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The Dynamic Occupational Therapy Cognitive

Assessment for Children (DOTCACh):


A New Instrument for Assessing Learning Potential
Noomi Katz, Sarina Golstand, Ruthie Traub Bar-Ilan, Shula Parush

KEY WORDS OBJECTIVE. To describe the development and psychometric properties of the Dynamic Occupational
attention deficit hyperactivity Therapy Cognitive Assessment for Children (DOTCACh), a dynamic criterion-referenced assessment of cog-
nitive abilities and learning potential for children with cognitive and learning difficulties.
disorder (ADHD)
cognition METHOD. A series of studies analyzed the age standards, criterion cutoff scores, and percentage of media-
tion cues required for typically developing children 612 years of age, as well as reliability and validity.
learning disability
pediatric RESULTS. MANOVA analyses determined four age groups that best fit the outcome data: 66.11, 78.11,
910.11, and 1112 years. Criterion cutoff scores of 25% for at-risk and under 10% for deficient performance
traumatic brain injury (TBI) were obtained for each age group. Dynamic percentage scores were determined. Significant high interrater reli-
ability and moderate to high internal consistency reliability were found. Construct validity was supported by
comparing children with traumatic brain injury and learning disabilities to typically developing children, and
ecological validity of children with attention deficit hyperactivity disorder by comparing performance on the
DOTCACh to the School Function Assessment.
CONCLUSIONS. The DOTCACh is a reliable and valid assessment that provides learning potential and
can facilitate intervention for cognitive difficulties that manifest themselves in daily functions among school-
age children.

Katz, N., Golstand, S., Traub Bar-Ilan, R., & Parush, S. (2007). The Dynamic Occupational Therapy Cognitive Assessment
for Children (DOTCACh): A new instrument for assessing learning potential. American Journal of Occupational
Therapy, 61, 4152.

Introduction
This article describes the development and validation of a new instrument
designed to assess the cognitive abilities and learning potential of children from
ages 6 to 12 years via a dynamic mediation testing process. Currently, no other
standardized occupational therapy assessment battery of childrens cognitive abili-
ties exists. This lack of an instrument presents a limitation for pediatric occupa-
tional therapists, who are uniquely suited and often called on to treat and facilitate
the participation and performance of children with cognitive deficits in a wide vari-
Noomi Katz, PhD, OTR, is Professor, School of ety of occupational domains. The Dynamic Occupational Therapy Cognitive
Occupational Therapy, Hebrew University, Assessment for children (DOTCACh), a criterion-referenced assessment, was
PO Box 24026, Mount Scopus, Jerusalem 91240, Israel; designed to fill this need. Originally based on the Loewenstein Occupational
noomi.katz@huji.ac.il
Therapy Cognitive Assessment (LOTCA), an assessment for adults with neu-
Sarina Goldstand, MSc, OTR, is Pediatric Clinician ropsychological deficits (Itzkovich, Averbuch, Elazar, & Katz, 2000; Katz,
and Staff Member, School of Occupational Therapy, Itzkovich, Averbuch, & Elazar, 1989), and the LOTCA Geriatric version for elder-
Hebrew University, Israel.
ly persons (Itzkovich, Elazar, & Katz, 1996), the DOTCACh represents an adapt-
Ruthie Traub Bar-Ilan, MSc, OT, is Graduate Student ed and modified format that is appropriate for use with school-age children.
and Lecturer, School of Occupational Therapy, Hebrew The DOTCACh was designed to serve two major purposes. First, it provides
University, Israel. a baseline measure for the intervention of children referred for occupational ther-
apy treatment because of various cognitive and learning difficulties. In addition,
Shula Parush, PhD, OT, is Chairperson, Graduate
Studies, School of Occupational Therapy, Hebrew due to its dynamic properties, the DOTCACh identifies potential areas of cogni-
University, Israel. tive strength that can be tapped so children may benefit from mediated learning.
The American Journal of Occupational Therapy 41
Table 1. DOTCACh Subtests
Cognitive Domains Subtests No. of Items
Orientation: Awareness of self in relation to surroundings. Requires 1. Orientation to Place (OP) 4
consistent and reliable integration of attention, perception, and 2. Orientation to Time (OT) 4
memory.

Spatial Perception: The active process of searching for corresponding 3. Directions on Body (SP1) 4
information, distinguishing the essential features of an object, 4. Spatial Relations Between Child and Objects in Near Space (SP2) 4
comparing the features of an object, comparing the features with 5. Spatial Relations in a Picture (SP3) 4
each other, creating appropriate hypotheses, and comparing these
hypothesis with the original data.

Praxis: The ability to plan and perform purposeful movement. 6. Motor Imitation (MI) 12
7. Utilization of Objects (UO) 5
8. Symbolic Actions (SA) 5

Visuomotor Construction: The ability to integrate visual stimuli and to 9. Copy Geometric Forms* (GF)
construct or draw a reproduction (Cermak, 1984). It consists of three 10. Reproduction of 2-D Model* (2-DM)
activities: copying, drawing, and building or assembling. 11. Pegboard Construction* (PC)
12. Colored Block Design* (CB)
13. Plain Block Design* (PB)
14. Reproduction of Puzzle (RP)
15. Drawing a Clock (DC)

Thinking Operations: Includes the ability to identify discrete features of 16. Categorization (CA)
objects, to appreciate them hierarchically, and to classify them. 17. ROC Unstructured (RU)
18. ROC Structured (RS)
19. Pictorial Sequence A (PSA)
20. Pictorial Sequence B (PSB)
21. Geometrical Sequence A (GSA)
22. Geometrical Sequence B (GSB)
Note. DOTCACh = Dynamic Occupational Therapy Cognitive Assessment for Children.
*Include immediate and delayed memory testing.
This table was adapted from Ziviani, Rodger, Pacheco, Rootsey, Smith, and Katz (2004) with permission from the publishers.

The DOTCACh battery consists of 22 subtests in 5 tive development, including the capacity for abstract rea-
cognitive domains: Orientation, Spatial Perception, Praxis, soning and the ability to use ever-more sophisticated strate-
Visuomotor Construction, and Thinking Operations (see gies for problem solving (Kipke, 1998). In recent years
Table 1). During the test development process, the tasks researchers have seen an increased awareness of the poten-
within each of the domains were determined to follow a tial ability of dynamic assessment techniques (Rothman &
hierarchal progression that corresponds to the development Semmel, 1990) to provide professionals with the opportu-
of cognitive function in children. In addition, to enhance nity to estimate a childs cognitive and learning potentional
the sensitivity of the measures, the subtests within the and receptiveness to instruction (Fabio, 2005; Feuerstein,
Visuomotor Construction and Thinking Operations 1979; Lidz & Elliot, 2000).
domains were designed to provide the examiner with infor- Dynamic assessment is based on Vygotskys (1978)
mation regarding speed of performance. Finally, immediate concept of the zone of proximal development, which refers
and delayed memory is tested in five of the Visuomotor to the discrepancy between what a child can do indepen-
Construction subtests. dently and what he or she can do with the help and guid-
ance of others (Grigorenko & Sternberg, 1998). This con-
Dynamic Assessment cept is somewhat similar to the mediated learning
Conventional standardized cognitive tests are static in experience, a concept that was independently developed by
nature, examining the current performance of a person for Feuerstein, Rand, Hoffman, and Miller (1980). In mediat-
the purpose of identifying and quantifying cognitive deficits ed learning, adults serve as catalysts for learning by modify-
(Toglia, 1998). Such static tests, however, fall short of the ing the childs internal arousal, as well as the specific task
goal of cognitive testing as described by Thorndike in 1924: demands, to allow for improved cognitive performance.
that, ideally, estimates of intelligence should be estimates of Thus, according to mediated learning theorists, the benefi-
the ability to learn (as cited in Guthke & Beckmann, 2000). cial effects of dynamic assessment and teaching techniques
Evidence suggests that in human development, brain on childrens ability to learn and use more effective cogni-
growth continues into adolescence, which stimulates cogni- tive strategies are not limited to children with deficits but
42 January/February 2007, Volume 61, Number 1
also can be applied to typically developing children in reg- Results from research performed on a sample of typi-
ular school settings (Grigorenko & Sternberg, 1998). In cally developing children (N = 240) from ages 6 to 12 years
line with these considerations, one should expect that even indicated that the LOTCA test items follow a hierarchical
among typically developing children, initial scores on progression that corresponds to the development of cogni-
dynamic assessments, such as the DOTCACh, should tive abilities in children (Averbuch & Katz, 1991; Itzkovich
improve after the dynamic mediation phase of the testing et al., 2000).These findings highlighted the tests potential
procedure, especially in the younger age ranges and the suitability as an assessment for children. Later, the test was
more complex cognitive domains. used in a study performed on two different cultural groups
Toglia introduced the use of a structured, graded sys- (i.e., Ethiopian and Bedouin children who were typically
tem of cues to the evaluation of cognitive and perceptual developing), the results of which determined the LOTCAs
deficits among adults with cognitive impairments (Toglia, sensitivity to cultural and environmentally based influences
1998, 2005). Following in the footsteps of earlier dynam- on childrens cognitive developmental performance (Katz,
ic cognitive theorists, she believed that the examiner could Kizony, & Parush, 2002; Parush, Sharoni, Hahn-
learn much about underlying information-processing Markowitz, & Katz, 2000; Rosenblum, Katz, Hahn-
strategies through the observation of a clients responses to Markowitz, & Parush, 2000).
such cues. In this way, dynamic assessment becomes natu- As a result of these findings, the original LOTCA bat-
rally linked to intervention and can be used as a baseline tery underwent a series of modifications to adapt it for use
for choosing and designing an intervention program with children. For example, in the subtests for Visuomotor
(Toglia, 1994, 2005). Construction, in addition to crediting children for com-
Specifically, in dynamic assessments such as the pleting the test items, the test developers added a measure
DOTCACh, a childs initial incorrect response is not taken of response time for each item. This modification results
as the final outcome measure of his or her performance. from the understanding that the time required for an indi-
Instead, the examiner uses a systematic approach to modify vidual to respond to a visual perceptionbased task is a
the task through prompts or other forms of mediation, more sensitive measure of processing ability than task accu-
which provides an understanding of the types of information racy alone (Hung, Fisher, & Cermak, 1987; Solan, 1987;
essential for the child in completing the task. This feature, Solan & Mozlin, 1986). Mozlin (1995) used the term per-
which is unique to dynamic assessments, also enables the ceptual speed to describe the time required to respond to
examiner to collect information that can be helpful in devel- visualperceptual tasks. These researchers suggested that the
oping effective intervention strategies (Rothman & Semmel, child with a perceptual speed deficit would require more
1990). Indeed, the use of such feedback during and after time and more of his or her attentional reserves to complete
testing demonstrates how dynamic assessment ascribes to an assignment than his or her peers.
the principle underlying the learning test concept, specifical- Another modification made by test developers was the
ly that learning can take place even within the actual testing evaluation of the individuals immediate and delayed mem-
process (Guthke & Beckmann, 2000). ory. This assessment component was added to five of the
seven subtests included in the Visuomotor Construction
domain of the DOTCACh. Immediate memory (short-
Test Development term working memory) typically lasts from about 30 sec-
The history of the DOTCACh began in 1974 with the onds to several minutes and serves as a limited capacity store
development of the LOTCA battery by a team of clinicians from which information is transferred to a more permanent
from the Loewenstein Rehabilitation Hospital, Israel. The store. It need be only of sufficient duration to enable a per-
LOTCA, designed as a primary cognitive evaluation for son to respond to ongoing events. In contrast, delayed
persons with head injuries (Itzkovich et al., 2000), was memory refers to the persons ability to store information
derived from a cumulation of clinical experience as well as for a longer period (Lezak, 1995).
from neuropsychological and delvelopmental theories and The major design modification made by the authors of
evaluation procedures (Averbuch & Katz, 2005). The the DOTCACh, however, was the introduction of a struc-
LOTCA battery has been standardized and researched tured dynamic test procedure, in addition to the original
extensively for its reliability and validity in various popula- static testing procedure. This modification followed from
tions and cultures (Annes, Katz, & Cermak, 1996; the increased awareness that dynamic assessment techniques
Averbuch & Katz, 2005; Cermak et al., 1995; Itzkovich et can supply information beyond what is obtainable through
al., 2000; Katz, Hartman Maeir, Ring, & Soroker, 2000; traditional static assessments. Specifically, these techniques
Katz et al., 1989). inform clinicians as to the persons problem-solving style and
The American Journal of Occupational Therapy 43
ability to benefit from instruction (Fabio, 2005; Rothman & pleted in a single session. The only constraint is that all of
Semmel, 1990; Toglia, 1998, 2005). the items within each individual cognitive domain must be
In accordance with the changes in test design that completed within a single testing session. Further, adminis-
resulted from these modifications, test developers estab- tration requires only limited space, a child-size table, and
lished a three-phase administration format (see Figure 1). two chairs; all other materials are provided in the test kit.
The initial phase of the test administration is the static The testing room should be well lit and ventilated and also
phase, in which the childs cognitive status, or baseline cog- free from noise and other distracting influences.
nitive performance, is measured. After this, in the dynamic Having completed the necessary modifications to the
phase of the test battery (i.e., Phase II), the examiner pro- test battery, the next stage of the DOTCACh test devel-
vides the child with structured hierarchical cues as required, opment process involved the determination of its psycho-
designed to elicit his or her maximum learning potential. metric properties. This article describes the steps taken for
The final retest phase of the DOTCACh was designed to this stage of the test development process.
determine the childs learning potential and receptiveness to
instruction. This is accomplished by having the examiner
readminister the test items and analyze whether the childs Method
performance has improved since the initial testing phase. It We conducted a series of studies to determine the psycho-
is important to note that mediation was incorporated into metric properties of the DOTCACh with respect to these
all test domains except for Orientation. This section of the three outcome categories: (a) Step 1standards of perfor-
battery is the only one requiring a verbal response alone and mance of typically developing children, such as age stan-
has a built-in recognition phase if the child cannot answer dards, criterion cutoff scores, and dynamic percentage
the questions. scores (i.e., percentage of mediation cues required across
The five structured levels of mediation used in the test domains and age groups); (b) Step 2interrater relia-
dynamic phase of the DOTCACh administration were bility and internal consistency; and (c) Step 3construct
adapted with permission from Toglia (1994). In order of and ecological validity.
increasing intensity of mediation, the levels are Level 1 Permission to perform the research studies was
general intervention; Level 2general feedback; Level 3 obtained from the Israeli Ministry of Education and the
specific feedback; Level 4structured feedback, pictorial Human Rights Committee of the Ministry of Health before
examples, or demonstration; and Level 5reduced task the data were collected. Additionally, written consent was
complexity. Each level indicates a type of mediation that is obtained from the participants parents and school princi-
most helpful to a specific child. Thus, the mediation level pals. In all phases of this research the DOTCACh was
required for a child to succeed serves to guide the clinician in administered by experienced occupational therapists trained
determining whether and how intervention should proceed. in its use, in accordance with the standardized protocol
The flexibility of the test design allows the described in the manual (Katz, Parush, & Traub Bar-Ilan,
DOTCACh to be used in either of two ways. If the pur- 2005). All participants were tested individually under simi-
pose of test administration is to establish a baseline measure lar environmental conditions.
of a childs cognitive performance, the static testing phase
can be administered alone. If the test, however, is being Step 1: Standards of Performance of Typically
administered to determine a childs ability to benefit from Developing Children
mediation or to plan intervention, all three phases of the Methods and procedure. Data were collected from a con-
battery should be used. venience sample of 381 typically developing children
Another advantage of the DOTCACh is its practical- between ages 6 and 12 years, in various schools around
ity. Although the administration of the entire battery can Israel. The participants were recruited by occupational ther-
take up to 1 hour and a half, it does not have to be com- apists who worked at the schools at the time of the study.
The age and gender distribution of the participants can be
found in Table 2.
The DOTCACh was administered by six trained and
Phase I Phase II Phase III
experienced occupational therapists. Reliability of scoring
Pretest Mediation Posttest among these examiners was established by having each of
(static test) (dynamic phase) (retest) them individually score a videotape of a child. Overall
agreement between them was found to be high, 91.8 (i.e.,
Figure 1. A Three-Phase Administration Format Orientation, 83%; Spatial Perception, 98.6%; Praxis,
44 January/February 2007, Volume 61, Number 1
Table 2. Gender Distribution in the Four Age Groups Results.
Age Range (in years) No. of Boys No. of Girls Total Standards of performance. On the basis of the MANO-
6 6.11 20 18 38 VA analysis, statistically significant differences for all of the
7 8.11 57 59 116
910.11 68 86 154 DOTCACh total domain scores were found between par-
1112.0 36 37 73 ticipants grouped according to the following age ranges:
Total 181 200 381
66.11 years, 78.11 years, 910.11 years, and 1112.0
Note. No significant difference chi square; (3) = 1.31, p = 0.73.
years (Table 3). In addition, chi-square analysis found no
significant differences across genders for participants within
88.9%; Visuomotor Construction, 95%; Thinking Opera- the four age groups (2 = [3] = 1.31, p = 0.73).
tions, 88.6%). For the few specific points in which raters The data indicate that mean performance increased
disagreed, consensus was reached after a group discussion. with age for all total scores in the five cognitive domains,
Data analysis. After the data were collected, multivariate including immediate and delayed memory components of
analysis of variance (MANOVA) was performed to deter- Visuomotor Construction, whereas mean performance
mine the age group divisions that would reflect statistically time significantly decreased (Figures 2 and 3). The ANOVA
significant differences between group performance across results demonstrated a similar pattern. These differences,
test domains. In addition, computations of one-way however, leveled out with increasing age, as can be seen by
ANOVA with post hoc Scheff comparisons were applied the post hoc comparisons that are significant with the
to compare the groups performance. exception of the results of the comparison between the two
Next, chi-square analysis was performed to determine older age groups (Table 3).
whether significant differences in test performance would be Cutoff scores by age groups. Criterion cutoff scores were
found between boys and girls within age groups. Descriptive obtained from the frequency analyses of scores received by
statistics for all five domain scores and their respective sub- children in each age group for all domains of the
tests (mean, standard deviations, minimum, and maximum) DOTCACh (Katz et al., 2005). These scores enable the
were performed for each of the four age groups found to best examiner to get a relative measure of a childs cognitive per-
fit the data. For each age group, cutoff scores were calculat- formance in each domain in comparison to his or her age-
ed, as well as the mean percentage level of mediation that group peers in the standardization sample. Specifically, chil-
was required for performance in each cognitive domain dren who obtain scores at or below the 10% level (i.e.,
(referred to as dynamic percentage scores). Finally, pretest and performed less well than 90% of the sample) scored between
posttest scores of the children in all age groups and cognitive minus 12 standard deviations of the mean standardized
domains were compared using paired t tests. score, indicating that their cognitive performance is defi-

Table 3. One-Way ANOVA for Total Cognitive Domain Scores of the DOTCACh Between Four Age Groups

A (66.11 Years) B (78.11 Years) C (910.11 Years) D (1112.0 Years)


DOTCACh Domains M (SD) M (SD) M (SD) M (SD) F
Orientation 12.61 (1.59) 13.97 (1.51) 15.28 (0.97) 15.22 (0.77) F(3,377) = 68.79
Spatial Perception 8.63 (2.19) 10.5 (1.76) 10.99 (1.58) 11.42 (1.15) F(3,372) = 27.21
Praxis 19.55 (4.27) 25.29 (6.7) 29.54 (5.66) 33.05 (4.38) F(3,200) = 36.21
Visuomotor Construction 20.79 (4.22) 25.83 (3.84) 27.74 (3.59) 28.47 (3.19) F(3,373) = 41.48
Immediate Memory 13.59 (4.07) 17.93 (4.20) 18.02 (4.06) 19.60 (4.16) F(3,373) = 16.59
Delayed Memory 20.18 (3.26) 21.35 (3.02) 23.03 (1.82) 23.38 (1.07) F(3,192) = 13.49
Thinking Operations 20.96 (3.88) 22.87 (4.59) 23.6 (4.02) 24.6 (2.15) F(3,377) = 7.98

Post Hoc Scheff

Total Area Scores A vs. B A vs. C A vs. D B vs. C B vs. D D vs. C


Orientation * * * * *
Spatial Perception * * * *
Praxis * * * * *
Visuomotor Construction * * * * *
Immediate Memory * * *
Delayed Memory * * * *
Thinking Operations * * *
Note. DOTCACh = Dynamic Occupational Therapy Cognitive Assessment for Children, ANOVA = analysis of variance. p < .0001 for all comparisons. Range of
scores possible: Orientation, 116; Spatial Perception, 112; Praxis, 144; Visuomotor Construction, 735; immediate, 5-25; Thinking Operations, 735.
* Indicates significant differences between 2 groups.

The American Journal of Occupational Therapy 45


Note. OR = Orientation; SP = Spatial Perception; P = Praxis; VC = Visuomotor Note. GF = copy geometric forms; 2-DM = reproduction of 2-D model; PC =
Construction; TO = Thinking Operations. One-way ANOVA significant at p < pegboard construction; CB = colored block design; PB = plain block design;
.0001 for all domains; post hoc Scheff varies. RP = reproduction of puzzle; DC = drawing a clock. One-way ANOVA signifi-
cant at p < .000 for all domains except 2-DM; post hoc Scheff varies.
Figure 2. DOTCACh Pretest Domain Means, by Age Groups:
Typically Developing Children Figure 3. Mean Times for Visuomotor Construction Subtests
by Age Groups: Typically Developing Children

cient. Further, children who obtained scores at or below the dren (i.e., 1112.0 years) required no mediation (i.e., a
25% level (i.e., performed less well than 75% of the sam- score of 0).The percentage of children requiring mediation
ple) scored between minus 1/2 1 standard deviations of the (i.e., with a score > 0) increases within each of the succes-
mean standardized score, indicating that they are at risk for sively younger age group, to a level of 36% in the youngest
cognitive dysfunction. Thus, for example, a 6-year-old child group (ages 66.11 years), among whom about 10% to
who obtains a total Visuomotor Construction score of 15, 17% required the use of maximum mediation (mediation
corresponding to the 10% cutoff score for this domain, per- at all available levels).
forms at 1.37 z score below the mean (M = 20.79, SD = The data indicate that even typically developing chil-
4.22) of the standardized sample within his or her age dren benefited from mediation, especially in the perfor-
group. This result would indicate to the examiner that the mance of the tasks in the more complex cognitive domains,
child has a cognitive deficiency in this domain relative to such as Visuomotor Construction and Thinking Opera-
same-age peers. Further, if this same 6-year-old had tions (Katz et al., 2005). In addition, when pretest and
obtained a score below 18.75, which corresponds to the posttest scores of the typically developing children were
25% cutoff score for Visuomotor Construction, this score compared in these cognitive domains, t test analyses
is 0.48 z score below the mean of the standardized sample revealed a significant improvement following mediation (t =
of this age group. This score would indicate to the examin- 9.61, p < .001 for Visuomotor Construction; t = 23.36, p <
er that the child is at risk for deficiency in this cognitive .0001 for Thinking Operations).
domain.
Dynamic percentage scores by age groups. The dynam- Step 2: Reliability Studies
ic percentage scores indicate the mean of the mediation
level used in each cognitive area for each age group. A score Methods and procedure. Interrater reliability of the test
of 0 indicates that no mediation was necessary, as is the case was determined on a group of 20 children who were typical-
for children who performed at the maximal score on the ly developing. These children were randomly selected from
pretest (static phase of the DOTCACh). A score of 1 indi- all the age groups within the original sample of 381 children
cates that only general intervention was required, represent- who were tested to determine performance standards of the
ing minimal mediation, whereas a score of 5 indicates that DOTCACh. Interrater reliability was examined through
either the child required the maximum amount of media- intraclass correlation (ICC) analysis, comparing the results
tion to perform a task, or that even given the maximum of the participants scores as obtained by two expert
mediation, he or she was unable to accomplish the task. For DOTCACh administrators. Internal consistency reliability
example, in the Praxis subtest, about 88% of the older chil- was performed using Cronbachs alpha on the entire sample.

46 January/February 2007, Volume 61, Number 1


Results. Results of the ICC analysis revealed very high girls and 7 boys) with learning disabilities were recruited
reliability coeficients for all cognitive domains, ranging from a sampling of regular schools across central Israel.
from .87 to .99 (Table 4). In addition, internal consistency These children were reported by specially licensed edu-
reliability, analyzed from the whole data pool, resulted in cational psychologists (approved by the Israeli Board of
moderate-to-high alpha coefficients ranging from .61 to .77 Education) as having learning disabilities. Next, the
for the different domains (Table 4). DOTCACh was administered to an age-matched conve-
nience group of 60 second-grade and third-grade children
Step 3: Validity Studies who were typically developing (mean age = 8.14 years, SD
= 0.6; 35 girls and 25 boys) and who had no history of
Construct validity. learning difficulties.
Methods and procedure. Construct validity was estab- Results. Comparison of children with TBI to children
lished by comparing DOTCACh scores of typically devel- who were typically developing showed significant differ-
oping children to an age-matched and gender-matched ences at pretest for all cognitive domains (p < .000) and
group of children with traumatic brain injury (TBI) and, in time to complete the Visuomotor Construction domain,
two separate comparative studies, to two samples of chil- except for Praxis (Table 5). Significant differences in
dren with learning disabilities. Data analyses were per- posttest scores were found for two domains (i.e., Visuo-
formed on pretest and posttest scores using MANOVA motor Construction [p < .002] and Thinking Operations
analyses over the 5 cognitive domains and 2 groups. [p < .000]. When scores in the other three domains were
In the TBI versus control study, a consecutive sample of examined, children with TBI had improved with mediation
44 children with TBI (ages ranging from 6 to 12 years, and performed more similarly to the typically developing
mean age 9.3 years, SD = 1.6; 26 girls and 18 boys), as children. Although differences were still found, they were
determined by a pediatrist neurologist and confirmed by nonsignificant. Unfortunately, in this study only the items
CT scanning, were recruited from two rehabilitation hospi- from the original short version of the Praxis domain were
tals day treatment centers. These participants were matched administered, which was the probable reason that no signif-
by age and gender to 43 typically developing children icant differences were found. In fact, these results were the
(mean age = 9.7, SD = 1.5; 25 girls and 19 boys) selected reason for the further, extensive elaboration of the Praxis
from the original pool of 381 typically developing children domain (Katz el al., 2005).
used to determine DOTCACh performance standards. For the two studies in which the scores of children with
In the children with learning disabilties versus control learning disabilities were compared to those of typically
studies, a convenience sample of 30 second-grade children developing children, only Visuomotor Construction and
(mean age = 7.5 years, SD = 0.6; 9 girls and 24 boys) and Thinking Operations were tested. MANOVA analysis
32 third-grade children (mean age = 9.0 years, SD = 0.4; 22 revealed significant (p < .01) differences between sample
groups in scores for all subtests at pretest and posttest except
one comparison at posttest (p < .05). Time to complete the
Visuomotor Construction domain also was significantly
Table 4. Interrater and Internal Consistency Reliability different at p < .01 (Table 5).
Interrater Reliability (n = 20) Overall, children with disabilities performed less well
DOTCACh Domains ICC and were slower during the pretest static phase (i.e., base-
Orientation .93 line); however, all improved with mediation, including chil-
Spatial Perception .95
Praxis .91
dren who were typically developing. In addition, statistical-
Visuomotor Construction .99 ly significant differences were found between pretest and
Immediate Memory .99 posttest scores of children in the three populations (typical-
Thinking Operations .87
ly developing, with learning disabilities, with TBI) (Katz &
Internal Consistency Reliability (n = 381) Parush, 2003). See Figure 4 for means of performance in
DOTCACh Domains Alpha Coefficient
the groups with learning disabilities and TBI.
Orientation .61 (8 items)
Spatial Perception .74 (12 items) Ecological Validity.
Praxis .70 (23 items)
Visuomotor Construction .61 (7 items) Methods and procedure. The initial examination of
Immediate Memory .64 (5 items)
Thinking Operations .77 (8 items)
ecological validity was performed by administering the
Note. DOTCACh = Dynamic Occupational Therapy Cognitive Assessment for DOTCACh to a convenience sample of 30 second-grade
Children, ICC = interclass correlation coefficiency. to fourth-grade children with attention deficit hyperactivity
The American Journal of Occupational Therapy 47
Table 5. MANOVA Analyses Comparing DOTCACh Domain Scores of Three Groups of Children
Children With TBI (n = 44) *Children With LD 2nd grade (n = 30), 3rd grade (n = 32)
vs. vs.
TD Children (n = 43) TD Children 2nd grade (n = 30), 3rd grade (n = 30)
Pretest Posttest Pretest Posttest
F p F p F p F p
DOTCA-CH Domains F p F p (2nd grade) (3rd grade) (2nd grade) (3rd grade)
Orientation 33.16 .000
Spatial Perception 19.22 .000 0.004 .949
Praxis 1.04 .311+ 3.49 .065
Visuomotor Construction 14.62 .000 10.03 .002 48.99 .01 16.15 .01 27.84 .01 5.80 .05
Immediate Memory 13.28 .01 12.30 .01
Thinking Operation 12.88 .000 19.81 .000 35.21 .01 12.64 .01 31.95 .01 17.07 .01
Note. DOTCACh = Dynamic Occupational Therapy Cognitive Assessment for Children, MANOVA = multivariate analysis of variance, TBI = traumatic brain injury,
TD = typically developing, LD = learning disabilities.
* Only 2 domains were tested; = not administered.
+
Original brief version of Praxis subtest was used in this study.

disorder (ADHD) (mean age 8.5 years, SD = 1.0; 25 boys Next, the relationship between the 5 total cognitive
and 5 girls) recruited from regular elementary schools in domain scores on the DOTCACh and teachers ratings of
northern Israel (De la Vega, 2004). The childrens diagnosis childrens functional performance in both physical and cog-
had been determined by a developmental pediatrician nitive/behavioral tasks of the SFA were analyzed by calcu-
according to the criteria of the DSM-IV (American latating Pearson correlation coefficients.
Psychiatric Association, 1994) and was confirmed by the Results. The study revealed significant correlations
scores obtained by their classroom teachers on the Conners (range .35.71, p < .05) between the childrens scores in the
Teacher Rating ScaleRevised (Conners, 1997), a question- Orientation, Visuomotor Construction, and Thinking
naire commonly used to identify the presence of character- Operations domains of the DOTCACh and their perfor-
istic behavioral symptoms of ADHD. In addition, the chil- mance of cognitivebehavioral tasks according to the SFA.
drens teachers were asked to complete the School Function Moreover, significant correlations, ranging from r = .36.63
Assessment (SFA), a tool used to rate childrens functional (p < .05) were obtained between the childrens scores in the
performance in both physical and cognitivebehavioral Spatial Perception, Praxis, Visuomotor Construction
tasks that they are expected to perform in the school envi- domains of the DOTCACh and their performance of
ronment (Coster, Deeney, Haltiwanger, & Haley, 1998). functional physical tasks of the SFA.

Note. DOTCACh = Dynamic Occupational Therapy Cognitive Assessment for Children, TBI = traumatic brain injury, LD = learning disability, SP = Spatial Perception,
P = Praxis, VC = Visuomotor Construction, TO = Thinking Operations. All comparisons statistically significant.

Figure 4. Mean Performance of Children With Traumatic Brain Injury and Learning Disabilities on DOTCACh Domains at Pretest and Posttest

48 January/February 2007, Volume 61, Number 1


Discussion complex cognitive domains (i.e., Visuomotor Construction
and Thinking Operations), as determined by the percentage
Currently, no standardized occupational therapy assessment of mean dynamic mediation scores. These findingsin
exists for the evaluation of cognitive functioning among chil- addition to the parallel findings of even greater improve-
dren. The DOTCACh, originally based on the LOTCA ments between pretest and posttest scores among the chil-
cognitive assessment for adults, was developed for two main dren with disabilitiessupport the validity of the dynamic
purposes. First, it provides an efficient and child-friendly mea- mediational component of the DOTCACh in facilitating
sure of cognition among children ages 612 years. Further, improvements in problem solving and learning potential in
through its dynamic testing properties, the DOTCACh pro- children with and without disabilities. In fact, it is this
vides a means of identifying potential areas of cognitive property of the mediated learning approach on which the
strength. It is believed that the dynamic testing properties of assessment and educational programs of classical dynamic
the DOTCACh could enable its use by pediatric practition- assessment theorists Vygotsky and Feuerstein were derived
ers as a tool for planning intervention strategies tailor-made (Grigorenko & Sternberg, 1998).
for the individual child under treatment.
As described previously, a series of studies were under- Reliability
taken with respect to 3 outcome categories related to the The reliability of an assessment refers to the stability and
DOTCACh: performance of typically developing children dependability of its scores across time (testretest reliability)
within four age groups (i.e., 66.11 years; 78.11 years; or examiners (interrater reliability) or of the items within a
910.11 years; and 1112.0 years), test reliability, and test scale (internal consistency reliability) (Crocker & Algina,
validity. 1986). Assessment reliability ensures that consistent scores
The results of the studies described revealed that the are obtained with each use and irrespective of the specific
mean performance of typically developing children signifi- person administering the test.
cantly increased in all of the cognitive domains of the In the analysis performed on 381 typically developing
DOTCACh, with a concomitant decrease in the mean children, the internal consistency of the DOTCACh
performance times for each successive age group (Katz et al., domains ranged from r = .61.77, indicating a medium, albeit
2005). These results strengthen the previous research find- adequate, level of homogeneity between the various subtest
ings that the test items sensitively measure the expected items in each area. Most likely these relatively moderate coef-
developmental progression of cognitive abilities in children ficient values were a consequence of the small number of sub-
(Averbuch & Katz, 1991; Itzkovich et al., 2000). Thus, tests in each area. With respect to the examination of the inter-
research on the DOTCACh seems to highlight its poten- rater reliability of the DOTCACh, as reported previously,
tial to accurately assess the difficulties experienced by some the scores obtained by two independent expert examiners on
children in progressing in accordance with expected norms, a group of 20 children were found to be high for all 5 test
with respect to their cognitive growth and development. domains. These results were similar to those of a recent pilot
The study of performance on the DOTCACh by typ- study in which high Kappa coefficients and percentage of
ically developing children also resulted in the determination agreement were found between rater scores in a small group of
of cutoff percentiles. These data are intended to provide Australian children (n = 11) (Ziviani et al., 2004). This simi-
clinicians with the means to correctly identify children who larity indicates that, overall, the process of administering and
are deficient in specific cognitive domains (i.e., performance rating the DOTCACh scores is clear and structured well
at percentiles 10%) and those who are at risk for learning enough so as to enable objective and reproducible results
difficulties and academic underachievement (i.e., perfor- between examiners.
mance at percentiles 25%). Early identification of poten-
tial cognitive deficiencies are vital to provide timely inter- Validity
ventions and prevent the development of secondary The construct validity of an instrument refers to its ability
behavioral and psychological sequelae (Creedy et al., 2005; to perform in a way that is consistent with the presumed
Williams & Holmes, 2004) that may lead to lower partici- underlying constructs (Law, 2001), which is critical in
pation in daily functioning. enabling users to judge the test results significance.
Finally, the research findings indicated that even the The findings of significantly better mean performance
scores of typically developing children improved from scores and decreases in performance time among the typi-
pretest to posttest DOTCACh scores, and a substantial cally developing children within four progressively older age
percentage of typically developing participants required groups (i.e., ages 612 years) indicated the validity of the
moderate and maximum levels of mediation in the more DOTCACh as a developmental measure of cognitive
The American Journal of Occupational Therapy 49
function. Furthermore, the results supported the validity of without DCD who were typically developing. As expected
the dynamic assessment procedure of the DOTCACh. in Yus study, of all the cognitive domains tested by the
Specifically, dynamic percentage score calculations indicat- DOTCACh, the children with DCD scored significantly
ed that even these children who were typically developing lower than the typically developing children only on the
benefited from the mediation procedure, especially in the Praxis domain. Thus, her findings support the validity of
more complex cognitive domains (i.e., Visuomotor the Praxis subtests of the DOTCACh in evaluating the
Construction and Thinking Operations). Moreover, t test motor planning abilities of children.
analysis comparing pretest and posttest scores in these Moreover, Yus study provided initial indications of the
domains indicated significantly better scores. concurrent validity of the praxis domain of the
Construct validity also was examined through a DOTCACh. Yu compared the DOTCACh Praxis scores
known-groups comparison technique in which the scores of her study sample to scores obtained for them on two
obtained by typically developing children on the pretest, other well-known assessments used for children with DCD.
posttest, and dynamic phases were compared to those of Specifically, these included the Movement Assessment
children with disabilities known to affect cognitive abilities, Battery for Children (MABC; Henderson, & Sugden,
such as children with learning disabilities and TBI. 1992), a widely used and well-recognized test to identify
Results indicated that significantly better scores in all children with praxis and movement difficulties, and the
three test phases were obtained by typically developing chil- Parent Questionnaire from the Perceived Efficacy Goal
dren, as compared to those of age-matched children with Setting System (PEGS; Missiuna, Pollock, & Law, 2004), a
learning disabilities. Similarly, when the scores of typically survey that assesses parental perceptions of the childs per-
developing children were compared to those of age- and formance on everyday motor tasks. Results revealed signifi-
gender-matched children with TBI, significant differences cant moderate correlations between the Praxis subtests
were found across cognitive domains with respect to pretest, scores of the children with DCD with the results of the
posttest, and mediation scores. MABC and the PEGS Parent Questionnaire.
These findings support the ability of the DOTCACh Finally, as previously described, De la Vegas (2004)
to distinguish between the baseline cognitive status of chil- findings of significant correlations between the scores of
dren who are typically developing and those with known children with ADHD on the DOTCACh and results of
cognitive difficulties and also reveals significant differences the SFA provide an initial indication of the ecological valid-
with respect to the amount of mediation they required. A ity of the DOTCACh. Ecological validity refers to the
much higher percentage of mediation is apparent among functional and predictive relationship between assessment
children with cognitive disabilities, indicating that they scores and behavior in a functional real-world setting (Long
require more elaborate and specific cuing during interven- & Sbordone, 1996; Silver, 2000). Thus, De la Vegas study
tion. Hence, this research supports the contention of the provides support for the ability of the DOTCACh scores
tools developers, that the DOTCACh provides a mea- to reflect the functional performance of children with cog-
sure of childrens strengths and weakness across cognitive nitive disabilities within the context of the school environ-
domains and can inform practitioners regarding the types ment. These relationships were discussed recently by
of mediational techniques that are successful in facilitating Cermak (2005), emphasizing the issues of attention and
task performance. The DOTCACh, therefore, enables executive functions in her in-depth writing of cognitive
therapists to treat children with cognitive impairments rehabilitation for children with ADHD.
through interventions individually tailored to the individ- In summary, the results of the research on the psycho-
ual child. Specifically, the intervention provided to a child metric properties of the DOTCACh assessment indicate
can accommodate his or her learning potential through its suitability to evaluate the cognitive status and learning
the use of the appropriate mediation approach (e.g., potential of children with cognitive difficulties that mani-
refocusing, verbal cuing, demonstration, and reducing task fest themselves in daily functions among school-age chil-
complexity). dren. Further studies are indicated to establish its relia-
The current study findings regarding the validity of the bility and validity in different cultural and diagnostic
DOTCACh were strengthened by the findings of Yu populations.
(2004). In her study, Yu compared the performance on the
DOTCACh battery of 20 Taiwanese children (mean age 9 References
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Cognition and Occupation Across the Life Span


MODELS FOR INTERVENTION IN OCCUPATIONAL THERAPY 2nd Edition
Edited by Noomi Katz, PhD, OTR
Foreword by M. Carolyn Baum, PhD, OTR, FAOTA

U
pdated and expanded, this 2nd edition provides an exten-
sive knowledge base covering the contribution of occupa-
tional therapy for children, adolescents, adults, and older
adults with cognitive and related dysfunctions. This text incorpo-
rates the concepts of the International Classification of Functioning,
Disability, and Health and the Occupational Therapy Practice
Framework; features a new section describing models of cognition
developed and applied to children; focuses on different client pop-
ulations, such as those with neurological disabilities and mental
health issues; and more. ISBN-13: 978-1-56900-198-1
ISBN-10: 1-56900-198-7
467 pages
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52 January/February 2007, Volume 61, Number 1