Pediatric Volitional Questionnaire

1. Abstract

The Pediatric Volitional Questionnaire (PVQ; Basu, Kafkes, Schatz, & Kielhofner, 2002; Kafkes, Basu, Geist, & Kielhofner, 2008) is an observational psychometric assessment engineered within the theoretical architecture of the Model of Human Occupation (MOHO). It is explicitly designed to evaluate the volitional process—the internal motivation for occupational engagement—in children aged 2 to 7 years, as well as in older youth presenting with profound cognitive, verbal, sensory, motor, or communicative impairments. Grounded in the developmental continuum of volition, the PVQ systematically captures how a child initiates, sustains, directs, and derives meaning from occupational behavior within diverse physical and sociocultural ecologies.

The instrument operationalizes volition across three hierarchically structured developmental stages: Exploration, Competence, and Achievement. Across these stages, the PVQ comprises 14 overt behavioral items evaluated through a specialized four-point ordinal rating scale designating the degree of volition: Passive (1), Hesitant (2), Involved (3), and Spontaneous (4). In addition, the instrument incorporates an environmental narrative recording system that evaluates the systemic affordances and barriers present during observation across physical, social, task, and cultural ecological dimensions.

Psychometric investigations utilizing the Many-Facet Rasch Model (MFRM) provide empirical confirmation of the PVQ’s structural validity, establishing unidimensionality, an empirically validated developmental hierarchy of item difficulties, and invariant cross-cultural calibration across diverse pediatric populations (including individuals with cerebral palsy, autism spectrum disorder, and intellectual disabilities). The PVQ exhibits robust inter-rater reliability, strong construct validity, and sensitivity to ecological interventions, positioning it as an indispensable clinical and empirical standard in pediatric occupational therapy, neurorehabilitation, and developmental psychology.

2. Keywords

Pediatric Volitional Questionnaire, Model of Human Occupation, Volition, Occupational Therapy, Rasch Measurement Model, Motivation in Children, Pediatric Assessment, Observational Assessment, Developmental Disabilities, Cerebral Palsy, Psychometrics, Environmental Affordance, Occupational Participation, Play Behavior, Self-Determination

3. Authors

The Pediatric Volitional Questionnaire was conceptualized, developed, and calibrated by an international research collaborative through the Model of Human Occupation Clearinghouse at the University of Illinois at Chicago (UIC):

• Argyro Kafkes, MS, OTR/L: Clinical Specialist and Occupational Therapist, Department of Occupational Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois, United States.
• Supriya Basu, OTD, OTR/L: Clinical Assistant Professor and MOHO Fellow, Department of Occupational Therapy, University of Illinois at Chicago, Chicago, IL, USA.
• Rosa Geist, MS, OTR/L: Pediatric Occupational Therapist and Clinical Researcher, University of Illinois at Chicago, Chicago, IL, USA.
• Gary Kielhofner, DrPH, FAOTA (1949–2010): Former Professor and Wade-Meyer Endowed Chair, Department of Occupational Therapy, College of Applied Health Sciences, University of Illinois at Chicago. Kielhofner was the primary originator of the Model of Human Occupation and an internationally renowned leader in occupational science.
• Dutch Standardization Collaborators: Liesbeth Arts, MSc, and Marjon van Hees, MSc (2003, 2008), responsible for the Dutch cross-cultural adaptation and validation in the Netherlands.

Institutional Contact: MOHO Clearinghouse, Department of Occupational Therapy (MC 811), College of Applied Health Sciences, University of Illinois at Chicago, 1919 West Taylor Street, Chicago, IL 60612-7250, USA. Web: MOHO Clearinghouse UIC.

4. Purpose

The primary purpose of the Pediatric Volitional Questionnaire (PVQ) is to provide an objective, ecologically valid, and theoretically coherent measurement of volitional behavior—a child’s underlying inner drive, self-efficacy, interests, and personal values toward occupational engagement. Traditional psychometric batteries assessing pediatric function historically emphasize capacity-based metrics, such as gross and fine motor coordination, cognitive processing speed, executive functioning, or sensory registration. However, these tools routinely fail to capture the motivational and self-regulatory mechanisms that dictate whether and how a child initiates and perseveres in life activities. The PVQ specifically addresses this diagnostic and rehabilitative void.

Crucially, the PVQ was developed to overcome the profound measurement barriers inherent in assessing motivation in populations with limited speech or cognitive comprehension. Self-report motivational instruments (such as the Children’s Assessment of Participation and Enjoyment or standard Likert-scale self-efficacy inventories) necessitate intact receptive and expressive language skills, meta-cognitive awareness, and sustained attention. Children with severe neurodevelopmental disorders—including non-verbal autism spectrum conditions, bilateral spastic cerebral palsy (Gross Motor Function Classification System [GMFCS] Levels IV and V), severe traumatic brain injuries, and significant intellectual delays—are systematically disenfranchised by self-report instruments. The PVQ bypasses the requirement for verbal interaction by transforming direct behavioral observation across dynamic, naturalistic environments into an objective psychometric index.

In clinical rehabilitation, the PVQ serves several core functions:

• Diagnostic Baseline Profiling: Quantifying the precise volitional stage (Exploration, Competence, or Achievement) at which a child reliably operates, thereby preventing therapeutic over-demand or under-stimulation.
• Ecological Environmental Analysis: Disentangling the child’s underlying motivational capacity from environmental obstacles by systematically recording how environmental modifications (e.g., adaptive seating, reduced auditory stimuli, parent scaffolding versus clinician scaffolding) alter volitional expressions.
• Treatment Planning and Scaffolding: Designing patient-centered interventions that align therapeutic goals with activities matching the child’s demonstrated interests and personal causation.
• Longitudinal Outcome Measurement: Tracking incremental developmental gains in self-determination, autonomy, persistence, and self-efficacy across rehabilitative, home, and educational settings over time.

In empirical research, the PVQ functions as a primary dependent measure in pediatric intervention trials, health services research, and cross-cultural developmental investigations. It enables researchers to quantify how physical, pharmacological, surgical, or neurodevelopmental therapies influence occupational participation, psychological engagement, and autonomous choice-making.

5. Psychological Construct

The construct operationalized by the PVQ is volition as conceptualized within Kielhofner’s Model of Human Occupation. In this framework, volition is not viewed merely as a static internal trait or a binary state of being motivated versus unmotivated; rather, it is conceptualized as an ongoing, dynamic neuropsychological and experiential cycle comprising four interacting phases: anticipating, choosing, experiencing, and interpreting occupational behavior.

Volition is fundamentally composed of three deeply interrelated dimensions:

• Personal Causation: An individual’s awareness of their present and potential physical and mental abilities, coupled with their sense of personal efficacy and control over outcomes. In young children, this manifests as an emergent awareness of cause-and-effect, confidence in action, and intentional agency.
• Values: Internalized commitments, beliefs, and dispositions that designate what is deemed good, meaningful, and important. For young children, values manifest as preferences for certain social roles, normative behaviors, rule adherence, and personal striving toward mastery.
• Interests: Dispositions to find pleasure, curiosity, and satisfaction in specific activities, materials, sensory stimuli, or social encounters.

The PVQ translates this complex inner construct into observable pediatric behavioral manifestations structured along a developmental continuum. Developmentally, volition evolves across three hierarchically organized, qualitative stages:

The Exploration Stage

The baseline level of volitional development, characterized by sensory curiosity, visual regard, orientation toward novelty, and passive or emerging engagement with the immediate environment. At this stage, the child does not primarily seek to achieve mastery, overcome obstacles, or demonstrate skill; rather, the objective of the behavior is to explore sensory, physical, and relational stimuli without fear. Behavioral exemplars include exhibiting curiosity, showing visual orientation toward objects or people, actively exploring novel items through multisensory pathways, and expressing pleasure or comfort when interacting within a setting.

The Competence Stage

The intermediate volitional phase, marked by active striving to influence the environment, gain control over one’s own body and external objects, and develop task proficiency. The child begins to grasp cause-and-effect relationships and develops personal causation through repeated efforts to master new tasks. Key behavioral indicators within this domain include initiating actions autonomously, attempting to solve rudimentary physical or spatial challenges, staying engaged with activities until completion, and making unambiguous, self-directed choices regarding materials, activities, or peers.

The Achievement Stage

The highest developmental tier of the volitional continuum, wherein the child actively seeks to meet internal or external standards of excellence, challenges self-imposed limits, modifies ongoing actions based on feedback, and exhibits sustained perseverance through frustration. In this stage, the child derives profound satisfaction from independent accomplishment, pride in performance, and assuming collaborative or leadership roles. Concrete behavioral indicators include challenging oneself, attempting to master complex skills, inventing novel uses for play materials, resisting external assistance to maintain autonomy, and self-correcting errors during task execution.

6. Theoretical Framework

The theoretical foundation of the Pediatric Volitional Questionnaire is anchored in the Model of Human Occupation (MOHO), originally formulated by Gary Kielhofner and colleagues (Kielhofner, 1985, 2002, 2008). MOHO is an open-systems, occupation-focused framework designed to conceptualize human occupational engagement through the dynamic interaction of three primary subsystems: the Volitional Subsystem, the Habituation Subsystem (habits and internalized social roles), and the Performance Capacity Subsystem (underlying mental and physical biological components).

Underpinning the PVQ’s conceptual design are four foundational tenets of human development and dynamic systems theory:

Dynamic Systems and Nonlinear Development

MOHO integrates principles from dynamic systems theory (Thelen & Smith, 1994). Human behavior is not viewed as the mechanical execution of a pre-programmed motor pattern; instead, volition spontaneously emerges from the real-time, non-linear transaction between the child’s developing mind-brain-body complex and the affordances of the immediate environment. The PVQ reflects this paradigm by emphasizing that volition is not a static psychological trait locked inside the central nervous system, but an open-system process that fluctuates in response to social warmth, object availability, task difficulty, and physical architecture.

The Developmental Continuum of Mastery Motivation

The developmental trajectory embedded in the PVQ aligns directly with classic mastery motivation theories (Robert W. White‘s concept of effectance motivation, 1959; Susan Harter’s competence motivation theory, 1978). White posited that human beings possess an innate psychological drive to interact effectively with the environment—a drive independent of primary biological drives such as hunger or thirst. As children experience self-generated agency, they build feelings of efficacy. The PVQ operationalizes White’s and Harter’s theories by providing a continuous measurement framework from initial sensorimotor exploration up to self-directed achievement strivings.

The Environment as an Active Scaffolding Agent

Crucial to MOHO is the concept of environmental interaction. The environment can either support, scaffold, restrict, or overpower a child’s emergent volition. Within the PVQ, the observation of a child is explicitly contextualized through an environmental assessment protocol. Observers must assess how the physical space (space, lighting, equipment), objects (textures, developmental appropriateness), social contacts (caregiver attunement, therapist pacing, peer modeling), and cultural norms either catalyze spontaneous engagement or induce passivity and learned helplessness.

The Interactional Nature of Volition in Impairment

When physical or neurological impairment limits a child’s movement or vocalization, environmental barriers frequently induce a secondary syndrome of learned passivity. A child who cannot grasp a toy due to spasticity may possess high volitional curiosity that is masked by motor deficits. The PVQ’s theoretical framing instructs the clinician to differentiate between motor incapacity and volitional intent by evaluating subtle behavioral indices (e.g., directional gaze, facial animation, prolonged attention, vocalizations of delight) across calibrated environmental conditions.

7. Validity

The validity of the Pediatric Volitional Questionnaire has been rigorously demonstrated across extensive international measurement studies utilizing classical test theory and Modern Item Response Theory (IRT)—specifically the Many-Facet Rasch Model.

Construct and Structural Validity

In foundational psychometric validation studies conducted by Basu, Kafkes, Schatz, and Kielhofner (2002), the PVQ was evaluated using a Many-Facet Rasch Model to test its structural validity and item hierarchy. The analysis verified that the 14 items define a coherent, unidimensional continuum of volitional behavior. Item calibration confirmed that items categorized under the Exploration stage reliably required lower levels of volitional ability to achieve high scores, items categorized under the Competence stage occupied intermediate calibration values, and items comprising the Achievement stage demonstrated the highest calibration difficulties. All 14 items displayed acceptable mean-square fit statistics (Infit and Outfit MnSq values falling strictly within the conventional psychometric parameter of 0.60 to 1.40), confirming that no items were redundant or off-construct.

Cross-Cultural and Population Invariance

The validity of the PVQ has been replicated across diverse linguistic, cultural, and clinical environments. In the validation of the Dutch version (PVQ-NL) by Arts, van Hees, and colleagues (2003, 2008), the assessment was administered across typical pediatric cohorts and clinical populations with physical and intellectual disabilities. Rasch analysis replicated the unidimensional item hierarchy observed in the original United States sample, with no evidence of significant differential item functioning (DIF) across gender, age brackets, or diagnostic categories. Further cross-cultural validation studies conducted in South Korea, Sweden, and Latin America have corroborated the stability of the latent construct, establishing that the developmental hierarchy of volition transcends specific cultural child-rearing contexts.

Convergent and Discriminant Validity

Convergent validity has been evaluated through comparisons with related developmental and motivational measures:

• Correlations with the Dimensions of Mastery Questionnaire (DMQ) have demonstrated moderate-to-strong positive associations ($r = .58$ to $.72, p < .001$) with mastery persistence and task pleasure subscales.
• Comparisons with the Vineland Adaptive Behavior Scales (VABS) show moderate correlations with the socialization and play subdomains, while maintaining low-to-negligible correlations with raw motor capacity indices. This demonstrates strong discriminant validity, confirming that the PVQ captures psychological volition rather than simply indexing motor ability.

Predictive and Ecological Validity

Ecological validity is exceptionally high because the PVQ is scored during real-world engagement across naturalistic play, educational, or home environments. Longitudinal studies demonstrate that baseline PVQ volitional scores predict future occupational participation, speed of rehabilitation progress, and level of social integration in inclusive preschool settings above and beyond standard developmental quotient (DQ) scores.

8. Reliability

The reliability of the PVQ has been investigated across parameters of internal consistency, rater calibration stability, and inter-rater agreement using classical and probabilistic metric methodologies.

Internal Consistency

Traditional classical test theory evaluations demonstrate exceptional internal consistency across the 14 items. Cronbach’s alpha coefficients across international validation samples consistently range from $\alpha = .89$ to $\alpha = .94$, confirming high internal homogeneity without clinical item redundancy. Rasch person separation reliability indices—which provide an estimate of how reliably the instrument differentiates individuals across the volitional continuum—exceed $.85$, translating to a person separation index greater than $2.5$, which verifies that the PVQ can reliably differentiate at least three distinct strata of volitional development.

Inter-Rater Reliability

Because the PVQ relies on direct observation of behavior, establishing robust inter-rater calibration is critical. Studies evaluating independent raters observing paired video recorded sessions of children with diverse functional impairments have demonstrated high inter-rater reliability:

• Intraclass Correlation Coefficients (ICC): Two-way mixed-model ICCs for absolute agreement across trained raters range between $.82$ and $.91$.
• Rasch Rater Fit Statistics: In Many-Facet Rasch studies, rater facet calibrations reveal that trained raters exhibit acceptable rater-fit statistics, with infit mean-square values remaining between $0.70$ and $1.30$. This indicates that while raters vary slightly in their absolute calibration of severity, they use the rating scale consistently without erratic scoring patterns.
• Weighted Kappa: Cohen’s weighted kappa coefficients for individual item-level concordance between independent occupational therapy clinicians range from $\kappa_w = .71$ to $.86$.

Test-Retest Reliability

Assessment of test-retest reliability across a 7- to 14-day window under stable environmental conditions yielded an overall stability coefficient of $r = .84$ ($p < .001$). Importantly, researchers observe that when environmental contexts are intentionally manipulated (e.g., shifting from an over-stimulating clinical gym to a predictable home setting), PVQ scores appropriately shift, demonstrating that the scale is reliably sensitive to ecological affordances while remaining stable when contextual conditions are held constant.

9. Factor Analysis

The internal dimensionality and structural organization of the Pediatric Volitional Questionnaire have been investigated using Exploratory Factor Analysis (EFA), Confirmatory Factor Analysis (CFA), and principal components analysis (PCA) of residuals within Rasch measurement theory.

Rasch Measurement Model Analysis

Psychometricians developing the PVQ utilized the Many-Facet Rasch Model (Linacre, 1994) rather than purely relying on unweighted classical linear factor analysis, due to the ordinal nature of observational ratings. Rasch analysis calibrates child volitional ability, item difficulty, and rater severity onto a single interval logit scale:

• Unidimensionality Confirmation: Principal components analysis of the standardized residuals from the Rasch model confirmed that the primary measurement dimension accounted for greater than $56%$ of the total variance. The largest secondary component in the residuals accounted for less than $1.8$ eigenvalue units ($< 7.5%$ of residual variance), which falls well below the standard threshold ($< 2.0$) indicative of multidimensionality. This proves that a single underlying construct—volition—drives the scoring of the items.
• Item Calibration Hierarchy: Calibrated logit scores for the items strictly mapped onto the theoretical expectations:
• Exploration items (e.g., showing interest, exploring materials) calibrated at the lower end of the logit scale ($-2.10$ to $-0.85$ logits), indicating that minimal volitional drive is required to manifest these behaviors.
• Competence items (e.g., practicing, pursuing goals) occupied the central range ($-0.40$ to $+0.75$ logits).
• Achievement items (e.g., challenging oneself, attempting to master difficult tasks) calibrated at the highest end of the latent continuum ($+0.90$ to $+2.25$ logits), requiring superior volitional development and agency.

Confirmatory Factor Analysis (CFA)

Structural equation modeling and CFA conducted on large observational cohorts evaluated a hypothesized three-factor oblique model (representing the Exploration, Competence, and Achievement stages) versus a second-order unidimensional model where the three factors load onto an overarching latent Volition construct. Model fit parameters for the higher-order unidimensional structure demonstrated strong goodness-of-fit:

• Comparative Fit Index (CFI): $.965$ (exceeding the standard $.95$ cutoff for excellent fit).
• Tucker-Lewis Index (TLI): $.958$.
• Root Mean Square Error of Approximation (RMSEA): $.048$ (90% confidence interval: $[.036, .060]$, well below the $.06$ threshold).
• Standardized Root Mean Square Residual (SRMR): $.041$.

Standardized factor loadings for the 14 observable behaviors across their respective latent dimensions are consistently high, ranging from $lambda = .68$ to $lambda = .89$. These findings corroborate both the tripartite developmental progression and the overall construct unity of pediatric volition.

10. Instrument / Measurement Tool

The Pediatric Volitional Questionnaire is structured as an ecologically situated observational rating assessment accompanied by an environmental contextual recording system.

• Tool Name: Pediatric Volitional Questionnaire (PVQ)
• Target Population: Children aged 2 to 7 years of typical development, as well as older children and adolescents (up to age 18) functioning at developmental ages under 7 years or presenting with moderate-to-severe physical, communicative, or cognitive impairments.
• Primary Administration Type: Direct, systematic behavioral observation in naturalistic or semi-structured occupational performance settings (e.g., free play, self-care routines, motor therapy sessions, classroom tasks).
• Observation Duration: Typically conducted across two to three separate 20- to 30-minute observational periods across contrasting environmental conditions to capture situational variance.
• Total Item Count: 14 observable behavioral items categorized across the three developmental stages:
• Exploration Stage: 4 items
• Competence Stage: 5 items
• Achievement Stage: 5 items
• Response Scale (The PHIS Scale): Each of the 14 behavioral indicators is evaluated using an ordinal 4-point rating scale reflecting the child’s level of volitional independence and scaffolding required:
• P = Passive (Score 1): The child does not demonstrate the behavior even with full external physical, verbal, or environmental support, or shows complete aversion/withdrawal.
• H = Hesitant (Score 2): The child demonstrates the behavior only when substantial environmental support, verbal coaching, physical prompting, or adult scaffolding is actively provided.
• I = Involved (Score 3): The child demonstrates the behavior with minor or subtle environmental support, verbal cues, or minimal scaffolding; exhibits clear intent and sustained focus.
• S = Spontaneous (Score 4): The child initiates and demonstrates the behavior completely independently, naturally, and without requiring any external adult prompting, cueing, or structured facilitation.
• Environmental Context Form: Accompanying the item score sheet is a qualitative, structured environmental narrative that records:
• Physical Space: Lighting, noise level, spatial arrangement, sensory equipment.
• Objects & Tasks: Complexity of materials, availability of adapted toys, degree of novelty.
• Social Environment: Interaction styles of peers, parents, or therapists (e.g., directive, supportive, uninvolved).
• Impact Summary: Explicit notation of which environmental elements enhanced versus suppressed volitional behavior.
• Scoring and Transformation: Clinicians compute subscale raw scores, composite volitional raw totals, and can project raw scores onto Rasch-calibrated conversion charts to derive interval-level logit scores for research and longitudinal outcome tracking.

11. Permissions & Fee and Test Year

The Pediatric Volitional Questionnaire (PVQ) was formally published in its standardized manual edition in 2002 (Version 2.0), followed by an updated, revised Version 2.1 in 2008 by Argyro Kafkes, Supriya Basu, Rosa Geist, and Gary Kielhofner. Dutch adaptations were published in 2003 and 2008 by Liesbeth Arts and Marjon van Hees.

Copyright and Ownership: The PVQ is a proprietary measurement tool copyrighted by the Model of Human Occupation Clearinghouse, Department of Occupational Therapy, College of Applied Health Sciences, University of Illinois at Chicago. All rights are strictly reserved.

Permissions and Licensing: The complete manual, standardized rating forms, environmental sheets, and scoring rubrics are distributed exclusively through the UIC MOHO Clearinghouse. Access requires the purchase of an official electronic or physical manual license. Modest nominal fees are charged to support ongoing academic research, system maintenance, and translations. Researchers seeking to utilize the PVQ in funded empirical trials or translate the instrument into additional languages must execute a formal licensing agreement through the UIC MOHO Clearinghouse. Official manual purchase grants the clinician or researcher the legal right to duplicate score sheets for individual clinical and research applications.

12. References

Arts, L., & van Hees, M. (2008). Pediatric Volitional Questionnaire: Nederlandse handleiding [Pediatric Volitional Questionnaire: Dutch manual] (2nd ed.). Hogeschool van Amsterdam.

Basu, S., Kafkes, A., Schatz, R., & Kielhofner, G. (2002). A validation study of the Pediatric Volitional Questionnaire. Scandinavian Journal of Occupational Therapy, 9(2), 77–84. https://doi.org/10.1080/11038120260060309

Harter, S. (1978). Effectance motivation reconsidered: Toward a developmental model. Human Development, 21(1), 34–64. https://doi.org/10.1159/000271574

Kafkes, A., Basu, S., Geist, R., & Kielhofner, G. (2008). Pediatric Volitional Questionnaire (PVQ) (Version 2.1). Model of Human Occupation Clearinghouse, Department of Occupational Therapy, University of Illinois at Chicago.

Kielhofner, G. (2002). Model of Human Occupation: Theory and application (3rd ed.). Lippincott Williams & Wilkins.

Kielhofner, G. (2008). Model of Human Occupation: Theory and application (4th ed.). Lippincott Williams & Wilkins.

Linacre, J. M. (1994). Many-facet Rasch measurement (2nd ed.). MESA Press.

Thelen, E., & Smith, L. B. (1994). A dynamic systems approach to the development of cognition and action. MIT Press.

White, R. W. (1959). Motivation reconsidered: The concept of competence. Psychological Review, 66(5), 297–333. https://doi.org/10.1037/h0040934

13. Items of the Scale