J Autism Dev Disord
DOI 10.1007/s10803-016-3005-0
ORIGINAL PAPER
Test of Gross Motor Development-3 (TGMD-3) with the Use
of Visual Supports for Children with Autism Spectrum Disorder:
Validity and Reliability
K. A. Allen1 · B. Bredero1 · T. Van Damme1 · D. A. Ulrich2 · J. Simons1
© Springer Science+Business Media New York 2017
Abstract The validity and reliability of the Test of
Gross Motor Development-3 (TGMD-3) were measured,
taking into consideration the preference for visual learn-
ing of children with autism spectrum disorder (ASD).
The TGMD-3 was administered to 14 children with ASD
(4–10 years) and 21 age-matched typically developing chil-
dren under two conditions: TGMD-3 traditional protocol,
and TGMD-3 visual support protocol. Excellent levels of
internal consistency, test–retest, interrater and intrarater
reliability were achieved for the TGMD-3 visual support
protocol. TGMD-3 raw scores of children with ASD were
significantly lower than typically developing peers, how-
ever, significantly improved using the TGMD-3 visual sup-
port protocol. This demonstrates that the TGMD-3 visual
support protocol is a valid and reliable assessment of gross
motor performance for children with ASD.
* J. Simons
johan.simons@kuleuven.be
K. A. Allen
kirstyallen_@hotmail.com
B. Bredero
Beeleke.bredero@kuleuven.be
T. Van Damme
Tine.vandamme@kuleuven.be
D. A. Ulrich
Ulrichd@umich.edu
1 Several internationally recognised and standardised
Department of Rehabilitation Sciences, Faculty
of Kinesiology and Rehabilitation Sciences, KU Leuven,
O&N IV, bus 1510, 3000 Leuven, Belgium
2
School of Kinesiology, University of Michigan, 1402
Washington Hts, Ann Arbor, MI, USA
Keywords Test of Gross Motor Development-3 · Autism
spectrum disorder · Visual supports · Validity · Reliability ·
Gross motor performance
Introduction
It is shown that children with ASD exhibit significant
delays in motor development, impaired movement per-
formance and impaired motor planning compared to their
typically developing peers (Fournier et al. 2010; Hilton
et al. 2012; Ming et al. 2007). Due to the increasing evi-
dence that motor delays can be identified during infancy
(Bhat et al. 2011; Leonard et al. 2014; Liu 2012; Lloyd
et al. 2011; Shetreat-Klein et al. 2014; Teitelbaum et al.
1998), early administration of movement skill assessments
and screening for delays in motor milestones may facilitate
early detection of ASD (Bhat et al. 2011; Liu 2012; Ozo-
noff et al. 2008). Moreover, in recent years, motor impair-
ment in children with ASD has received an increasing
amount of attention. Abundant evidence clearly indicates
a high prevalence of motor impairment in children with
ASD. However, one of the major challenges in the adminis-
tration of motor assessment in this population concerns the
task understanding. However, before motor performance
can be considered as a principal characteristic of ASD, it is
essential to establish a valid and reliable motor assessment
for use in children with ASD that incorporates appropriate
adaptations to facilitate task understanding and to ensure an
accurate evaluation of motor performance can be achieved.
movement skill assessments exist and have been used
extensively throughout the literature to evaluate the motor
performance of infants, children and adolescents with ASD
in comparison to normative data, typically developing
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peers and other disabilities (Staples et al. 2012). The most
frequent of these assessments used include; the Test of
Gross Motor Development (TGMD and TGMD-2), the
Movement Assessment Battery for Children (MABC and
MABC-2), the Bruininks-Oseretsky Test of Motor Profi-
ciency (BOTMP and BOT-2), the Peabody Developmen-
tal Motor Scales (PDMS and PDMS-2), and the Bayley
Scales of Infant and Toddler Development (BSID, BSID-
II and Bayley-III) (Bayley 1969, 1993, 2006; Bruininks
1978; Bruininks and Bruininks 2005; Folio and Fewell
1983, 2000; Henderson and Sugden 1992; Henderson et al.
2007; Ulrich 1985, 2000). Staples and Reid (2010) used
the TGMD-2 to evaluate the fundamental motor skills of
25 children with ASD in comparison to typically develop-
ing children. Children with ASD scored significantly lower
on both the TGMD-2 locomotor and object control sub-
tests, and their performance was comparable to typically
developing children half their chronological age (Staples
and Reid 2010). Liu et al. (2014) compared the TGMD-2
performance scores of 21 children with ASD, and 21 age-
matched typically developing children. The TGMD-2
scores revealed that the gross motor performances of chil-
dren with ASD were significantly lower than typically
developing peers, with 91% of ASD participants displaying
impaired gross motor performance (Liu et al. 2014).
In related research, the MABC-2 was used to identify
differences between the fine and gross motor performances
of 30 children with ASD and 30 age-matched typically
developing children (Liu and Breslin 2013a). Liu and Bres-
lin (2013a) reported that 77% of participants with ASD
demonstrated motor impairments, and that a significant
difference was shown between the MABC-2 performance
scores of children with ASD and the MABC-2 perfor-
mance scores of typically developing children. Dewey et al.
(2007) compared the BOTMP scores of children and ado-
lescents with ASD, developmental coordination disorder
(DCD), attention deficit hyperactivity disorder (ADHD),
and typically developing children. The overall BOTMP
scores for the ASD group were significantly lower than
the other groups, and identified that 59% of the 49 partici-
pants with ASD had deficits in motor performance (Dewey
et al. 2007). The fine and gross motor skills of 19 children
with ASD were assessed using both the BSID-II and the
PDMS-2 (Provost et al. 2007). Provost et al. (2007) showed
that all children with ASD had a delay in motor perfor-
mance to some degree, with 84% of participants exhibiting
significant delays on the BSID-II and 95% attaining below
average on the PDMS-2.
Despite the extensive use of movement skill assessments
in ASD research, the validity and reliability of these assess-
ments do not take into consideration individuals with ASD,
with the exception of the BOT-2 and the Vineland Adap-
tive Behavior Scales, Second Edition (Vineland-II), which
13
J Autism Dev Disord
have both been validated for ASD populations (Bruininks
and Bruininks 2005; Cools et al. 2009; Lavay and Lasko-
McCarthey 1992; Sparrow et al. 2005; Staples et al. 2012).
Studies have suggested that the reduced motor perfor-
mance observed among children with ASD may not exclu-
sively be the result of impaired motor functioning or a lack
of competency in fundamental motor skills, but rather a
misunderstanding of task requirements (Berkeley et al.
2001; Bhat et al. 2011; Green et al. 2009; Staples and Reid
2010). Green et al. (2009) proposed that the motor perfor-
mance results of children with ASD may be compromised
as a result of their inability to comprehend verbal instruc-
tions and follow physical demonstrations that are provided
during movement skill assessments. Staples and Reid
(2010) recognized that children with ASD had difficulty
interpreting verbal instructions that were provided during
TGMD-2 assessments and that physical demonstrations
alone were not reliable in facilitating task understanding
or performance. The assessment protocol was adapted to
simplify the complexity of the verbal instructions presented
and physical guidance techniques were implemented,
resulting in improved TGMD-2 performance scores (Sta-
ples and Reid 2010). In addition, Berkeley et al. (2001)
observed that during the completion of the TGMD-2, chil-
dren with ASD disregarded verbal instructions and physical
demonstrations during locomotion tasks. Instead, children
with ASD performed locomotion tasks placing emphasis
on achieving the task objective (i.e., moving from one cone
to the indicated cone) rather than focusing on the move-
ment execution to achieve that goal (e.g. skipping).
Consequently, when administering motor assessment
instruments, these aspects should be taken into account. In
order to ensure reliability, the focus should lie on reducing
barriers towards understanding of task instructions. Previ-
ous research had suggested that additional visual support
might be useful in order to enhance understanding and
results in improvement of the motor performance scores
(Breslin and Liu 2015).
Many children with ASD also exhibit impaired cogni-
tive function and experience delays in the development of
expressive and receptive communication skills (Bhat et al.
2011; Dziuk et al. 2007; Ghaziuddin and Butler 1998;
Green et al. 2009; Whyatt and Craig 2012). Research has
shown that deficits in cognitive ability and language devel-
opment are highly correlated with the severity of motor
impairments in children with ASD as a result of a misun-
derstanding of task requirements (Bhat et al. 2011; Dziuk
et al. 2007; Ghaziuddin and Butler 1998; Green et al. 2009;
Whyatt and Craig 2012). Ghaziuddin and Butler (1998)
observed the fine and gross motor skills of children with
ASD using the BOTMP and found a significant relation-
ship between BOTMP performance scores and intelligence
quotient (IQ). However, the correlation between IQ and
J Autism Dev Disord
BOTMP performance scores was not significant, suggest-
ing that cognitive ability is the main perpetrator of motor
impairments in children with ASD.
Deficits in communication and cognitive function among
children with ASD contributes to a reduced comprehension
of auditory information, body language, movement imi-
tation and expressive gestures (Dewey et al. 2007; Green
et al. 2009; Zachor et al. 2010). As a result, task under-
standing is jeopardized, impacting motor skill acquisition
and consequently, affecting performance on movement
skill assessments (Green et al. 2009). This demonstrates
the importance of ensuring movement skill assessments
are suitably adapted to facilitate task understanding among
children with ASD.
Movement assessment tasks are typically explained
using a combination of physical demonstrations and ver-
bal instructions, and therefore do not take into considera-
tion the communication difficulties of children with ASD.
Studies have shown, however, that an improved understand-
ing of task requirements and an accurate measure of motor
performance for children with ASD can be facilitated by
minimizing the degree of verbal instructions provided and
incorporating the use of visual supports (Breslin and Rud-
isill 2011; Liu and Breslin 2013b). Breslin and Rudisill
(2011) demonstrated that the addition of picture task cards
to the TGMD-2 protocol enhanced task understanding and,
as a result, significantly increased the gross motor perfor-
mance of children with ASD compared to the TGMD-2
traditional protocol. Furthermore, Liu and Breslin (2013b)
found that the incorporation of a picture activity schedule
protocol significantly improved the MABC-2 scores of
children with ASD by approximately 20% compared to the
MABC-2 traditional protocol.
It has been shown that children with ASD respond better
to visual stimuli when compared with verbal communica-
tion methods (Fittipaldi-Wert and Mowling 2009; Houston-
Wilson and Lieberman 2003; Quill 1995; Rao and Gagie
2006; Tissot and Evans 2003). They tend to disassociate
with verbal instructions and prefer to process information
with the use of visual supports, which allows for easier
cognitive understanding, improving memory retention,
concentration, communication, stereotypical behavior, skill
development and social interactions (Fittipaldi-Wert and
Mowling 2009; Green and Sandt 2013; Houston-Wilson
and Lieberman 2003; Meadan et al. 2011; Quill 1995; Rao
and Gagie 2006; Schultheis et al. 2000; Tissot and Evans
2003; Waugh et al. 2007). Visual supports also assist with
predictability and create an ordered and structured learn-
ing environment, which in turn reduces levels of anxiety
in children with ASD (Fittipaldi-Wert and Mowling 2009;
Houston-Wilson and Lieberman 2003; Meadan et al. 2011;
Menear and Smith 2011; Quill 1995; Rao and Gagie 2006;
Schultheis et al. 2000).
The inclusion of visual supports in movement skill
assessments may help to establish a valid and reliable
assessment instrument for children with ASD that provides
instructional information in a preferable format, which
would facilitate a more accurate measure of motor perfor-
mance. A valid and reliable movement skill assessment that
incorporates a visual support protocol is yet to be devel-
oped for children who have difficulty processing auditory
information, such as children with ASD (Bruininks and
Bruininks 2005). The purpose of this study is to measure
aspects of validity and reliability of the Test of Gross Motor
Development-3 (Ulrich 2016: TGMD-3, http://www.kines.
umich.edu/tgmd3) for assessing the gross motor perfor-
mance of children with ASD, with the inclusion of a visual
support protocol, to facilitate task understanding, compared
to age-matched typically developing children.
The TGMD-3 is a process-orientated assessment that is
designed to assess the gross motor performance of young
children, aged 3–10 years (Ulrich 2016, http://www.kines.
umich.edu/tgmd3). The assessment includes a selection of
locomotor skills and ball skills that represent fundamental
motor skills that are commonly taught in primary physical
education curriculum on an international scale. A critical
function of the TGMD-3 is to identify delays and deficits
in gross motor development in early childhood, as well as
serving as a research tool to explore and compare the gross
motor development of both typically developing children
and children with atypical movement function (Ulrich
2016, http://www.kines.umich.edu/tgmd3).
The previous editions of the TGMD-3, the TGMD-2 and
the TGMD, have not included a visual support protocol and
have only been validated using U.S. normative data for typ-
ically developing children (Evaggelinou et al. 2002; Kim
et al. 2014; Ulrich 1985, 2000; Valentini 2012), children
with Down syndrome (Ulrich 2000), visual impairments
(Houwen et al. 2010), hearing impairments (Dummer
et al. 1996) and for children with intellectual disabilities
who exhibit cognitive processing difficulties (Simons et al.
2007). However, these conclusions cannot be generalised
for the revised TGMD-3 protocol or for use among indi-
viduals with ASD (Yun and Ulrich 2002).
This study will measure aspects of construct validity and
reliability of the TGMD-3 for children with ASD and age-
matched typically developing children under two assess-
ment conditions; (a) TGMD-3 traditional protocol, and
(b) TGMD-3 visual support protocol. To the researcher’s
knowledge, this will be the first study to examine aspects
of validity and reliability of the TGMD-3 for children
with ASD and with the inclusion of a visual support pro-
tocol to establish whether this addition facilitates a better
task understanding, consequently improving motor perfor-
mance. The reliability of the TGMD-3 for measuring the
gross motor performance of children with ASD (TGMD-3
13

traditional protocol and TGMD-3 visual support protocol)
and typically developing children (TGMD-3 traditional pro-
tocol only) will be established by determining the internal
consistency, test–retest reliability, interrater reliability and
intrarater reliability. We hypothesized that acceptable lev-
els of internal consistency, test–retest reliability, interrater
reliability and intrarater reliability will be achieved for both
the TGMD-3 traditional protocol and the TGMD-3 visual
support protocol for children with ASD, and the TGMD-3
traditional protocol for typically developing children.
To support aspects of construct validity of the TGMD-3
raw scores for children with ASD and typically developing
children. We hypothesized that the TGMD-3 raw scores of
age-matched typically developing children will be signifi-
cantly greater than the TGMD-3 traditional protocol raw
scores of children with ASD. Furthermore, we hypoth-
esized that the TGMD-3 visual support protocol will pro-
duce significantly greater TGMD-3 raw scores than the
TGMD-3 traditional protocol for children with ASD.
Competency in fundamental movement skills has been
shown to follow a developmental trajectory, with motor
performance improving with chronological age (McKenzie
et al. 2002; Okely and Booth 2004; Williams et al. 2008;
Ulrich 2000). We hypothesized that a strong correlation
between chronological age and TGMD-3 raw scores will
be observed in typically developing children. Children with
ASD are believed to follow a similar developmental trajec-
tory to typically developing children. However, improve-
ments in fundamental movement skills are obtained at
a slower rate than typically developing peers (Hauck and
Dewey 2001; Landa and Garrett-Mayer 2006; Lloyd et al.
2011; Staples and Reid 2010). As a result, we hypothe-
sized that a correlation between TGMD-3 raw scores and
chronological age will occur for children with ASD in the
TGMD-3 traditional protocol and TGMD-3 visual pro-
tocol, while also indicating that the difference between
the TGMD-3 raw scores for children with ASD and the
TGMD-3 raw scores of typically developing children will
become more prominent with chronological age.
Methods
Participants
Participants for the ASD sample were obtained through a
convenience sampling approach. Fourteen children with
ASD, aged between 4 and 10 years, were recruited. Chil-
dren were included in the ASD sample if they were: (a)
aged between 3.0 and 10.11 years at the time of data col-
lection, (b) had a primary diagnosis of ASD in accordance
with the DSM-V guidelines, (c) had no associated diag-
nosis other than ASD and (d) did not have an impairment
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J Autism Dev Disord
or injury that restricted participation in physical activ-
ity. Using a snowball sampling method (Biernacki and
Waldorf 1981), 21 typically developing children, aged
between 4 and 10 years, were recruited. A large propor-
tion of the typically developing participants were siblings
of children in the ASD sample (N = 9) and the remainder
were recruited through parent referral, predominantly
friends and classmates of children already participating
in the study (N = 12). Children were included in the typi-
cally developing sample if they were: (a) aged between 3.0
and 10.11 years at the time of data collection and (b) did
not have an illness or injury that restricted participation in
physical activity.
Ethical clearance was received from the human ethics
committee of the School of Human Movement Studies,
University of Queensland (UQ), and all procedures of the
study complied with the ethical guidelines outlined by UQ
and the ‘National Statement on Ethical Conduct in Human
Research’. Legal guardians provided written informed con-
sent and participant medical information on behalf of the
study participants prior to the commencement of data col-
lection. Verbal agreement was obtained from each partici-
pant at the beginning of the testing session. Participants’
TGMD-3 assessment results were made available to their
legal guardians once the study had been completed.
An overview of the demographics for ASD and typi-
cally developing groups are summarized in Tables 1 and 2,
and are categorized based on the assessment protocol per-
formed (i.e. TGMD-3 typical protocol or TGMD-3 visual
support protocol). Participants’ socioeconomic status (SES)
was established using the residential postcodes provided.
The ASD and typically developing groups were matched
by chronological age (within a 3 month window) and sex
to accurately evaluate the relationship between ASD and
typically developing motor performance. Ten pairs met
this criteria (≤1 month N = 6, ≤3 months N = 10), whereas
four pairs had age differences that ranged between 4 and
9 months. A diagnosis of ASD, as defined in the DSM-V
guidelines, was provided predominantly by pediatricians,
psychiatrists and psychologists and confirmed based on
medical information reported by the legal guardian on the
participants’ medical screening form and supporting docu-
mentation provided (APA 2013).
Instrument
Participants’ gross motor performances were evaluated
using the TGMD-3. Motor performance is observed and
evaluated based on predetermined qualitative performance
criteria that represent each TGMD-3 assessment item.
Scores are determined for each respective criterion based
on whether the criterion was fulfilled (score awarded = 1)
or not (score awarded = 0) (Ulrich 2016, http://www.kines.
J Autism Dev Disord

Table 1  Demographic data of Interrater and intrarater reli- Test–retest reliability Aspects of validity (visual
ASD participants ability, internal consistency vs. traditional protocol
and aspects of validity only)
Traditional Visual Traditional Visual Traditional Visual
N = 14 N = 12 N=8 N=8 N = 12 N = 12

Age (months)
M (SD) 89.1 (24.4) 93.9 (22.6) 98.4 (25.4) 98.4 (25.4) 93.9 (22.6) 93.9 (22.6)
Range 52–131 60–131 60–131 60–131 60–131 60–131
Sex, n (%)
Male 10 (71.4) 8 (66.7) 6 (75.0) 6 (75.0) 8 (66.7) 8 (66.7)
Female 4 (28.6) 4 (33.3) 2 (25.0) 2 (25.0) 4 (33.3) 4 (33.3)
Ethnicity, n (%)
Caucasian 12 (85.7) 10 (83.3) 7 (87.5) 7 (87.5) 10 (83.3) 10 (83.3)
Asian 2 (14.3) 2 (16.7) 1 (12.5) 1 (12.5) 2 (16.7) 2 (16.7)
SES, n (%)
Upper 6 (42.9) 6 (50.0) 4 (50.0) 4 (50.0) 6 (50.0) 6 (50.0)
Middle 7 (50.0) 5 (41.7) 3 (37.5) 3 (37.5) 5 (41.7) 5 (41.7)
Lower 1 (7.1) 1 (8.3) 1 (12.5) 1 (12.5) 1 (8.3) 1 (8.3)

SES socioeconomic status; Traditional TGMD-3 traditional protocol; Visual TGMD-3 visual support pro-
tocol

Table 2  Demographic Interrater and intrarater reliability, inter- Test–retest reliability Aspects of validity
data of typically developing nal consistency and aspects of validity (TD vs. ASD only)
participants
Traditional (N = 21) Traditional (N = 17) Traditional (N = 14)

Age (months)
M (SD) 88.0 (21.0) 90.3 (20.8) 88.9 (23.8)
Range 49–125 49–125 49–125
Sex, n (%)
Male 12 (57.1) 10 (58.8) 10 (71.4)
Female 9 (42.9) 7 (41.2) 4 (28.6)
Ethnicity, n (%)
Caucasian 20 (95.2) 16 (94.1) 14 (100.0)
Asian 1 (4.8) 1 (5.9) 0 (0.0)
SES, n (%)
Upper 15 (71.4) 12 (70.6) 10 (71.4)
Middle 6 (28.6) 5 (29.4) 4 (28.6)
Lower 0 (0.0) 0 (0.0) 0 (0.0)

umich.edu/tgmd3). Two trials are completed for each motor Procedures

skill item and scored accordingly (Ulrich 2016, http://www.
kines.umich.edu/tgmd3). The total score for each item is
established by the summation of all performance criteria
scores for both trials, which are accumulated to determine
the total locomotor and ball skills subtest scores and the
overall TGMD-3 raw score for gross motor performance
(Ulrich 2016, http://www.kines.umich.edu/tgmd3). The
maximum score a participant can obtain on the TGMD-
3, for the locomotor subtest, ball skills subtest and overall
gross motor performance, is 46, 54 and 100, respectively
(Ulrich 2016, http://www.kines.umich.edu/tgmd3).
Testing sessions were completed in an indoor gymna-
sium at the School of Human Movement Studies, UQ.
Two TGMD-3 assessment protocols were administered
to ASD participants across two consecutive days, includ-
ing; (a) TGMD-3 traditional protocol, where assessment
items were demonstrated using a combination of physical
and verbal instructions, and (b) TGMD-3 visual support
protocol, where assessment items were explained using
a combination of picture cards, short verbal prompts and
physical demonstrations. To minimize the possibility of a

13

carryover effect influencing performance results, the order
of protocol delivery was counterbalanced and performed in
random sequence. Protocol randomization was determined
by a fair coin flip (tails equaled traditional protocol, heads
equaled visual protocol) and were divided evenly within the
ASD group by chance (N = 7 commenced with the tradi-
tional protocol, N = 7 commenced with the visual support
protocol). Typically developing participants were assessed
using the TGMD-3 traditional protocol only. For test–retest
reliability the TGMD-3 assessment protocol/s were admin-
istered to a selection of ASD (N = 8) and typically devel-
oping participants (N = 17) who repeated the assessment/s
under identical testing conditions to the initial testing ses-
sions, approximately 1–2 weeks later. Where possible, the
TGMD-3 was administered at the same time and day of the
week as the participants’ initial testing session/s to elimi-
nate external factors influencing performance results.
Participants were familiarized with the testing envi-
ronment and procedures before commencing each test-
ing session. In addition, ASD participants were provided
with social stories at least 1 week prior to testing, includ-
ing images of the testing environment, equipment and the
research team (Bryan and Gast 2000). Strategies were intro-
duced to minimize distractions and stimulate participation.
These included consistent room setup, reward systems,
activity schedule, individual assessment, and the use of 13
color-coordinated activity station markers for positioning
during demonstrations. A 45 min period was provided for
ASD participants to complete the testing sessions, based
on previous recommendations and taking into considera-
tion the inclusion of an additional test item and the use of
visual supports (Pan et al. 2009). A 30 min time frame was
allocated for the typically developing group based on previ-
ous recommendations and the addition of the extra test item
(Ulrich 2000).
All TGMD-3 assessment trials, excluding practice trials,
were videotaped for data evaluation. A series of computer-
generated Picture Communication Symbols (PCS) were
displayed as one picture card for each TGMD-3 assessment
item, representing the performance criteria for the respec-
tive motor skill (see Appendix for the visual supports used
in the TGMD-3 visual support protocol). Before a physi-
cal demonstration was provided for an assessment item
in the TGMD-3 visual support protocol, a picture card
was presented on a hand-held display board (dimensions:
21 × 30 cm) and the Velcro picture card was removed by
the child once an understanding of the assessment item was
acquired.
The TGMD-3 was administered individually to each
participant by the principal investigator and two research
assistants, all of whom were familiar with the purpose
of the study. To ensure interrater-reliability, one of the
research assistants received additional training in the
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J Autism Dev Disord
TGMD-3 standardized scoring procedures. To ensure
scoring precision and consistency and that agreement
was established between the principal investigator and
the research assistant, TGMD-3 performance videos
of typically developing children (used for training pur-
poses only) were analyzed in detail and then scored inde-
pendently. Before analysis of participants’ videotaped
TGMD-3 performances could be completed, scoring
was repeated on the training videos until at least a 90%
concurrence was achieved between the two raters on two
successive days. To measure interrater reliability, the
principal investigator and the trained research assistant
independently scored all typically developing (N = 21)
and ASD (TGMD-3 traditional protocol N = 14, TGMD-3
visual support protocol N = 12) participants’ videotaped
performances using the same TGMD-3 scoring criteria.
To determine intrarater reliability, the principal investiga-
tor repeated scoring procedures for the same videotaped
performances of all typically developing and ASD par-
ticipants, approximately 1 month after the initial scoring
had been completed.
Data Analysis
Video analysis software, Dartfish (version 7.0), was used
to evaluate the videotaped TGMD-3 performances. To
minimize the risk of the examiners’ knowledge of results
influencing the data collection process, TGMD-3 per-
formances for the typically developing and ASD groups
were evaluated only after all participants had completed
testing. As international normative data for the TGMD-3
is currently under review, TGMD-3 standard scores, per-
centiles, age equivalent scores, and gross motor quotient
scores could not be used for analysis in this study. As a
result, participants’ TGMD-3 locomotor and ball skills
subtest raw scores, and overall gross motor performance
raw scores were interpreted as the principal depend-
ent variables. Statistical Package for the Social Sciences
(SPSS, software version 22.0, IBM Corp, 2013) was used
to perform statistical analysis to investigate aspects of
validity and reliability for the TGMD-3 traditional and
visual support protocols for both the typically developing
and ASD groups. A significance level was established at
α = 0.05.
The Shapiro–Wilk test of normality was used to examine
the distribution of the TGMD-3 performance data applied
for the analysis of aspects of validity and reliability (Sha-
piro and Wilk 1965). As the assumptions required for the
application of parametric analysis was predominantly met,
parametric tests were used to evaluate aspects of validity
and reliability for the TGMD-3 traditional and visual sup-
port protocols.
J Autism Dev Disord
Reliability
Cronbach’s coefficient alpha was used to evaluate the inter-
nal consistency of the TGMD-3 locomotor and ball skills
subtests and total gross motor performance for the typically
developing (TGMD-3 traditional protocol) and ASD groups
(TGMD-3 traditional protocol and TGMD-3 visual support
protocol) (Cronbach 1951). According to the coefficient
alpha size guidelines recommended by Nunnally (1978)
and Cicchetti and Sparrow (1990), correlations ≥0.70 are
interpreted as acceptable levels of internal consistency;
correlations ranging from 0.80 to 0.89 demonstrate a good
level of clinical significance, and ≥0.90 as excellent (Cic-
chetti 1994; Cicchetti and Sparrow 1990). An estimation of
the standard error of measurement (SEM) was calculated,
using the Cronbach’s alphas calculated for internal consist-
ency to determine the accuracy of the scores obtained for
the TGMD-3 locomotor and ball skills subtests and overall
gross motor performance (Weir 2005).
Interrater, intrarater and test–retest reliability of the
TGMD-3 locomotor and ball skills subtests and TGMD-3
overall gross motor performance scores were assessed
using the intra-class correlation coefficient (ICC) and
corresponding 95% confidence intervals (McGraw and
Wong 1996; Shrout and Fleiss 1979; Weir 2005). A two-
way random, single-measures ICC (model 2,1) was used
to estimate the degree of absolute agreement between the
examiners’ measures of participants TGMD-3 raw scores
(McGraw and Wong 1996; Shrout and Fleiss 1979; Weir
2005). The following criteria for intra-class correlations
were used: a reliability coefficient of <0.40 demonstrates a
poor level of clinical significance, fair when the reliability
coefficient is between 0.40 and 0.59, good when between
0.60 and 0.74, and an excellent level of clinical significance
when between 0.75 and 1.00 (Cicchetti and Sparrow 1981).
SEMs were also determined using the interrater, intrarater
and test–retest reliability coefficients for the TGMD-3 loco-
motor and ball skills subtests and TGMD-3 overall gross
motor performance scores (Weir 2005).
Validity
A two tailed paired t test was used to analyze the differ-
ence between the TGMD-3 traditional protocol perfor-
mance raw scores and the TGMD-3 visual support protocol
performance raw scores of the ASD group. Effect size (d)
was calculated, using the standard deviations and means
from the TGMD-3 performance raw data, to establish the
magnitude of the difference (Durlak 2009). Effect sizes
were interpreted in compliance with Cohen’s (1988) rec-
ommendations for effect size i.e. small d < 0.20, medium
d = 0.20–0.50, large d = 0.50–0.80, very large d ˃ 0.80. Pear-
son product-moment correlation coefficient (Pearson’s r)
was determined to further evaluate the association between
the TGMD-3 traditional protocol performance scores and
TGMD-3 visual support protocol performance scores for
the ASD group.
To further demonstrate the construct validity of the
TGMD-3 a two tailed independent t test was used to meas-
ure the difference between the TGMD-3 traditional pro-
tocol performance scores of the typically developing and
ASD groups. Effect size (d) and corresponding 95% con-
fidence intervals were established to observe the extent of
the difference. A point-biserial correlation was calculated
to further assess the relationship between the typically
developing and ASD groups’ TGMD-3 traditional proto-
col performance scores. A two tailed paired t test was also
performed to observe the difference between the TGMD-3
traditional protocol performance scores of the chronologi-
cally aged matched pairs (TD Age M = 88.9; ASD Age
M = 89.1). The Pitman-Morgan test was executed to estab-
lish the homogeneity of the variances (Morgan 1939; Pit-
man 1939). In addition, effect size (d) and corresponding
95% confidence intervals were calculated.
Pearson’s r was used to evaluate the correlation between
TGMD-3 gross motor performance scores and chrono-
logical age for both the typically developing (TGMD-3
traditional protocol) and ASD groups (TGMD-3 tradi-
tional protocol and TGMD-3 visual support protocol).
As assumptions necessary for the application of the inde-
pendent t test were not met, including unequal group vari-
ances and sample sizes, the relationship between TGMD-3
gross motor performance scores and sex for both the typi-
cally developing (TGMD-3 traditional protocol) and ASD
groups (TGMD-3 traditional protocol and TGMD-3 visual
support protocol) were analyzed using the Welch’s t test
(Kohr and Games 1974; Welch 1947).
Results
Reliability
Table 3 illustrates the resultant Cronbach’s coefficient
alphas and associated SEMs for the TGMD-3 subtests and
TGMD-3 overall gross motor performance scores for the
typically developing and ASD groups. The corresponding
average Cronbach’s coefficient alphas and rounded SEMs
for the TGMD-2 are also presented in Table 3 for compari-
son with the TGMD-3 results of this study (Ulrich 2000).
Acceptable levels of internal consistency were obtained for
the TGMD-3 locomotor and ball skills subtests, and overall
gross motor performance of both the typically developing
(TGMD-3 traditional protocol) and ASD groups (TGMD-3
traditional protocol and TGMD-3 visual support protocol),
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 J Autism Dev Disord

Table 3  Internal consistency of the TGMD-3 subtests and over- (TGMD-3 traditional protocol) and ASD groups (TGMD-3
all gross motor performance for the typically developing and ASD traditional protocol and TGMD-3 visual support protocol).
groups
For interrater reliability, excellent levels of rater agree-
TGMD-3 Cronbach’s alpha SEM ment were established for the TGMD-3 subtests and
Typically developing (N = 21)
TGMD-3 overall gross motor performance for both the typ-
Locomotor skills 0.70 3.20
ically developing (TGMD-3 traditional protocol) and ASD
Ball skills 0.60 3.86
groups (TGMD-3 traditional protocol and TGMD-3 visual
Overall 0.74 5.18
support protocol). Furthermore, the intrarater reliability
ASD—Traditional (N = 14)
demonstrated excellent levels of agreement between the
Locomotor skills 0.82 3.90
principal investigators’ repeated analysis of the TGMD-3
Ball skills 0.75 4.63
performances for all typically developing (TGMD-3 tradi-
Overall 0.88 6.03
tional protocol) and ASD participants (TGMD-3 traditional
ASD—Visual (N = 12)
protocol and TGMD-3 visual support protocol). All corre-
Locomotor skills 0.93 3.28
lation coefficients demonstrated narrow confidence inter-
Ball skills 0.81 4.39
vals to further support the excellent agreement achieved.
Overall 0.93 5.73
TGMD-2 (N = 1208)
Validity
Locomotor skills 0.85 1.00
Ball skills 0.88 1.00
A statistically significant difference was shown between
Overall 0.91 5.00
the TGMD-3 traditional protocol and TGMD-3 visual
support protocol for the ASD group. Table 5 illustrates
SEM standard error of measurement; Overall overall gross motor that the TGMD-3 subtests and overall gross motor perfor-
performance. TGMD-3 traditional protocol (typically developing).
mance scores for the ASD group when assessed using the
TGMD-3 traditional protocol (ASD). TGMD-3 visual support proto-
col (ASD) TGMD-3 visual support protocol were significantly larger
than the TGMD-3 traditional protocol. Moderate effect
sizes were established, additionally supporting the differ-
with the exception of the ball skills subtest in the typically ence between performance scores for the TGMD-3 locomo-
developing group. tor and ball skills subtests, and overall gross motor perfor-
Table 4 summarises the ICC reliability coefficients mance, with d = 0.50 (−0.32, 1.31), d = 0.26 (−0.54, 1.07),
and corresponding 95% confident intervals, and SEMs, and d = 0.40 (−0.41, 1.21), respectively (Cohen 1988).
for test–retest, interrater and intrarater reliability of the Furthermore, there were very strong positive correlations
TGMD-3 for both the typically developing and ASD between the performance scores of the TGMD-3 traditional
groups. Excellent levels of agreement for test–retest reli- protocol and the TGMD-3 visual protocol in the locomo-
ability were achieved for both the typically developing tor subtest, r(10) = 0.94, p < 0.001, 95% CI (0.80, 0.98),

Table 4  Test–retest, interrater ASD—visual ASD—traditional Typically developing

and intrarater reliability of the
TGMD-3 subtests and overall ICC 95% CI SEM ICC 95% CI SEM ICC 95% CI SEM
gross motor performance for
typically developing and ASD Test–retest N=8 N=8 N = 17
group Locomotor 0.92 (0.65, 0.98) 2.99 0.92 (0.65, 0.98) 2.24 0.81 (0.54, 0.93) 2.22
Ball skills 0.83 (0.39, 0.96) 2.83 0.82 (0.31, 0.96) 2.93 0.84 (0.62, 0.94) 2.45
Overall 0.92 (0.66, 0.98) 4.62 0.91 (0.63, 0.98) 4.06 0.92 (0.78, 0.97) 2.72
Interrater N = 12 N = 14 N = 21
Locomotor 0.98 (0.94, 1.00) 1.75 0.98 (0.92, 0.99) 1.30 0.91 (0.79, 0.96) 1.76
Ball skills 0.96 (0.86, 0.99) 2.02 0.97 (0.91, 0.99) 1.60 0.92 (0.81, 0.97) 1.73
Overall 0.99 (0.95, 1.00) 2.17 0.98 (0.94, 1.00) 2.46 0.94 (0.87, 0.98) 2.49
Intrarater N = 12 N = 14 N = 21
Locomotor 0.99 (0.95, 1.00) 1.24 0.97 (0.88, 0.99) 1.59 0.97 (0.93, 0.99) 1.01
Ball skills 1.00 (0.98, 1.00) 0.71 0.99 (0.96, 1.00) 0.93 0.91 (0.68, 0.97) 1.83
Overall 0.99 (0.98, 1.00) 2.17 0.99 (0.92, 1.00) 1.74 0.95 (0.84, 0.98) 2.27

ICC intra-class correlation coefficient, CI confidence interval, SEM standard error of measurement, Overall
overall gross motor performance

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J Autism Dev Disord

Table 5  Difference between the Visual (N = 12) Traditional t-value df p 95% CI difference
TGMD-3 traditional protocol (N = 12)
and the TGMD-3 visual support
protocol performance scores for M SD M SD
the ASD group
Locomotor skills 26.2 12.4 20.6 9.98 4.24 11 0.001 (2.69, 8.48)
Ball skills 32.7 10.1 30.1 9.73 2.35 11 0.038 (0.17, 5.00)
Overall 58.8 21.7 50.7 18.7 4.21 11 0.001 (3.90, 12.4)

ball skills subtest, r(10) = 0.93, p < 0.001, 95% CI (0.76,
0.98), and overall gross motor performance, r(10) = 0.96,
p < 0.001, 95% CI (0.86, 0.99).
The difference between the TGMD-3 traditional proto-
col performance scores of the typically developing group
and the ASD group were statistically significant. The
results provided in Table 6 show that the TGMD-3 sub-
tests and overall gross motor performance scores for the
typically developing group were significantly larger than
the ASD group. In addition, very large effect sizes for the
TGMD-3 locomotor and ball skills subtests, and overall
gross motor performance were established, d = 1.43 (0.60,
2.26), d = 1.33 (0.51, 2.14), and d = 1.49 (0.65, 2.33),
respectively. Moderate positive correlations between the
TGMD-3 traditional protocol performance scores of the
typically developing group and the TGMD-3 traditional
protocol performance scores of the ASD group were also
shown in the locomotor subtest [r(26) = 0.59, p = 0.001,
95% CI (0.28, 0.79)], ball skills subtest [r(26) = 0.57,
p = 0.002, 95% CI (0.25, 0.78)], and overall gross motor
performance [r(26) = 0.61, p = 0.001, 95% CI (0.31, 0.80)].
Furthermore, when matched in accordance to chronological
age and sex, a statistically significant difference between
the typically developing group and the ASD group was
further highlighted. In this analysis, the typically devel-
oping group scored significantly higher on the TGMD-3
traditional protocol than the ASD group for the locomo-
tor subtest, [t(13) = 3.80, p = 0.002, 95% CI (4.72, 17.1)],
ball skills subtest, [t(13) = 3.36, p = 0.005, 95% CI (3.92,
18.1)], and overall gross motor performance, [t(13) = 3.86,
p = 0.002, 95% CI (9.67, 34.2)].
Moderate to large and statistically significant correla-
tions were established between TGMD-3 gross motor per-
formance scores and chronological age for the typically
developing group in the locomotor [r(19) = 0.46, p = 0.035,
95% CI (0.035, 0.74)] and ball skills [r(19) = 0.83,
p < 0.001, 95% CI (0.62, 0.93)] subtests, and overall gross
motor performance [r(19) = 0.77, p < 0.001, 95% CI (0.51,
0.90)], with TGMD-3 performance scores increasing
with age. Correlations between TGMD-3 traditional pro-
tocol performance scores and chronological age for the
ASD group, however, were non-significant in the locomo-
tor [r(12) = 0.26, p = 0.37, 95% CI (−0.31, 0.69)] and ball
skills [r(12) = 0.14, p = 0.62, 95% CI (−0.42, 0.62)] sub-
tests and overall gross motor performance [r(12) = 0.21,
p = 0.47, 95% CI (−0.36, 0.67)]. Similarly, non-significant
correlations were found between the TGMD-3 visual sup-
port protocol performance scores and chronological age
for the ASD group in the locomotor [r(10) = 0.18, p = 0.58,
95% CI (−0.44, 0.68)] and ball skills [r(10) = 0.16, p = 0.61,
95% CI (−0.46, 0.67)] subtests, and overall gross motor
performance [r(10) = 0.18, p = 0.58, 95% CI (−0.44, 0.68)].
Table 7 illustrates that sex had a non-significant effect
on the TGMD-3 gross motor performance scores for the
typically developing group (TGMD-3 traditional protocol)
and the ASD groups (TGMD-3 traditional protocol and
TGMD-3 visual support protocol). Small effect sizes and
wide confidence intervals further support that TGMD-3
gross motor performance scores were not influenced by
sex for the typically developing group in the locomotor
[d = 0.13, 95% CI (−0.73, 1.00)] and ball skills [d = 0.082,
95% CI (−0.94, 0.78)] subtests, and overall gross motor
performance [d = 0.029, 95% CI (−0.84, 0.89)]. Similar
conclusions were obtained for the ASD group, with small
effect sizes and wide confidence intervals established for
the locomotor [d = 0.27, 95% CI (−0.89, 1.44)] and ball
skills [d = 0.25, 95% CI (−0.91, 1.41)] subtests, and over-
all gross motor performance scores [d = 0.28, 95% CI
(−0.88, 1.45)] of the TGMD-3 traditional protocol. Fur-
thermore, the effect sizes and 95% confidence intervals for

Table 6  Difference between the ASD—tradi- TD—traditional t-value df p 95% CI difference

TGMD-3 traditional protocol tional (N = 14) (N = 14)
performance scores of the
typically developing group and M SD M SD
the ASD group
Locomotor skills 20.6 9.19 31.6 5.85 3.75 26 0.001 (4.94, 16.9)
Ball skills 31.0 9.25 42.0 7.22 3.51 26 0.002 (4.55, 17.4)
Overall 51.6 17.4 73.6 11.5 3.93 26 0.001 (10.5, 33.4)

13
 J Autism Dev Disord

Table 7  Difference between Males Females t-value p value 95% CI difference

TGMD-3 subtests and overall
gross motor performance M SD M SD
scores and sex for the typically
developing group and the ASD Typically developing N = 12 N=9
groups Locomotor skills 30.8 6.03 31.6 5.92 0.31 0.76 (−4.73, 6.34)
Ball skills 41.8 6.94 41.3 5.20 0.19 0.85 (−6.04, 5.04)
Overall 72.6 11.9 72.9 7.98 0.070 0.95 (−8.79, 9.40)
ASD Traditional N = 10 N=4
Locomotor skills 21.4 8.76 18.8 11.4 0.42 0.69 (−19.4, 14.1)
Ball skills 31.7 6.33 29.3 15.7 0.30 0.78 (−26.5, 21.6)
Overall 53.1 13.9 48.0 26.7 0.36 0.74 (−45.6, 35.4)
ASD visual N=8 N=4
Locomotor skills 25.9 11.2 26.8 16.5 0.096 0.93 (−23.5, 25.3)
Ball skills 33.1 7.10 31.8 15.9 0.17 0.88 (−25.5, 22.7)
Overall 59.0 17.3 58.5 31.9 0.029 0.98 (−48.4, 47.4)

the TGMD-3 visual support protocol performance scores
of the ASD group were, d = 0.069, 95% CI (−1.13, 1.27),
d = 0.12, 95% CI (−1.08, 1.32), and d = 0.022, 95% CI
(−1.18, 1.22), respectively.
Discussion
The purpose of this study was to evaluate the psychomet-
ric properties (aspects of construct validity and reliabil-
ity) of the TGMD-3 traditional protocol and the modified
TGMD-3 visual support protocol. In doing so, the aim was
to establish whether the TGMD-3 is suitable in assessing
the gross motor performance of typically developing chil-
dren, and if the inclusion of the TGMD-3 visual support
protocol is an appropriate instrument to accurately measure
the gross motor performance of children with ASD.
Reliability
The results support the hypothesis that the TGMD-3 tra-
ditional protocol and the TGMD-3 visual support protocol
are reliable in measuring the gross motor performance for
typically developing children and children with ASD. The
good levels of internal consistency, and excellent levels of
test–retest, interrater and intrarater reliability achieved for
the typically developing group and using both TGMD-3
protocols for the ASD groups in the current study, are
comparable to previous studies that have observed the
reliability of the TGMD-2 (Barnett et al. 2013; Kim et al.
2014; Ulrich 2000; Valentini 2012). However, formulat-
ing assumptions between the results obtained in this study
and with previous studies would not be entirely accurate as
these studies have used different versions of the TGMD,
sample characteristics, geographical locations and statisti-
cal procedures.
Aside from the differing versions of the TGMD and the
small sample size used in the current study, geographical
location is an influencing factor in the discrepancy between
the internal consistency of the TGMD-3 for the typically
developing sample in this study, and in previous studies.
Cultural tendencies, such as sporting preferences, differ
internationally, and can influence the fundamental motor
skills children learn and develop competency in. In the
United States the prevalence of baseball can contribute to
children being more proficient in skills such as the two-
hand strike in the TGMD, compared to children in Aus-
tralia, where sports like tennis may be more common. This
may have been reflected in the low internal consistency
achieved in the TGMD-3 ball skills subtest for the typically
developing group. This outcome is consistent with previ-
ous studies which have been conducted in countries outside
the United States (Simons and Van Hombeeck 2003). As
normative data for the TGMD-3 is currently not available
internationally, including within Australia, no cultural com-
parisons could be made to determine if the results obtained
in this study are a reflection of the fundamental motor skill
competency of typically developing children in Australia.
Future research is recommended in this area when norma-
tive data becomes available.
The SEMs reported for internal consistency, are consid-
erably larger in this study in comparison to previous stud-
ies that have used the TGMD-2 (Ulrich 2000; Weir 2005).
Increased SEMs were anticipated for children with ASD in
this study, compared to typically developing children, due
to a reduced consistency in their motor performance, which
could be a reflection of an inadequate understanding of the
task requirements. As the SEMs are marginally smaller
in the TGMD-3 visual support protocol compared to the
TGMD-3 traditional protocol for the ASD group, this lends
support to the hypothesis that the inclusion of picture task
cards in the TGMD-3 visual support protocol improves task

13
J Autism Dev Disord
understanding for children with ASD. Although the SEM
values were larger than in previous studies, the average
amount of error in the scores for this study was similar for
both the TGMD-3 traditional protocol and TGMD-3 visual
support protocol.
The test–retest reliability, obtained for both the typi-
cally developing group and ASD groups are consistent with
typically developing populations in earlier studies (Kim
et al. 2014; Ulrich 2000; Valentini 2012). Somewhat larger
SEMs and wider confidence intervals were calculated for
the test–retest reliability of the ASD groups in this study.
The divergence in scores is likely to be associated with the
inconsistency and variation in motor performance which is
typically observed among children with ASD.
The excellent levels of interater reliability established
across the board in this study are in agreement with other
studies that have measured the interrater reliability of the
TGMD-2 for typically developing children (Barnett et al.
2013; Kim et al. 2014; Ulrich 2000; Valentini 2012). In this
study, the majority of ICCs for intrarater reliability for the
typically developing group and ASD groups were higher
than interrater reliability. This finding supports previous
evidence that an examiner is more likely to have higher
scores for the intrarater reliability test, as opposed to the
interrater reliability test, whereby differences in individual
viewpoints and methods between examiners can result in
lower scores (Portney and Watkins 1993).
Validity
In this study, children with ASD achieved significantly
lower raw scores on the TGMD-3 traditional protocol com-
pared to typically developing peers who were matched for
chronological age and sex. This is consistent with existing
studies and literature, whereby children with ASD exhibit
reduced competency in fundamental movement skills
compared to typically developing children (Dewey et al.
2007; Hilton et al. 2007, 2012; Liu and Breslin 2013a; Liu
et al. 2014; Pan et al. 2009; Provost et al. 2007; Staples
and Reid 2010). This verifies the ability of the TGMD-3
to successfully identify children who display deficits in
gross motor performance (Ulrich 2000). Previous editions
of the TGMD-3 have also demonstrated the efficiency of
the assessment instrument and its capacity to distinguish
between the gross motor ability of two divergent groups of
children (Simons et al. 2007; Ulrich 1985, 2000).
The results of this study illustrate that when compared
to the TGMD-3 traditional protocol, the administration of
the TGMD-3 visual support protocol produced significantly
higher raw scores for children with ASD for both the loco-
motor and ball skills subtests, and overall gross motor per-
formance. Of the 12 children with ASD that were tested,
11 showed significant improvements in their gross motor
performance when measured using the TGMD-3 visual
support protocol. The results obtained in this study high-
light the importance of including picture task cards in the
TGMD-3 to improve task understanding and provide an
accurate interpretation of gross motor performance. The
enhanced motor performance achieved using the TGMD-3
visual support protocol in this study is consistent with pre-
vious studies that have modified movement skill assess-
ments with the inclusion of visual supports to accommo-
date for children with ASD (Breslin and Rudisill 2011; Liu
and Breslin 2013b). Liu and Breslin (2013b) found that the
addition of a picture schedule in the MABC-2 significantly
improved the fundamental motor skills of children with
ASD. Furthermore, Breslin and Rudisill (2011) found that
a picture task card protocol produced significantly greater
TGMD-2 performance scores for children with ASD when
compared to the traditional TGMD-2 protocol and a picture
schedule protocol.
Furthermore, the results show a statistically signifi-
cant correlation between the TGMD-3 raw scores and
chronological age for typically developing children, with
TGMD-3 performance improving with age. This has been
demonstrated in previous research, which has shown that
competency in fundamental movement skills improves
with chronological age, highlighting the effectiveness of
the TGMD-3 to identify developmental changes associated
with age among typical developing children (McKenzie
et al. 2002; Okely and Booth 2004; Williams et al. 2008;
Ulrich 2000). In relation to the TGMD-2, Ulrich (2000)
showed comparable results to this study in that the gross
motor performance of typically developing children was
highly associated with chronological age for both loco-
motor (r = 0.69–0.72, p < 0.05) and ball skills subtests
(r = 0.71–0.75, p < 0.05).
Previous studies have also shown that the motor perfor-
mance of children with ASD improves with age, albeit at
a slower rate than their typically developing peers (Hauck
and Dewey 2001; Landa and Garrett-Mayer 2006; Lloyd
et al. 2011; Staples and Reid 2010). In contrast, this study
did not establish a significant correlation between the
TGMD-3 raw scores and chronological age for either ASD
groups (TGMD-3 traditional protocol and TGMD-3 visual
support protocol). Although not comparable with stud-
ies observing the motor development patterns of children
with ASD, the results are comparable to studies of children
with other disabilities that are also associated with delays
in motor development. Simons et al., (2007) found that
the TGMD-2 performance scores for children with intel-
lectual disabilities were not associated with chronological
age for the locomotor subtest (r = 0.16, p = 0.12), however,
a very small correlation was observed for the ball skills
subtest (r = 0.25, p < 0.05). Further research is required to
determine whether the differences in motor development
13

observed in this study are a reflection of the small sample
size, particularly within each age category, or if the motor
development trajectory of children with ASD is inconsist-
ent compared to typically developing children. Another
possibility is that the motor skill development of children
with ASD plateaus and remains in a plateau longer than
typical developing children unless they experience a higher
frequency and intensity of training as they age.
There were no significant differences between the
TGMD-3 raw scores of males and females for the typi-
cally developing group or ASD groups. These results differ
from the literature, which illustrates that the fundamental
motor skill performance of typically developing children
is greatly influenced by gender, particularly for ball skills
(Barnett et al. 2010; Hardy et al. 2010; Okely and Booth
2004; Ulrich 2016). As such, it is believed that the results
obtained in the present study are influenced by the small
sample size. Particularly when compared to studies with a
considerably larger sample size, where there was a marked
difference between male and female TGMD-2 gross motor
performance scores for the ball skills subtest (Parks et al.
1999; Ulrich 2000).
In addition, a reduced number of female participants
recruited for the ASD group of this study could have
affected the test’s capacity to identify a true difference
between TGMD-3 gross motor performance and gender
in the ASD groups. Lloyd et al. (2011) concluded that
no significant differences in fine and gross motor skills
occurred between male and female toddlers with ASD
(p = 0.39). However, these results could have also been
affected by the considerably smaller number of female
participants compared to males in their study. Inconclu-
sive evidence throughout the literature makes it difficult to
confirm whether gender differences in motor performance
exist among children with ASD, partially due to the pre-
dominance of males in the ASD population (CDC 2014).
Further research with larger sample size and female repre-
sentation is required before assumptions can be made about
whether gender contributes to competency of fundamental
movement skills among children with ASD.
Limitations and Future Research
Occasionally during the delivery of the TGMD-3 visual
support protocol it was observed that some children had dif-
ficulty processing the visual information displayed on the
picture task cards. While the majority of participants dem-
onstrated that they understood the picture cards presented,
the combination of a series of PCS (between three and five
PCS per picture card) and a large amount of text may have
been overwhelming and affected TGMD-3 performance.
Research has recommended that picture task cards used in
physical activity environments should be kept simple and
13
J Autism Dev Disord
only display the essential visual information (Fittipaldi-
Wert and Mowling 2009; Grenier and Yeaton 2011; Hou-
ston-Wilson and Lieberman 2003; Waugh et al. 2007). The
overuse of pictures and text on a single picture task card
can be distracting and cause confusion during the process-
ing of the visual information presented (Fittipaldi-Wert and
Mowling 2009; Grenier and Yeaton 2011; Houston-Wilson
and Lieberman 2003; Waugh et al. 2007). Taking this into
account, if a child was having difficulty comprehending the
visual information displayed on the picture card, the prin-
cipal investigator would focus the child’s attention on one
singular image that best depicted each TGMD-3 assess-
ment item to improve understanding.
Furthermore, Meadan et al. (2011) and Schultheis et al.
(2000) recommended that the choice of visual supports
should complement the developmental age of the individ-
ual. This could also explain why some children appeared
overwhelmed by the picture cards provided, as these chil-
dren were in the lower end of the age range and could
not comprehend the text incorporated as they were yet to
achieve reading competency. As this study did not take into
consideration the developmental age of participants, and a
wide chronological age range existed, having both images
and text available on the picture cards catered for all par-
ticipants’ preferred visual learning style and comprehen-
sion level. Reducing the amount of text to singular words
or short phrases that correspond with each PCS may fur-
ther facilitate improved understanding (Menear and Smith
2011). Future researchers, practitioners and authors of
movement skill assessments who are considering the use of
picture task cards and other visual support techniques are
encouraged to adopt a minimalistic approach that is devel-
opmentally appropriate for the population of interest when
designing visual supports to ensure maximum benefits are
obtained.
A lengthy acclimatisation period was unfeasible to
incorporate in the study design. Block et al. (1998) out-
lined the importance of familiarizing children with ASD
to the testing environment, equipment, procedures and
the research team prior to commencing testing in order to
prevent anxiety and distractions influencing performance
results. Breslin and Rudisill (2011) and Whyatt and Craig
(2012) demonstrated the effectiveness of including a famil-
iarization period when using the TGMD-2 and MABC-2
to measure the gross motor performance of children with
ASD. Not only did they find it beneficial in reducing
anxiety and facilitating performance, but it also allowed
researchers to establish a relationship with the child and
become acquainted with the child’s abilities and charac-
teristic mannerisms. If practical, future studies are advised
to include an acclimatisation period in their study design
when testing children with ASD to maximise the child’s
performance.
J Autism Dev Disord
This study did not take into consideration the IQ level,
cognitive function or communication ability of participants
with ASD in comparison to typically developing peers. Pre-
vious research has shown that the severity of gross motor
impairments is related to IQ level and language competency
in children with ASD (Ghaziuddin and Butler 1998; Green
et al. 2009; Whyatt and Craig 2012). It is also thought that
reduced cognitive function may affect the comprehension
of tasks in physical activity environments, further contrib-
uting to delays in gross motor performance (Green et al.
2009). Controlling for these components would clarify the
extent to which task understanding, and consequently gross
motor performance, genuinely improved with the incorpo-
ration of picture task cards in the TGMD-3 visual support
protocol.
Time constraints did not allow for diagnostic assess-
ments to be included in the study design to confirm par-
ticipants’ diagnosis. As a result, a diagnosis of ASD was
established based only on the medical information provided
by participants’ legal guardian. In Australia, children are
generally referred to a paediatrician, psychiatrist and/or a
psychologist for screening and diagnosis of ASD (Skel-
lern et al. 2005). However, the diagnostic procedures and
terminology used for ASD within Australia vary consid-
erably between the different states/territories, and when
compared to overseas practices (Parner et al. 2011; Skel-
lern et al. 2005; Williams et al. 2005). In addition, medi-
cal practitioners in Queensland have reported an increased
incentive to authorise ASD diagnoses so individuals can be
eligible for government benefits, such as funding and spe-
cial education services, despite not meeting all the diagnos-
tic criteria (Skellern et al. 2005). The classification systems
and assessment instruments used also vary among medical
practitioners within Australian states and territories, further
contributing to the conflicting diagnostic procedures (Skel-
lern et al. 2005; Williams et al. 2005).
Within this study, there were a number of limitations
linked to the participant samples which were used. Both the
typically developing group and the ASD groups contained
small sample sizes, including the total participant sample,
and across gender and age categories. The challenge of
obtaining an appropriately sized homogenous sample to
produce meaningful results has been recognized in adapted
physical activity research, including research investigat-
ing the fundamental motor skills of children with ASD
(Berkeley et al. 2001; Breslin and Rudisill 2011; Lavay and
Lasko-McCarthey 1992; Pan et al. 2009; Sutlive and Ulrich
1998). Future research exploring the benefits of the inclu-
sion of visual supports in movement skill assessments to
accurately assess the motor performance of children with
ASD should consider a larger sample size across all gender,
age categories and geographical regions.
Similarly, the inclusion of siblings in this study
accounted for 43% (N = 9) of all participants in the typi-
cally developing sample. Of the nine siblings, one was an
identical twin to a child in the ASD sample and one was
an opposite sex fraternal twin to a child in the ASD sam-
ple. The inclusion of siblings in the typically developing
sample is not believed to have influenced the analysis of the
difference between the TGMD-3 gross motor performance
scores of typically developing children and children with
ASD. All typically developing siblings performed greater
than siblings with ASD, irrespective of chronological age,
including both sets of identical and fraternal twins. Hilton
et al. (2012) uncovered similar results, whereby children
who were undiagnosed with ASD had significantly better
motor performance than their siblings with ASD.
Picture task cards were chosen for use in the TGMD-3
visual support protocol of this study because they are an
economical, portable and easily replicated visual aid, and
have been demonstrated to improve performance on the
TGMD-2 (Breslin and Rudisill 2011; Meadan et al. 2011).
However, future research should consider exploring options
beyond the traditional picture task cards used in this study
to determine the most effective visual approach in facilitat-
ing task understanding in the TGMD-3 and to provide an
accurate measure of gross motor performance. For exam-
ple, electronic tablet applications are regularly used among
children with developmental disabilities, including ASD,
and have been demonstrated as an effective approach in
developing communication skills and encouraging pur-
poseful participation in leisure, academic and employ-
ment environments (Kagohara et al. 2013). It has also been
observed that children with ASD have reduced levels of
motivation to engage in physical activity, which may influ-
ence TGMD-3 performance scores (Obrusnikova and Cav-
alier 2011; Pope et al. 2012). Future studies may also find
it beneficial to observe whether adaptations to the TGMD-3
testing conditions stimulate improved performance, such as
the inclusion of reward systems, verbal encouragement and
goal-directed activities (Lang et al. 2010; Pope et al. 2012;
Reid et al. 2003).
Conclusion
This study demonstrated that the TGMD-3 visual sup-
port protocol is valid and reliable for measuring the
motor performance of children with ASD. The TGMD-3
was modified to incorporate visual supports to facilitate
task understanding and provide a true representation of
their motor performance. Although children with ASD
were found to have reduced motor performance compared
to typically developing peers, the inclusion of visual
13

supports was established as an effective means of improv-
ing their TGMD-3 performance scores.
The application of the visual support protocol demon-
strates the importance of the inclusion of visual supports,
such as picture task cards, in movement skill assessments.
At present, there are no widely available movement skill
assessments which include visual supports for application
among children with developmental disabilities, includ-
ing children with ASD. Due to the tendency of children
with ASD to process tasks visually, assessments of motor
performance that incorporate visual supports can reduce
anxiety levels, facilitate a greater task understanding, and
should be more readily available.
Promoting and highlighting the availability of a valid
and reliable movement skill assessment for children with
ASD will assist health practitioners and physical educa-
tors to obtain a better understanding of the child’s motor
ability to develop more accurate individualized motor
skill interventions. This will generate an improved com-
petency in fundamental motor skills and encourage life-
long physical activity behaviors. As a result, the devel-
opers of movement skill assessments are encouraged to
modify assessment protocols to include visual supports to
assist the performance of children with ASD.
As this study was conducted on a relatively small
scale, with a focus solely on Australian children,
researchers are encouraged to replicate this study on a
broader scale internationally so that the results can be
corroborated and refined to determine additional ben-
efits of visual supports when used as part of the TGMD-
3. A greater sample size consisting of a broader scale of
13
J Autism Dev Disord
ethnicities, gender division and SES would offer a more
conclusive representation of the true potential of visual
supports in assisting children with ASD and other devel-
opmental disabilities.
Author Contributions All authors made a substantial contribu-
tion to the study. The study was designed by KA and JS. JS and DU
supervised the study and KA collected the data. KA and JS conducted
the statistical analyses. All authors contributed to the writing of the
manuscript, and have read and approved the final manuscript.
Compliance with Ethical Standards
Conflict of interest K. Allen, B. Bredero, T. Van Damme, D. Ulrich
and Johan Simons declare they have no conflict of interest.
Ethical Approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed consent Informed consent was obtained from all individ-
ual participants included in the study.
Appendix: TGMD‑3 Visual Supports
The Picture Communication Symbols 1981–2013 by Dyna-
Vox Mayer-Johnson LLC. All Rights Reserved Worldwide.
Used with permission. Adapted by University of Michi-
gan, School of Kinesiology, Centre for Physical Activity &
Health in Pediatric Disabilities (see Figs. 1, 2, 3, 4).
J Autism Dev Disord

Fig. 1  Locomotor skills picture

task cards (run, gallop and hop)

13
 J Autism Dev Disord

Fig. 2  Locomotor skills picture

task cards (skip, horizontal
jump and slide)

13
J Autism Dev Disord

Fig. 3  Ball skills picture task cards (two-hand strike, one-hand forehand strike, dribble and catch)

13
 J Autism Dev Disord

Fig. 4  Ball skills picture task

cards (kick, overhand throw and
underhand throw)

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