Miller Function & Participation Scales (MfunPS) - Critical Review
A Critical Review of the Miller Function & Participation Scales (M-Fun)
Key Words: School-based occupational therapy, assessment, Miller Function & Participation Scales (M-Fun), Developmental Co-ordination Disorder (DCD)
Download pictures relating to the review (PowerPoint)
The Miller Function and Participation Scales (M-Fun) is a standardised tool designed to assess young children’s performance abilities as well as participation in their daily life within their school and home environment (Miller 2006). This review will critically examine this relative new addition to the occupational therapy assessment toolkit. A particular focus will be placed on school-based occupational therapy practice with young and very young children with developmental co-ordination disorder (DCD) and/ or developmental motor delays which impact on their participation in school. Additionally, consideration will be given to the suitability and usefulness in the UK practice context.
Fig 1 to 3 (right): The M-Fun assesses children’s performance skills in typical school work occupations, including activities such as writing, drawing, colouring as well as cutting with scissors.
The M-Fun is the third assessment tool developed by Lucy Miller for the assessment of young children with developmental delays and challenges (Miller 1988, 1993, 2006). The First STEP (Miller 1993) and Miller Assessment for PreschoolersTM (MAPTM) (Miller 1988) have been recognized as valid and sound tools, demonstrating the author’s expertise in test development. As the latest addition to the assessment tools developed by Miller, the M-Fun reflects more recent developments in overall health care as well as occupational therapy theory and practice (Miller 2006). Most notably, the M-Fun moves away from assessing isolated behaviours in non-functional tasks without consideration of the child’s participation in daily life.
The International Classification of Functioning, Disability and Health (ICF) and the more recent International Classification of Functioning, Disability and Health – Children & Young People Version (ICF-CY) (WHO 2001, 2007) promote a “bio-psycho-social” approach to an individual’s functioning and disability. Participation, activities, body structure and body function as well as environmental factors are core elements or domains of the ICF and ICF(CY) (WHO 2007). The M-FUN clearly reflects these core elements of domains in its overall design as well as within individual test activities; in particular as a child’s performance is assessed within the context of meaningful and functional activities which are commonly part of child’s life (Miller 2006, Simeonsson et al 2003). Overall the M-Fun is congruent with key features of this important conceptual framework for contemporary health care service provision.
The M-Fun has also been notably influenced by developments within occupational therapy in the USA, most notably the uniform terminology (AOTA 1994) and occupational therapy practice framework which replaced the earlier terminology document (AOTA 2002, 2008). While the framework and terminology are widely known and used within the states, they may be less familiar to British practitioners. In addition, these documents differ in some areas and terms from similar UK documents (COT 2004, Creek 2003, Creek at al 2005). Although this might be initially confusing to some, chapter 4 of the manual comprehensively outlines and defines key concepts and terms as used in the M-Fun (Miller 2006, p 83 to 85).
The M-Fun is likely to be most suitably used for children largely considered to have mild to moderate motor difficulties, which may fall under the umbrella diagnosis of developmental delay or developmental co-ordination disorder. The tool was designed for children in the age range of 2 years 6 months to 7 years 11 months; however, the M-Fun could be used for older children for intervention planning or as an outcome measure without the normative component (Miller 2006).
Components & Key Features of the M-Fun
The M-Fun is divided into a performance and a participation component.
Fig 4 to 7 (right): The M-Fun evaluates children’s performance skills in typical PE, sports and play activities, such as jumping and hoping
The performance component of the assessment focuses on the child’s functional abilities, in particular visual motor, fine motor and gross motor performance skills. The child’s performance skills and related neurological foundations, most notably hand function, postural abilities and executive functioning, are assessed. This part entails 15 activities for very young children aged 2:6 – 5:11 and 16 activities for young children aged 6:0 to 7:11.
Test items closely resemble activities which are usually part of typical childhood occupations, with a particular focus on occupations and activities relevant to successful participation in school life. The activities - provided in a workbook format - resemble common school work activities, in particular those requiring functional use of tools, within an early education and/ or Primary school classroom, such as writing, drawing, tracing and cutting. The play activities and gross motor games are similar to, or a key component of functional mobility, common PE and after school sports activities, including jumping, hoping and skipping.
Due to the enjoyable and playful nature of the activities children are usually highly engaged and focused throughout the administration of the M-Fun. For example, each child uses an individual workbook which in appearance resembles more a fun “dot-to-dot” or “colouring” book which can be purchased from a stationary shop, than an answer booklet for a standardised assessment tool.
The M-Fun includes two measures of the child’s participation in their typical environments, a home observation checklist and a classroom observation checklist (Miller 2006). In addition, selected key performance skills and abilities are also included in the checklists. The checklists can be completed by caregivers and school staff respectively in their own time or administered by the therapist in an interview format.
The home observation checklist focuses on the child’s participation in daily life at home, in particular execution of activities of daily living (ADL), school-related work and leisure activities in the home environment. The classroom observation checklist assesses the child’s participation in a range of classroom activities. These two checklists provide highly relevant information about the child’s ability to participate in typical life situations and carry out common childhood activities, supplementing the information obtained through the standardized component of the assessment in a meaningful manner.
In addition, the test observations checklist assesses the child’s participation and behavior in an individual work situation, in particular during the test situation.
Purpose of the M-Fun
As the M-Fun assess a child’s participation in school and evaluates their fine motor, gross motor and visual motor performance skills, the tool could be used for a number of reasons and in different clinical situations based on the practitioner’s professional reasoning. The M-Fun may be used to:
- measure a child’s performance skills (body structures & functions), execution of school tasks (activities) and involvement in school and home life (participation)
- establish if a child has developed the performance skills relevant for successful participation in early education settings and Primary school
- determine a child’s strengths, difficulties and delays in specific performance skills areas and tasks
- determine eligibility for school-based occupational therapy services
- plan for further school-based assessment, for example classroom observations during specific school work tasks
- plan effective school-based intervention, including identifications of modifications of the classroom environment, adaptations of school work tasks and generic and child-specific strategies
- evaluate a child’s individual change over time
- evaluate the effectiveness of school-based occupational therapy as part of service evaluation or research.
Development & Standardisation Process
The development and standardisation process of the M-Fun took place in the USA (Miller 2006). Overall the process can be only described as thorough, which has contributed to the sound nature of the assessment tool.
Focus groups of experienced practitioners were held in a number of states in 2003. Through these focus groups, key features such as combining the subjective parenting and school staff rating with objective information obtained through a standardised means within in one tool (Miller 2006). A literature review identified current and relevant theoretical concepts and framework (AOTA 2002, 2008; WHO 2001, 2007), while a review of existing assessment tools assisted with the development of individual test activities (Miller 1988). Through these individual development activities, the M-Fun emerged (Miller 2006).
Some individual test activities and questionnaire items may reflect the cultural context of the M-Fun’s development. For example, young children attending some early education or primary school setting in the UK maybe less likely to carry their meals on trays in a cafeteria, however this may also vary from one school to another. The contrast between the level of complexity of the “origami game” and the simplicity of the “snack game” for younger children might be another illustration of possible cultural differences in childhood occupations and accordingly variations in children’s level of competencies in specific activities due to practice.
The standardisation took place in 2004 and 2005. The normative sample for the standardisation consisted of 414 American children. The sample was distributed equally throughout age bands and gender groups. The children lived in a range of geographical areas of the USA, the educational level of their parent education varied (indicator of socio-economic status) as did their ethnic backgrounds. The normative data has been provided in 6 month age groupings except for the age range from 5:0 to 7:11, which is provided for 1 year periods. The sample size for each individual age band ranged from 45-60 children. 6.8% of the children received some type of school service or were identified as having a specific condition requiring occupational and/ or physiotherapy. At present, the M-Fun has not been standardised for any other population outside continental USA. While this may be the case for a number of tools commonly used by occupational therapists, normative UK data would be desirable for the future.
Fig 8 to 11 (Above right): The M-Fun also includes items which focus on kicking a ball as required for playing football as well as bouncing, throwing and catching a ball which are essential components of many common ball games.
As the M-Fun is a standardised tool, it is essential that the scores and overall findings obtained are valid and reliable. The performance component of the tool is norm-referenced, while the participation component is criterion-referenced (Miller 2006).
On the whole, the performance component of the M-Fun has been established as a valid and reliable tool. However, more attention could be paid in the future to the psychometric properties (e.g. test-retest reliability) of the participation component (in particular home and classroom checklist) of the M-Fun. Additionally, further independent research would be of benefit to validate the data obtained through the initial standardisation study, which results are outlined in detail in the M-Fun manual and key aspects summarised the following sub-sections.
The M-Fun manual outlines the content validity, internal structure and concurrent validity to establish that the assessment tool measures what it is intended to measure (Miller 2006). In addition, sensitivity and specificity as diagnostic validity statistics were attained (Miller 2006).
In terms of content validity, the overall structure, components and measurement areas of the M-Fun were designed based on current theories and frameworks (AOTA 2002, 2008; WHO 2001, 2007). For example, the observational checklists evaluate social participation and execution of activities in the home and classroom; which is a reflection of constructs of the ICF and ICF(CY) (WHO 2001, 2007). For further details, see theoretical background section. Furthermore, the M-Fun reflects developmental progression of abilities and performance skills in children with expected age trends (Miller 2006). The performance skills assessed through the M-Fun are also widely considered relevant to tasks leading to early school success (Miller 2006).
In terms of internal structure, the moderate correlations (0.47 to 0.58) between individual performance skills scaled scores supports the concept that these are indexes of different aspects of performance skills and related neurological foundations. Concurrent validity (relationship to other measures) was mainly established through correlations between the M-FUN scores and MAP, which ranged from moderate to high (0.47-0.83) (Miller 1988, 2006).
Sensitivity (the probability that someone who has the condition will test positive for it) varies for different areas of the M-Fun depending on the standard deviation (SD) chosen (Miller 2006), but can be mostly be considered as good to excellent. The M-Fun has overall strong specificity (the probability that someone who does not have the condition will test negative) throughout each subscale and for all scores, ranging between .80 and 1.00. The M-Fun’s ability to correctly and clearly identify children with significant developmental delay, impacting on their performance in key functional activities relevant for success in early school, highlights its potential use for diagnostic purposes and to determine eligibility for services.
Test-retest reliability, internal consistency and inter-rater reliability have been established for the M-Fun.
Test-retest reliability was established on a sample of 27 children (12 males, 14 females; across the age range & socio-economic spread) by administering the M-Fun, by the same five examiners, on two separate occasions (Miller 2006). The reliability coefficients ranged from .77 to .82 depending on scale (Visual Motor and Gross Motor versus Fine Motor) across all ages (Miller 2006), which can be considered as moderately high and an indication that children’s performance of the test activities is quite reliable.
Internal consistency focuses on test items in the domain under investigation measuring one construct, which was obtained using the standardisation sample for performance as well as the participation component of the M-Fun (Miller 2006). The average reliability coefficients for the visual motor performance component part was 0.85, which could be considered as good, and 0.90 for fine motor performance component part and 0.92 for the gross motor performance component part, which could be considered as excellent. For the participation component of the M-Fun, the average reliability coefficients ranged from 0.95-0.96, which could be also excellent. Reliability for the clinical group was established using a smaller sample of the overall standardisation sample, demonstrating equal reliability for measuring performance skills of children within the “general population group” and children “at risk of motor impairment”. The lowest reliability score (0.67) emerged for the visual motor section for 7:0-7:11 age band may be considered fairly low, which may have to be considered when using and interpreting this section of the M-Fun.
The inter-rater reliability describes the correlation between separate raters in terms of consistency in clinical judgement and accordingly stability in scoring. The inter-rater reliability for visual-motor performance component was 0.91, for the fine motor performance component 0.93 and the gross motor performance component 0.91 (Miller 2006), suggesting a high degree of consistency.
Utility in Day-to-Day School-based Occupational Therapy Practice
Due to the performance areas covered in the M-Fun, it might be utilized as an alternative to other currently used assessment tools. Practitioners may choose to assess a child’s fine and gross motor performance, as well visual perceptual skills, frequently using a number of measures to do so. The M-Fun offers an efficient and time-saving alternative, which could be considered an affordable “multiple test in one” approach.
Preparation for Administration
The M-Fun does require some preparation, in particular the “snack section” entails having crackers and a water bottle on hand, however this could be considered as reasonable compared to pre-requisites to the administration of other assessment tools.
The overall administration time of 45 to 60 minutes may be a challenge for some children, in particular the very young ones and those struggling considerably with individual tasks. However, there are number of alternative administration options. Administration may be carried with small breaks during one session, or split between two separate assessment sessions. Another option may be to consider administering and scoring sections independently from each other, which is possible within the design of the tool. In most cases practitioners are likely to be able to carry out the assessment in one session due the engaging and fun nature of the activities which keep children focused.
Administration & Recording
The administration of individual subtests require focus from the therapist, while at the same time observing the child carefully and recording all of the components according to the standardised instructions. This might pose a challenge in particular for novice therapists or those unfamiliar with the M-Fun, however, through sound familiarisation with the test material, examiner and administration manual, in addition to practice, this does become much easier in time. In some services children with developmental co-ordination disorders are initially assessed jointly by a physiotherapist and occupational therapist, which may allow one assessor to administer the assessment while the other observes and records.
Scoring & Interpretation of Findings
The manual provides extensive and accessible information about the scoring process as well as some support with the interpretation of the findings. Experienced practitioners will find the information obtained easy to develop and translate into meaningful intervention, while novice therapists may benefit from some support or supervision.
M-Fun within the School-based Occupational Therapy Assessment Process
While considering an assessment tool and/ or outcome measure individually has its merit, in practice and research these tools are frequently used in conjunction with other measures and data collection methods. The M-Fun as a standardised assessment tool does provide a valuable piece of data, however to get a more complete picture it would be beneficial to supplement it with information obtained through skilled classroom observations as well as interviews with school staff, the student and family members.
Occupational therapists working with children, their families and school staff may also choose to start their assessment process with an individualised, client-centred tool (Tam, Teachman & Wright 2008), such as the Canadian Occupational Performance Measure (COPM) (Law et al 2005) and/ or Perceived Efficacy and Goal Setting System (PEGS) (Missiuna, Pollock & Law 2004), which would assist them with identifying occupational performance issues which are a priority for the client(s). The M-Fun could follow as a next step of the assessment process to identify the child’s performance in an objective manner, and add to the therapist’s understanding about the child’s participation in daily life.
The M-Fun, which is conducted outside the classroom, could also be used well in conjunction with ecological assessment methods, e.g. classroom observations, and tools, such as the School Assessment for Motor and Process Skills (School AMPS) (Fisher et al 2007), which provide information about a child’s performance during real-life classroom school work activities in their typical classroom environment. The compiled information might provide further insight into possible differences in a child’s performance in different environments, e.g. individual test situations versus classroom, consequently highlighting the influence of environmental factors. As both tools assess certain motor skills and process or executive functioning, the use of these tools together offers an opportunity to validate or challenge practitioners’ hypothesis about a child’s motor performance and build a more holistic and complete picture.
Familiarisation Process – Learning to administer, score & interpret the M-Fun
Professionals intending to use the M-Fun require a relevant qualification as health care or educational professional (Miller 2006) - contact the publisher for further details. Knowledge of test statistics and previous experience of assessing children would be of benefit, the latter in particular in terms of the interpretation of the results and designing meaningful intervention from it. Occupational therapists experienced in working with children, their families and school staff will find some elements of the M-Fun familiar, as well as the novel components straightforward. While a novice practitioner may benefit from some assistance of senior colleagues, the process would most certainly offer a valuable learning opportunity.
The manual provides extensive information for health, educational practitioners, and researchers in related fields wishing to familiarise themselves with the tool in self-study. The information presented in the manual is accessible as well as comprehensive, guiding the therapist through the assessment as well as providing clear answers to queries. For example, the examiner’s manual provides the objectives of each test activity, outlining the information that you obtain about the child’s performance capacities and motor skills, what these performance results may indicate with regards to a child’s participation in their home or school environment, and an item analysis that indicates the neurological foundations for each task and the corresponding items (Miller 2006, p. 23 – 36).
Summary & Conclusion
The M-Fun is a useful addition to the assessment toolkit of occupational therapists, in particular those working in school-based occupational therapy with young and very young children with mild to moderate movement difficulties such as those diagnosed with developmental co-ordination disorder (DCD). The tool might be also considered a promising outcome measure, which may assist with documenting individual children’s progress over time, service evaluation and research of school-based occupational therapy. Due to the relatively recent publication of the M-Fun, further research is required to validate and extend our understanding of the tool and its uses with different client groups within children’s therapy services in the United Kingdom.
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The author would like to thank Pearson Assessment UK for providing the test kit and respective manual. In addition, this review would have not been possible without the support, contribution and encouragement of the service managers and practitioners of the children’s therapy services in Dorset (NHS Poole Hospital Foundations Trust & NHS Dorset County Foundations Trust). Lastly, the children, parents and school staff who received occupational therapy through these children’s therapy services, with the M-Fun being part of their assessment process.
Review by: Andrea Hasselbusch, Phd candidate, MOccTh, Bc OT, PG Cert Ed, Dip OT Senior Practice Fellow