activity Log; PQRS = Performance Quality Rating Scale; PRT = Pediatric Reach Test; PSI-Short form = Parenting Stress
Index-Short Form; QUEST = Quality of Upper Extremity Skills Test; ROM = Range of Motion; SAS = Sitting Assessment
Scale; SIPT = Sensory Integration and Praxis Test; SPPC = Harter Self-Perception Profile; SSC = Sense and Self-Regulation
Checklist; SWMs = Semmes Weinstein Monofilaments; TAUT = Toddler Arm Use Test; TCMS = Trunk Control Measurement
Scale; THS-R = Test of Handwriting Skills–Revised; TIMP = Test of Infant Motor Performance; TIS = Trunk Impairment Scale;
TVPS3 = Test of Visual Perceptual Skill -non-motor; VAS = Visual Analogue Scale; VMI = Beery–Buktenica Developmental
Test of Visual–Motor Integration; VOAA = Video Observations Aarts and Aarts].

Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 1, p. 168-185, 2019

 Peters, C. et al. 173

Table 1. Continued...
Author, Year Assessments
Kirkpatrick et al. (2016) ABILIHANDS-kids, AHA, MA2
https://doi.org/10.1111/dmcn.13109
Kruijsen-Terpstra et al. (2016) APCP, COPM, GAS, GMFCS, GMFM-66,
https://doi.org/10.1111/dmcn.12966 MACS, PEDI-CAS, PEDI-FSS, Nijmeegse
Ouderlijke Stress Index- Kort
Law et al. (2011) APCP, GMFCS, GMFM-66, PEDI, ROM, Family
https://doi.org/10.1111/j.1469-8749.2011.03962.x Empowerment Scale
Lidman et al. (2015) AHA, COPM, ROM
https://doi.org/10.1111/dmcn.12739
Lin et al. (2011) BOT, CFUS, PDMS-2, PMAL, PSI
https://doi.org/10.1016/j.ridd.2011.01.023
Louwers et al. (2011) AHA, GMFCS, MACS, Zancolli classification,
https://doi.org/10.1111/j.1469-8749.2010.03849.x House classification
Luna-Oliva et al. (2013) AMPS, GMFCS, GMFM, JTTHF, PRT
https://doi.org/10.3233/NRE-131001
Mackey et al. (2008) MAS, Melbourne, 3-D Kinematics
https://doi.org/10.1111/j.1468-1331.2008.02271.x
Mclean et al. (2017) AHA, BBT, COPM, GAS, fTORT, Sense-Assess
https://doi.org/10.5014/ajot.2016.024968 kids, Wrist position test
Man and Wong (2007) Assessment of Comfort, WinFitts
https://doi.org/10.5014/ajot.61.3.355
Matusiak-Wieczorek et al. (2016) GMFCS, SAS
https://doi.org/10.5604/15093492.1205024
McConnell, Johnston and Kerr (2014) Melbourne
https://doi.org/10.3109/01942638.2013.866611
McGarry, Moir and Girdler (2012) Powered Mobility Program Assessment Battery,
https://doi.org/10.3109/17483107.2011.637283 GMFCS
Millard, Benore and Mosher (2013) GMFCS, WeeFIM
https://doi.org/10.1037/cpp0000005
Novak, Cusick and Lowe (2007) GAS, PEDI, QUEST
http://doi.org/10.5014/ajot.61.4.463
Ostensjø, Oien and Fallang (2008) COPM, GAS
https://doi.org/10.1080/17518420802525500
Palsbo and Hood-Szivek (2012) ETCH, THS-R, Print tool, VMI
https://doi.org/10.5014/ajot.2012.004556
Note: [6MWT = Six-Minute Walk Test; AHA = Assisting Hand Assessment; AIMS = Alberta Infant Motor Scale;
AMPS = Assessment of Motor and Process Skills; APCP = Assessment of Preschool Children’s Participation; BBT = Box
and Block Test; BFMF = Bimanual Fine Motor Function scale; BOT = Bruininks–Oseretsky Test of Motor Proficiency;
CAPE = Children’s Assessment of Participation and Enjoyment; CBC = Child Behavior Checklist; CFUS = Caregiver
Functional Use Survey; CHEQ; Children’s Hand-Use Experience Questionnaire; CHQ = Australian Authorised Adaptation of
the Child Health Questionnaire; CHUEQ = Children’s Hand-Use Experience Questionaire; COPM = Canadian Occupational
Performance Meausure; CPQOL-Child = Cerebral Palsy Quality of Life Questionnaire for Children; ENNAS = Einstein Neonatal
Neurobehavioral Assessment Scale; ETCH = Evaluation Tool of Children’s Handwriting; FES Family Empowerment Scale;
fTORT = functional Tactile Object Recognition Test; GAS = Goal Attainment Scale; GMA = General Movements Assessment;
GMFCS = Gross Motor Function Classification System; GMFM = Gross Motor Function Measure; GMFM- 66 = Gross Motor
Function Measure – 66; GMFM-88 = Gross Motor Function Measure – 88; ICFI = International Classification of Functioning
Interview; JTTHF = Jebsen-Taylor Hand Function Test; LIFE-H = Assessment of Life Habits; MA2 = Melbourne Assessment 2;
MACS = Manual Ability Classification System; MAS = Modified Ashworth Scale; Melbourne = Melbourne Assessment
of Unilateral Upper Limb Function; MHA = Minnesota Handwriting Assessment; NHDC = Neurological Hand Deformity
Classification; NSMDA = Neurosensory Motor Developmental Assessment; PAC = Preferences for Activity of Children;
PAFT = Pediatric Arm Function Test; PDMS-2 = Peabody Developmental Motor Scales II; PEDI = Pediatric Evaluation of
Disability Inventory; PedsQL = Pediatric Quality of Life Inventory; PGMS = Peabody Gross Motor Scale; PMAL = Pediatric
Motor Activity Log; PQRS = Performance Quality Rating Scale; PRT = Pediatric Reach Test; PSI-Short form = Parenting Stress
Index-Short Form; QUEST = Quality of Upper Extremity Skills Test; ROM = Range of Motion; SAS = Sitting Assessment
Scale; SIPT = Sensory Integration and Praxis Test; SPPC = Harter Self-Perception Profile; SSC = Sense and Self-Regulation
Checklist; SWMs = Semmes Weinstein Monofilaments; TAUT = Toddler Arm Use Test; TCMS = Trunk Control Measurement
Scale; THS-R = Test of Handwriting Skills–Revised; TIMP = Test of Infant Motor Performance; TIS = Trunk Impairment Scale;
TVPS3 = Test of Visual Perceptual Skill -non-motor; VAS = Visual Analogue Scale; VMI = Beery–Buktenica Developmental
Test of Visual–Motor Integration; VOAA = Video Observations Aarts and Aarts].

Cad. Bras. Ter. Ocup., São Carlos, v. 27, n. 1, p. 168-185, 2019

174 An integrative review of assessments used in occupational therapy interventions for children with cerebral palsy

Table 1. Continued...
Author, Year Assessments
Pham et al. (2016) GMFCS, GMFM-66, TCMS, TIS
https://doi.org/10.3109/01942638.2015.1127867
Phipps and Roberts (2012) GMFCS, MACS, PEDI
https://doi.org/10.5014/ajot.2012.003921
Psychouli and Kennedy (2016) Melbourne, QUEST
https://doi.org/10.1097/PEP.0000000000000227
Robert et al. (2013) MACS, Melbourne, SWMs, UE PROM
https://doi.org/10.1111/dmcn.12219
Rostami et al. (2012) BOT, MAS, PMAL
https://doi.org/10.3233/NRE-2012-00804
Ryan, Rigby and Campbell (2010) GMFCS, MHA
https://doi.org/10.1111/j.1440-1630.2009.00831.x
Ryll, Bastiaenen and Eliasson (2017) AHA, CHEQ, MACS
https://doi.org/10.1080/01942638.2016.1185498
Sakzewski et al. (2011) AHA, COPM, JTTHF, LIFE-H, MAS, Melbourne
https://doi.org/10.1177/1545968311400093
Sakzewski et al. (2012) CPQOL, MACS
https://doi.org/10.1111/j.1469-8749.2012.04272.x
Sakzewski et al. (2015) AHA, MACS
https://doi.org/10.1111/dmcn.12702
Schneiberg et al. (2010) CSI, Disk-Criminator, Light touch/position,
https://doi.org/10.1111/j.1469-8749.2010.03768.x Melbourne, SWMs
Schrank (2013) GMFM-88, WeeFIM
https://doi.org/10.1097/PEP.0b013e31827abaf4
Silva et al. (2012) PGMS, SSC
https://doi.org/10.5014/ajot.2012.003541
Snider et al. (2008) AIMS, ENNAS, GMA, TIMP
https://doi.org/10.1016/j.earlhumdev.2007.07.004
Steenbeek et al. (2010) GAS, GMFCS, GMFM-66, MACS, PEDI
https://doi.org/10.1177/0269215511407220
Storvold and Jahnsen (2010) AHA, Dynamometer, GAS, GMFCS, GMFM-66,
https://doi.org/10.1097/PEP.0b013e3181dbe379 PEDI
Thompson et al. (2015) Dynamometer, QUEST, PEDI, ROM
https://doi.org/10.1097/PEP.0000000000000111
Note: [6MWT = Six-Minute Walk Test; AHA = Assisting Hand Assessment; AIMS = Alberta Infant Motor Scale;
AMPS = Assessment of Motor and Process Skills; APCP = Assessment of Preschool Children’s Participation; BBT = Box
and Block Test; BFMF = Bimanual Fine Motor Function scale; BOT = Bruininks–Oseretsky Test of Motor Proficiency;
CAPE = Children’s Assessment of Participation and Enjoyment; CBC = Child Behavior Checklist; CFUS = Caregiver
Functional Use Survey; CHEQ; Children’s Hand-Use Experience Questionnaire; CHQ = Australian Authorised Adaptation of
the Child Health Questionnaire; CHUEQ = Children’s Hand-Use Experience Questionaire; COPM = Canadian Occupational
Performance Meausure; CPQOL-Child = Cerebral Palsy Quality of Life Questionnaire for Children; ENNAS = Einstein Neonatal
Neurobehavioral Assessment Scale; ETCH = Evaluation Tool of Children’s Handwriting; FES Family Empowerment Scale;
fTORT = functional Tactile Object Recognition Test; GAS = Goal Attainment Scale; GMA = General Movements Assessment;
GMFCS = Gross Motor Function Classification System; GMFM = Gross Motor Function Measure; GMFM- 66 = Gross Motor
Function Measure – 66; GMFM-88 = Gross Motor Function Measure – 88; ICFI = International Classification of Functioning
Interview; JTTHF = Jebsen-Taylor Hand Function Test; LIFE-H = Assessment of Life Habits; MA2 = Melbourne Assessment 2;
MACS = Manual Ability Classification System; MAS = Modified Ashworth Scale; Melbourne = Melbourne Assessment
of Unilateral Upper Limb Function; MHA = Minnesota Handwriting Assessment; NHDC = Neurological Hand Deformity
Classification; NSMDA = Neurosensory Motor Developmental Assessment; PAC = Preferences for Activity of Children;
PAFT = Pediatric Arm Function Test; PDMS-2 = Peabody Developmental Motor Scales II; PEDI = Pediatric Evaluation of
Disability Inventory; PedsQL = Pediatric Quality of Life Inventory; PGMS = Peabody Gross Motor Scale; PMAL = Pediatric
Motor Activity Log; PQRS = Performance Quality Rating Scale; PRT = Pediatric Reach Test; PSI-Short form = Parenting Stress
Index-Short Form; QUEST = Quality of Upper Extremity Skills Test; ROM = Range of Motion; SAS = Sitting Assessment
Scale; SIPT = Sensory Integration and Praxis Test; SPPC = Harter Self-Perception Profile; SSC = Sense and Self-Regulation
Checklist; SWMs = Semmes Weinstein Monofilaments; TAUT = Toddler Arm Use Test; TCMS = Trunk Control Measurement
Scale; THS-R = Test of Handwriting Skills–Revised; TIMP = Test of Infant Motor Performance; TIS = Trunk Impairment Scale;
TVPS3 = Test of Visual Perceptual Skill -non-motor; VAS = Visual Analogue Scale; VMI = Beery–Buktenica Developmental
Test of Visual–Motor Integration; VOAA = Video Observations Aarts and Aarts].

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 Peters, C. et al. 175

Table 1. Continued...
Author, Year Assessments
Uswatte et al. (2012a) MACS, PAFT, TAUT
https://doi.org/10.1097/PHM.0b013e318269ec76
Uswatte et al. (2012b) MACS, PAFT, PMAL-R
https://doi.org/10.1037/a0028516
Wallen et al. (2011) AHA, COPM, GAS, MAS, PMAL, Tardieu Scale
https://doi.org/10.1080/17518420701640897
Wallen, O’Flaherty and Waugh (2007) COPM, CHQ, GAS, Melbourne, PEDI, QUEST,
https://doi.org/10.1016/j.apmr.2006.10.017 Tardieu Scale
Wallen et al. (2008) AHA, COPM, GAS, GMFCS, MACS, MAS,
https://doi.org/10.1111/j.1469-8749.2011.04086.x Melbourne, PMAL-R, Tardieu Scale
Wang et al. (2017) BBT, BOT-2, MA2, PMAL-R
https://doi.org/10.1016/j.apmr.2017.01.024
Yabunaka et al. (2011) GMFCS, GMFM-66
https://doi.org/10.1097/PHM.0b013e3181fc7ddf
Yasukawa and Uronis (2014) Melbourne
http://doi.org/10.1097/JPO.0000000000000022
Ziebell et al. (2009) BOT, GMFCS, SPPC
https://doi.org/10.1111/j.1440-1630.2008.00775.x
Note: [6MWT = Six-Minute Walk Test; AHA = Assisting Hand Assessment; AIMS = Alberta Infant Motor Scale;
AMPS = Assessment of Motor and Process Skills; APCP = Assessment of Preschool Children’s Participation; BBT = Box
and Block Test; BFMF = Bimanual Fine Motor Function scale; BOT = Bruininks–Oseretsky Test of Motor Proficiency;
CAPE = Children’s Assessment of Participation and Enjoyment; CBC = Child Behavior Checklist; CFUS = Caregiver
Functional Use Survey; CHEQ; Children’s Hand-Use Experience Questionnaire; CHQ = Australian Authorised Adaptation of
the Child Health Questionnaire; CHUEQ = Children’s Hand-Use Experience Questionaire; COPM = Canadian Occupational
Performance Meausure; CPQOL-Child = Cerebral Palsy Quality of Life Questionnaire for Children; ENNAS = Einstein Neonatal
Neurobehavioral Assessment Scale; ETCH = Evaluation Tool of Children’s Handwriting; FES Family Empowerment Scale;
fTORT = functional Tactile Object Recognition Test; GAS = Goal Attainment Scale; GMA = General Movements Assessment;
GMFCS = Gross Motor Function Classification System; GMFM = Gross Motor Function Measure; GMFM- 66 = Gross Motor
Function Measure – 66; GMFM-88 = Gross Motor Function Measure – 88; ICFI = International Classification of Functioning
Interview; JTTHF = Jebsen-Taylor Hand Function Test; LIFE-H = Assessment of Life Habits; MA2 = Melbourne Assessment 2;
MACS = Manual Ability Classification System; MAS = Modified Ashworth Scale; Melbourne = Melbourne Assessment
of Unilateral Upper Limb Function; MHA = Minnesota Handwriting Assessment; NHDC = Neurological Hand Deformity
Classification; NSMDA = Neurosensory Motor Developmental Assessment; PAC = Preferences for Activity of Children;
PAFT = Pediatric Arm Function Test; PDMS-2 = Peabody Developmental Motor Scales II; PEDI = Pediatric Evaluation of
Disability Inventory; PedsQL = Pediatric Quality of Life Inventory; PGMS = Peabody Gross Motor Scale; PMAL = Pediatric
Motor Activity Log; PQRS = Performance Quality Rating Scale; PRT = Pediatric Reach Test; PSI-Short form = Parenting Stress
Index-Short Form; QUEST = Quality of Upper Extremity Skills Test; ROM = Range of Motion; SAS = Sitting Assessment
Scale; SIPT = Sensory Integration and Praxis Test; SPPC = Harter Self-Perception Profile; SSC = Sense and Self-Regulation
Checklist; SWMs = Semmes Weinstein Monofilaments; TAUT = Toddler Arm Use Test; TCMS = Trunk Control Measurement
Scale; THS-R = Test of Handwriting Skills–Revised; TIMP = Test of Infant Motor Performance; TIS = Trunk Impairment Scale;
TVPS3 = Test of Visual Perceptual Skill -non-motor; VAS = Visual Analogue Scale; VMI = Beery–Buktenica Developmental
Test of Visual–Motor Integration; VOAA = Video Observations Aarts and Aarts].

Melbourne Assessment of Unilateral Upper Limb 4 Discussion

Function (MUUL), Pediatric Motor Activity Log
(PMAL), Quality of Upper Extremity Skills Test This integrative review depicted the current
(QUEST), and Jebsen-Taylor Hand Function Test trend of assessments used in research involving OT
(JTHFT). Table 2 lists these ten assessments and interventions for children with CP. The evidence
their associated properties. determined the AHA, PEDI, GMFCS, COPM, GAS,
Additionally, a prominent trend was observed MACS, MUUL, PMAL, QUEST, and JTTHF,
in which a majority of the articles utilized more to be the most frequently used ten assessments in
than one assessment. Specifically, 66 out of the research in descending order. Additionally, 66 out
76  articles used two or more assessments. Using of 76 articles used a combination of two or more
more than one assessment shows the complexity and assessments. Since CP is a complex condition affecting
need of assessing the unique skills and behaviors of several functional domains, using more than one
children with CP. assessment allowed the researchers to address the

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 Table 2. Top Ten Assessments and their Frequency of Use, Assessment Type, Purpose, Age Range, Psychometrics, Administration Time, and Price.
176

Type of Price of
Assessment Frequency Purpose of Assessment Age Range Psychometrics Administration Time
Assessment Assessment
AHA 22 Skilled observation Evaluates assisting hand in 18 months to Interrater reliability = 0.98 10-15 minutes play USD $350 for
(KRUMLINDE- by clinician bilateral hand use activities 12 years old (two rater design) and 0.97 session of child test kit
SUNDHOLM et al., using videotaped play (20-rater design) Scoring time USD $260-
2007; WAGNER; session Intra-rater reliability = 0.99 dependent on $320 for
DAVIDS, 2012) therapist’s experience 3-day training/
with AHA certification
process
PEDI 17 Behavior checklist/ Examines functional 6 months to Inter-rater reliability = 0.84- 20-60 minutes USD $115 for
(ASHER, 2007; rating scale capabilities and typical 7.5 years old; 1.00, 0.74-0.94; depending on manual
LIVINGSTONE; completed via performance to detect can utilize for Internal consistency = 0.95- therapist’s experience USD $35 for
PALEG, 2016) structured interview functional delay, track older children 0.99; with PEDI score forms
or professional progress after intervention, if functional Good validity with children (x25)
observation and assess intervention capabilities with CP
outcome do not exceed
those of 7.5

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year old
children with
no disabilities
GMFCS 16 Family report 5-Level system that classifies 0 to 18 years Inter-rater reliability = 0.93; < 5 minutes if familiar Free
(CANCHILD, questionnaire according to current gross old Test-retest reliability = 0.79; with child;
2018; WOOD; motor abilities/ limitations, Demonstrated face validity 15-20 minutes if
ROSENBAUM, 2000) and level of need for unfamiliar with
assistive technology and child and require
wheeled mobility observation session
An integrative review of assessments used in occupational therapy interventions for children with cerebral palsy
 Table 2. Continued...
Type of Price of
Assessment Frequency Purpose of Assessment Age Range Psychometrics Administration Time
Assessment Assessment
COPM 14 Semi- structured Self-perception of identified 7+ years old Inter-rater reliability: 30-40 minutes COPM Manual
(ASHER, 2007; interview- based occupational performance performance = 0.63-0.89, and 100 Forms
LIVINGSTONE; rating scale satisfaction = 0.76-0.88; (e-book) = USD
PALEG, 2016) Internal consistency: $29.51
performance = 0.73,
satisfaction = 0.83;
Demonstrated content/
construct/criterion validity;
Responsive to change (able
to detect medium sized
effect size in children with
hemiplegic CP)
GAS 14 Patient reported Self-identified patient goals All ages Inter-rater reliability = 0.82; Variable Free
(ABILITYLAB, 2014; outcome and measurement criteria Intra-rater reliability = 0.64
LIVINGSTONE; Criterion validity = 0.44;
PALEG, 2016; Content/convergent validity
STEENBEEK et al., established for children with
Peters, C. et al.

2010) CP (77-88% of ratings met

GAS criterion);
Excellent responsiveness to
change in goals of children
with CP at all GMFCS levels
MACS 13 Family/patient/ System for classifying hand 4 to 18 years Interrater reliability between Variable Free MACS
(ELIASSON et al., caregiver report use in daily activities old therapists = 0.97 (95% chart and
2006) questionnaire confidence interval 0.96- identification
0.98); download
Interrater reliability between Instructional
parents and therapists = 0.96 DVD = USD
(95% confidence interval $35.17
0.89-0.98); Good validity

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177
 Table 2. Continued...
178

Type of Price of
Assessment Frequency Purpose of Assessment Age Range Psychometrics Administration Time
Assessment Assessment
MUUL 12 Therapist Uses video-based 2.5 to 15 Interrater reliability: Total time = 50-60 USD $1165.75
(ASHER, 2007; THE observation scale measurement to examine years old total scores = 0.961, minutes including per assessment
ROYAL…, 2018) unilateral upper limb fluency correlation for 20-30 minutes to for orders
movements based on test components = 0.902; administer and 30 outside Australia
activities involving ROM = 0.866, quality of minutes to score
grasp, release, reach and movement = 0.683,
manipulation Validity: clinically valid for
children 2.5 years and older
and positively correlated
with Quality of Upper
Extremity Skills Test scores
PMAL 10 Parent report/semi- Evaluates how often and 7 months to 8 Revised PMAL by 5-15 minutes to Free
(USWATTE et al., structured interview how well the involved upper years old Uswatte et al. (2012a): complete
2012a; WALLEN et al., extremity is used in the Internal consistency = 3 minutes to score
2009) natural environment 0.93; Test-retest reliability

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= 0.89; Strong support for
convergent validity
Revised PMAL by
Wallen et al. (2009):
How Often Scale test-retest
reliability = 0.94 with
strong evidence of construct
validity; How Well Scale
test-retest reliability = 0.93
with strong evidence of
construct validity
QUEST 9 Performance Examines the quality of 18 months to Interrater reliability = 0.93; 45 minutes USD $99
(ABILITYLAB, based checklist upper extremity movement 8 years old Test-retest reliability =
2016; ASHER, 2007; for therapist associated with grasp, 0.95; Excellent internal
LIVINGSTONE; observation weightbearing, protective consistency; Validity =
PALEG, 2016) Criterion- extension, and dissociated strong correlation with
referenced movement in a play context PDMS-FM scales
An integrative review of assessments used in occupational therapy interventions for children with cerebral palsy
 Table 2. Continued...
Type of Price of
Assessment Frequency Purpose of Assessment Age Range Psychometrics Administration Time
Assessment Assessment
JTTHF 9 Performance test Timed test of effective hand 5 years old Test-retest reliability = 15-20 minutes USD $300+ for
(ABILITYLAB, 2012; Norm-referenced use in daily activities and older 0.98-0.99 commercially
ASHER, 2007) sold test kit
(instructions,
test items,
carrying bag,
forms)
If self-created
kit, can cost as
low as $0 to
$10.
Peters, C. et al.

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179
180 An integrative review of assessments used in occupational therapy interventions for children with cerebral palsy

multiple needs of this population. Additionally, use of quality assessment measures to implement
the use of assessments in clinical practice guides evidence-based practice. Therefore the use of a toolbox
OTs not only during interventions, but also to containing OT assessments specific for children with
establish therapeutic goals (BREWER; POLLOCK; CP will ultimately enable a universal approach to
WRIGHT, 2014) guide clinicians in the rehabilitative community
The findings of this study have the following to measure outcomes and gauge effectiveness of
implications for OT practice: their treatment.

• B
ecause OT is a field striving towards
5 Conclusion
evidence‑based practice, OT practitioners
working with children with CP can utilize the These research studies showed the complexity
evidence from this article to aid their selection of assessing children with CP. The clinical OTs
of assessments for use in clinical practice. must be aware of these complexities and that more
• W
ith this growing focus on evidence-based than one assessment may be needed to capture the
practice, OT practitioners should conduct unique skills and behaviors of the children with CP.
research that adds to the development of As for study limitations, only two databases
a universal toolbox to establish a standard (PubMed and OVID) were used to search for
approach of measuring OT intervention articles that contain the targeted keywords. Utilizing
outcomes for children with CP. more databases can widen the scope of search for
studies that contain assessments and strengthen
Data from this study helped to establish the most the evidence by increasing the frequency count.
frequently used assessments in research studies. Additionally, even though a good portion of the
Further investigation is needed to determine what articles originated from countries other than the
assessments are currently used in clinical OT practices United States, the reviewing of English-language
in order to develop a toolbox of assessments for only articles excluded data that could have provided
children with CP. For instance, AHA, represents a more accurate depiction of assessments used for
the only standardized tool of spontaneous play that children with CP on a global scale. Future research
measures bimanual hand use. This is a unique scope studies are needed to expand on the current study, to
of use, which may have contributed to its frequent provide additional justifications for assessment use,
selection by researchers despite the high cost for the and contribute to the development of an assessment
test kit and certification process (HOLMEFUR; toolbox for children with CP that is specific to
KRUMLINDE-SUNDHOLM; ELIASSON, measure outcomes for OT interventions.
2007; KRUMLINDE-SUNDHOLM et al., 2007).
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 Peters, C. et al. 185

Author’s Contributions
Carly Peters - took the leadership role in searching for the articles, organizing the result and discussion
sections. Amy Chang - Assited with the articles search, result and discussion sections. Abigail Morales
- Assited with the articles search, result and discussion sections. Karin Barnes - had a consultant role
due to her expertise in pediatrics. Ana Allegretti - is the academic mentor of the students and principal
investigator of the research study. All authors approved the final version of the text.

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