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Construct Validity of the Test of Infant Motor Performance

Article  in  Physical Therapy · July 1995

DOI: 10.1093/ptj/75.7.585 · Source: PubMed

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Research Report

Construct Validity of the Test of Infant Motor

Performance

Background and Purpose. The purpose of this study was to assess the con- Suzann K Campbell
struct validity of the Test of Infant Motor Performance (72MP),specijically the Thubi HA Kolobe
test's sensitivity for assessing age-related changes in motor skill and correlation Elizabeth T Osten
with risk for developmental abnormality. Subjects. Subjects were 13 7 term and Maureen Lenke
pretemz itzfants stratified by postconceptional age, medical complications score Gay L Girolami
on the Problem-Oriented Perinatal Risk Assessment System, and ethnicity and
race (non-Latino Caucasian, African-American, and Latino). Methods. Sub-
jects were tested on the TiMP at ages ranging from 32 weekspostconceptional
age to 3.5' monthspast term-equivalent age. Scores (Rasch logit ability mea-
sures) were correlated with postconceptional age. A multiple regression analysis
was used to assess the contributions of age, risk, and etbnicity to the variance
in 7TMP scores. Results. The correlation between postconceptional age and
iTMPpe$brmance measures was .83. Risk and age together eaplained 72% of
the variance in TlMPperformance (R= .85, P< .00001). No dzfferences related
to ethnicity were found. Conclusion and LHscussbn The TlMP has validity
for assessing age-related development of functional motor skills in young in-
fants and is sensitive to risk for poor developmental outcome. [Campbell SK,
Kolobe W A , Osten El: et al. Construct validity of the Test of Infant Motor Per-
formance. Phys Ther. 1995;75:5855%.1

Key Words: Infant motor development; Motor skills; Pediatrics, deuelopment; Tests
and measurements,functional.

The evolution of high-technology

neonatal care units has resulted in the
SK Campbell, PhD, PT, FAPTA, is Professor and Director of Graduate Studies, Department of
Physical Therapy, University of Illinois at Chicago, M/C 898, 1919 W Taylor St, Chicago, IL 60612 presewation of life for a growing
(USA) (S.K.CA4MPBELL@UIC.EDU). Address all correspondence to Dr Campbell. number of infants at high risk for
mortality, resulting in a large number
THA Kolobe, PhD, PT, is Lecturer, Depanment of Physical Therapy, University of Illinois at
Chicaeo. of children who have high risk for
-- - -
r r -
ET Osten, OT, is in private practice in Skokie, Ill. She is also Clinical Instructor, Department of
Occupational Therapy, University of Illinois at Chicago. mately 25% to 30% of at-risk Infants
exhibit some form of neuromotor
M Lenke, OT, is Clinical Supervisor Pediatrics, Department of Occupational Therapy, Lutheran disturbance early in As a result,
General Hospital, Park Ridge, IL 60068.
physical therapists and occupational
GL Girolami, PT, is Director, Pathways Center for Children, Glenview, IL 60025 therapists have increasingly become
This study was approved by the University of Illinois at Chicago (H-89-422) and Lutheran Gen-
incorporated as regular members of
eral Hospital (#888) institutional human subjects review boards. the neonatal special care team, provid-
ing assessment and treatment for ba-
This project was supported in part by a grant from the Foundation for Physical Therapy Inc. Dur-
ing the course of this project, Dr Campbell and Dr Kolobe were partially supported by Grant MCJ bies at especially high risk for devel-
IL 179590, Maternal and Child Health Bureau, US Public Health Service. opmental dysfunction.*In addition,
therapists provide education to those
This work was previously presented at the 1993 Annual Meeting of the American Academy for
Cerebral Palsji and Developmental Medicine and received the Patricia Miller Award for research in caring for these children.
physical therapy; as a result, an expanded version of the paper was presented at the 1994 Annual
Meeting of the American Academy for Cerebral Palsy and Developmental Medicine. Despite several decades of involve-
This article was submitted August 5, 1994, and was accepted March 2, 1995 ment by therapists in special care

Physical Therapy / Volume 75, Number 7 /July 1995

nurseries, little research exists to docu-
ment the effectiveness of their servic-
es.5 Studying the effects of these thera-
pies for hlgh-risk &ants is hindered
by the lack of functional motor out-
come measures appropriate for this
population. In addition, available tests
do not provide an adequate range of
items to allow for detailed quantitative
assessment of motor development,
and characterization of deviations from
the norm, in infants during the first
few months after birth. The purpose
of this research was to assess the sen-
sitivity to age-related change and to
risk for poor developmental outcome
of a new test, the Test of Infant Motor
Performance (TIMP). The TIMP was
developed for use by physical thera-
pists and occupational therapists in
assessing the components of func-
tional motor performance in high-risk
premature and very young term-born
infants.
A Theoretical Approach to
Developmental Motor
Assessment
Movement is a way that the infant
establishes control over the world,
communicates needs, and explores the
environment; movement is a basis for
early learning as well as being impor-
tant in its own right for developing
and maintaining musculoskeletal integ-
r i t ~Infants
.~ use movement to orga-
nize their environment; to cornmuni-
cate and interact physically with
objects or people; to change postures
or to adjust positions; to respond to
environmental demands; and for self-
consolation, such as thumb-sucking.
Active movement has been shown to
be necessary for optimal perceptual
development? an area that is fre-
quently problematic in prematurely
born children.8 The goal of physical
therapy or occupational therapy' for
young Infants with neurologic dys-
function is to assist them in develop-
ing these functional uses of movement
and to limit disability. No test has yet
been developed, however, that reflects
'Because intervention provided by physical therapists and occupational therapists in the very
early months of life is similar, no distinctions are made between them in this article. At later ages,
much more differentiation between therapeutic approaches is common.
the movements that are basic to these
functional competencies in newborns.
Because poor postural control can
limit the rate at which functional skills,
such as manipulation and mobility, are
acquired during deveI0pment,9-~~
therapists often use assessment of
postural control as a basis for deter-
mining the need for intervention to
promote motor development.
Shumway-Cook and Wo~llacott~~
define postural control as control of
the body's position in space for stabil-
ity (balance) and orientation. Stability
is the ability to maintain the center of
body mass within the base of sup-
port.12 Orientation is the alignment of
the body segments with respect to one
another as appropriate for the task.12
Thelen and colleagues13 place special
emphasis on the physical and social
contexts of actions in daily life as
aspects of the organization of postural
and movement responses. Interactions
among environmental and task charac-
teristics, physical and neurologic prop-
erties of the individual infant's body,
and the inherent self-organizing prop-
erties of the human sensorimotor
system are the principal components
of their dynamical systems model of
infant motor development.l3The two
related theoretical approaches, those
of Shumway-Cook and Woollacottl2
and Thelen and colleagues,~3have
Influenced the structure and develop-
ment of the TIMP.
The systems model of motor develop-
ment described by Shumway-Cook
and Woollacott12 assumes that the
processes of postural control include
(1) development of sensory systems
and central neural processes that orga-
nize visual, vestibular, and somatosen-
sory inputs for orientation of the body;
(2) musculoskeletal change, such as
increasing strength and changing body
morphology; (3) development of neu-
romuscular synergies to maintain sta-
bility; (4) development of adaptive
mechanisms to modlPy control pro-
Physical Therapy / Volume 75, Number 7 /July 1 9 5
cesses for posture in response to
changing environmental and task
demands; and (5) development of
anticipatory postural control processes
to prepare for destabilizing internal
and external forces. In their model,
motor behaviors are divided into four
functional categories: (1) sustaining
posture; (2) regaining posture; (3)
transitions between postures; and (4)
integration of posture into movements
such as locomotion, manipulation, and
exploration. The TLMP assesses behav-
iors in the first three categories that
we believe to be the basic sktlls lead-
ing to performance of activities at the
fourth level. Head control and other
functions are assessed in active and
alert states, for example, by testing the
ability of the child to maintain head
stability in a variety of spatial orienta-
tions, right the head when the body is
tilted, turn the head in various posi-
tions, and stabilize or orient the head
in response to interesting visual or
auditory events. A variety of position-
ing and stimulus materials (ie, toys,
examiner's face) across items allows
infants to demonstrate their abilities to
perform in a number of environmental
and task contexts.
Comparison of the Test of
Infant Motor Performance WM
Available Infant Tests
Available tests primarily assess infant
neurobehavioral responses, social
interactions, and reflexes and muscle
t0ne."l*-~9Each of these tests has one
or more problems that limits its use in
clinical practice, such as lack of sum-
mary or quantitative scores, excessive
length, or questionable or inade-
quately demonstrated reliability or
validity.20 In the tests developed by
Dubowitz and Dubowitz16 and by
Komer and colleague^,^^^^* the exam-
iner stabilizes the child's head position
when testing many items, thus limiting
the infant's ability to express indepen-
dent postural control capacities. Many
of these tests, however, do contain
small numbers of items that assess the
ability to control the head and trunk in
several spatial orientations and in
response to interesting stimuli in the
environment.
 seated position and when sus-
pended in the prone position, and the
ability to flex the arms from an ex-
OBSERVED SCALE tended position in a prone posture;
1. Head in midline 2s and items developed by Arniel-Tison
2/3. R/L head turn 180" and GrenieF for eliciting evidence of
4. Hands together in midline developing postural control in sitting
5/6. R/L mouths hand and side-lying positions. In each case,
7/8. R/L individual finger movements however, new scoring descriptors
9/10. R/L individual wrist movements were developed to reflect the goals of
11/12. R/L financing objects the TLMP.
13. Pelvic lift
14. Bilateral hip and knee flexion Movements reflecting the qualitative
15/16. R/L individual ankle movements changes in coordination (oscillating
17. Kicking movements and ballistic [ie, rapid,
18/19. R/L head turn 180" in prone position forceful] movements) recently identi-
20. Head lift in prone position fied by Hadders-Algra and Prechtl22
23. Antigravity bilateral forearm movements and Cioni and Precht123are also
24. Antigravity bilateral arm movements scored when they occur spontane-
25. Ballistic movements ously. The presence of ballistic move-
26. Oscillating movements ments (called "swipes" and "swats") at
27. Reaching 7 to 10 weeks postterm is thought to
reflect increasing amounts of recipro-
ELICITED SCALE cal innervation in muscular coordina-
1. Neck rotation with visual stimulation in semiupright position tion, which makes these rapid, forceful
2. Head control in seated position movements possible.24 Because these
3. Trunk extension in seated position qualitative developments do not ap-
4. Head lifting from full neck flexion pear in children with spastic cerebral
5. Head lifting from full neck extension palsy, their absence at an appropriate
6. Head control when lowered from sitting to supine position age may have diagnostic signifi-
7. Inhibition of trunk rotation with head turn ~ a n c e . All
~ 5 other items in the TIMP
8/9. Midline head alignment withouvwith visual stimulation are original in conception and scor-
10/11. R/L neck rotation with visual stimulation in supine position ing26727; a complete list is presented in
12/13. Neck stretch/arm reactions to face covering Figure 1.
14. Antigravity hip/knee flexion in supine position
15. R/L rolling to prone position with leg adduction The TIMP requires an average of 36
16. R/L rolling to prone position with arm adduction minutes to administer and to score,
17. Neck flexion on pull-to-sit and it consists of two scales, one for
18. Lateral head and trunk righting with elbow extension rating the presence of spontaneous
19. Lateral hip abduction reaction motor behaviors and the other for
20. Neck and trunk extension in prone suspension rating the infant's responses to being
21. Crawling in prone position positioned and handled in a variety of
22. Head lift in prone position spatial orientations and to interesting
23. R/L head turning in prone position with auditory stimulation types of visual or auditory inputs.
24. Recovery of arm position after displacement in prone position Items on both scales are scored only
25. Standing when infants are in quiet alert or ac-
26. R/L head righting with tilt in upright suspension tive alert behavioral states, as defined
by Brazelton.l5
Figure 1. List of items in the Test of Infant Motor Performance (Version 2.3).Miss- The Observed Scale on TIMP Version
ing items were deleted after psychometric analysis. (WL= rightAeJ.)
2.3 (items denoted by 0-1 consists of
27 dichotomously scored behaviors
The TlMP is designed for prematurely infant tests.15J6These include items
reflecting the infant's spontaneous
born infants from 32 weeks' gesta- developed by Brazelton15involving
attempts to change positions or to
tional age up to about 4 months after orientation in response to visual and
orient the body in various ways, to
term-equivalent age or for full-term auditory stimuli and reactions to a
selectively move individual body seg-
mfants up to 4 months of age.21Some cloth over the eyes; items from the test
ments, and to perform the qualitative
items in the test were selected from by Dubowitz and Dubowitz16 involv-
types of movements mentioned earli-
those in the previously mentioned ing control of the head in the upright
er.22-24Examples include the ability to

Physical Therapy / Volume 75, Number 7 /July 1995


Figure 2. Three-month-oldinfant demonstrating spontaneous pet$omance of
head lifting in prone position (Obsewed Scale item 20).
center the head in line with the mid-
line of the body in the supine posi-
tion, bring the hand to the mouth,
produce ballistic movements of the
arms or legs, and llft the head in the
prone position (Fig. 2).
The second part of the test is the Elic-
ited Scale (items denoted by E-), made
up of 26 items (6 of which are scored
separately for each side of the body),
each rated on five- or six-point scales.
Performance on these items reflects
the infant's ability to solve movement
"problems" posed to elicit evidence of
developing postural control in a vari-
ety of spatial orientations. Examples
include rolling to a prone position
with head righting when the leg is
rotated across the body (Fig. 3); inhib-
iting rolling when the head is turned
to one side; turning the head to follow
a visually interesting object or to
search for a sound in a prone, supine,
or supported sitting position; and
aligning the legs, trunk, and head in a
12 / 588
delivery of effective interventions to
improve motor development.
The analyses presented in this article
address the first two of these issues, as
well as possible ddterences related to
ethnicity of the infant. Our hypotheses
were that ability on the TIMP would
be positively correlated with postcon-
ceptional age and that ability on the
TIMP would be negatively correlated
with degree of perinatal medical com-
plications related to increased mortal-
ity and developmental deviance. The
literature on motor performance in
children of ddterent racial and e t h c
backgrounds also suggests that Cauca-
sian children might be expected to
have lower scores than African-
American children.2B-3O
Method
Subjects
The subjects in this study were 137
Infants born prematurely or after a
full-term pregnancy who were tested
one to three times (with the exception
of 1 child who was tested four times),
yielding 174 measures of performance
on the TIMP. Subject selection was
made in accordance with a preestab-
vertical orientation when placed in a
lished plan for stratifying mfants by
standing position.
postconceptional age, medical risk,
and race or ethnicity. Based on this
Purpose and Hypotheses
plan, we attempted to recruit 3 mfants
of each racial or e t h c group at each
The purpose of this article is to
of three levels of risk for developmen-
present preliminary evidence of the
tal disability for a total of 27 mfants in
construct validity of the TIMP. If the
each of seven predefined postconcep-
test is truly a measure of the postural
tional age ranges (Tab. 1). Most of the
and selective control underlying func-
sample was cross-sectional (ie, tested
tional motor performance, it should
once); however, 9 infants who were
possess certain characteristics. Perfor-
tested three or four times constituted a
mance measures (or total scores)
sample of convenience for longitudi-
should vary as a function of (1) age-
nal assessment. Children were tested
related changes in motor performance;
in their homes or in one of two inpa-
(2) the presence of risk factors for
tient special care nurseries (the Uni-
developmental disability, such as ex-
versity of Illinois Hospital, Chicago, Ill,
treme prematurity or perinatal as-
or Lutheran General Hospital, Park
phyxia; (3) medical diagnosis, such as
Ridge, Ill).
chronic lung disease or cerebral palsy;
(4) the presence of developmental
Age was calculated from the expected
deviance in any of the subsystems that
date of confinement for each infant's
contribute to the organization of func-
mother. For all subjects, the average
tional movement (eg, visual or audi-
gestational age at birth was 33 weeks
tow impairment, altered reflex activity
(SD=5); 29 of the subjects were full
or defects in motor control); or (5)
term at birth (38-42 weeks), and the
Physical Therapy / Volume 75, Number 7 / July 1995
 born mfants at postconceptional ages
32 weeks to 37 weeks; a term age
group consisting of 10 full-term infants
and 19 prematurely born infants who
had reached term-equivalent age; and
three groups of infants who were 2 to
13 weeks past term-equivalent age,
defined as 40 weeks postconception
(Tab. 1). The three oldest age groups
consisted of 9, 11, and 11 full-term
infants. The average gestational age at
birth (last column of Tab. 1) of infants
tested within each of the seven
postconceptional age groups varied
from 30 to 35 weeks.

Risk assignment (high, medium, low)

was made based on scores on the
Newborn form of the Problem-
Oriented Perinatal Risk Assessment
System (POPRAS),s1,s2derived from
Figure 3. Tbree-month-old infant demonstrating ability to roll to prone position reviews of medical records. Scores of
with head righting ajfer right leg adduction across body in supine position (Elicited 2 to 60 were considered low risk,
Scale item 15L). Scale scores: @pelvis lrjfs passively off surface; l=peluis lifts from scores of 61 to 90 were considered
support s u ~ a c eand head turns, but trunk and a m do not respond; .?=pelvis and medium risk, and scores over 90were
trunk lift fmm suppott surface and head turns to side, but a m remains behind trunk;
3=pelvis, trunk, and a m lift from support surface, head turns to side, and infant rolls considered to be high risk.
part way but not onto side; 4=peluis, trunk, and a m lift from support surface, head
turns, and infant rolls onto side or ouer without head righting; 5=when traction is Ethnicity/race was taken from each
applied to leg at the end of the maneuver, infant rolls to prone position with head infant's medical record. Only children
righting. who were African-American, Latino, or
non-Latino Caucasian were included
rest were born prematurely. Subjects postconceptional age into seven in the sample. Thirty-five percent of
were selected for stratification by groups: three groups of prematurely the infants were non-Latino Caucasian,
36.5% were African-American, and
28.5% were Latino, distributed across
all categories of age and risk.
Table 1. Number of Tests by Postconceptional Age Group, Medical Risk, and
Average Gestational Age at Birtha Testing

Gestational Age Informed consent was obtained from

Risk (wk) the parents of each mfant, and permis-
-
Age Groupb Low Moderate High Total X SD Range sion to test was obtained from the
mfant's physician or nurse before
assessment began. Children who were
1 (12%)
observed repeatedly were never tested
2 (18%) more than once while they were in
3 (16%) the same age category. Chronologic
4 (17%) age at the time of testing of the chil-
5 (10%) dren below term-equivalent postcon-
6 (13%) ceptional age averaged 20 days
7 (14%) (SD = 18, range=>68) for the 32- to
Column total 33-week-old mfants, 26 days (SD=20,
Total percentage range= 1-81) for the 34- to 35-week-
olds, and 29 days (SD=27, range=
"Percentage of total sample shown in parentheses for age and risk groups 1-77) for the 36- to 37-week-olds.
' ~ g egroup 1.=32-33 weeks postconceptional age; age group 2=34-35 weeks postconceptional
age; age group 3=36-37 weeks postconceptional age; age group 4=38-41 weeks postconcep- Five therapists (three physical thera-
tional age; age group 5=2-5 weeks postterm; age group 6=6-9 weeks postterm; age group pists, two occupational therapists)
7=10-13 weeks postterm. tested all infants in the study. Their

Physical Therapy / Volume 75, umber 7 /July 1995

intrarater and interrater reliability on scores by imposing this measurement Item calibrations are shown in Figure
14 videotaped tests of ~nfantsfrom all model definition on the observed 4, in which every dichotomous item in
three ethnic and racial groups and responses of tested individuals evalu- the test and each level within multi-
with a variety of ages and degrees of ates the extent to which the data fit level items is placed at its median
medical risk was analyzed with the the model. Those parts of the data that dilf~cultycalibration in logits. The
FACETS computer program.33~34The do not fit the model are identified easiest item (0-14) is observed sponta-
analysis allows the investigator to with misfit statistics. If the data pro- neous hip and knee flexion or being
assess whether raters use items sys- vide an overall fit to the measurement able to flex the hips and knees in the
tematically across subjects and model, a scale has been formed that is supine position so that the legs are off
whether different raters use item rat- assumed to be based on a unidimen- the supporting surface at least mo-
ings similarly. All testers met the pre- sional construct (all items measure the mentarily; the most dficult item ( 0 -
determined criterion35 of fewer than same thing) and to approximate an 26) is spontaneous demonstration of
5% misfittingt ratings. interval-level scale (ie, measurement an oscillating quality of arm or leg
units are the same size over the whole movement.22Other dficult skills are
Data Analysis range of the scale), a property that reaching (0-27), and Arniel-Tison and
generally does not hold true for the Grenier19items for evolung evidence
Test performance for all children on original raw scores on items. Data of the development of lateral control
the TIMP was subjected to psychomet- from a scale with these properties can of the head and body in space (E-18
ric analysis for fit to a theoretical Ra- be used to order individuals by ability and E-19). Items demonstrating s d a r
sch measurement modeP7-39 using the and can be analyzed with parametric levels of dficulty, such as items
BIGSTEPS computer program.@In this statistics.*l 0-2/3, E-10/11, and E-16 R/L, are
model, raw ordinal-level scores for primarily items that rate the same
success in passing items, or levels Items on the TIMP were calibrated activity but on different sides of the
within items, are transformed into a according to dilficulty level and as- body. A few items of similar degree of
linear scale of mea~urement.~' The sessed for fit to the measurement dficulty involve use of different body
number of successes (S) indicates the model. Both item dficulties and per- parts (eg, 0-2/3 involve spontaneously
infant's level of function, and the num- son ability measures are expressed in turning the head a full 180°, 0-13
ber of levels the infant failed to pass logits, or logarithmically transformed involves pelvic control, and 0-23
(F) is the dficulty of the item. Taking probabilities of success given a partic- involves antignvity forearm move-
the log(S) and the log(F) can yield B ular level of ability (log-odds probabil- ments with elbows on the support
(the ability of individuals) and D (the ity scaling), ranging from about - 5.0 surface). These abilities, therefore,
dficulty of items), which, if plotted to +4.0 for the TIMP and forming a seem to appear at about the same
for the group, would be linear. The hierarchical linear scale with equal time during the course of
measurement model focuses on the inter~als.3~ The internal consistency development.
difference between ability and d f i - coefficient was .98, indicating that the
culty; thus, B - D = log(S) - log@) items on the TIMP form a coherent Floor or ceiling effece have not been
= 10g(S/F).~lThis statement is refor- scale. Clarity of the measure, as re- noted (ie, item difficulties extend well
mulated into a more general statement flected by the item separation index, below the lowest perfomance mea-
about probabilities (ie, the chances of was 7.38 (root mean square er- sures obtained for the subjects tested),
success on items by infants), so that ror=0.19). The practical meaning of and the highest or lowest ratings pos-
the model for dichotomously scored this measure is that the TIMP items sible for a few item have not been
items is described as log[P,/P,] = B can be separated into more than seven attained by any subjects. We therefore
- D. The model has an additional ddferent average levels of dficulty suspect that the test could be sensitive
term for the ddficulty of the various across the 5-month age span of the to reflecting the ability of children
steps in the item when several levels children tested. who are younger and older than those
of ratings are possible within each in our sample. Before the TIMP could
item. Analysis of the raw ordinal-level be used on older or younger children,
however, further research will be
needed. Items 0-21 and 0-22, sponta-
neous rolling to side-lying R/L, seri-
+The computer program is designed to identify as a misfit any observed item rating that differs ously misfit the Rasch model and have
with high probability from the rating that was expected based on the psychometric model of
unidimensionality of item structure. Fit to the model requires that higher item ratings are achieved been eliminated from the test because
by persons with higher ability (greater total raw score) and that persons with a given functional they did not show consistent differ-
level have a greater probability of scoring higher on easier items than o n more difficult items; the ences with increasing age. After con-
mean square fit statistic is used to identify ratings that deviate from the e~pectations.3~Ratings can
misfit because items are not well defined, because raters apply the item definitions inconsistently, sultation among the raters, several
or because infants perform in unexpected ways (eg, failing easy items relative to their overall additional misfitting item definitions
ability). Misfitting item scorings were deleted from the reliability analysis when unusual child were subsequently revised slightly to
performance appeared to cause misfit to the model but examiners' ratings were in close agree-
ment. A 5% occurrence of misfitting ratlngs could be expected by chance alone, so this criterion eliminate ambiguities in descriptors we
was used to establish an acceptable level for rater reliability, both within and across raters. were able to identdy as potentially

14 / 590 Physical Therapy / Volume 75, Number 7 /July 1995

 responsible for misfit or to better re-
flect the developmental sequence
observed in the Rasch analysis.
LOGITS: -6 -4 -2 0 2 4 6
E-SCALE ITEM
E26 TILT L
E26 TILT R
0
0
1Descriptive statistics were calculated
EASY
1
for each age group and risk group,
1 2 3 . 4 HARD
4
4
E25 STAND 0 STEP 1 . 2 34 5 STEP 5 and correlation and multiple regres-
E24 ARM REL 0 1 . 2 3 4 5 . 5
E23 TURN L 1 234 5 6 . 6 sion analyses were used to assess the
E23 TURN R 1 2.34 5 6 . 6 sensitivity of the test to reflect age-
E22 PRONE 0 1 . 2 . 3 4 5 . 5 related changes in motor develop-
E21 CRAWL 0 1 2 . 3 4 4
EZO SUSPEND 0 1 . 2 3 4 . 4 ment, ethrucity and race, and the risk
E l 9 LAT TRUN 0 1 2 . 3 3 for developmental deviance.
E l 8 ARM PROP 0 1 2 . 3 4 4
E l 7 PTS 0 . 1 2 . 3 4 .5 5
E l 6 ROLL L/A 2 3 . 4 . . 5 5
E l 6 ROLL R/A 2 3 . 4. . 5 5
El5 ROLL L/L 2 . 3 4 . 5 . 5
El5 ROLL R/L 2 . 3 4 . 5 5 The calibration of chld performance
E l 4 HIP/KN F 0 1 2 3 . 4 measures on the TIMP is given in
E l 3 OEFEN AR 0 1 . . 2 3 5 . 5 logits in Table 2, which shows the
E l 2 OEFEN HD 0 1 2 3 4 . 4
E l l L ROTATE 0 1 2.3 4 4 means, standard deviations, and
E l 0 R ROTATE 0 1 23 4 4 ranges for each age group and risk
E9 HO MIO/V 0 1 . 2 3 4 5 5
E8 HO MIO/SU 0 .1 2 3 . 4 4 group in the stratified sample. The
E7 INHIB NCK 0 1 2 .345 5 mean score progressively increased
E7 INHIB NCK 0 . 1 2 .345 5
E6 HEAD LOVE 0 1 2 3 4 . 4
with age, reflecting the sensitivity of
E5 LIFT FLEX 1 . 2 3 4 4 the test to development of motor
E4 LIFT EXT 0 1 2 . 3 4 5 5 slulls. The Pearson Product-Moment
E3 TRUNK BEN 0 1 2 .3 4 . 4
E2 HEAD CTL/ 0 1 2 . 34 5. 5 Correlation Coefficient between
E l TRN HEAD/ 0 1 2 3 4 . 4 postconceptional age in days and the
t I I I I I
i performance measure in logits on the
-6 -4 -2 0 2 4 6
TIMP was .83. The Rasch analysis
DISTRIBUTION 1211121111 derived a person separation index of
OF INFANTS: 1 1 1 14133356389401120636543214112 1 1 1
6.02 (root mean square error=0.21),
LOGITS: -6 -4 -2 0 2 4 6 indicating that the children tested can
0-SCALE ITEM be separated into at least six different
026 " OSCILLAT O .1 HARD 1
027 REACH 0 1 . ITEM 1 levels of ability across the 5-month age
025 BALLISTI 0 1 . 1 range tested.
0 9 R WRIST 0 1 1
010 L WRIST 0 1 1
07 R FING MV 0 1 1 Initial demonstration of the sensitivity
020 PRONE LF 0 1 1 of the TLMP to age-related change in
015RANK 0 1 1
016 L ANK 0 1 1 individual children is shown in Figures
0 8 L FING M 0 1 1 5 and 6 for nine children who were
04 HANDS TOG 0 .1 1
018 R TRN PR 0 1 1
assessed on three to four different
019 L TRN PR 0 1 1 occasions at least 12 days apart (with
012 FINGOBJ 0 1 1 one exception when two tests were
011 FINGOBJ 0 1. 1
06 L HAND MO 0 1 . 1 separated by only 6 days). Figure 5
05 R HAND MO 0 1 1 shows the performance of five infants
023 FOREARM 0 1 1
02 TURN L 0 1 1
013 PELV LIF 0 1 1
03 TURN R 0 1 1
024 ARMS OFF 0 1 1 The frequency distribution of child abil-
01 MI0 HEAD 0 .1 EASY 1 ity measures is located on the same logit
017 KICK 0 1. ITEM 1 scale and is shown in the middle of the
014 HIP/KN F 0 1 1 figure. Average performance is located at
I I I I
I I
I I I 0 logits (obtained by 11 infants) on the
-6 -4 -2 0 2 4 scale and indicates that the average
child in our sample would have about .5
Figure 4. Calibration ~ u r s t o n threshold
e median dzjiculty lew0 of Test of Infant probability of passing Observed Scale
Motor Pe$brmance items (in logits) based on Rasch psychometric analysis (after dele- item 4 (hands together in midline) and
tion of misfitting items). Top: Elicited Scale items in test-item order illustrating dzficulty a high probability of passing Observed
of each step within the item rating scale, with easiest step to the left and hardest step to Scale items with dzjiculty calibrations to
the rrght. tlottom: Observed Scale items arranged in order of dzficulty from items easy the left of item 4, and a .5probability of
to pass by less skilled, younger infants to hard items passed only by oldest and most receiving scores of 3 on Elicited Scale
able infants. The measurement ruler is shown at the top and bottom of each section. items 3, 7, 11, and 23, and so on.

Physical Therapy / Volume 75, Number 7 /July 1995

 Multiple regression analysis demon-
strated the joint and unique contribu-
Table 2. Test of Infant Motor PerJomzance Logit Ability Measures by Age Group
and by Medical Risk Within Age Group tions to explaining variance in TIMP
performance measures of postconcep-
tional age, medical risk, and 0/1 di-
Logit Scoreb chotomous variables for ethmcity/race.
-
Age Groupa Risk X SD Range N The combination of these independent
variables in predicting TIMP logit
Total sample
measures resulted in a multiple R of
.85 ( K .00001). Seventy-two percent
1
of the variance in TIMP scores was
Low
explained by the combination of these
Moderate three variables. Postconceptional age
High was a sigmficant variable (beta= .80;
K .00001). Medical risk, as reflected
Low in the infant's total Newborn POPRAS
Moderate score, was also significant at K.OOO1
High (beta= -3.92). The negative coefficient
indicates that ability decreased with
Low increasing degree of medical risk; the
Moderate
simple correlation between TIMP and
High
POPRAS scores was -.29. Differences
in performance based on race/ethnic-
ity did not reach the .05 level of prob-
Low
ability. Figure 7 shows the relationship
Moderate among postconceptional age, POPRAS
H~gh risk score, and TIMP performance
measures in a three-dimensional plot.
Low
Moderate Discussion
High
The results of these analyses demon-
Low strate that the TIMP meets two impor-
Moderate
tant criteria necessary for potential
usefulness as a tool for assessing in-
High
fants at risk for poor motor outcome.
Scores increase systematically with
Low
increasing postconceptional age, and
Moderate children with greater numbers of med-
High ical complications do less well than
same-age peers. In infants assessed
"Age group 1=32-33 weeks postconceptional age; age group 2=34-35 weeks postconceptional over time, the average change in TIMP
age; age group 3=36-37 weeks postconceptional age; age group 4=38-41 weeks postconcep- scores over 2 weeks was more than
tional age; age group 5=2-5 weeks postterm; age group 6=6-9 weeks posttem, age group
7= 10-13 weeks postterm.
twice the error of measurement, and
rates of change were approximately
?he mean logit score is greater than zero because scores were anchored after about 60% of the
data were collected. linear. These findings suggest that it
will be possible to develop norms for
at low or moderate risk for poor mo- decreases of 0.04, 0.04, and 0.12- performance of premature and young
tor outcome; Figure 6 shows the data over periods of 12, 14, and 24 days, full-term infants that will be useful in
for four infants at high risk for poor respectively. Two infants were at high identlrying those chlldren whose mo-
motor outcome. Based on the data risk and one Infant was at low risk for tor performance is poorer than
points from all infants assessed repeat- poor motor outcome. Each was a expected.
edly, the average change in scores young premature infant who subse-
over a 2-week period would be ex- quently showed gains between the Of other tests for newborns that have
pected to be about 0.48 logit, greater second and third tests of 0.93, 1.09, been published, only the test devel-
than twice the average error value and 1.35 logits, respectively. The num- oped by Komer and c o l l e a g u e ~ ~ 7 ~ ~ ~
(0.21). Three children demonstrated bers of days between these later tests was designed for the purpose of mea-
ranged from 16 to 47 days. suring age-related change in behavior.
essentially no change in s c o r e s
Their test has been shown to be sensi-

16 / 592 Physical Therapy / Volume 7 5 , Number 7 /July 1995

 passively positioned in a midline
orientation.

The test developed by Dubowitz and

200 220 240 260 280 300 320 340
PostconceptionalAge (d)
Figure 5. Longitudinalperformance (in logits) on the Test of Infant Motor Perfor-
mance offive infants at low or moderate risk forpoor motor outcome.
tive in preterm infants to weekly
changes in alertness and orientation to
sensory stimulation, irritability, and
muscle extensibility (degree to w h c h
a muscle can be passively extended or
elongated). Despite including a di-
Dubowitz16similarly requires hation
of the mfant's head in midline when
most items are tested. Testing the
infant with a passively positioned
head may explain the insensitivity of
the test in Darrah and colleagues'
research on the effects of waterbed
use to promote more flexed postures
in premature infants,42which we
would have expected to result in
improved ability to independently
center the head. Because head control
is an important aspect of postural
development in the early months of
life and is frequently impaired in chil-
dren with cerebral palsy, the infant's
360 380 400
ability to independently control head
position in a variety of spatial orienta-
tions and in response to a variety of
sensory and social stimuli is a major
construct assessed in the TIMP.
mension called "motor development,"
Further evidence of the construct
however, the test of Korner and col-
validity of the TIMP is found in the
leagues is not useful for therapists
hierarchy of average item difficulty
interested in the development of pos-
identdied by the Rasch analysis. For
tural control because many of the
example, oscillating (0-26) and ballis-
items require that the child's head be
tic (0-25) movements are ranked as
very dficult (ie, passed only by in-
fants with overall high scores), com-
mensurate with Hadders-Algra and
Prechtl'sZ2 and Cioni and Prechtl'sa
identification of the initial appearance
of these aspects of movement at about
7 to 10 weeks of age postterm. Other
dficult items are those involving lat-
eral righting of the head and trunk
(E-18, E-19, E-26). Diagonal and rota-
tional components of movement re-
quire advanced levels of skill relative
to sagittal-plane movements of flexion
and extension, as clearly demonstrated
by the developmental sequence of
behaviors on the Alberta Infant Motor
S~ale.~3

To be useful for the purpose of identi-

fying children who might benefit from
physical therapy or occupational ther-
apy in the period of early infancy, the
200 220 240 260 280 300 320 340 360 380 400
TIMP should demonstrate (1) accept-
PostconceptionalAge (d)
able rater reliability among therapists
who were not involved in test devel-
Figure 6. Longitudinal performance (in logits) on the Test of Infant Motor Perfor- opment and (2) test score stability
mance of four infants at high risk for poor motor outcome. across short time periods. Other as-

Physical Therapy / Volume 75, Number 7 / July 1995

 comes of sitting alone and beginning
to grasp objects, which are expected
of children at 4 to 6 months of age, or
whether other paths to achievement of
these skills are possible. Longitudinal
research would be necessary to inves-
tigate this question and related ques-
tions that could be posed based on
Shumway-Cook and Woollacott's
model. l2

Although item scaling is ordered hier-

archically, the Rasch model does not
assume strict adherence to an order
on the part of an infant when deriving
a logit ability mea~ure.39.~~ Perfor-
mance on items that is strictly hierar-
chical generates a misfit statistic be-
cause such regularity is considered
suspect. The statistical model is instead
a probability model that generates an
Figure 7. nree-dimensional representation of individual Test of Infant Motor expectation of obtaining certain per-
Performance (TIMP) iogit measures by postconceptional age and Pwblem-Oriented
Perinatal Risk Assessment System (POPRAS) risk score. Each peak represents an indi- formances, given the difficulty calibra-
vidual's TIMP score (in logits). Infants'per$ormance increased with age (right arrow) tion of each item and the child's over-
and decreased with degree of medical complications on the POPRAS (lej arrow). all ability as estimated from the total
raw score. Because of this characteris-
pects of construct validity also remain performance related to this variable tic, one advantage of the Rasch model
to be assessed, such as responsiveness also warrant further attention with for clinical use is that small numbers
to change produced by effective inter- larger samples before the test is of item ratings can be missing from a
ventions and sensitivity to important normed for diagnostic use. child's test without compromising the
deviations from the norm, including ability to derive an overall ability mea-
the presence of signs of motor perfor- Future research might also assess the sure based on the item performances
mance deficits or delayed develop- TIMP from the perspective of dynami- available. The presence of multiple
ment. For example, we are currently cal systems theory.44For example, if items (or steps w i h n items) with
planning a research project to assess this theory holds, children with visual similar difficulty calibrations also
the discriminative validity of the TIMP or auditory impairment should dem- means that not all items may
in identifying differences in develop- onstrate poorer performance on those need to be used in any given test
mental growth curves of defined head control items in which stimuli administration.
groups of infants. These groups will are used to which they are unable to
include infants with documented brain respond when compared with perfor- One aspect of our research plan in-
insults, chronic lung disease, and mance on head control items that do volves attempting to develop individu-
extreme prematurity at birth without not require use of their impaired sub- ally tailored testing. With this ap-
brain or severe lung impairments, as system. If task characteristics are deter- proach, the therapist would assess the
well as both premature and full-term minants of motor responses, altering child on a small number of items that
infants at low risk for poor motor the toys used to elicit responses might cover a wide age range (eg, items E-3,
outcome. Developmental outcome at also reveal variations in age-related E-13, E-14, and E-17 in Fig. 4) to de-
1 year will be assessed with the Al- performance. rive an initial estimate of the child's
berta Infant Motor S ~ a l e . This
~ 3 will be ability. Then only items with difficulty
done to assess the predictive validity Dynamical systems theory also sug- calibrations slightly above and below
of the TIMP using a test with a similar gests that children might use different the child's estimated ability would be
theoretical basis emphasizing postural developmental paths to achieving used for further testing, and items
control during functional activities. sirmlar motor milest0nes.~5The overall expected to be too hard or too easy
Because the regression coefficients for item sequencing and individual item for the child could be omitted. Al-
ethcity/race were close to signifi- scaling on the TLMP, therefore, should though Infants have tolerated the time
cance (P= .lo, non-Iatino Caucasian be evaluated to determine whether the currently needed for testing with no
children's ability was lower than sequence of item difficulty indeed adverse effects, tailored testing would
African-American children's ability; forms a hierarchy of postural control be useful to reduce the time required
African-American and Latino children skills that all children need to achieve of the therapist and the demand on
performed s~milarly),differences in to reach the functional motor out- the infant.

Physical The]rapy / Volume 75, Number 7 /July 1995

Two other major issues of construct
validity currently being addressed in
our research on the TIMP are (1) the
relationship between postnatal age
and TIMP performance and (2) the
ecological validity of TIMP items. A
group of Infants born at a variety of
gestational ages is being assessed at 36
weeks postconceptional age to evalu-
ate whether earlier exposure to the
extrauterine environment affects TIMP
performance and, if so, which items
vary by postnatal age. Ecological valid-
ity is being studied by comparison of
the items involving use of handling
during test administration (E-scale)
with actual demands for movement
provided by parents' handling of their
own infants daily routines such as
bathing, dressing, and playful interac-
tion. Eventually, we could also study
whether parents change the way they
interact with their infants after observ-
ing administration of the TIMP. We
have found that parents enjoy watch-
ing the test and often report seeing
evidence of skills they did not realize
their possessed. U1timatelysOur
plans also include a national norma-
tive study to establish standards for
diferent ages and risk (and
ethnicity and race, if necessary) and
investigation
" of whether the TIMP has
value in developmental diagnosis by
defining 'limits its . . and
. functional movement, In: Campbell SK,
sensitivity for identification of develop-
mental deviance.
Conciusion
Our research to date has ~roduceda
standardizedversion of a;nique, new
test of infant motor performance that
is based on a clinical - .
pers~ective fo-
cused on the ~osturalcontrol and
characteriz-
ing the
behavior. The test was found to form
an internally consistent scale that is
highly correlated with age-related
changes in motor performance and
that is sensitive to dserences in devel-
o~mentalrisk as a result of ~erinatal
The 'pet-
trum of research activities described in
this article will, however, be necessary
to fully establish the construct validity
of the TIMPfor '& intended purposes.
Physical Therapy / Volume 75, Number 7 /July 1995
Acknowledgments
Appreciation is expressed to Mary
Murney, PT, Joyce Laskey, RN, David
Sheftel, MD, Lucky Jain, MD, Dharma-
puri Vidyasagar, MD, and the nursing
staff of the special care nurseries at
Lutheran General Hospital and Univer-
sity of Illinois Hospital for assistance in
subject recruitment. We also thank the
parents of our subjects for their will-
ingness to allow their babies to be
tested and videotaped.
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Physical Therapy Treatment
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Granger CV, Gresham GE, eds. New Develop-
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