Adapted Physical Activity Quarterly, 2017, 34, 1  -18

https://doi.org/10.1123/APAQ.2016-0010
© 2017 Human Kinetics, Inc. ORIGINAL RESEARCH

Balance and Coordination Capacities

of Male Children and Adolescents
With Intellectual Disability
Ken Pitetti and Ruth Ann Miller Michael Loovis
Wichita State University Cleveland State University

Children and adolescents with intellectual disability (ID) exhibit a mixture of cogni-
tive, motor, and psychosocial limitation. Identifying specific inadequacies in motor
proficiency in youth with ID would improve therapeutic management to enhance
functional capacity and health-related physical activity. The purpose of this study
was to initiate descriptive data collection of gross motor skills of youth with ID
and compare those skills with competency norms. The Bruininks-Oseretsky Test
of Motor Proficiency (BOT-2) was used to measure 6 items for balance (BAL),
5 items for upper limb coordination (ULC), and 6 items for bilateral coordina-
tion (BLC) of 123 males (ages 8–18) with ID but without Down syndrome. The
authors performed 2,840 assessments (10–32 for each item); 944, 985, and 913
for BAL, ULC, and BLC, respectively. Mean scores for all age groups for BAL,
ULC, and BLC were consistently below BOT-2 criteria. Overall motor skills of
males with ID are below the competence expected for children and adolescents
without disabilities.

Keywords: Bruininks-Oseretsky Test of Motor Proficiency, gross motor skills, ID

Motor proficiency is determined by qualitatively different aspects of both

gross motor (movement and coordination of limbs, shoulder, pelvic, and trunk
musculature) and fine motor (movement of wrist, hands, fingers, feet, and toes)
development (Bruininks, 1978). Gross motor proficiency involves balance and
coordination of large body parts, and for children and adolescents with and with-
out disabilities, adequate levels of gross motor proficiency contribute positively to
functional capacity and health-related physical activity (Krombholz, 2006; Wall,
2004; Watkinson et al., 2001; Wrotniak, Epstein, Dorn, Jones, & Konditis, 2006).
Although motor proficiency of children and adolescents with intellectual disabili-
ties (ID) has been systematically assessed in Taiwan (Wuang, Lin, & Su, 2009;
Wuang & Su, 2009; Wuang, Wuang, Huang, & Su, 2009) and the Netherlands

Pitetti is with the Dept. of Physical Therapy, and Miller, the Dept. of Electrical Engineering, Wichita
State University, Wichita, KS. Loovis is with the Dept. of Health, Physical Education, Recreation &
Dance, Cleveland State University, Cleveland, OH. Address author correspondence to Ken Pitetti at
ken.pitetti@wichita.edu

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 2  Pitetti, Miller, and Loovis

(Vuijk, Hartman, Scherder, & Visscher, 2010), little research in this domain has
been performed recently in the United States.
The Bruininks-Oseretsky Test of Motor Proficiency (BOT-2) is widely used
to evaluate motor proficiency in children and adolescents (Bruininks & Bruininks,
2005). Specifically, it is used by occupational therapists, physical therapists, and
developmental adapted physical education teachers as a standard for providing
information on motor skills and motor deficits (Flegel & Kolobe, 2002). The
BOT-2 manual reported that youth with ID have lower scores in motor proficiency
concerning balance (BAL), bilateral coordination (BLC), and upper limb coordi-
nation (ULC) than typically developing youth due to deficits in motor functioning
(Bruininks & Bruininks, 2005). However, the number of male participants (37)
and, therefore, the number of assessments in the sample of youth with ID age 5–21
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years was limited (Bruininks & Bruininks, 2005).

Given the limited number of assessments of youth with ID that were evalu-
ated during development of BOT-2 (Bruininks & Bruininks, 2005), Wuang et al.
(Wuang, Lin, & Su, 2009; Wuang & Su, 2009) analyzed the test-scoring system of
the BOT-2 using 446 Taiwanese children and adolescents with ID. Wuang and Su
reported good to excellent test–retest reliability scores for the BOT-2 subtests for
BAL, BLC, and ULC. Test data collected by Wuang, Lin, and Su were analyzed
with Winsteps software using the partial-credit Rasch model for polytomous items,
which was similar to the methodology used to develop the BOT-2 scoring system
(Bruininks & Bruininks, 2005). That is, raw scores were combined to point scores
and point scores were normalized to produce scaled scores. From these test data, a
revised scoring scheme for the BOT-2, called the revBOT-2, was developed specifi-
cally for children and adolescents with ID (Wuang, Lin, & Su, 2009).
An issue when considering the BOT-2 and revBOT-2 concerns scaled scores.
Reporting motor-proficiency scores in a scaled or normative manner (point-score
method) is less sensitive to actual differences than raw scores. For instance, for the
BAL-4 (standing with feet apart on a line, eyes open), a child could balance for
3.1 s and receive a scale score of 2, while another child could balance for 9.8 s and
receive a scale score of 3. Accordingly, raw point scores associated with specific tests
would provide more objective and comparable measurement, as well as affording
better indicators of motor problems and/or motor improvements after treatment,
especially for children with developmental delays (Jobling, 1999; Wilson, Kaplan,
Crawford, & Dewey, 2000; Wilson, Polatajko, Kaplan, & Faris, 1995).
Another limitation in Wuang, Lin, and Su (2009) concerns the number of items
reported. In the BOT-2 for the subtests BAL, BLC, and ULC there are 9, 7, and 7
items, respectively. In conforming to the partial-credit Rasch model, Wuang, Lin,
and Su did not report items if there were fewer than 10 participants per item, if
score data did not monotonically increase by age of participants, and if category
in-fit/out-fit mean-square values deviated from the model prediction. This resulted
in a reduction of items for the BAL, BLC, and ULC to 4, 4, and 3, respectively.
The combination of the ambiguity of scaled scores, the significant reduction in
the number of items reported, and the potential of cultural methodological factors
suggests that measuring motor proficiency of children and adolescents with ID in
the United States using the BOT-2 should be reexamined.
Therefore, the primary purpose of this study was to investigate the BOT-2
and revBOT-2 subtests for BAL, BLC, and ULC for Midwestern male adolescents

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 Balance and Coordination Capacity in Male Youth With ID   3

and children with ID by reporting raw scores of the items stratified for age. The
secondary purpose was to gauge the gross motor capacities of Midwestern male
children and adolescents with ID according to the criteria established by the BOT-2
(Bruininks & Bruininks, 2005). A tertiary purpose involved comparing the results
of the current study with scores reported for the revBOT-2 (Wuang, Lin, & Su,
2009). This latter comparison attempted to determine if differences exist between
Midwestern youth in the United States and Taiwanese youth with ID.

Method
Participants
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A total of 123 males (age 8–18 years) participated in data collection. Participants
were dressed in shorts and a short-sleeve shirt (e.g., T-shirt), and data were collected
in a classroom or gymnasium. The participants were engaged in general classroom
activity before testing. Standing height (cm) and weight (kg) were obtained with
participants not wearing shoes with a portable stadiometer (Seca 214 Portable Height
Rod, Hamburg, Germany) and scale (Healthometer Scale, Model #HDM037–01).
Body-mass index (weight [kg]/height [m]2) was calculated from measured data.
Participant descriptive statistics at the time of testing are found in Table 1.
The participants were from a Midwestern metropolitan area (population
~350,000), and all participants had been classified as having intellectual disability
(ID) by school administrative personnel according to the model of diagnosis by
the American Association on Intellectual and Developmental Disabilities (2010).
Intellectual Quotient (IQ) scores ranged from 45 to 70 (moderate to mild intel-
lectual disability). Although male and female children and adolescents with and
without Down syndrome (DS) were assessed, this study only reports the results
of male participants without DS. Data from male participants with DS and female

Table 1  Descriptive Statistics, M (SD)

Age (years) Height (m) Weight (kg) BMI (kg/m2)
8 (n = 16) 1.34 (0.11) 34.0 (12.7) 18.9 (5.7)
9 (n = 19) 1.35 (0.07) 36.0 (0.4) 19.5 (3.0)
10 (n = 19) 1.43 (0.13) 38.3 (8.6) 18.8 (3.7)
11 (n = 21) 1.52 (0.14) 53.0 (19.7) 23.0 (5.9)
12 (n = 25) 1.56 (0.13) 55.2 (18.5) 22.7 (5.8)
13 (n = 31) 1.60 (0.12) 65.8 (30.2) 25.8 (9.3)
14 (n = 35) 1.63 (0.08) 64.8 (17.8) 24.2 (5.4)
15 (n = 31) 1.70 (0.11) 75.7 (26.9) 26.3 (7.7)
16 (n = 33) 1.70 (0.09) 68.8 (19.2) 23.9 (6.0)
17 (n = 25) 1.70 (0.08) 75.8 (22.2) 26.3 (7.7)
18 (n = 24) 1.75 (0.07) 72.8 (21.6) 23.7 (5.8)
Note. BMI = body-mass index.

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 4  Pitetti, Miller, and Loovis

participants with and without DS were not reported at this time due to an insuf-
ficient number of evaluations.
Participants were chosen from a convenience sample from local public schools
and activity programs for youth with ID. The sample design was purposive in that
participants had to meet the criterion for ID and could not have any known acute
or chronic neuromuscular or joint conditions that would hinder their ability to
perform evaluation maneuvers. Informed parental consent and participant verbal
assent (i.e., answered “yes” when asked to participate) were obtained before par-
ticipation in this study. Approval of this study was obtained from the university’s
institutional review board.

Procedures and Instruments

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Specific items for the BOT-2 subtest used in this study for BAL, BLC, and ULC
can be found in Table 2. Criteria for selecting BOT-2 items for BAL, BLC, and
ULC were based on those identified by Wuang, Lin, and Su (2009) as appropriate
for children with ID and included BAL-4, BAL-5, BAL-7; BLC-1, BLC-4, and
BLC-6; and ULC-1,ULC-3, ULC-5, and ULC-6. The following items were added
to increase our understanding of participants’ gross motor abilities: BAL-1, BAL-2,
and BAL-3; BLC-2, BLC-3, and BLC-7; and ULC -2.
The first author developed and supervised the procedural process for examin-
ers and proctored all evaluations to ensure proper measurements. Eight different
examiners took part in the evaluations. These examiners were in the second year of
their doctor of physical therapy program and had classroom and clinical practice
in neuromuscular interventions. To ensure that the examiners were familiar with
the BOT-2 items of the ULC, BLC, and BAL subtests used in this study, as well
as the mental capacities and behavioral tendencies of this population of youth,
the following procedural protocol was used. All phases were supervised by the
first author.
1. Instructional phase: Examiners practiced (i.e., peer supportive learning) the
BOT-2 items in this phase. Performance and instruction of BOT-2 items was
according to the BOT-2 methodology as demonstrated in the training video
(Bruininks & Bruininks, 2007). The duration of this phase was approximately
90 days, within which 20 instruction and practice hours were completed by each
examiner.
2. Preparatory phase: In this phase, examiners performed live application of
BOT-2 evaluations learned in the instructional phase. For this phase, approxi-
mately 25 children and adolescents (7–18 years) with ID were recruited
from recreational programs supported and administered by organizations for
the disabled in the same geographical area. The duration of this phase was
approximately 45 days.
3. Data-collection phase: All test scores for statistical analysis were collected
during this phase. The duration of this phase was approximately 75 days.
This procedural protocol has been previously established in other physical thera-
peutic evaluations (Pitetti, Miller, & Beets, 2015).
The BOT-2 protocol involves one demonstration and one practice before
evaluation (Bruininks & Bruininks, 2007). However, literature suggests that

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 Balance and Coordination Capacity in Male Youth With ID   5

Table 2  Items for Subtests of the Bruininks-Oseretsky Test of Motor

Proficiency
Score
Subtest Item Title Unit range
ULC 1 Dropping and catching ball, both hands Catches 0–5
2 Catching a tossed ball, both hands Catches 0–5
3 Dropping and catching a ball, one hand Catches 0–5
5 Dribbling a ball, one hand Dribbles 0–10
6 Dribbling a ball, alternating hands Dribbles 0–10
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BAL 1 Standing feet apart on a line, eyes open Seconds 0–10

2 Walking forward on a line Steps 0–6
3 Standing on one leg on a line, eyes open Seconds 0–10
4 Standing with feet apart on a line, eyes closed Seconds 0–10
5 Walking forward heel-to-toe on a line Steps 0–6
7 Standing on one leg on a balance beam, eyes open Seconds 0–10
BLC 1 Touching nose with index finger, eyes closed Touches 0–4
2 Jumping jacks Jumps 0–5
3 Jumping in place, same sides synchronized Jumps 0–5
4 Jumping in place, opposite sides synchronized Jumps 0–5
6 Tapping feet and fingers, same sides synchronized Taps 0–10
7 Tapping feet and fingers, opposite sides synchronized Taps 0–10
Note. ULC = upper limb coordination; BAL = balance; BLC = bilateral coordination.

inferior test scores of coordination and balance displayed by youth with ID may
not reside in their innate motor and coordination capacities but in failing to adopt
cognitive strategies designed to facilitate skill acquisition (Elliott & Bunn, 2004).
Furthermore, literature suggests that when testing for motor skills, it is important
to “structure skill acquisition sessions to optimize the processing of task relevant
information” (Elliott & Bunn, 2004, p. 140). That is, the target movement must be
demonstrated in a manner that is understood clearly by a participant with ID. To
address this concern, each item assessment incorporated a familiarization protocol.
The familiarization protocol involved the following:
1. The movement was demonstrated to the participant twice.
2. The participant practiced the movement twice with prompting.
3. The participant practiced without prompting.
4. The participant performed the movement twice, with the best score used for
data analysis.

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 6  Pitetti, Miller, and Loovis

If, during steps 2 and 3, the child demonstrated that she or he did not understand
the instructions (i.e., did not make an effort to perform the test), no score was taken
for data analysis (i.e., a score of 0 was not given).
Two investigators were assigned per child, with one demonstrating the item
procedures and the other ensuring safety (i.e., preventing falls) and prompting
when necessary. Prompting consisted of manually correcting for the proper place-
ment of limbs. Prompting did not occur when participants performed for data
collection.

Data Analysis
To organize and manage ongoing data collection, a Microsoft Access 2010
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database was developed. Queries were written, and means and standard devia-
tions were calculated for item scores in each subtest. These means and standard
deviations were calculated on data grouped according to age at the time of data
collection. As established by Wuang, Li, and Su (2009) for each age and test-
item group, a minimum of 10 individual assessments (i.e., 10 children) was
required to report data on individual test items. That is, 10 or more evaluations
were necessary in meeting the criteria to fit the expected Rasch model to dif-
ferentiate performance of a child with ID to different levels of motor ability
(Linacre, 1999).
Although reliability for these BOT-2 items for children with ID has previously
been established (Wuang, Li, & Su, 2009; Wuang & Su, 2009), intraclass correla-
tion coefficients (ICC) with 95% confidence intervals (95% CI) were calculated for
BAL, BLC, and ULC test items to determine test–retest reliability in the current
study (Shrout & Fleiss, 1979).
Results reported by Wuang, Li, and Su (2009) and the current study were
compared in the following manner: comparing estimated raw scores reported by
Wuang, Li, and Su with raw scores in present study and degree of difficulty (dif-
ficulty logit) of BOT-2 items reported by Wuang, Li, and Su of the 95% confidence
range of average for all assessments in the current study.
Data were collected over a 4-year period. Some participants were evaluated
two to four times as they advanced in age group (Table 3). Previous work has
established that BOT test scores assessed on a yearly basis are not influenced
by a practice effect in youth with ID (Jobling, 1999; Wuang, Wuang, et al.,
2009).

Table 3  Frequency of Yearly Assessments

Number of times evaluated Participants
1 78
2 26
3 14
4 5

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 Balance and Coordination Capacity in Male Youth With ID   7

Results
The parameters were examined over an age trajectory for motor proficiency from
middle childhood (8–11 years) to adolescence (12–18 years). For each age group,
means and standard deviations and number of assessments for each item in the
BAL, BLC, and ULC subtests are presented in Tables 4, 5, and 6, respectively. Age
groups with less than the minimum of 10 assessments were left blank.
The highest possible score (ceiling score) for each item established by BOT-2
standards appears in Tables 4–6 (Bruininks & Bruininks, 2005). Highest possible
scores are expressed in seconds or number of completed actions (e.g., steps, taps,
touches, jumps, catches, or dribbles). Results are graphically illustrated across age
groups for each item of the BAL, BLC, and ULC subtests in Figures 1–7, which
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are provided as an attachment to the online PDF for this article.

To gauge the gross motor capacities of male children and adolescents with ID
in comparison with criteria established by the BOT-2, the following approach was
developed. The BOT-2 manual provides median point scores graphs for the BAL,
BLC, and ULC subtests (Bruininks & Bruininks, 2005, pp. 58–59). These figures
illustrate that the median subtest scaled total scores reach approximately 85% for
ULC, 92% for BLC, and 95% for BAL of ceiling by 8 years of age and then level
off somewhat above those percentages in the 9- to 21-year-old range. Therefore,
the gray line in Figures 1–7 represents 85% of ULC ceiling, 92% of BLC ceiling,
or 95% of BAL ceiling.

Balance
Results of the six items across age groups for the BAL subtest are found in Table
4 and illustrated in Figures 1 and 2 (see online supplemental PDF). A total 944
assessments were performed. Below-criterion scores for most age groups were
seen in four of the six BAL subtests.

Bilateral Coordination
Results of the six items across age groups for the BLC subtest are found in Table 5
and illustrated in Figures 3–5 (see online supplemental PDF). A total of 985 assess-
ments were performed. With the exception of item BLC-1 (Figure 3), below-criterion
scores were seen for most age groups throughout the BLC subtests.

Upper Limb Coordination

Results for the five items across age groups for the ULC subtest are found in Table
6 and illustrated in Figures 6 and 7 (see online supplemental PDF). A total of 913
assessments were performed. Below-criterion scores were consistently seen for all
groups throughout ULC subtests.

Intraclass Correlation Coefficients

Fifteen to 37 participants performed each of the BOT-2 test items on two different
days, with 3–4 weeks between evaluations. ICCs with 95% CIs for BAL, BLC,
and ULC test items are found in Table 7. An ICC of ≥.80 reflected high reliability;

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8
Table 4  Balance (BAL) Subtest Scores on the Bruininks-Oseretsky Test of Motor Proficiency, M (SD)
BAL-5: walking BAL-7: standing
BAL-1: standing BAL-2: walking BAL-3: standing BAL-4: standing forward on 1 leg on a
with feet apart on forward on a on 1 leg, eyes with feet apart on heel-to-toe balance beam,
a line, eyes open (s) line (steps) open (s) a line, eyes closed (s) on a line (steps) eyes open (s)
Ceiling score 10 6 10 10 6 10
Age (years)
 8 8.4 (2.5) (n = 11) 5.5 (1.0) (n = 15) 7.2 (3.8) (n = 11)
 10 5.9 (3.5) (n = 12) 4.4 (1.9) (n = 17) 5.5 (3.3) (n = 16)
 11 8.0 (3.5) (n = 11) 5.3 (1.3) (n = 12) 6.7 (3.8) (n = 15) 6.7 (3.7) (n = 11) 4.1 (2.2) (n = 15) 4.8 (2.7) (n = 13)
 12 9.4 (2.0) (n = 12) 5.2 (1.5) (n = 12) 7.1 (3.4) (n = 12) 7.7 (3.3) (n = 12) 4.2 (2.1) (n = 18) 4.1 (3.0) (n = 19)
 13 8.9 (3.4) (n = 16) 5.5 (1.2) (n = 16) 7.9 (3.0) (n = 15) 7.7 (3.0) (n = 19) 4.7 (1.9) (n = 27) 5.7 (3.4) (n = 25)

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 14 9.9 (1.3) (n = 18) 5.6 (1.0) (n = 19) 9.2 (1.8) (n = 19) 7.4 (3.0) (n = 25) 4.4 (2.1) (n = 31) 5.6 (3.6) (n = 30)
 15 9.9 (0.5) (n = 15) 5.5 (1.2) (n = 14) 8.3 (2.9) (n = 15) 7.5 (3.0) (n = 19) 4.9 (1.9) (n = 27) 5.8 (3.4) (n = 24)
 16 9.9 (0.4) (n = 20) 5.7 (1.0) (n = 20) 8.7 (2.8) (n = 21) 7.6 (3.3) (n = 23) 4.7 (2.0) (n = 30) 5.6 (3.3) (n = 30)
 17 9.2 (2.5) (n = 19) 5.5 (1.4) (n = 20) 8.6 (3.0) (n = 20) 7.1 (3.5) (n = 22) 5.0 (2.0) (n = 27) 5.3 (3.1) (n = 27)
 18 7.5 (3.3) (n = 11) 4.8 (2.0) (n = 14) 5.0 (3.1) (n = 14)
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Table 5  Bilateral-Coordination (BLC) Subtest Scores on the Bruininks-Oseretsky Test of Motor Proficiency, M (SD)
BLC-3: jumping BLC-4: jumping
BLC-1: touching in place, in place, BLC-6: tapping feet BLC-7: tapping feet
nose with index same sides opposite sides and fingers, and fingers,
finger, eyes BLC-2: jumping synchronized synchronized same sides alternate sides
closed (touches) jacks (jumps) (jumps) (jumps) synchronized (taps) synchronized (taps)
Ceiling score 4 5 5 5 10 10
Age (years)
 8 3.6 (2.0) (n = 11) 3.2 (2.3) (n = 11) 7.5 (3.5) (n = 11)
 10 3.3 (1.2) (n = 18) 2.8 (2.2) (n = 17) 8.6 (2.6) (n = 16)
 11 3.4 (1.5) (n = 14) 4.1 (1.7) (n = 12) 4.1 (1.8) (n = 12) 3.1 (2.1) (n = 14) 8.9 (1.7) (n = 14) 7.6 (3.8) (n = 12)
 12 3.3 (1.3) (n = 19) 3.7 (2.1) (n = 12) 3.8 (1.7) (n = 12) 3.3 (2.0) (n = 18) 8.8 (2.4) (n = 19) 8.0 (3.6) (n = 12)

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 13 3.8 (0.8) (n = 28) 4.6 (1.3) (n = 16) 4.6 (1.3) (n = 16) 3.5 (2.0) (n = 26) 9.4 (1.8) (n = 28) 8.3 (3.5) (n = 16)
 14 3.8 (0.7) (n = 31) 4.6 (1.3) (n = 19) 4.8 (0.5) (n = 19) 3.8 (1.9) (n = 30) 9.3 (2.5) (n = 32) 9.3 (0.9) (n = 19)
 15 3.9 (0.5) (n = 27) 4.8 (0.8) (n = 13) 4.7 (0.6) (n = 13) 3.8 (1.8) (n = 27) 9.5 (1.9) (n = 27) 9.4 (1.0) (n = 14)
 16 3.6 (0.8) (n = 32) 4.2 (1.6) (n = 19) 4.9 (0.2) (n = 19) 3.3 (2.2) (n = 31) 8.9 (2.9) (n = 32) 8.9 (2.3) (n = 20)
 17 3.8 (0.8) (n = 29) 3.7 (2.0) (n = 20) 4.5 (1.3) (n = 19) 3.4 (2.2) (n = 28) 8.9 (2.5) (n = 29) 8.1 (3.0) (n = 20)
 18 4.0 (0.0) (n = 14) 4.0 (1.9) (n = 14) 8.7 (2.6) (n = 14)

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10
Table 6  Upper Limb–Coordination (ULC) Subtest Scores on the Bruininks-Oseretsky Test of Motor Proficiency,
M (SD)
ULC-1: dropping ULC-2: catching ULC-3: dropping ULC-5: dribbling ULC-6: dribbling
and catching a ball, tossed ball, 2 and catching a ball, a ball, 1 hand a ball, alternating
2 hands (catches) hands (catches) 1 hand (catches) (dribbles) hands (dribbles)
Ceiling score 5 5 5 10 10
Age (years)`
 8 3.8(1.2) (n = 12) 4.0(1.6) (n = 11) 5.4(3.9) (n = 12)
 9 4.5 (0.8) (n = 10) 6.0 (3.1) (n = 10)
 10 4.3 (1.2) (n = 17) 3.6 (2.1) (n = 10) 7.9 (2.4) (n = 17) 6.1 (3.9) (n = 10)
 11 4.6 (0.6) (n = 17) 4.1 (1.5) (n = 15) 5.0 (0.0) (n = 12) 7.9 (2.6) (n = 19) 6.5 (3.6) (n = 14)
 12 4.1 (1.3) (n = 19) 4.3 (1.5) (n = 19) 4.8 (0.6) (n = 12) 7.6 (2.9) (n = 21) 6.2 (3.4) (n = 18)

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 13 4.3 (1.4) (n = 26) 4.6 (0.9) (n = 23) 4.6 (1.3) (n = 16) 7.7 (2.9) (n = 27) 5.9 (3.4) (n = 23)
 14 4.4 (1.3) (n = 26) 4.4 (1.1) (n = 28) 4.8 (0.5) (n = 19) 7.5 (3.0) (n = 28) 6.6 (3.2) (n = 27)
 15 4.4 (1.2) (n = 23) 4.1 (1.5) (n = 25) 4.5 (1.1) (n = 15) 8.0 (2.9) (n = 23) 6.7 (3.4) (n = 22)
 16 4.6 (1.0) (n = 27) 4.5 (1.3) (n = 28) 4.8 (0.9) (n = 21) 8.1 (2.9) (n = 27) 7.2 (3.0) (n = 25)
 17 4.4 (1.3) (n = 25) 4.5 (1.1) (n = 24) 4.6 (1.3) (n = 20) 8.1 (3.0) (n = 25) 7.6 (2.8) (n = 23)
 18 4.5 (1.0) (n = 11) 4.8 (0.6) (n = 10) 9.5 (1.8) (n = 11) 7.6 (2.4) (n = 10)
 Balance and Coordination Capacity in Male Youth With ID   11

Table 7  Test–Retest Reliability, M (SD)

Reliability
(Baumgartner &
Test item Age (years) Test 1 Test 2 ICC (95% CI) Jackson, 1999)
BAL-1 (n = 27) 13.7 (3.4) 9.1 (2.2) 9.2 (2.1) .55 (.28–.74) poor
BAL-2 (n = 29) 14.1 (3.3) 5.9 (0.3) 5.5 (1.0) .67 (.44–.81) moderate
BAL-3 (n = 28) 13.2 (4.1) 8.0 (2.8) 7.7 (3.1) .63 (.39–.78) moderate
BAL-4 (n = 16) 14.0 (3.7) 7.5 (3.6) 7.8 (3.2) .91 (.81–.96) high
BAL-5 (n = 17) 13.9 (3.7) 4.0 (2.3) 4.6 (2.0) .76 (.52–.89) moderate
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BAL-7 (n = 17) 13.6 (3.7) 6.9 (3.4) 6.8 (3.4) .94 (.87–.97) high
BLC-1 (n = 17) 13.9 (3.7) 3.7 (1.1) 3.7 (1.0) .88 (.74–.95) high
BLC-2 (n = 17) 13.9 (3.5) 4.0 (1.3) 3.9 (1.4) .84 (.72–.91 high
BLC-3 (n = 17) 14.4 (3.1) 4.2 (1.2) 4.3 (1.2) .62 (.37–.78 moderate
BLC-4 (n = 17) 13.7 (3.5) 2.7 (1.6) 2.9 (1.4) .86 (.71–0/93) high
BLC-6 (n = 15) 13.8 (3.8) 9.9 (0.5) 9.2 (1.5) .26 (.18–.62) poor
BLC-7 (n = 26) 13.6 (3.4) 6.0 (3.3) 7.0 (2.9) .83 (.68–.91) high
ULC-1 (n = 17) 13.7 (3.5) 4.0 (1.5) 4.5 (1.1) .52 (.16–.76) poor
ULC-2 (n = 30) 13.6 (3.5) 4.4 (1.1) 4.5 (0.9) .85 (.73–.92) high
ULC-3 (n = 28) 13.8 (3.4) 4.7 (0.9) 4.7 (0.9) .90 (.82–.95) high
ULC-5 (n = 22) 14.2 (3.7) 8.6 (2.3) 8.2 (2.2) .85 (.70–.92) high
ULC-6 (n = 37) 14.1 (3.2) 6.9 (3.2) 6.9 (2.9) .63 (.43–.77) moderate
Note. ULC = upper limb coordination; BAL = balance; BLC = bilateral coordination.

≥.60, moderate reliability; and <.60, poor reliability (Baumgartner & Jackson,
1999). Data demonstrated high to moderate test–retest reliability for all items
except BAL-1, BLC-6, and ULC-1.

Comparison With revBOT-2

Although raw scores were not reported, the revised scoring scheme of the revBOT-2
suggested lower raw scores in youth with ID. That is, Wuang, Li, and Su (2009)
adjusted the point-scoring system in a manner in which the maximum scale scores
were lower. For example, for Item 1 in the ULC subtest (ULC-1, dropping and
catching the ball with two hands), the BOT-2 scale has a maximum score of 5
points, whereas that revBOT-2 has a maximum score of 2. In a similar item of
catching (ULC -3, dropping and catching the ball with one hand), the BOT-2 has
maximum of score 5, whereas the revBOT-2 has a maximum score of 3. In these
two items, raw scores are matched to scale score in the BOT-2. The lower scale
score for these two items in the revBOT-2 suggests that the average number of
catches was lower for the Taiwanese children and adolescents with ID. In the cur-
rent study, the mean number of catches for both ULC-1 and ULC-3 for all ages
ranged from 4 to 5 (Figure 6). According to the scoring scheme of the BOT-2, four

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 12  Pitetti, Miller, and Loovis

and five catches would have resulted in point scores of 4 and 5. Consequently, the
adjusted lower point-scoring system for these items of the revBOT-2 may not apply
to Midwestern youth with ID
Similar scoring is seen for timed items. For item 4 in the BAL subtest
(BAL-4, standing with feet apart on a line, eyes closed), the BOT-2 scale has
a maximum score of 4 points whereas the revBOT-2 has a maximum score of
2 points. This suggests that Taiwanese children and adolescents with ID were
not able to balance for more than 6 s. In the current study, the mean time for
the BAL-4 ranged from 6 to 8 s (Figure 1), which would have scored 3 points
in the scoring scheme of the BOT-2. These results again suggest differences in
balancing capacity between Taiwanese and Midwestern youth with ID.
The Rasch model used by Wuang, Li, and Su (2009) reported difficulty
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logit for each item in the subtests. The difficulty logit determines the odds of a
person performing the item correctly as a function of the person’s ability and
the item’s difficulty and can range from a 99% (+5.0 logit) to 1% (–5.0 logit)
probability of success (Wright & Mok, 2000).
In an attempt to compare the results of the current study with those of
Wuang, Li, and Su (2009) in relation to the difficulty logit, the 95% CI range
of averages for all assessments in this study was calculated over an age range
of 8–18 years. The 95% CI range of averages for all assessments was com-
pared with difficulty logit for each item reported by Wuang, Li, and Su (see
Table 8).
In terms of difficulty, when comparing the results of the current study with
those of Wuang, Li, and Su (2009), there were three ways the youth in this
study performed in comparison with Taiwanese youth with ID: more skilled,
less skilled, and equally skilled. On the ULC-2; BAL-1, -2, and -4; and BLC-6
subtests, the youth in the current study performed well (i.e., at or above crite-
rion), just as Taiwanese youth performed (i.e., high logit score). On the ULC-2
and -3, BAL-3 and -5, and BLC-1, -2, and -3 subtests, the youth in the current
study performed well (at or above criterion), whereas Taiwanese youth per-
formed poorly (low logit scores). For the ULC-5 and -6, BAL-7, and BLC-4
and -7 subtests, the youth in the current study performed poorly (low criterion
scores), while Taiwanese youth performed well (high logit scores). Accordingly,
similarities of score difficulty were only seen in 5 of the 17 items. In addi-
tion, Table 8 contains criterion scores established by the BOT-2 (Bruininks &
Bruininks, 2007).

Discussion
There are three important methodological differences between Bruininks and
Bruininks (2005) and the current study that should be noted:
• In the Bruininks and Bruininks (2005) report, the total number of 66 partici-
pants with ID were both male (n = 37) and female (n = 29), age 5–21.
• It is not known if participants with DS were included.
• The familiarization protocol followed in the current study was not reported to
occur in the study by Bruininks and Bruininks (2005).

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 Balance and Coordination Capacity in Male Youth With ID   13

Table 8  Comparing Mean Scores of Present Study With Criterion Scores

and Difficulty Logit/Probability of Success
Current Study Difficulty logit
Criterion score (probability
Number of Average Average (Bruininks of success)
assessments mean lower mean upper & Bruininks, (Wuang, Lin, &
Item (8–18 years) 95% limit 95% limit 2005) Su, 2009)
ULC-1 131 4.25 4.59 4.8 1.64 (80%)
ULC-2 130 4.26 4.64 4.8 –2.19 (12%)
ULC-3 93 4.52 4.84 4.8 –3.50 (2–5%)
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ULC-5 152 7.65 8.46 9.5 0.36 (55–60%)

ULC-6 153 6.43 7.29 9.5 2.20 (90%)
BAL-1 100 8.95 9.59 8.5 3.59 (95%)
BAL-2 129 5.52 5.80 5.1 2.49 (90%)
BAL-3 108 7.51 8.49 8.5 –0.51 (38%)
BAL-4 112 6.54 7.65 8.5 –1.79 (12–20%)
BAL-5 139 4.48 5.05 5.1 –1.73 (12–20%)
BAL-7 161 4.80 5.76 8.5 1.48 (80%)
BLC-1 133 3.58 3.83 3.7 –4.20 (2%)
BLC-2 100 3.85 4.39 4.6 –3.54 (2–5%)
BLC-3 101 4.14 4.61 4.6 –4.39 (1%)
BLC-4 144 3.33 3.90 4.6 2.84 (90%)
BLC-6 130 8.56 9.28 9.2 2.72 (90%)
BLC-7 106 7.98 8.86 9.2 1.4 (80%)
Note. ULC = upper limb coordination; BAL = balance; BLC = bilateral coordination.

Notwithstanding these differences, the general results of this study complement

those described by Bruininks and Bruininks (2005) in that mean raw scores were
consistently below ceiling and most fell below criterion level.
The familiarization protocol in this study was to ensure that the participants
clearly understood the movement so that their scores reflected their innate motor
and coordination capacities. In addition, after the familiarization protocol, if a
participant did not make an effort (e.g., sitting or standing idly) or would not per-
form the movement (e.g., verbally refused), a score was not assigned (i.e., it was
not scored as 0). This was to ensure that results were not biased due to behavioral
or cognitive limitations. That is, youth with ID demonstrate a varying mixture of
cognitive, motor, and/or psychosocial differences from the norm. The familiariza-
tion protocol allows occupational therapists, physical therapists, and developmental
adapted physical education teachers to screen youth with ID for a specific limitation
in gross motor balance and/or coordination proficiency and enable better assign-
ment to developmental programs.

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 14  Pitetti, Miller, and Loovis

The familiarization protocol differed from that of the BOT-2 in that partici-
pants were provided two demonstrations with verbal instructions and allowed two
practices, with prompting, for each movement. This differed from the BOT-2,
which only provided one demonstration and allowed one practice (Bruininks &
Bruininks, 2005). However, it is stated in the BOT-2 manual that “examiners would
be encouraged to tailor instructions to the needs of each examinee, using verbal
instructions, physical demonstrations, and/or photos” (Bruininks & Bruininks,
2005, p. 39). The possibility exists that examiners for the BOT-2 could have assisted
those with ID using techniques similar to those in the current study and, therefore,
might account for similar results.
Note that reporting the results as raw scores rather than scaled scores allowed
for identification of specific areas in each subtest where delays potentially exist.
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When considering the BAL subtest, with the exception of standing feet apart on a
line with eyes open (BAL-1) and walking forward on a line (BAL-2), mean scores
for most items across age groups were below criterion. Although improvements were
seen from childhood into early adolescents in three of the BLC subtests involving
jumping with same sides synchronized and touching nose, mean raw scores for
movements that involved the synchronization of opposite sides jumping, tapping
feet and fingers, and jumping jacks tended to be below criterion. Finally, means
scores for ULC suggested delays in dribbling and catching a ball.
When comparing the results of the current study with those of Wuang, Li, and
Su (2009), the youth in the current study performed at a higher ability in seven,
equal ability in five, and lower ability in five of the BOT-2 subtests (Table 7).
Accordingly, the results of the current study indicate that data reported by Wuang,
Li, and Su may not be representative of the motor capacities of Midwestern youth
with ID. More research is necessary to determine if the results of the current study
are representative of youth with ID in North America.
It is difficult to compare the test–retest reliability scores seen in the current
study with the reliability scores reported in the BOT-2 (Bruininks & Bruininks,
2005) and revBOT-2 (Wuang, Li, & Su, 2009) due to methodological differ-
ences. The BOT-2 (Bruininks & Bruininks, 2005) and revBOT-2 (Wuang, Li, &
Su, 2009) compared the test–retest reliability of the composite scores for each
subtest. That is, raw scores for each item in the subtest were converted to scale
scores, and scale scores were combined to produce a composite score for BAL,
BLC, and ULC subtests. Therefore, the test–retest reliability of raw scores for
each item were not reported. The ICCs reported in the revBOT-2 (Wuang, Li,
& Su, 2009) were .99, .96, and .96 for BAL, BLC, and ULC composite scores,
respectively. For the BOT-2 (Bruininks & Bruininks, 2005) the Pearson cor-
relation coefficients were .45–.61, .32–.65, and .45–.50 for BAL, BLC, and
ULC composite scores, respectively. However, the purpose of this study was to
initiate data collection to develop normative tables based on raw scores. With
the exception of BAL-1, BLC-6, and ULC-1, moderate to high reliability scores
were observed. For the three items with poor reliability (BAL-1, BLC-6, and
ULC-1), it is recommended that these items be assessed on two different days
to ensure that participants achieve their highest score. In addition, only males
were assessed in the current study; more research is needed to determine if
these test–retest reliability scores are applicable to female youth with ID and
youth with DS.

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 Balance and Coordination Capacity in Male Youth With ID   15

Similarities in the results of this study are seen when compared with those
reported by Jobling (Jobling, 1999) and Vuijk et al. (2010). Jobling used the initial
Bruininks-Oseretsky Test of Motor Proficiency (Bruininks, 1978; BOTMP) in
evaluating motor proficiency of children and adolescents (10–16 years) with DS.
The BOTMP (Bruininks, 1978) consisted of subtest items similar to those of the
BOT-2 for BAL, BLC, and ULC. Although the existing body of research indicates
that youth with DS have inferior physical capacities when compared with their peers
with ID but without DS (Pitetti, Baynard, & Agiovlasitis, 2013), some similarities
exists between the current study and that of Jobling. Specifically, Jobling reported
that balance proficiency, bilateral coordination, and upper limb coordination dem-
onstrated low levels of proficiency in youth with DS when compared with standards
of the BOTMP (Bruininks, 1978).
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The study by Vuijk et al. (2010), using the Movement Assessment Battery for
Children (Henderson & Sugden, 1992), compared the motor performance of children
(7–12 years) with mild ID (50 ≤ IQ ≤ 70) with that of children with borderline ID
(71 ≤ IQ ≤ 84). Consistent with the current study, Vuijk et al. reported borderline to
definitive motor problems in balls skills and balance for participants with mild ID.
There is considerable literature on other tests of gross motor competence
and limitations used for children and adolescents with and without disabilities.
However, most are limited to childhood and young adolescent ages (0–16 years),
are disability specific, and/or focus on identifying risk of falls. For instance, The
Berg Balance Scale (Berg, Wood-Dauphinee, & Williams, 1995; Berg, Wood-
Dauphinee, Williams, & Maki, 1992), Functional Reach Test (Donahoe, Turner, &
Worrell, 1994; Niznik, Turner, & Worrell, 1995; Norris, Wilder, & Norton, 2008),
and Pediatric Balance Scale (Franjoine, Gunther, & Taylor, 2003) are primarily
applied in determining the risk for falls or standing balance while reaching that
are specific to the elderly or are employed for the same purpose in children with
moderate to mild motor impairments. The Peabody Development Motor Scale-2
and Test for Gross Motor Development are restricted to toddlers and children, and
the Movement ABC-2 is restricted to children and adolescents below the age of 17
years (Ulrich, 2000; Volman, Visser, & Lensvelt-Mulders, 2007). The Functional
Gait Assessment is for children with vestibular impairments (Wrisley, Marchetti,
Kuharsky, & Whitney, 2004), and the Gross Motor Functional Measure (Linder-
Lucht et al., 2007; Russell et al., 2000), timed up-and-down stairs (Held, Kott, &
Young, 2006; Zaino, Gocha Marchese, & Westcott, 2004), and timed up-and-go
(Nicolini-Panisson & Donadio, 2014) are primarily used to assess motor function,
fall risk, and functional-ability changes for children with cerebral palsy, acquired
brain injury, or other motor impairments.
Although the BOT-2 is used by occupational therapists and physical therapists
as the standard for identifying motor deficits (Cairney, Hay, Veldhuizen, Missiuna,
& Faught, 2009; Jobling, 1999; Yoon, Scott, Hill, Levitt, & Lambert, 2006), the
BOT-2 also provides information on the proficiency of motor-control skills, thus
allowing for comparative studies among the general school population. That is,
BOT-2 motor-proficiency scores have been used to identify relationships between
motor proficiency and physical activity (Wrotniak et al., 2006), generalized self-
efficacy toward physical activity and participation in organized and free-play sports
(Cairney, Hay, Faught, Wade, et al., 2005), and overweight and obesity (Cairney,
Hay, Faught, & Hawes, 2005). Therefore, the normative BOT-2 data reported in

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 16  Pitetti, Miller, and Loovis

the current study could also be used to determine if similar relationships exist for
children and adolescents with ID with respect to these same or other issues.
The results of this study complement and extend the findings of Bruininks and
Bruininks (2005) in that this study reports data that indicate the motor proficiency
of males with ID for balance and bilateral/upper limb coordination to be below the
competence expected for children and adolescents without disabilities. Although
this report is limited to males with ID and without DS, continued collection of data
in the manner described in this study would allow for similar data to be reported
for male age groups not reported in this study, males with DS, and females with
and without DS. These data would allow for the establishment of age and gender
percentile rankings in motor skills for children and adolescents with ID, with and
without DS, for clinical application.
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Acknowledgments
The authors wish to thank the teachers and the staff of the Youth Education Social Summer
(YESS) program, the Arc of Sedgwick County, and the physical educators and the children
and adolescents of the schools who participated in this study.

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APAQ Vol. 34, No. 1, 2017