A New Assessment for Activities of Daily Living in Spanish Schoolchildren: A Preliminary Study of its Psychometric Properties.

Background: Activities of daily living (ADL), which are divided into basic (BADL) and instrumental (IADL), allows us to survive and to live in the society. Cognitive skills are a key aspect in BADL outcomes. After reviewing existing BADL tools for Spanish schoolchildren, issues such as not covering the full age range or not having a BADL-centred vision were found. We aim to develop a new tool for BADL assessment in Spanish schoolchildren. Methods: The new tool was administered to 375 participants (47.2% boys and 52.8% girls) from 6 to 12 years of age. Analyses were carried out to find out the structure (semiconfirmatory factor analysis) and internal consistency (ordinal alpha) of BADL. Results: Four scales formed the instrument (Eating, Personal Hygiene, Getting Dressed, and General Functioning) with an interpretable solution of 12 factors (Manual Dexterity, Proprioception, Oral Sensitivity, Good Manners, Hygiene and Grooming, Toileting Needs Communication, Bladder and Bowel Control, Showering, Independent Dressing Tasks, Full Dressing, Executive Functions, and Self-Regulation) with 84 items + 6 qualitative items for girls. The reliability values obtained were acceptable (.70–.88). Conclusions: The tool seems to be a practical and reliable instrument to assess BADL and cognitive skills during BADL in Spanish schoolchildren.

. Summary of BADL and adaptative behavior measurements for Spanish children.

BADL-Centered Assessment
Adaptive Behavior Assessment System II -ABAS II [31,32] yes/yes yes no Checklist of Adaptive Living Skills -CALS [33,34] yes/yes yes no Inventory for Client and Agency Planning -ICAP [35,36] yes/yes yes no Vineland Adaptive Behavior Scales II -VABS II [37] yes/no yes no Pediatric Evaluation of Disability Inventory-Computer Adaptive Test -PEDI-CAT [38] yes/no yes yes Supports Intensity Scale -SIS [39,40] yes/yes yes no Battelle Developmental Inventory -BDI [41,42] yes/yes no no Merrill-Palmer-Revised Scales of Development -MP-R [43,44] yes/yes no no Portage Guide to Early Education [45,46] yes/yes no no BADLs: basic activities of daily living.
To the best of our knowledge, a comprehensive tool to evaluate a full range of BADL is needed, especially to help OT practitioners in their clinical interventions. It is not our intention to develop a diagnostic measurement, but to describe as broadly as possible the performance of the pediatric population in BADL. We also aim to obtain screening information about the cognitive processes that influence BADL. The study aims to present a new tool to evaluate BADL performance in Spanish schoolchildren from 6 to 12 years of age showing its psychometric properties.

Participants
Inclusion criteria were being from 6 to 12 years old with typical development and providing a written informed consent form signed by legal guardians to the investigators. 375 schoolchildren of both genders participated in the study (177 boys, 47.2%, and 198 girls, 52.8%). Their age ranged from 6 to 12 years old (M = 8.5 years, SD = 2.1 for the total; M = 8.4 years, SD = 2 for boys; and M = 8.6 years, SD = 2.1 for girls). A probabilistic polietapic sample design was used, recruited through regular schools and sporting events in the community of Extremadura (Spain).

Instruments
The material used was the Activities of Daily Living Evaluation in Schoolchildren (ADL-E), a new tool created for Spanish schoolchildren, which covers a wide range of BADL. The instrument is made up of 4 different scales: 3 for measuring BADL (Eating, Personal Hygiene, and Getting Dressed) and 1 scale for cognitive aspects that influence BADL performance. The final version has 84 items + 6 qualitative items for girls ( Table 3).
The Eating scale has 20 items. Aspects related to choosing, manipulating, chewing food, or drinks and keeping good manners during mealtime are explored. The Personal Hygiene scale is composed of 29 items. They help to obtain information about grooming, washing, brushing, showering, toileting, using supplies and cosmetics, and bladder and bowel control. Within this scale, 6 extra qualitative items about hairstyle and menstruation management for girls were included. The Getting Dressed scale has 19 items and explores aspects about choosing and adjusting clothes and accessories, and the dressing and undressing sequence, including shoes. The General Functioning scale has 18 items, which provide information about cognitive aspects related to EF and SR. 3. She knows how to apply a pad.
4. The pad is changed at an appropriate frequency, without too many accidents. 5. She leaves used pads inside containers.
6. She washes her hands after changing the pad.
ADL-E: Activities of Daily Living Evaluation in Schoolchildren.
The ADL-E must be completed by conducting a family-therapist interview with caregivers, which must provide answers based on the behaviors they observe in their children. Each item must be answered by marking one of the four response options (Table 4). Therapists should obtain evidence/s that parents' answers are as detailed as possible, so blank spaces for observations are provided. Table 4. Activities of Daily Living Evaluation in Schoolchildren (ADL-E) response options.

Always
The child can perform the task/activity independently. It always happens.

Sometimes
The child is learning to do the task/activity. The child needs help (visual, verbal, or physical) from an adult.
It happens sometimes.

Never
The child cannot perform the task/activity. An adult does the essential parts of the activity's tasks.
It never happens.

Not known; no opportunity
The informant cannot answer. The child has never faced that situation.

Procedure
After reviewing available instruments, it was decided to create a new one which meets several conditions: being culturally adapted, suitable for schoolchildren (6-12 years), and with an ADL-centered perspective. Cognitive items that influence occupational performance were added to help OT practitioners in their clinical intervention or recommending a thorough evaluation of dysfunction suspicion. A group of experts in the fields of psychology and OT created a preliminary version using the OT practice framework [1] and their clinical experience as the baseline (Figure 1). A pilot study was carried out with 15 families obtaining the version used for this study. Once administered to the sample, the items were analyzed by the group of experts, discarding those which did not fit on the theoretical model. This process resulted in the final version of the ADL-E as shown in Figure 2. This protocol adhered to the updates of the Declaration of Helsinki [47], and it was approved by the Committee on Biomedical Ethics of the University of Extremadura (198/2019).

Statistics
Microsoft Office TM Excel v.16, FACTOR v.10.10.02, and IBM TM SPSS v.25 were used for data analysis. An exploratory factor analysis (EFA) was carried out to find out the internal structure of every scale and to check the factorial weights of every item. Before the EFA, the two necessary conditions were verified: adjustment of the data to the normal curve and adequate sample adjustment indicators through the Kaiser-Meyer-Olkin (KMO) and Bartlett's sphericity tests [48,49].
Due to the ordinal nature of the data, the EFA was used for the calculation of polychoric correlations using the robust unweighted least squares method (RULS) for the extraction of factors with oblique rotation because we started from the premise that factors were correlated. Items with factorial weights < .30 were maintained, and those with lower values were deleted [50]. This procedure, carried out with FACTOR, also allowed us to explore the goodness-of-fit data for each of the factor solutions [51,52]. This semiconfirmatory factor analysis of the items (SCFA) is suitable to prevent errors such as the ones of the "Little Jiffy" approach in psychometry [53][54][55].
To evaluate the goodness-of-fit of the model, the following were used: a) the chi-squared probability taking as appropriate non-significant values (p > .05); b) the comparative fit index (CFI) and the non-normed fit index (NNFI) considering > .90 as an indicator of good fit; c) the root mean square error of approximation (RMSEA), considering values < .06 acceptable; and e) the root mean square of residuals (RMSR) considering values < .05 acceptable [49,56]. Thus, the study of the EFA and the matrix of correlations between the factors together with the bibliographic review provided elements of judgment for the establishment of a theoretical model of relationships between the different scales and their factors.
To find out the internal consistency of the ADL-E, the ordinal alpha was used, which is an alternative to the Cronbach's Alpha more accurate with Likert scale responses, including ordinal items. Preferred values are between < .80 and >.90, but .70 is considered acceptable [57,58].

Results
After performing the analyses, the items from the ADL-E were reduced from 124 (study version) to 84 + 6 qualitative items in the final version. The 4 scales are easily explained by a conceptual model with 12 factors. Each scale with its factors is explained below.

Eating Scale
The Eating scale aims to obtain information about choosing, manipulating, chewing food, or drinks, keeping good manners, and other aspects during mealtime. We found an interpretable solution with 4 factors (Table 5): Manual Dexterity (6 items), Proprioception (4 items), Oral Sensitivity (3 items), and Good Manners (7 items). The Manual Dexterity factor consists of the items related to the use of tools to open or manipulate food and drinks with manual or bimanual coordination requirements. The items in Proprioception are about the correct application of strength to manage food, drinks, or containers. In the Oral Sensitivity factor, the items are about sensory processing of food. The Good Manners during Mealtime factor groups items into several categories: cognitive, attentional, executive, sensory, motor, behavioral, and cultural ones. For example, a child who cannot stay seated during mealtime can have inhibition issues (executive), postural problems (sensory or motor), or he/she may not be interested in food (behavioral). Despite this, we named it Good Manners, because they all are considered correct behaviors in our society. For the KMO test, a value of .71, and for the Bartlett's test, p <.0.001 were found, both considered good to perform the EFA. Initially, this scale was formed by 28 items, but 8 items did not reach the weight of < .30, so they were not kept (Table 6). Thus, a total of 20 items form this scale in the final version of the instrument. Table 6. Deleted items from the Eating scale.

Item Number Item
1 He/she asks for food or water when hungry or thirsty. 6 If necessary, he/she collaborates, taking his/her medication. 8 He/she drinks liquids without spilling from the glass or the bottle. 10 He/she chews food until crushed before swallowing. 18 He/she can open wrappers. 20 He/she can eat pieces of food with his/her hands. 22 He/she can use a spoon without spilling food. 23 He/she can prick food with a fork.

Personal Hygiene Scale
The Personal Hygiene scale aims to obtain information about taking care of oneself. We found an interpretable solution with 4 factors ( Table 7): Hygiene and Grooming (18 items), Toileting Needs Communication (2 items), Bladder and Bowel Control (4 items), and Showering (5 items). In the Hygiene and Grooming factor, information about hair, skin, and nail care, use of cosmetics, nose-blowing, washing hands, brushing teeth, and toilet management, but also about keeping everything clean and caring about having a good appearance is grouped. Factors 2 and 3 are about Bladder and Bowel Control: the first one is about being able to communicate toilet needs, and the second one is about being aware of these needs. Factor 4 contains all the items related to showering/bathing. For the KMO test, a value of .921, and for the Bartlett's test, p <.0.001 were found, both considered good to perform the EFA. Initially, this scale was formed by 42 items, but 7 items did not reach the weight of < .30, so they were not kept ( Table 8). The 6 qualitative items for girls were not included in the EFA. Thus, a total of 29 + 6 items forms this scale in the final version of the instrument. He/she brushes for at least one minute. 23 He/she is stressed while brushing teeth. 27 He/she can check and adjust the water temperature. 30 When he/she washes his/her hands, he/she wipes himself/herself completely dry. 31 He/she can wash his/her face. 37 He/she is stressed when nails or hair are cut.

Getting Dressed Scale
The Getting Dressed scale aims to obtain information about dressing tasks. We found an interpretable solution with 2 factors (Table 9): Independent Dressing Tasks (13 items) and Full Dressing (4 items). In the Independent Dressing Tasks factor, all the items are related to specific and individual tasks needed for dressing (accessories, zippers). These can be tasks with essential cognitive functions (choosing and taking care of clothes) or about manual dexterity and praxis (fastening and adjusting clothes and accessories). In the Full Dressing factor, the items are about the complete activity of getting dressed or undressed. For the KMO test, a value of .92, and for the Bartlett's test, p < .0.001 were found, both considered good to perform the EFA. Initially, this scale was formed by 30 items, but 13 items did not reach the weight of < .30, so they were not kept (Table 10). Thus, a total of 17 items form this scale in the final version of the instrument. He/she always wants to wear the same clothing. 7 He/she can remove socks. 9 He/she can put footwear on his/her feet. 10 He/she places a shoe on the right foot. 11 He/she can remove shoes without fasteners. 12 He/she can remove shoes with fasteners. 13 He/she can remove simple garments without closures (pants, underwear). 21 He/she opens and closes Velcro fasteners. 23 He/she can zip up and down. 25 He/she can unbutton. 29 He/she can tie his/her shoes.

General Functioning Scale
The General Functioning scale aims to obtain information about the cognitive aspects that can influence BADL performance. We found an interpretable solution with 2 factors (Table 11): Executive Function (8 items) and Self-Regulation (10 items). The Executive Function factor contains several subprocesses related to planning, sequencing, keeping focused on the task, time control, and solving problems. In the Self-Regulation factor, all the items are about self-control and being able to manage thoughts, attention, feelings, and responses related to stimuli. For the KMO test, a value of .65, and for the Bartlett's test, p < .0.001 were found, both considered good to perform the EFA. Initially, this scale was formed by 19 items, but 1 item, "Asks for help when necessary in his/her daily life activities", did not reach < .30, so it was not kept.

Correlations Between Factors
Correlations between factors were also explored, as showed in Table 12 [59].

Goodness-of-Fit Indices
As mentioned previously, the FACTOR software explores the goodness-of-fit data (see Table 13). All the indices are acceptable [49,56].

Reliability
To find out the internal consistency of the ADL-E, ordinal alpha was used ( Table 14). As mentioned previously, the preferred values are < .80 and > .90, but < .70 is considered acceptable.

Discussion
Our main contribution is to present a new tool to assess BADL performance in Spanish schoolchildren. To our knowledge, no valid and reliable tool that covers the complete school age range and is BADL-centered to capture the occupational performance exists. Finally, 4 scales form the ADL-E: Eating, Personal Hygiene, Getting Dressed + General Functioning. A total of 12 factors offer a conceptual model we think is relevant: the Eating scale is formed by 4 factors: Manual Dexterity while Eating (6 items), Proprioception (4 items), Oral Sensitivity (3 items), and Good Manners (7 items); the Personal Hygiene scale is formed by 4 factors: Hygiene and Grooming (18 items), Toileting Needs Communication (2 items), Bladder and Bowel Control (4 items), and Showering (5 items); the Getting Dressed scale is formed by 2 factors: Independent Dressing Tasks (13 items) and Full Dressing (4 items); and the General Functioning scale is formed by 2 factors: Executive Function (8 items) and Self-Regulation (10 items). This structure is different and more accurate than the one presented by other instruments: for example, Adaptive Behavior Assessment System II (ABAS II) groups all the BADL items in a single section called Self-Care; the Inventory for Client and Agency Planning (ICAP) joins all the BADL items in the Personal Life Skills section; Vineland Adaptive Behavior Scales II (VABS II)-in the Daily Living Skills Domain-Personal; the Merrill-Palmer-Revised Scales of Development (MP-R)-in Adaptive Behavior and Self-Care, and the Portage Guide to Early Education-in the Self-Care section. More specific, but not BADL-centered, are the Battelle Developmental Inventory (BDI) with the following sections in the Adaptive Scale: Attention, Mealtime, Getting Dressed, Personal Responsibility, and Hygiene; and the CALS, with Socialization, Mealtime, Hygiene and Grooming, Toileting, Getting Dressed, Health Care (this is an IADL), and Sexuality. The Computer Adaptive Test (PEDI-CAT), which is the closest to the ADL-E, is formed by 4 domains: Daily Activities (including BADL and IADL), Mobility, Social/Cognitive, and Responsibility, but it is not culturally validated in Spain.
Related to correlations between factors, several facts need to be considered. Manual Dexterity in the Eating factor has a strong correlation with the Independent Dressing Tasks factor, which can be explained by the critical motor requirements of that kind of tasks/activities. Good Manners during Mealtime and Self-Regulation also have a strong correlation, which also can be explained by the need to inhibit and manage behaviors to keep seated following cultural customs. The Hygiene and Grooming factor also has a high correlation with Showering (some of the steps in hygiene are common in showering), Independent Dressing Tasks (also requires developed motor skills) and the Self-Regulation factor (high demand of self-control while performing these tasks). The ADL-E shows good psychometric properties, both in validity and reliability (internal consistency).
Continuing with the ADL-E structure and exploring the number of items, the final number is 84 + 6 qualitative items for girls, so the time to complete the interview should be 45-90 minutes, which can be reasonable and accessible for OT practitioners and other professionals. Some of the reviewed tools have a much lower number of items, so perhaps they do not provide enough information (e.g., the ICAP with 21 items, ABAS II with 24, or the Vineland with 41), and others had a much higher number, so maybe the professionals have not got the time to properly administer them (e.g., the CALS with 814 items). The ADL-E can be a useful tool to help therapists to make clinical decisions. As mentioned previously, OT practitioners need assessments to help them to characterize the BADL performance, because it is one of the most demanded interventions within their scope. The ADL-E can also be useful for educational professionals and families to have a reference about the right acquisition of BADL abilities by their students or children.
This research had some limitations. The sample was recruited in the community of Extremadura. We tried to establish a development trajectory for the BADL considered universal, but maybe social and cultural differences in this kind of activities should be more deeply checked. Another important aspect is that the information is completed through caregivers. Although instruments completed by families are considered to be valid tools [60], some authors warn us to be careful, because parents could overestimate or underestimate development of their children [61,62]. We also need to improve concurrent validity using well-established tools.
Concerning future lines of research, we have several appreciations to do. In the occupational therapy, tools to measure BADL are necessary. For physically disabled children, we have specific tools to assess the issues they usually have with their ADL: for example, the Pediatric Evaluation of Disability Inventory (PEDI) [63], or the Functional Independence Measure for Children (WeeFIM) [64], which are very focused on physical problems with mobility BADL. So, an important future line should be using the ADL-E with specific populations with cognitive disorders or impairments, because to the best of our knowledge, there is blank space in this area. For example, children diagnosed with neurodevelopmental disorders suffering from alterations or delays in the development of functions related to the maturation of the central nervous system that causes difficulties to adapt to the environment [65] should be an interesting group to explore. Within this group, autism spectrum disorders (ASD), intellectual disability (ID), attention deficit and hyperactivity disorders (ADHD), motor disorders, specific learning disorder, communication disorders, etc. are included. Some authors have found differences in ADL profiles between these populations: worse performance in ASD children in hygiene or dressing than in the ID population [66] or worse performance in dressing, personal hygiene, and eating skills, including postural control and fine motor skills, in children with developmental coordination disorder compared with normally developed children [11], so it should be interesting to try to find specific BADL profiles.

Conclusions
The ADL-E is a practical and easy-to-apply tool which assesses BADL (Eating, Personal Hygiene, and Getting Dressed) in Spanish schoolchildren aged 6-12. The ADL-E also offers monitoring of the influence of EF and SR during these activities, showing good psychometric properties in both validity and reliability.