A Correlational Study Between Structured Clinical Observations and The Sensory Integration and Praxis Test

A CORRELATIONAL STUDY BETWEEN STRUCTURED CLINICAL
OBSERVATIONS AND THE SENSORY INTEGRATION AND PRAXIS TEST
by
Gustavo Alejandro Reinoso
Submitted in partial fulfillment o f the requirements for the degree o f

Doctor o f Philosophy in the
Occupational Therapy Department
College o f Allied Health and Nursing
Nova Southeastern University
December, 2005
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
UMI Number: 3216358
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Reinoso, Gustavo Alejandro
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NOVA SOUTHEASTERN UNIVERSITY
COLLEGE OF ALLIED HEALTH AND NURSING
OCCUPATIONAL THERAPY DEPARTMENT
FORT LAUDERDALE, FL 33328
This dissertation, written by Gustavo Alejandro Reinoso under the direction of his
Dissertation Committee, and approved by all o f its members, has been presented to and
accepted, in Partial fulfillment of requirements for the degree of
DOCTOR OF PHILOSOPHY
December, 2005
DISSERTATION COMMITTEE
Ferol Menks Ludwig, PhD, OTR/L, FAOTA, GCG
Carol Niman Reed, EdD, OTR/L, FAOTA
Em a Imperatore Blanche, PhD, OTR/L, FAOTA
Abstract
The purpose o f this study was to determine i f structured observations were associated
with the Sensory Integration and Praxis Tests (SIPT). Structured observations have been
utilized in sensory integration for many years to assist therapists in assessing children
with sensory integration dysfunction. The sample fo r this study consisted o f 21 children
ages 5-8 treated with a sensory integration frame o f reference in a treatment and training
center in west Los Angeles. Sensory integration dysfunction was tested using the SIPT
and a set o f 10 different structured observations including the supine flexion postural
test, prone extension, slow motions, postrotary nystagmus, diadochokinesis, finger-to-
thumb opposition, fmger-to-nose, the modified Schilder ’s arm extension test, and the
heel-to-toe measure o f balance. Results show a small degree o f association and highlight
the complementary role o f both measures. Data reduction indicated that a few structured
observations better described two profiles o f the SIPT; the low average bilateral
integration and sequencing and visuo-somatodyspraxia. Three factors best described the
most common structured observations in the group o f children with low average bilateral
integration and sequencing disorder and included aspects o f motor planning and
bilateral sequencing; vestibulo-proprioceptive and cerebellar aspects o f speed,
acceleration, and trajectory. The forward linear regression analysis indicated that
structured observations could only predict a small portion o f the variability o f the
different measures o f the SIPT.
Acknowledgements
I would first like to thank my dissertation committee for their continuous dedication and
support through this long process. To my mother for planting the seed o f curiosity, and to
Thomas for his long hours of editing and insightful comments. To Mariel for all her help
and support. To the directors and staff o f Therapy West, Inc. for their flexibility and help,
and especially to all the families and wonderful children who were part o f this project.
Table of Contents
Chapter 1: Introduction.........................................................................................................1
Introduction o f the Chapter.......................................................................................................1
Rationale and Need for the Study...............................................................................1
Theoretical Framework.............................................................................................................4
Statement o f the Problem......................................................................................................... 7
Purpose of the Study................................................................................................................. 7
Significance o f the Problem........................................................................................ 8
Significance and Relevance to the Profession o f Occupational T herapy............ 8
Research Questions and H ypotheses...................................................................................... 9
Research Questions...................................................................................................... 9
Research Question # 1 ..................................................................................... 10
Research Question # 2 ..................................................................................... 10
Research Hypotheses................................................................................................... 10
Hypothesis #1................................................................................................... 10
Hypothesis #2................................................................................................... 10
Limitations o f the Study............................................................................................................ 11
Definition o f Terms....................................................................................................................12
Summary..................................................................................................................................... 14
Chapter 2: Selected Review of the Literature.................................................................. 16

Introduction to the C hapter.......................................................................................................16
Neurological Soft Signs and Structured Observations..........................................................18
Insights from the Adult Literature..............................................................................19
Patients Diagnosed as having Schizophrenia...............................................19
Patients diagnosed as having Obsessive Compulsive D isorder............... 23
Patients with Bipolar Disorder...................................................................... 25
Cohort Studies.................................................................................................. 26
Homicidal Men with Antisocial Personality............................................... 27
Summary........................................................................................................................27
Studies Involving Adolescents....................................................................................30
Conduct Disorder and Attention Deficit Hyperactivity D isorder............ 30
Adolescents Diagnosed as having Schizophrenia.......................................31
Summary........................................................................................................................32
Studies Involving C hildren......................................................................................... 32
Attention Deficit Hyperactivity D isorder....................................................34
Academic Achievement and Learning Disabilities.................................... 35
Emotional D isorders....................................................................................... 36
Congenital Muscular D ystrophy................................................................... 36
vi
High R isk ......................................................................................................... 37

Psychiatric Vulnerability............................................................................... 37
Sickle Cell D isease......................................................................................... 37
Mainstream P u p ils.......................................................................................... 38
Summary..'..................................................................................................................... 38
Sensory Integration Theory......................................................................................... 40
Structured Observations Within Sensory Integration............................................. 43
Contemporaneous Research on Structured O bservations......................... 49
Measurement Considerations.........................................................................51
Objectivity........................................................................................... 52
Structured Observations in this Study........................................................................53
Supine flexion postural test 53
Prone extension...................................................................................55
Postrotary nystagm us.........................................................................56
Finge-to-nose......................................................................................61
Slow m otions......................................................................................62
Diadochokinesis..................................................................................63
Finger-to-thumb opposition..............................................................65
Modified Schilder’s arm extension te s t.......................................... 67
H eel-to-toe.......................................................................................... 69
Jumping jacks...................................................................................... 71
The Sensory Integration and Praxis Tests (SIPT).................................................... 73
Contribution o f this Study to the Literature........................................................................... 76
Summary.....................................................................................................................................77
Chapter 3: Research Design and M ethodology................................................................ 81

Introduction to the Chapter...................................................................................................... 81
Specific Methods and R ationale..............................................................................................82
Specific Procedures...................................................................................................... 82
Threats to Internal V alidity......................................................................................... 83
Maturation E ffect.............................................................................................83
Instrumentation................................................................................................85
Random Sampling........................................................................................... 89
Threats to External V alidity........................................................................................ 89
Study D esign.................................................................................................... 90
Correlational Research....................................................................................90
Tentative Factor M odel...................................................................................90
Forward Linear Regression M o d el...............................................................91
Subjects.......................................................................................................................... 91
Inclusion C riteria............................................................................................ 92
Exclusion C riteria........................................................................................... 92
Characteristics.................................................................................................. 93
Recruitment Procedures..................................................................................93
Ethical Considerations....................................................................................94
The Research Setting................................................................................................... 94
Equipment......................................................................................................................95
Independent and Dependent Variables Operationalized.........................................96
Instruments.....................................................................................................................96
Data C ollection.............................................................................................................97
Data Analysis................................................................................................................ 97
Statistical Package for the Social Sciences (S P S S )................................... 98
Reliability and Validity................................................................................................ 99
Summary..................................................................................................................................... 101
Chapter 4: Results....................................................................................................................103
Introduction to the Chapter.......................................................................................................103
Research Question # 1 ...................................................................................................105
Space Visualization..........................................................................................105
Figure Ground Perception..............................................................................106
Finger Identification.........................................................................................107
Localization of Tactile Stim uli...................................................................... 108
Design C opying............................................................................................... 109
Oral P rax is........................................................................................................ 109
Sequencing Praxis.......................................................................................... 111
Bilateral Motor Coordination........................................................................112
Standing and Walking Balance...................................................................... 113
Postrotary N ystagm us..................................................................................... 114
Relationship between different structured observations and the SIPT ... 115
Research Question # 2 ...................................................................................................116
Domains o f Function.....................................................................................................116
Close fit to the Low Bilateral Integration and Sequencing Prototypic Group.... 116
Close fit to the Visuo- and Somatodyspraxia Prototypic Group............................117
Theoretical and Tentative Data Reduction M odel................................................... 118
Structured Observation as Predictors......................................................................... 120
Summary..................................................................................................................................... 126
Chapter 5. Discussion......................................................................................................... 129
Introduction to the Chapter.......................................................................................................129
Individual Relationships between both M easures.................................................... 130
Space Visualization......................................................................................... 130
Figure Ground Perception...............................................................................132
Finger Identification.........................................................................................133
Localization of Tactile Stim uli...................................................................... 134
Design C opying............................................................................................... 134
Oral P rax is........................................................................................................135
Sequencing Praxis............................................................................................136
Bilateral Motor Coordination......................................................................... 138
Standing and Walking Balance...................................................................... 139
Postrotary N ystagm us..................................................................................... 140
Association with prototypic groups............................................................................141
The low average bilateral integration and sequencing prototypic group 141
The visuo- and somatodyspraxia prototypic group..................................... 142
Theoretical and tentative data reduction m odel........................................................143
Forward Linear Regression M odel.............................................................................144
Implications for Practice........................................................................................................... 145
Implications for further Research and Recommendations................................................... 147
Limitations o f the Study............................................................................................................ 151
Summary..................................................................................................................................... 152
Appendixes.................................................................................................................................157
Appendix A F ly e r...................................................................................................................... 155
Appendix B Data Collection Instrument.................................................................................157
References..................................................................................................................................207
Copyright Perm ission.............................................................................................................227
IX
List of Tables
Table 1 Structured observations, their nomenclature, name, type, and level o f
measurements (Appendix C) p. 161
Table 2 The sensory integration and praxis tests, their nomenclature, name, type, and
level o f measurements (Appendix C) p. 161
Table 3 Sample characteristics (Appendix D) p. 164
Table 4 Spearman Rho Correlation Coefficients among all dependent variables

(Appendix E) p. 165
Table 5 Space Visualization (SV) and its correlations with the Slow Motions (SM) and
the Southern California Postrotary Nystagmus Test (SCPNT) structured
observations p. 99
Table 6 Figure Ground (FG) and its correlations with the Prone Extension (PE); Finger-
to-Nose, right (FN-R); Finger-to-thumb Opposition, Total Score (FTO-TS)
structured observations p. 100
Table 7 Finger Identification (FI) and its correlations with the Slow Motions (SM) and
the Southern California Postrotary Nystagmus Test (SCPNT) structured
observations p. 101
Table 8 Focalization o f Tactile Stimuli and its correlation with the Finger-to-Nose, Right
(FN-R) structured observation p. 102
Table 9 Design Copying (DC) and its correlation with the Prone Extension Quality (PEQ)
structured observation p. 103
Table 10 Oral Praxis (OPR) and its correlations with the Finger-to-Nose, right (FN-R);
Finger-to-Nose, left (FN-F); and Diadochokinesis, Total Score (DIA) structured
observations p. 104
Table 11 Sequencing Praxis (SP) and its Correlations with the Slow Motions (SM),
Finger-to-Nose, Feft (FN-F); the Modified Schilder’s Arm Extension Test (SAT),
and the Jumping Jacks, Total Score (JJ-TS) structured observations p. 105
Table 12 Bilateral Motor Coordination and its Correlations with the Southern California
Postrotary Nystagmus Test (SCPNT) p. 106.
Table 13 Standing and Walking Balance (SWB) and its correlation with the Finger-to-
Thumb Opposition, Non Stress Condition (FTO-NS) p. 107
Table 14 The Postrotary Nystagmus (PRN) and its Correlation with the Southern
California Postroatry Nystagmus Test (SCPNT) p. 108
Table 15 Total variance explained p. 112
Table 16 Rotated Component Matrix p. 114
Table 17 Southern California Postrotary Nystagmus Test (SCPN) and Jumping Jacks,
Total Score, and the Variability o f Space Visualization (SV); (Appendix F)
Table 18 Heel-to-Toe Eyes Open Soft Surface (HTT-O-S), Prone Extension Quality
(PEQ) and Finger-to-Thumb Opposition Total Score (FTO-TS) and the
Variability o f Design Copying (Appendix F)
Table 19 Finger-to-Nose, Right (FTN-R) and Left (FN-L) and the Variability o f Oral
Praxis (Appendix F)
Table 20 Diadochokinesis Non Stress (DIA-NS) the Southern California Postrotary

Nystagmus Test and the Variability o f Postrotary Nystagmus (Appendix F)
Table 21 The Heel-to-toe Eyes Closed (HTT-C-S) Soft Surface and the Prone Extension
And The Variability of Standing and Walking Balance (Appendix F)
Table 22 The Eleel-to-Toe Eyes Open Firm Surface (HTT-O) and the Finger-to-Thumb
Opposition Total Score (FTO-TS) and the Variability o f the Graphesthesia
(Appendix F)
Table 23 The Southern California Postrotary Nystagmus Test (SCPNT) and the
Variability o f the Finger Identification (Appendix F)
Table 24 The Slow Motions (SM) and the Variability o f the Sequencing Praxis
(Appendix F)
Table 25 The Southern California Postrotary Nystagmus Test (SCPNT) And the
Variability o f the Bilateral Motor Coordination (Appendix F)
Table 26 The Finger-to-Nose and the Variability o f the Localization o f Tactile Stimuli
(LTS, Appendix F)
Table 27 The Finger-to-Thumb Opposition Total Score (FTO-TS) and the Variability of
Figure Ground (Appendix F)
Table 28 The Southern California Postrotary Nystagmus Test (SCPNT) and the
Variability o f Manual Form Perception (Appendix F)
Table 29 The Heel-to-Toe Eyes Open Firm Surface (HT-O) and the Variability o f Motor
Accuracy (Appendix F)
Table 30 The Finger-to-Nose, Right (FN-R) and the Variability o f Postural Praxis
(Appendix F)
1
CHAPTER 1: INTRODUCTION
Introduction to the Chapter
Occupational therapists working within a sensory integration frame o f reference
often utilize a number o f assessment tools including standardized testing, questionnaires,
clinical observations, and interviews in order to understand the child’s sensory integration
difficulties affecting movement and behavior. However the relationship between these
assessment tools is not well understood. This is particularly true in the case o f different
structured observations and the sensory integration and praxis tests (SIPT). The following
study explored how a specific group of structured observations correlated w ith the SIPT
in a sample o f 21 children with sensory integration dysfunction.
First, this chapter describes the rationale for the present study, its theoretical
framework and purpose, and its significance for clients and clinicians. Second, the study
hypotheses, limitations, definitions of terms, and a summary are presented.
Rationale and Need fo r the Study
In sensory integration, clinical observations are a group o f structured and
unstructured observations o f sensory processing and its effects on movement and
behavior originally described by Jean Ayres (Ayres, 1963, 1965, 1966a, 1966b, 1969a,
1969b). Dr. Jean Ayres developed a set o f structured clinical observations that
supplemented standardized test results or became the primary assessment tool when
standardized measures were not appropriate.
Theorists and clinicians use the term “clinical observation” to refer to objective
data collected during an assessment. In contrast, the term “structured observations” is
chosen when a clinician controls environmental factors and organizes a task for the child
to carry out while noting salient aspects o f his or her performance. Therefore, structured
observations are similar to test items and their utilization often requires the clinician to
follow a protocol for their administration and scoring. The information collected by
means o f observations is often used as complementary information in the process of
sorting out the underlying deficits in sensory integration and are assumed to be related to
the functioning o f different sensory systems as informed by evolving theory and research
in sensory integration.
Numerous theorists have secured the role o f structured clinical observations in the
assessment process o f children with suspected functional difficulties (Adams, Jenci, &
Estes, 1974; Alsworth, 1978; Dunn, 1981; Fisher, 1984; Fisher and Bundy, 1982;
Imperatore Blanche, 2001; B.N. Wilson, Pollock, Kaplan & Faw, 1994, 2000). Although
it is true that most clinical observations are not standardized assessments, research in
sensory integration has determined the responses o f typically developing children when
performing different observations, as well as those with known or suspected dysfunctions
(Dunn, 1981; Gregory-Flock &Yerxa, 1984; B.N. Wilson, Pollock, et al., 1994, 2000).
Analysis o f children’s performance on different structured observations is
important because it provides the therapist with information regarding the nature o f the
child’s existing problems. Theorists have described the performance o f children in
3
different observations with movement components such as balance, postural control,
coordination, and skill development (Gregory-Flock &Yerxa, 1984; Shumway-Cook &
Horak, 1986); functional performance and sensory integration dysfunction such as those
present in children with learning disabilities (Ayres, 1972); high risk infants and young
children; visual deficits and blindness (Smith Roley and Schneck, 2001); cerebral palsy
(Imperatore Blanche & Nakasuji, 2001), autism (Mailloux, 2001), and reading disability
(Silver, 1960; Silver & Hagin, 1952). Systematic data collection by means o f structured
observations allows clinicians to hypothesize the nature o f a child’s problem. Thus,
structured observations may be interpreted according to sensory integration theory. These
interpretations guide further assessment and clinical reasoning during intervention.
The potential benefit of the present study is to help clinicians in the field of
pediatric occupational therapy to better understand how a group o f specific structured
clinical observations relate to each other, what underlying factors they represent, as well
as their specific relationship to sensory integration. In addition, this study explored how
common structured observations related to two common prototypic groups o f the SIPT,
the visuo- somatodyspraxia and the low average bilateral integration and sequencing.
The role o f different structured observations in identifying sensory processing
deficits in children has been outlined by several writers (Blanche, 1999; Blanche,
Boticelli & Hallway, 1995; Gilligan, Mayberry, Stewart, Kenyon, & Gebler, 1981;
Gregory-Flock et al., 1984; Haack, Short-DeGraff, & Hanzlik, 1993; Harris, 1981;
Izraelevitz, Fisher & Bundy, 1985; Magalhaes, Koomar, & Cermark, 1989; Silver &
Hagin, 1960). Furthermore, at least three clinical protocols are being used in pediatric
clinical practice to formally assess different sensory processing deficits in children
4
(Dunn, 1981; Imperatore Blanche, 2001; B.N. Wilson et al. 1994). These protocols will
be examined in more detail in chapter 2. The selection o f structured observations for this
study was based on these protocols. However, only those structured observation that
reported scores in typically developing children were selected from the literature for the
purposes o f comparison with the sample studied. Thus, a group of 10 structured
observations was selected.
Structured observations have been proposed and revised to assess the functioning
o f different systems and underlying skill performance. Pivotal are the works o f Ayres,
1963, 1965, 1966a, 1966b, 1969a, 1969b; Dunn, 1981; Fisher, Murray, and Bundy, 1991,
2002; Imperatore Blanche, 2001; and B.N. W ilson et al., 1994, 2002 who have attempted
in several studies to unravel the importance o f different structured observations as part of
the information gathering process when assessing children with disabilities, utilizing a
sensory integrative framework. In addition, structured observations are also
recommended in most standardized pediatric occupational therapy assessments that
clinicians use in their daily practice (Ayres, 1989; Bruininks, 1978; Miller, 1982, 1988).
Theoretical Framework
Sensory integration as a frame o f reference evolved out o f the clinical work and
research of Dr. Jean Ayres in the 1960s. Sensory integration refers to both a way o f
viewing the neural organization o f sensory information for functional behavior and a
clinical frame o f reference for the assessment and treatment o f persons who have
functional disorders in sensory processing (Parham & Mailloux, 1996). Sensory
5
integration takes into account an individual’s neurobiological ability to process and
integrate sensory information and considers how that ability allows the individual to plan
his actions to enhance participation in a wide array o f environments (Ayres, 1979, 2005).
Jean Ayres’s sensory integration theory is a developmental theory based on
principles o f phylogenetic and ontogenetic development as well as a hypothesized
development o f the sensory integrative process throughout life. Currently, pediatric
occupational therapists use a sensory integrative frame of reference with diverse
populations (Smith Roley, Imperatore Blanche, & Schaaf, 2001). Some examples are
children diagnosed with autism (Ayres & Tickle, 1980); cerebral palsy (Imperatore
Blanche & Nakasuji, 2001); Fragile X syndrome (Stackhouse, 1994); hearing impairment
(Schaffer-Pullan, Polatajko, & Sansom, 1991); mental retardation (F.A. Clark, Miller,
Thomas, Kucherawy, & Azen, 1978; Kielhofner & Miyake, 1981; Sowers & Powers,
1995; Storey, Bates, McGhee, and Dycus, 1984); premature birth (Anderson, 1986);
prenatal drug exposure (Stallings-Sahler, 1993); and visual impairments (Smith Roley &
Schneck, 2001).
Numerous studies have described the increasing recognition and importance of
sensory processing and praxis in children’s performance o f occupations (Baranek et al.,
2002; Baranek, 1998; Cermak and Daunhauer, 1997; Daly, 2000; Dunbar, 1999; Dunn,
1997; Dunn & Bennett, 2002; Dunn & Brown, 1997; Dunn, Myles, & Orr, 2002;
Imperatore Blanche, 2001; Johnson-Ecker, & Parham, 2000; Kay, 2001; LaCroix,
Johnson & Parham, 1997; Lewerenz & Schaaf, 1996; Mulligan, 1996; Ottenbacher, 1982;
Parham, 1987, 1998; Poissons & DeGangi, 1991; Rife, 2000; Sears, 1994; Watling,
Deitz, & White, 2001; Wilbarger, 1995). These studies have determined the nature and
6
extent o f sensory processing deficits in children with several diagnoses. Furthermore,
these studies have highlighted the relationship between difficulties in sensory processing
and decreased occupational and functional performance.
From its inception, sensory integration has been interested in creating theory as
well as in identifying accurate means o f assessment for the identification o f the nature
and extent o f the deficits presented by the recipients o f occupational therapy services.
Several factor analytic studies conducted by Ayres (1963, 1965) identified groups o f
children with clear and distinct difficulties. More and more children are being identified
as having difficulties related to sensory integration. Some researchers have mentioned 5%
to 10% of typically developing children (McIntosh, Miller, Shyu & Hagerman, 1999). It
is also interesting to note that new research efforts with larger samples have found
patterns o f sensory integrative deficits that are consistent with A yres’s original findings
(Mulligan, 1996; 2000).
Since the time when Ayres devoted herself to the creation o f the Southern
California Sensory Integration and Praxis Tests and their revision, the Sensory
Integration and Praxis Tests (SIPT) (Ayres, 1989), observations have been described and
their utilization recommended. Recent publications have carefully related different
observations to interpretations that guide clinician’s clinical reasoning during the
assessment and treatment of children with sensory integration dysfunction (Imperatore
Blanche, 2001). This line of inquiry will assist clinicians in making sound evidenced-
based associations between difficulties during structured observations and their correlate
on standardized testing. This is particularly useful for those situations in which
standardized procedures may not be practical.
7
Statement o f the Problem
Although commonly utilized in clinical practice, no one has ever researched the
relationship between structured observations and the SIPT, a standardized assessment
considered the “gold standard” (Windsor, Smith Roley, & Szklut, 2001) when assessing
children with suspected sensory processing deficits. Research in this area may clarify,
complement, and refine the assessment and intervention process aimed at improving the
functional status o f children with sensory processing deficits.
Purpose o f the Study
The purpose of this study is to determine how different structured observations
relate to each other by means o f correlational analysis and to determine their specific
correlations with the different measures o f the SIPT (Ayres, 1989) in a group o f children
with identified sensory processing problems while receiving clinic-based pediatric
occupational therapy services utilizing a sensory integration frame o f reference. In order
to further the understanding of structured observations, the present study proposes to
analyze their intercorrelations to reveal if and how they group together by means of
exploratory factor analysis techniques. Factor analysis was conducted for illustrative
purposes to determine if structured observations that share commonalities would group
together in children with sensory integration deficits.
8
Significance o f Problem
Clients referred to occupational therapy services who are suspected o f having a
sensory integration dysfunction, would benefit directly from the results o f this study. On
one hand, although the SIPT is the most comprehensive test in sensory integration and
continues to be widely used, it has its limitations. Some o f these limitations include time
and financial constraints as well as its feasibility with diverse populations (Spitzer, Smith
Roley, Clark and Parham, 1996). To meet the challenging and changing demands o f
present clinical practice, other assessment tools have been generated. Structured and
unstructured observations are examples o f how clinicians make meaningful
interpretations o f the client’s interactions with sensory stimuli. Observations possess the
flexibility to be used with all populations, in all settings, and within various time
constraints (Spitzer, et al.). Determining how the child responds to tasks such as
sustaining extension in prone or performing diadochokinetic movements relates with the
SIPT, is of great interest to clinicians. The nature o f these relationships will provide
diagnostic and descriptive information and may aid the clinician when interpreting the
results o f structured observations.
Significance and Relevance to the Profession o f Occupational Therapy
Elucidating specific deficits in sensory processing as they directly impact the
performance o f specific task performance, is o f most importance to clinicians. Therapists
rely on this information to design accurate treatment protocols that target children’s
occupational performance at home, school, and in the community. Numerous children
may not be suitable to be assessed with standardized testing such as the SIPT because of
difficulties related to the nature o f their deficits such as lack o f attention, poor
organization o f behavior, increased motor activity, or lack o f financial resources.
Clinicians usually rely on different observations which are more appropriate in these
situations. In addition, it is possible that structured observations tap into different areas o f
performance and provide additional information to the SIPT. Therefore, structured
observations have the potential to greatly contribute to the assessment process of children
who are not suitable for highly structured standardized tests or to supplement the
information collected by those means.
Research Questions and Hypotheses
Two research questions and two hypotheses have been postulated to be researched
in the present study. The research hypotheses establish a tentative answer to the research
questions formulated by this study. These hypotheses have been formulated in order to
determine the direction o f the relationship among the dependent variables. The direction
of this relationship has not been determined after reviewing the literature.
Research Questions
The following research questions were formulated after the review o f the
literature on structured observations or neurological soft signs in children, adolescents
and adults. There have not been any attempts to correlate different structured
observations with the SIPT in children with sensory processing difficulties. The
10
following research questions were formulated and will be answered in chapter 4 and then
discussed and contrasted with the existing state o f knowledge in chapter 5.
Research Question #1.
What is the relationship among a specific group o f selected structured
observations and individual tests of the sensory integration and praxis tests?
Research Question #2.
How do scores on a group o f selected structured observations explain a specific
single score or a group of scores in the SIPT profiles?
Research Hypotheses
Two research hypotheses were proposed for this research study. As follows:
Hypothesis #J.
There are no significant relationships between scores in a protocol o f structured
observations and scores in the SIPT in a sample o f children with sensory integrative
dysfunction.
Hypothesis #2.
A group o f scores on different structured observations could describe SIPT
profiles
11
Limitations o f the Study
One of the most important limitations o f the present study lies in the use o f its
methodology: correlational research and exploratory factor analysis. Results o f research
using this methodology may not be entirely valid, stable, or clearly interpretable. In all
likelihood, the results o f a first attempt to achieve this will reveal a variety o f problems;
e.g., attributes which do not represent factors as intended, the occurrence o f unanticipated
factors, the absence o f anticipated factors, etc. Correlational research has a very
important cumulative effect (Stein & Cutler, 1991). However, the result of correlational
research is not sufficient to be conclusive. It is very unlikely that such phenomena can be
avoided in an initial study in a domain, simply because o f the lack o f knowledge about
the nature and dynamics o f the underlying factors (Kim & Muller, 1978; Tucker &
MacCallum, 1997;). The advantages and weaknesses o f both methodological approaches
will be further explored in chapter 3 and discussed in chapter 5.
Another limitation of this study is its small sample size. The sample size used in
this study cannot be assumed to be normally distributed and therefore is better analyzed
and understood by utilizing non-parametric statistics. External validity o f non-parametric
statistics is weak and requires careful interpretation and replication studies.
The most significant limitation o f this study is the diversity from which the scores
were derived when scoring all structured observations. Most structured observations
scores were derived from different studies that included different samples and that were
tested by different theories.
12
Definition o f Terms
The following is a list o f operational terms used in this and the following
chapters:
1. Sensory integration: “The brain’s ability to filter, organize, and integrate masses of
sensory information” (Ayres, 1968a) and “the organization o f sensations for use” (Ayres,
1979, p.5).
2. Clinical observations: Non-standardized assessments by the therapist of particular
neuromotor behaviors, reactions, and functions (Spitzer et al., 1996). Clinical
observations can be understood as structured or unstructured tasks that represent the
foundations and functioning o f specific neuromotor behaviors. Clinical observations refer
to general observations o f specific functions during functional performance.
3. Structured observations: The observation utilized in this study. This term refers to a
clinician controlling environmental factors and organizing a task for the child to carry out
while noting salient aspects o f his or her performance. The group o f structured
observations selected and utilized in this study are: a) supine flexion, b) prone extension,
c) finger to nose, d) slow motions, e) diadochokinesis, f) fmger-to-thumb opposition, g)
extension o f the arms or modified Schilder’s arm extension test, h) heel-to-toe, and i)
jumping jacks. The postrotary nystagmus test (Ayres, 1977) was also utilized.
4. Supine flexion: This observation consisted o f having the child hold his or her head,
arms, and legs flexed and off the surface on which the back rests.
5. Prone extension: This observation required the child to raise his or her head, arms,
upper trunk, and legs into an extended pattern.
13
6. Postrotary nystagmus: This test measured the duration o f an involuntary, rapid, back-
and-forth movement o f the eyeballs followed by rotation.
7. Finger to nose: This observation required the child to touch the tip o f his or her nose
with eyes closed.
8. Slow motions: This observation required the child to bring in his or her hands toward
his or her shoulders slowly.
9. Diadochokinesis: This observation required the child to quickly pronate and supinate
the hand and forearm o f both upper extremities together.
10. Finger-to-thumb opposition: This observation required the child to rapidly and
smoothly touch the tip o f each finger to the tip o f the thumb in sequence, beginning with
the fifth finger.
11. Extension of the arms or modified Schilder’s arm extension test: In this observation
the child is asked to stand with his or her feet together and his or her head centered, and
then to stretch out his or her arms, palms downwards, for twenty seconds with eyes
closed. The head is passively rotated to the right and left.
10. Fleel-to-toe: A structured observation for the assessment o f balance and postural
control. The position was tested under four different conditions: a) eyes open, b) eyes
closed, c) eyes open standing on a soft surface, and d) eyes closed standing on a soft
surface.
11. Jumping jacks: In this observation the child is asked to perform a series o f jumps by
abducting and adducting his or her arms and legs.
12. Sensory integration and praxis tests: A group o f standardized tests, designed to assess
several different practic abilities; various aspects o f the sensory processing status o f the
14
vestibular, proprioceptive, kinesthetic, tactile, and visual systems; and the major
behavioral manifestations of deficits in integration o f sensory inputs from these systems
(Ayres, 1989).
13. Correlational research: A type o f research in which the investigator compares the
relationships between variables and populations by measuring differences (Stein &
Cutler, 1991).
14. Exploratory factor analysis: A type o f research analysis that seeks to discover simple
patterns of relationships among different variables. In particular, it seeks to discover if
the observed variables can be explained largely or entirely in terms o f a much smaller
number of variables called factors. It has also been described as a statistical method to
categorize data into identifiable factors. The procedure is an extension o f a correlation
matrix where a set o f variables are correlated with each other (Thorndike, 1978).
Summary
The following study was designed to explore how structured observations
measures commonly used in sensory integration, correlate with the SIPT, when assessing
children with sensory integration dysfunction. The sample is constituted o f children with
sensory integration dysfunction and receiving occupational therapy treatment with a
sensory integration frame o f reference. The observations utilized in this study have been
described as structured observations, in which the examiner controls environmental and
task factors. Some distinctive responses in these observations by typically developing
children have been described in the literature. However, whether specific correlations
15
with the SIPT do exist is unknown. Researching these relationships may add knowledge
for the assessment and intervention process o f children with sensory processing deficits.
16
CHAPTER II: SELECTED REVIEW OF THE LITERATURE
The purpose o f this study is to determine how different structured observations
relate to each other and their specific correlations with the SIPT in a group o f children
with sensory processing deficits. Thus, the intention o f this literature review is first to
examine the state o f knowledge o f different structured observations and their correlate,
neurological soft signs in patients with different diagnoses. The emphasis is on how these
observations are related to different areas o f dysfunction in adults, adolescents, and
children. Second, a brief description o f sensory integration theory and the history o f how
structured observations evolved is introduced, as well as their relationship to the theory
and practice of occupational therapy using a sensory integration frame o f reference. Last,
the measurement properties o f the SIPT and the contribution o f this study to the current
professional literature is explored.
Different types o f structured observations have been utilized in different
disciplines; in the medical literature these observations are often referred to as
neurological soft signs (Wilson et al., 1994, 2000). The presence and severity o f these
neurological soft signs in children are directly related to their difficulties in functional
performance during, play, school, and other activities o f daily living. The medical
literature infers from the presence and severity o f these signs the loci
17
that produce a specific deficit. For example in neurology the presence o f neurological soft
signs may indicate compromised cerebellar integrity, an extrapiramidal component, or
central nervous system immaturity. In sensory integration theory these neurological soft
signs or observations are hypothesized to be related to poor processing of sensory
information or a neuromotor component which guides further assessment and
intervention.
The first section o f this chapter presents a review o f how the fields o f neurology,
psychiatry, psychology, rehabilitation, and special education have utilized observations
for the purpose o f detecting, determining, diagnosing, and discriminating among areas of
function and dysfunction in adults, adolescents, and children. Next, an historical review
o f the theory and research literature on the topic o f sensory integration and the SIPT is
presented. Finally, the contribution o f different structured observations in identifying
different patterns o f sensory integration dysfunction is described.
In chapter 1 structured observations were referred to as situations in which a
clinician controls environmental factors and organizes a task for the child to carry out
while noting salient aspects of his or her performance. Structured observations have been
utilized as part o f the assessment process that provides objective data that could be
identified, measured, and interpreted by clinicians. Neurological soft signs are
characterized by abnormalities in motor, sensory, and integrative functions (Lindberg,
Tani, Stenberg, Apperlberg, Porkka-Heiskanen, & Virkkunen, 2004).
18
Neurological Soft Signs and Structured Observations
Although neurological signs have been consistently reported in populations of
patients with different diagnoses, their clinical relevance, and the actual impact of
treatment or their evolution during the disease have not been well clarified, possibly
because o f the methodological limitations o f the available tools (Pine et al., 1996).
Growing evidence has been placed on neurological soft signs as being characterized by
abnormalities in motor, sensory, and integrative functions in a person without a
neurological disorder which can be determined as its focus (Guz & Aygun, 2004). B.N.
Wilson et al. (2000) reported that neurological soft signs have been studied in different
fields, particularly in neurology, psychiatry, psychology, rehabilitation, and special
education. In the occupational therapy literature, and in particular pediatric occupational
therapy, different authors have referred to neurological soft signs as clinical observations,
formal observations, and informal observations.
Neurological soft signs have been studied in adult populations with several
disorders including patients with schizophrenia (Dazzan et al., 2004) and patients with
bipolar disorder (Negash et al., 2004) to name just a few. Neurological soft signs have
also been researched in different samples involving children. Thus, some studies have
explored neurological soft signs in children with academic difficulties and learning
disabilities (Poblano, Borja, Elias, Garcia-Pedroza, & Arias, 2002); children with
emotional disorders (Pine, Shaffer & Schonfeld, 1993) among others. Research has not
yet fully addressed the study o f neurological soft signs in adolescents.
19
The following sections will present how neurological soft signs have been studied
following different lines o f inquiry by presenting relevant studies that have examined
neurological soft signs or structured observation in adults, adolescents, and children.
Insights from the Adult Literature
The research literature regarding studies focusing on neurological soft signs in
adult populations was extensive and includes, in decreasing order o f importance:
1. Patients diagnosed as having schizophrenia
2. Patients diagnosed as having obsessive compulsive disorder
3. Other disorders: including patients diagnosed as having bipolar disorder, at risk birth
cohorts, and homicidal men with antisocial personality.
Patients Diagnosed as Having Schizophrenia
Neurological soft signs were extensively studied and described in subjects
diagnosed as having schizophrenia. Neurological soft signs have been described as
nonspecific indicators o f brain dysfunction that were found to be in excess in patients
with schizophrenia (Dazzan et al., 2004). These included poor motor coordination,
sensory perceptual difficulties, and difficulties in sequencing complex motor tasks (Das
et al., 2004).
Eleven studies performed between 1996 and 2004 had described different
neurological soft signs as characteristic o f patients with schizophrenia. Lane et al. (1996)
claimed that 98% o f a sample comprised o f patients with schizophrenia demonstrated at
least one neurological soft sign. In addition, these neurological soft signs appeared to be
20
o f a stable nature. Following a trend that considered neurological soft sign constancy
among diverse populations, Smith, Hussian, Chowdhury, and Steams (1999a) proposed
that neurological soft signs are trait-like and therefore scores on these measures should be
relatively stable over time and should not be related to changes in patients
psychopathology or medication. The neurological soft signs measured by Smith, Hussian
et al. were very similar to those described in the literature o f children with sensory
integration deficits. Some examples included: (a) convergence, (b) Romberg, (c) tandem
walk, (d) rapid alternating movements, (e) finger-thumb opposition, (f) rhythm tapping
copied and spontaneous, (g) stereognosis, (h) graphesthesia, and (i) two-point
discrimination.
Although sharing the view o f neurological soft signs as trait-like, Whitty et al.
(2003) findings were somewhat different. They followed a group o f patients with first-
episode schizophrenia at presentation and 6 month follow-up for neurological soft signs
and psychopathology. They found significant improvement in overall neurological
function, primarily in motor-related and cortical signs, which were associated with
improvement in psychopathology. Therefore, they proposed that neurological soft signs
evidenced state-like characteristics that varied with clinical course, while harder signs
evidenced more static, trait like characteristics that were more related to a
neurodevelopmental base.
Other lines o f inquiry had included the study o f neurological soft signs in
subgroups o f patients diagnosed with schizophrenia. A study by Bersani, Clemente, and
Gherardelli (2004) explored the relationship between executive functioning, neurological
soft signs, and psychopathological features in a sample o f 26 adults with schizophrenia.
21
They found that patients with lower executive functioning showed greater severity o f
neurological soft signs. However, no significant differences between the groups emerged
for any psychopathological features. These findings seemed to be suggestive o f a
common neurobiological abnormality that could underlie cognitive deficits, especially
concerning executive functioning, and minor neurological soft signs but appeared to deny
that such dysfunction correlates with the psychopathological features o f schizophrenia.
Supporting this view was a study conducted by Mohr et al. (2003). They
examined a group of first-episode schizophrenic patients for neurological soft signs and
neuropsychological functioning. Morh et al. (2003) found that when patients were split
based on their high or low performance on neurological soft signs, they differed in the
level o f neuropsychological performance but did not show differential deficits. They
concluded that neurological soft signs influenced neuropsychological performance and
were correlated to a generalized neuropsychological deficit rather than to any specific
neuropsychological functions. The findings o f these studies suggested that the severity of
a disorder could be correlated with greater severity or amount o f neurological soft signs.
It remains to be determined if a significantly lower performance on measures of
neurological soft signs positively correlates with greater deficits in the functional
performance o f occupations. In addition, this relationship has not been explored in
children with sensory integrative dysfunctions.
Just recently the relationship between brain structure by means o f high resolution
magnetic resonance imaging and neurological soft signs was investigated. Dazzan et al.
(2004) found higher rates o f soft neurological signs associated with reduction o f grey
matter volume o f subcortical structures, particularly the putamen, globus pallidus, and
thalamus. Signs o f sensory integration deficits were additionally associated with volume
reduction in the cerebral cortex including the precentral, superior, and m iddle temporal
and lingual gyri. They found that these signs and their associated brain changes were
independent o f antipsychotic drug exposure. No hypothesis had been generated regarding
the validity o f these findings and their possible reversibility by means o f interventions
based on neural plasticity. Could neurological soft signs reflecting poor sensory
integration in adults with schizophrenia whose origin seemed to be based on a volume
reduction o f grey matter be responsive to sensory integration intervention? Is high
resolution magnetic resonance imaging a feasible method to measure changes in the
structures responsible for sensory integration? If sensory integration intervention is an
efficacious method for facilitating brain structure changes, what specific morphological
changes will occur in children with similar diagnoses?
Another group o f studies attempted to determine if neurological soft signs could
discriminate between a specific disorder and healthy individuals. A study by Krebs et al.
(2000) utilized a scale o f 23 neurological soft signs in 161 subjects including controls and
patients diagnosed with schizophrenia and recurrent mood disorder. The results o f this
study indicated that on the total score, significant differences (F 2 , 49 = 37.4; p < 10'4) were
found between healthy controls (mean ± SD: 5.0 ± 2.5) and both schizophrenic (14.6 ±
8.5) and mood disordered patients (12.0 ± 7 .1 ). The discrimination o f these items was
also examined by the authors and found to be significant between patients with
schizophrenia and controls with the exception o f tongue protrusion, homogeneity o f
lateralization, and mirror movements. This study also explored neurological soft signs
that are commonly reported in studies o f children with sensory integration deficits such
23
as (a) heel-to-toe balance, (b) finger opposition, (c) abnormal movements or posture, (d)
asymmetry, (e) stereognosis, (f) drawing a cube, and (g) graphesthesia. It was interesting
to note that Krebs et al. was the only study that shed some light about the most
appropriate level o f measurement (i.e. nominal, ordinal, etc.) when examining
neurological soft signs. They suggested that these should be measured on qualitative
rather than all-or-nothing scales. Principal component analysis found five consistent
factors as follow: (a) motor coordination, (b) motor integrative function, (c) sensory
integration, (d) involuntary movements or posture, and (e) quality o f lateralization.
With the exception o f Cuesta et al. (2002) no study has attempted to determine
threshold criteria that could distinguish between normal individuals and patients
diagnosed with psychosis or to investigate the predictive power o f neurological soft signs
for cognitive impairment. They assessed 56 patients diagnosed with psychosis and 26
controls and found evidence that supported neurological signs as having greater
predictive power for cognitive impairment than psychopathological dimensions.
However, although neurological soft signs were highly efficient predictors o f the
presence of severe cognitive impairment related to psychosis, their ability to discriminate
between individuals with psychosis and normal controls was modest.
Patients Diagnosed as Having Obsessive Compulsive Disorder
Research in adult patients diagnosed as having obsessive compulsive disorder
(OCD) have demonstrated an increased number o f neurological soft signs (Bihari, Pato,
Hill, &Murphy, 1991) as well as neuro-anatomic abnormalities detected with modem
imaging techniques (Nickoloff, Radant, Reichler, & Hommer 1991).
24
Contradicting this view, Thienemann and Koran (1995) performed a study with
21 outpatients diagnosed with OCD and studied the presence o f five neurological soft
signs before and after 10 to 12 weeks o f treatment with serotonin reuptake inhibitors.
Patients showed a mean o f 1.8 soft signs, the most common being agraphesthesia, mirror
movements, impaired cube drawing, adventitious movements, and finger-to-finger, in
that order. This study found that neither the presence o f specific neurological soft signs,
the number o f signs present nor a combination o f signs and test abnormalities predicted a
poorer response to pharmacological treatment. In addition, Thienemann and Koran
reported some evidence about baseline neurological soft signs that disappeared at
endpoint in medication responders and non-responders but with no clear pattern of
change.
Few discriminative studies have attempted to support the view that neurological
soft signs could differentiate between a specific disorder and a control group o f healthy
individuals. Guz and Aygun (2004) identified abnormal scores in graphesthesia and two-
point discrimination. In addition, total scores on neurological soft signs were significantly
higher in the group with OCD than the control group. There were no other significant
differences in neurological soft signs between the patients and the control group.
Mataix-Cols et al. (2003) investigated neuropsychological performance and
neurological soft signs, and found evidence that supported that patients with OCD
presented with more neurological soft signs than controls on both sides o f the body, and
were impaired on the free recall and organization scores o f neuropsychological
performance. Moreover, nonverbal memory deficits in patients with OCD were predicted
independently by organizational strategies and neurological soft signs. The authors
25
proposed that two variables appeared to be independently mediating nonverbal memory
deficits in obsessive compulsive disorder as follows: (a) a cognitive organization and
planning component and (b) a complex motor regulatory component.
Nickoloff et al. (1991) reported a study in which more specific neurological soft
signs were examined in patients diagnosed with OCD. This study examined smooth
pursuits and saccadic eye movements o f 8 patients diagnosed with OCD and 12 normal
controls using infrared oculography, computerized pattern recognition software and
measures of soft neurological signs. Study findings revealed that despite having an
increased number o f neurological soft signs, the performance o f patients with OCD on a
variety of measures o f eye movement was not significantly impaired. N ickoloff et al.
concluded that patients with OCD did not have prominent oculomotor dysfunction and
that eye movement dysfunction and neurological soft signs were not inextricably linked.
Patients with Bipolar Disorder
Negash et al. (2004) examined the extent to which neurological soft signs were
associated with bipolar disorder cases compared to healthy controls, the possible
relationship between neurological soft signs and the clinical dimensions of the disorder,
and the association o f sociodemographic characteristics with the occurrence o f
neurological soft signs. They found that patients with bipolar disorder performed
significantly worse on items related to sensory integration and motor coordination items.
The highest difference was sequencing o f complex motor acts. No significant
associations were found between neurological soft signs, clinical dimensions, and
sociodemographic characteristics.
26
This study adds to the growing evidence that supports the presence o f
neurological soft signs in patients with different diagnoses. “Sensory integration” items
were related to discriminative function o f the tactile system. They closely resemble the
tactile tests of the SIPT. “Sequencing o f complex motor acts” items resemble some o f the
items in the bilateral motor coordination, sequencing, and postural praxis subtests o f the
SIPT. It would be interesting to know if patients in this diagnostic group show evidence
of sensory integrative disorders similar to those observed in children with sensory
processing difficulties or if they are responsive to sensory integration treatment.
Cohort Studies
A study performed by Leask, Done, and Crow in 2002 reviewed medical
examinations on over 12,000 members o f a cohort at ages 7 and 11 years. The study
investigated the possible associations o f adult-onset psychosis with neurological soft
signs and common infectious illness in childhood. Leask et al. measured the following
neurological soft signs: (a) hand control, (b) coordination, (c) speech difficulties, (d)
bowel control, (e) tics, (f) twitches, (g) enuresis, (h) incontinence, (i)
coordination/balance, (j) neurological problem, (k) speech defect, (1) dysarthria, (m) left
handed, (n) left thrower, (o) left kicker, (p) clumsy, (q) unsteady, and (r) convulsions.
Leask et al. (2002) performed factor analysis of the measured soft signs and found
seven factors consisting o f more than one measure as follows (a) left preference, (b)
clumsy and unsteady, (c) hand control and speech problems, (d) general coordination and
neurological, (e) tic/twitches, (f) speech problems, and (g) incontinence. These factors, in
27
general, represented meaningful clusters o f related soft signs, suggesting a common
neurological origin.
Homicidal Men with Antisocial Personality
Followed by a trend in assigning neurological soft signs to neurodevelopmental
dysfunction and as evidence of central nervous system defect resulting in considerable
sociopsychological dysfunction, Lindberg et al. (2004) conducted a study aimed at
examining neurological soft signs in an adult criminal population. They compared a
group o f 14 men referred to pre-trial forensic psychiatric examination with a history o f
recurrent violent acts, a group o f patients diagnosed as having schizophrenia consisting o f
8 age-matched men, and a group o f healthy controls. Lindberg et al. reported that
neurological soft signs in antisocial offenders were significantly increased compared with
those o f the healthy controls; whereas no significant differences were observed between
the scores o f offenders and those o f patients with schizophrenia. W hen comparing the
group o f offenders and healthy controls, the items that were significantly over
represented by the offenders were blunt/sharp discrimination, tapping rhythm,
dysdiadokokinesis, blink reflex, and complex motor acts. Thus, Lindberg et al.
speculated that neurological soft signs indicate a nonspecific vulnerability factor in
several psychiatric syndromes.
Summary
Observations have been utilized in different disciplines to determine the nature
and extent o f a hypothesized dysfunction in adult patients with several diagnoses. These
28
observations have been denominated by neurological soft signs in different fields.
Linderberg et al. (2004) has defined them as being characterized by abnormalities in the
motor, sensory and integrative functions. These signs and their significance have been
studied in persons affected by different diagnoses and utilizing different methods of
observation.
This review o f literature has been organized in three categories: studies involving
adults, studies involving adolescents, and studies involving children. In the first group,
studies involving adults, the information was organized describing: (a) patients diagnosed
as having schizophrenia, (b) patients diagnosed as having obsessive compulsive disorder,
and (c) other disorders.
In adults diagnosed as having schizophrenia, it appears that m ost patients in this
group present with at least one neurological soft sign (Lane et al., 1996). Bersani et al.
(2004) and Morh et al. (2003) provided evidence that neurological soft signs are related
to cognitive and executive functioning in this group. Patients with lower executive
functioning showed greater severity o f neurological soft signs. The neurological soft
signs described in adults with schizophrenia fall in the following categories: (a) motor
coordination and sequencing, (b) sensory integration, and (c) developmental reflexes.
Krebs et al. (2000) found four factors: (a) motor coordination, (b) motor integrative
functions, (c) sensory integration, and (d) involuntary movements. A cohort study by
Leask et al. (2002) studied the relationship between adult onset psychosis, childhood
illnesses, and neurological soft signs. They grouped neurological soft signs in seven
categories: (a) left preference, (b) clumsy and unsteady, (c) hand control and speech
problems, (d) general coordination and neurological, (e) tic/twitches, (f) speech problems,
29
and (g) incontinence. Most of the neurological soft signs examined in this study were
designed to capture information related to coordination skills and may have provided
information related to vestibular and proprioceptive functions.
Other studies have attempted to pin point a neurological substrate for these
observations. Dazzan et al. (2004) utilized imaging techniques and found increased rates
o f neurological soft signs to be associated with reduction o f grey matter volume o f
subcortical structures, specifically in the putamen, globus pallidus and thalamus. Krebs et
al. (2000) found evidence that supported the assumption that some neurological soft signs
could discriminate between a specific disorder and healthy individuals. In relationship to
clinical course, neurological soft signs appear to have a stable nature in adults with
schizophrenia that is independent o f changes in psychopathology and neuroleptic
treatment. Whitty et al. (2003) proposed state-like characteristics that varied with clinical
course. The opposite may be true for patients with OCD. It is unknown if neurological
soft signs that are present in childhood would remain through adolescence and adulthood.
However, it is most likely that they will subside if patients are treated with selective
serotonin reuptake inhibitors (Thienemann & Koran, 1995). It is known that patients with
OCD do not appear to present with prominent oculomotor dysfunction (Nickoloff et al.,
1991). Moreover, they appear to represent some form o f impaired sensory processing
related to the tactile or proprioceptive systems (Bihari, et al., 1991).
The term “sensory integration” in different studies examining neurological soft
signs is obscure. The most common uses refer to discriminative functions o f the tactile
system. The most often cited are stereognosis, graphesthesia, and two point
discrimination. In addition, most neurological soft signs described in the literature are
30
related to the visual, somatosensory, and vestibular systems (Bersani et al., 2004; Boks,
liddle, Russo, Knegtering, & Van der Bosch, et al., 2003; Das et al., 2004; Dazzan et al.,
2004; Dazzan & Murray, 2002; Gourion et al., 2003; Krebs et al., 2000; Lane et al., 1996;
Malla, Norman, Aguillar, and Cortese, 2003; Morh et al., 2003; Niethammer et al., 2000;
Smith Hussian, et al., 1999; Whitty et al., 2003; Yazici, Demir, Yacici, and Gogus, 2002).
The literature on neurological soft signs in patients with bipolar disorder suggest a
possible connection between the disorder and deficits in functions related to sensory
integration, specifically, the performance o f tasks requiring sequencing o f complex motor
acts (Negash, et al., 2004). Lindberg et al. (2004) found an increased rate o f neurological
soft signs in patients with a criminal history. It is interesting to note that the most evident
neurological soft signs in these as well as in other populations, such as patients with
bipolar disorder, appear to be related to a praxis component.
Studies Involving Adolescents
The research literature on studies focusing on neurological soft signs in
adolescents has just begun to be explored. The few studies examining neurological soft
signs in adolescents have concentrated on the diagnosis o f ADHD and schizophrenia.
Conduct Disorder and Attention Deficit Hyperactivity Disorder
Patients with ADHD have been shown to have a high prevalence o f comorbid
conditions, including language disorders, learning disabilities, graphomotor dysfunction,
and impairments in fine and gross motor skills. Some o f these conditions have been
studied under the general category o f soft neurological signs (Spreen, Risser, and Edgell,
31
1995). Aronowitz et al. (1994) compared neuropsychiatric and neuropsychological
evaluations performed in adolescents including three groups: subjects with conduct
disorder (CD) comorbid with ADHD versus CD only, all subjects with ADHD versus all
non-ADHD, and all subjects with CD versus all non-CD. The CD and ADHD group had
increased left-sided soft signs compared with the CD group.
Similarly, Vitiello, Stoff, Atkins, and Mahoney (1990) examined the relationship
between neurological soft signs and disruptive behavioral disorders in 31 boys 6-13 years
o f age with disruptive behavior disorders and 45 age-matched boys without pathology.
After being corrected for age, neurological soft signs correlated positively with
impulsiveness responding in different measures but not with intelligence quotient or
clinical impulsivity scores. The findings o f this study suggested a relationship between
neurological dysfunction/immaturity and performance on specific tasks requiring
response inhibition.
Adolescents Diagnosed as having Schizophrenia
Obiols, Serrano, Caparros, Subira, and Barrantes (1999) compared 140 normal
adolescents with 162 at risk individuals on neurological soft signs, IQ, frontal lobe
function, and schizotypy. They found associations between neurological soft signs and
attention deficit. Furthermore, subjects with higher scores on neurological soft signs were
characterized by lower IQ scores, poorer performance on frontal lobe tests, and greater
problems with social interaction. There was also a trend for an association between male
sex and both left-handedness and neurological soft signs. These studies have found
32
information consistent with neurological soft signs in the left hemi-body which are
suggestive o f right brain dysfunction.
Summary
There is a lack o f research examining neurological soft signs in adolescents with
different diagnoses. Neurological soft signs in adolescents have been examined in
individuals diagnosed as having attention deficits, conduct disorder, and schizophrenia.
Research studies seem suggestive o f an increased incidence o f neurological soft signs in
adolescents with attention deficits, conduct disorder, and schizophrenia. In adolescents
with schizophrenia, neurological soft signs appeared suggestive o f right brain
dysfunction.
Studies Involving Children
Although systematic correlations between neurological soft signs and
characteristic symptoms o f certain adult disorders have been controversial, partial
evidence suggested that the opposite may be the case when examining neurological soft
signs in children. The existence o f brain dysfunction manifesting itself in both the
neurological and behavioral dimensions has been the focus o f many studies. Different
research studies have emphasized different domains o f function. M ost o f the symptoms
described by those studies included clumsiness (Gubbay, Ellis, W alton & Court, 1965),
visuomotor and visual perceptual difficulties (M. Walker, 1965), delayed maturation
(Illinworth, 1968), and increased amount o f associated movements (Abercrombie &
Tyson, 1964). More recently sensory integration and sensory processing difficulties were
33
proposed in diverse populations (Smith Roley et al., 2001). These studies proposed
different ways of examining children to determine the nature and extent of their
difficulties. However, the examination o f structured observations or neurological soft
signs remained common to all o f them.
In the assessment o f children who present with functional performance
difficulties, occupational therapists have relied on both standardized and non
standardized assessments and on different observations. Structured observations within a
sensory integration frame o f reference entail the child performing a series o f tasks
demonstrated by the therapist that reflect intactness in the central nervous system. Ayres
included these observations as items in her factor and cluster analytic studies (Ayres,
1965; 1966a; 1966b; 1969b; 1977).
The field of neurology, neuropsychology, rehabilitation, occupational therapy,
and physical therapy have examined neurological soft signs in children for quite some
time. Although no universal system has been adopted to examine children with minor
neurological irregularities or delayed maturation o f the sensory or motor systems, most
studies included similar assessments. They have included, but have not been limited to,
examination o f the child in different developmental positions such as sitting and standing,
different parts of the body such as head or trunk, examination o f the motor system
including muscle power, passive movements and range o f movements, and examination
of reflexes (Touwen & Prechtl, 1970).
A review o f the most recent studies involving neurological soft signs revealed a
renewed interest in the subject since the 1960s. Thus, some studies have investigated the
nature and significance of neurological soft signs in children with attention deficit
34
disorder (Guftafsson Theralund, Ryding, Rosen, &Cerdblad, 2000), Gilles de la Tourette
syndrome (Smerczi, 2000), academic achievement and learning disabilities (Poblano et
al., 2002), congenital muscular dystrophy (Mercuri, Dubowitz, et al., 1995), convulsive
disorders (Hara & Fukuyama, 1992), emotional disorders (Pine et al., 1993), children at
high risk (Pine Wasserman, Fried, Parides, & Schaffer, 1997), psychiatric vulnerability
(Diaz Atienza & Blanquez Rodriguez, 1990); sickle cell disease (Mercury, Faundrez, et
al., 1995), and mainstream pupils (Fellick, Thomson, Sills and Hart, 2001). Most o f these
studies have also incorporated more accurate measures such as photon emission
computed tomography EEG, cerebral blood flow (Guftafsson, Mercuri, Faundez, et al.),
and magnetic resonance imaging techniques (Dubowitz , et al.).
Attention Deficit Hyperactivity Disorder
Guftafsson et al. (2000) examined a group o f children with ADHD hyperactivity
disorder using single photon emission computed tomography and EEG. They found that
some o f these children had abnormal distribution o f the regional cerebral blood-flow and
some had abnormal EEG findings. The authors performed a factor analysis on the
regional cerebral flow in different regions o f interest and found two main factors. A
factor with low regional cerebral blood flow in the temporal and cerebellar regions and
high regional cerebral blood flow in the subcortical and thalamic regions that was
significantly associated with the degree o f motor impairment and results on cognitive
testing. Another factor consisting o f high regional cerebral blood flow in the frontal and
parietal regions had a significant negative correlation with the degree o f behavior
35
symptoms. In addition, Guftafsson et al. found a negative correlation between the
regional cerebral blood flow in the right frontal regions and the degree o f behavioral
symptoms and the number o f minor physical abnormalities in the frontal lobes bilaterally.
These authors concluded that in children with ADHD there were at least two functional
disturbances, one specific neurodevelopmental disturbance o f the frontal lobe, especially
the right hemisphere, related to behavioral disturbances. The other was a disturbance o f
the integration o f the temporal lobes, cerebellum, and subcortical structures, related to
motor planning and aspects of cognition.
Academic Achievement and Learning Disabilities
A study conducted by Poblano et al. (2002) collected data in a group o f 778
children ages 6-12 years mainly from low and middle economic strata and diagnosed
with specific reading disability. The study collected data on age, gender, diagnosis,
school grade, food intake, maternal complications during pregnancy, perinatal and
postnatal neurological risk factors, neurological soft signs, and handedness. They
concluded that a high frequency o f perinatal risk factors and neurological soft signs were
common among the sample studied.
Proponents o f outside sources o f information have claimed that the examination
o f neurological soft signs is o f very little help in diagnosing children with learning
disabilities. In a study by Brunquell, Russman, and Lerer (1991) 119 questionnaires were
sent to children’s neurologists who were asked to rank the importance o f 8 different
sources of information. All pairwise comparisons o f the eight sources revealed significant
36
differences except for psychological reports and medical histories which were ranked
equally. Analysis o f the six remaining sources demonstrated the following: teacher’s
reports were deemed more helpful than the mental status examination, and questionnaires
distributed to parents and teachers were more useful than findings on the remainder o f the
neurological examination. Social services reports took precedence over soft signs which
were considered least diagnostically helpful.
Emotional Disorders
Pine et al. (1993) performed a prospective epidemiological study that found the
combination o f childhood neurological soft signs and anxious behavior to be a strong risk
factor for adolescent emotional disorders. This study found that the at-risk subjects were
shown to exhibit a persistent and specific pattern o f both motor abnormalities and
anxiety, obsessive-compulsive, or depressive symptoms over time. Pine et al. (1993)
recommended that children who present with anxious and depressive symptoms be
examined for motor soft signs.
Congenital Muscular Dystrophy
Mercuri, Dubowitz, et al. (1995) examined 22 children with pure congenital
muscular dystrophy in which there were not structural changes in the brain or severe
mental retardation. The researchers tested for neurological soft signs related to white
matter changes. The group o f children was divided into two groups for analysis
depending on the presence or the absence o f diffuse white matter changes. A significant
difference was found between the group with congenital muscular dystrophy with normal
37
magnetic resonance imaging and the group with diffuse white matter changes. The results
demonstrated that perceptual motor difficulties and minor neurological soft signs were a
consistent feature in congenital muscular dystrophy children with diffuse magnetic
resonance imaging changes, but not with normal magnetic resonance imaging (Mercuri,
Dabowitz, et al., 1995).
High Risk
Pine et al. (1997) studied the stability o f neurological soft signs and their
association with psychiatric symptoms in high risk young boys. They found that
neurological soft signs exhibited marked stability across the one-year period. The authors
concluded that performance on neurological soft signs examination is stable over a one
year period and that this examination correlates to both internalizing and externalizing
symptoms in young boys.
Psychiatric Vulnerability
Diaz Atienza and Blanquez Rodriguez (1990) conducted a study with 60 children
ages 4-15 years and found a significant quantity o f neurological soft signs with regard to
the gravity o f the psychiatric disorder. They recommended their evaluation to determine
the child’s neuro-maturational condition and psychiatric vulnerability.
Sickle Cell Disease
Neurological soft signs have also been examined in their ability to predict medical
complications. Stroke, one o f the most frequent complications o f sickle cell disease and
occurring in 7-17% o f children, motivated Mercuri, Faundez et al. (1995) to study 14
children diagnosed as having sickle cell disease. They questioned if minor lesions
observed on imaging could be associated with soft neurological signs not detectable on
conventional neurological examination. Eight o f the 14 children scanned showed lesions
on MRI but only 3 were abnormal on standard neurological examination. However, all o f
the eight children with MRI lesions also showed abnormal signs. All the children with
normal MRI were normal on all the tests performed. Mercuri Faundez, et al. concluded
that neurological soft signs may reliably identify the presence o f even minor MRI lesions
and may also help to identify the population at risk for developing strokes.
Mainstream Pupils
When neurological soft signs were examined in a sample o f mainstream pupils
Fellick et al. (2001) found that after being assessed with a measurement o f six
neurological soft signs, motor skills, cognitive function, and behavior, those children who
presented with higher scores in neurological soft signs performed worse on the other
three measures. Specifically, they concluded that a soft sign score above the 90th
percentile had a sensitivity o f 38% for detecting cognitive impairment, 42% for detecting
coordination problems, and 25% for detecting possible attention deficit hyperactivity
disorder.
Summary
Research studies that have examined neurological soft signs in children with
different diagnoses appeared to suggest different manifestations. Behavioral disturbances,
39
motor planning, and cognition appear to be more significant in children with attention
deficits (Guftafsson, et al., 2000). A high frequency o f neurological soft signs has been
reported in children with specific reading disability (Poblano et al., 2002). On the other
hand, Brunquell et al. (1991) advocated against the diagnostic value o f neurological soft
signs when compared with other sources o f information such as parent questionnaires.
Neurological soft signs have been reported in children with convulsive disorders (Hara &
Fukuyama, 1992).
The predictive value o f structured observations or neurological soft signs has also
been examined. Pine et al. (1993) suggested a relationship between these signs and
anxiety in childhood as a factor for later emotional disorders.
Some studies have concentrated their research efforts on how neurological soft
signs could identify or even predict risk factors. This line o f inquiry offers pediatric
occupational therapists with important information, as the examination and correct
interpretation of some neurological soft signs may indicate a progressive or degenerative
disorder. Following this line of inquiry Mercuri, et al. (1995) examined neurological soft
signs in children with congenital muscular dystrophy. This examination was able to
differentiate between children with structural changes confirmed via imaging techniques.
Similarly, Mercuri, Dubowitz et al. (1995) detected children with m inor MRI lesions but
normal neurological examinations in children with sickle cell disease, a population very
susceptible to stroke.
The diagnostic value of neurological soft signs or structured observations appears
to be o f more weight than those found in adult patients. These signs appear to be stable
even across a one year period (Pine, et al., 1997) and be related to the severity or gravity
40
o f a psychiatric disorder (Diaz Atienza & Blanquez Rodriguez, 1990). Fellick et al.
(2001) presented evidence on neurological soft signs sensitivity in detecting cognitive
impairment, coordination problems, and attention deficits.
Sensory Integration Theory
Sensory integration theory was introduced by Jean Ayres as a neurobehavioral
theory (Ayres, 1972). The core concept o f sensory integration is that neural integration of
sensation is an essential component o f movement and learning. In addition to the visual
and auditory sensory systems contributions to movement and learning that were
emphasized in Ayres’s time, the role o f the vestibular, kinesthetic, proprioceptive and
tactile systems are highlighted by sensory integration theory (K.F. Walker, 2004).
Ayres’s theory development proceeded from the examination o f children with
learning, movement, and behavioral problems without a known neurological insult. In an
attempt to alleviate some of the problems that children experienced, Ayres proceeded to
develop test instruments, conduct factor analytic studies to refine a typology o f sensory
integrative dysfunction, design a therapeutic setting to treat these problems, and conduct
efficacy studies (K.F. Walker, 2004).
Some important aspects o f Ayres’s theory included the notion o f sensory
information as nourishing the central nervous system, making meaning through
integration o f sensations and developing through a series o f adaptive responses or goal
directed responses to sensory experiences (Ayres, 1972). Important contributions also
included a formulation o f how sensory integration developed from infancy to middle
adulthood and the importance o f sensation in the understanding o f how the brain works,
41
including how different types o f sensation were processed and integrated at different
levels o f the central nervous system.
Departing from how the processes o f integrating sensation occurred in normal
individuals, Ayres proceeded to describe what constituted sensory integration dysfunction
including their symptoms and causes (Ayres, 1972). She mentioned the possibility of
hereditary and environmental factors and a process that she described as “internal sensory
deprivation” (Ayres, 1972 p. 51). Using this term she hypothesized that children with
sensory integration dysfunction could have experienced normal sensory stimulation but
somehow these sensations did not nourish every part o f the brain that needed them.
Since its inception, sensory integration theory has expanded, and most o f its
principles have been revised and reformulated. These revisions have incorporated more
contemporaneous visions o f the central nervous system, human development, and how
sensory integration contributes to daily occupations. Thus, research has furthered sensory
integration theory as well as its relationship with how children perform a variety o f
occupations (Spitzer et al., 1996). Contemporaneous scientists have correlated sensory
integration functioning with arithmetic and reading achievement in school aged children
(Parham, 1998); play skills in preschoolers, (Schaaf, 1990); deficits in tactile modulation
with rigid or inflexible behavior, repetitive verbalizations, visual stereotypes, and
abnormally focused affections in children with developmental disabilities (Baranek,
Foster, & Berkson, 1997); sensory defensiveness with negative emotions such as
annoyance, frustration, and fear when encountering occupations that involved various
sensory stimuli (Kinnealey, Oliver, & Wilbarger, 1995).
42
Current research in sensory integration theory has not refuted the initial principles
o f sensory integration theory originally proposed by Ayres, but it has increased its
importance. New avenues of inquiry and methods o f measurements have promoted newer
discoveries and conceptualizations including a syndrome o f sensory modulation
dysfunction (Miller, Reissman, McIntosh, and Simon, 2001); specific deficits in
proprioceptive processing (Imperatore Blache & Shaaf, 2001); wider views o f praxis
(Giuffrida, 2001; Imperatore Blanche, 2001; May-Benson, 2001) and praxis and
organization of behavior in time and space (Imperatore Blanche & Parham, 2001) as well
as the application o f sensory integration principles to the treatment o f diverse populations
(Smith Roley, Imperatore Blanche, & Shaaf, 2001).
The theory of sensory integration has devoted great efforts in developing
assessment tools to capture sensory integration deficits in children and adults. These
assessment tools have the purpose o f documenting the nature and extent of sensory
integration dysfunction. Several o f these assessments are currently available to
occupational therapists including sensory histories such as the sensory profile (Dunn,
1999) and the Evaluation of Sensory Processing (Parham & Ecker, 2000); clinical
protocols that include observations o f neuromotor behaviors (Dunn, 1981; Imperatore
Blanche, 2002; B.N. Wilson et al., 1994; 2000) and formal assessments such the SIPT
(Ayres, 1989).
Sensory integration theory was selected for this research because the children who
participated in this study had documented sensory integration dysfunction in their clinical
charts. They were being treated using a sensory integration frame o f reference after a
43
formal assessment by a pediatric occupational therapist with formal training in sensory
integration linked the presenting problems to inadequate sensory processing.
Structured Observations Within Sensory Integration
Within a sensory integration frame o f reference, structured observations were
defined as situations in which a clinician controls environmental factors and organizes a
task for the child to carry out while noting salient aspects o f his or her performance. The
structured observations had, as neurological soft signs, been utilized as part o f routine
examinations to provide objective data that could be identified, measured, and interpreted
by clinicians. In this respect, when examining Ayres’ early publications, it became
evident that she was looking into different means for measuring the nature and extent of
dysfunction in the perceptual motor domain. In her early studies she used different
structured measures that provided her with information regarding children’s perceptual
motor abilities. Some o f these observations were not standardized until later when she
received her doctoral degree in educational psychology. She expressed “I needed to
develop tests in order to really get at the problem, and in learning situations, problems are
not easily measured, determined, even recognized. When I started out, there weren’t any
really good tests for looking at dysfunction in children” (A. J. Ayres, personal
communication, June 29, 1981 as cited in K.F. Walker, 2004).
Ayres conducted numerous factor analytic studies in order to construct and refine
typologies o f sensory integrative dysfunctions. Ayres established her first typology in
1963 and refined it in 1965. In 1963, Ayres published a paper titled “The Development
o f Perceptual Motor Abilities: A Theoretical Basis for Treatment o f Dysfunction”. This
44
research was Ayres’ first attempt to explain the presence o f taxonomic categories or
syndromes o f dysfunction in children with known perceptual motor dysfunction (Ayres,
1963). She was inspired by the trend in the use o f factor analysis in the social and
medical sciences and thought that factors o f interrelated observations o f perceptual motor
function would emerge from her research in children with learning and behavioral
problems. Aware o f the factor analytic limitations, she pursued her research, thinking that
the children she encountered in her clinical practice would parallel those
neurophysiological processes, such as spasticity or athetosis that accounted for the
behavioral manifestations o f children affected by cerebral palsy (K.F. Walker, 2004).
This original research study identified five major syndromes, which emerged from the
analysis o f factors, and the mean or actual factual loadings o f observations in the
perceptual-motor area o f functioning. Different syndromes were represented by different
constellations o f deficits o f function. As a result o f her research, Ayres (1963) named the
following syndromes: (a) apraxia, (b) perceptual dysfunction: form and position in space,
(c) deficits o f integration o f function o f the two sides o f the body, (d) perceptual
dysfunction: visual figure-ground, and (e) tactile defensiveness.
In 1965, Ayres conducted a similar study with a larger sample that included
typically developing children in addition to those with suspected perceptual motor
dysfunction and a larger number o f tests. She ended with five major factors interpretable
as hypothesized behavioral correlates of patterns o f neurological dysfunction. Ayres
named and described the factors similarly to those identified in her research study
conducted in 1963 (Ayres, 1965). This classification scheme, presented in her Eleanor
Clarke Slagle lecture (Ayres, 1963), provided her with a framework for test development
45
and theory building in sensory integration (Ayres, 1963, 1965). Because the five discrete
syndromes identified by means o f factor analysis were not found in the normal subjects,
it was clear that Ayres achieved her goal o f isolating areas o f dysfunction that were not
typical of normal development (Ayres, 1965). In these early studies, Ayres (1963; 1965)
utilized several non-standardized and non-norm structured observations as follows: (a)
graphic skill, (b) kinesthetic memory, (c) localization o f tactile stimuli, (d) eye pursuits,
(e) skin designs, (f) manual perception of form, (g) standing balance I and II, (h) hand
test (i) motor planning: gross, (j) right-left discrimination, (k) finger identification, (1)
strength o f unilateral hand dominance, (m) degree o f agreement between eye and hand
dominance, (n) body visualization, (o) crossing the mid-line o f the body, (p) perception
o f joint movement, (f) fine motor planning: wire-grommet device, (g) fine motor
planning: string winding, (h) two point tactile discrimination, (i) superimposed figures, (j)
time and rhythm, (k) freedom from tactile defensive behavior, and (1) freedom from
hyperactive and distractible behavior.
In addition to different structured observations she utilized two o f her own tests,
the Southern California Motor Accuracy Tests and the Ayres Space Test (Ayres, 1962,
1964), a test o f visual perception o f verticality, five subtests o f the Marianne Frostig
Developmental Test o f Visual Perception, a test o f two-point tactile stimuli, a test of
Gestalt completion, and the Pacific State Hospital Number Concept Test.
Some of these structured observations laid the foundation for the development o f
more refined tests. Between 1962 and 1965 Ayres published two psychological tests: The
Ayres Space Test (Ayres, 1962) and the Southern California Motor-Accuracy Test
(Ayres, 1964). From a careful examination o f these tests it seemed reasonable to assume
that Ayres was using structured observations. Moreover, the similarities o f the problems
experienced by her clients lead her to the development o f more refined observations and
testing items prior to their standardization. In a personal communication, and referring to
children with learning disabilities, she expressed “they have certain conditions,
responsibility for modification o f which I assume; therefore, I must learn what I need to
know to ameliorate their condition” (A. J. Ayres, personal communication, June 24,
1981; as cited in K.F. Walker, 2004). It seems reasonable to believe that some of these
structured observations were not explored further and therefore clinicians continue to use
them to supplement their standardized testing findings or as Imperatore Blanche (2002)
points out: as the primary assessment tool when standardized measures were not
appropriate.
In 1966, Ayres conducted another research study on 64 adopted normal children
ages 4 though 8 years. The comparison o f the factor structure o f the scores o f this normal
group with previous factor analytic studies helped Ayres to clarify differences between
the two groups. The clearest difference between the factorial structure o f the scores from
the normal children and a group with dysfunction was the failure o f the dimensions o f
praxis and form and space perception to appear as separate factors in the normal group.
Ayres was not able to formulate a comparable hypothesis about the previously proposed
syndromes o f integration o f function o f the two sides o f the body or tactile defensiveness.
From the results o f this research Ayres elaborated on the advantage o f the use o f tests
which tapped into areas o f function which showed little variation in normal children but
considerable variation in children with disorders (Ayres, 1966a). In later research Ayres
compared her group o f perceptual motor tests to valid and reliable measures such as the
47
Gesell, which were scales known in her time to reflect the degree o f integrity and
maturation o f the nervous system (Gessell & Amatruda, 1947). In this study, Ayres was
able to demonstrate correlations between the Gesell developmental quotients and the
perceptual motor scores as significant at the .01 level (Ayres, 1969b).
A. Jean Ayres developed a theory centering on the developmental progression of
sensory integration in the central nervous system. Although the terms “sensation” and
“integration” appeared frequently in Ayres writings it was not until 1968 that she
combined these terms into “sensory integration” (K.F. Walker, 2004). Ayres used these
terms to describe the brain’s ability to filter, organize, and integrate the masses o f sensory
information (Ayres, 1968a). She viewed learning as a function o f this neuropsychological
ability and proposed that certain types o f learning disability could therefore be interpreted
partially in terms o f dysfunction within the brain’s integrative functions (Ayres, 1968b).
Ayre’s 1968 writings laid the foundation for the development o f her theory as she
introduced phylogenetic and ontogenetic developmental principles related to sensory
integration, linked learning and sensory integration, posed dysfunction in sensory
integration as being related to learning disabilities, and identified and related evaluation
and treatment strategies (K.F. Walker, 2004).
Later in 1969, Ayres pursued a research study using Q-factor analytic techniques
in 36 children with educational handicaps. In this study she attributed two major patterns
o f deficits associated with low academic functioning in the areas of: (a) auditory,
language and sequencing and (b) postural and bilateral integration. These deficits were
differentiated from apraxia and tactile defensiveness (Ayres, 1969a). This study seemed
to have finalized Ayre’s search for different types o f sensory integrative deficits among
48
children with academic and behavioral problems. Her later work appeared to be related to
the refinement o f her measuring devices and assessment tools. Some o f the testing items
used in her early research, mainly because o f their discriminative nature, became part o f a
later battery, the Southern California Sensory Integration Tests (Ayres, 1972) and the
Sensory Integration and Praxis Tests (1989). Contemporaneous research studies have
consistently ended with similar factor structures as those originally proposed by Ayres
even when the sample size has been as large as 10,475 children (Mulligan, 1996).
In 1976, Ayres was appointed adjunct faculty member to the Department o f
Occupational Therapy at the University o f Southern California. In 1977, she opened the
Ayres Clinic, a private facility in Torrance, California. In this carefully designed
environment for sensory integrative therapy, she provided therapy for children;
conducted research; and developed tests, instruments, and theory. An evaluation form
that listed several structured observations and that was utilized in the Ayres clinic
included several liberal estimates for different age groups o f typically developing
children drawn from the literature. However, most o f these observations were not
standardized for their administration or interpretation and lacked normative information
from the performance o f typical children or those with dysfunctions. The observations
included: (a) writing hand, (b) handwriting, (c) sighting eye, (d) eye movements
(pursuits, midline crossing, range, head movements, and convergence), (e) thumb-finger
touching, (f) associated reactions, (g) slow (ramp) motions, (h) finger to nose, (i) tongue
movements (to side o f mouth, to top o f mouth behind teeth, lick lips all the way around,
to bottom o f mouth behind teeth), (j) chin movements (to side, move down on command,
close mouth on command, move forward, move backward), (k) muscle tone, (1)
49
antagonist muscle co-contraction, (m) forearm rotation, (n) choreoathetosis, (o) arm
extension test (p) supine flexion, (q) prone extension, (r) heel-toe walking, and (s)
vertical writing of Fukuda.
In 1982, Ayres elaborated on the use and interpretation o f structured observations
when assessing sensory integration dysfunctions. In this manuscript she elaborated the
significance and interpretation o f the following observations: (a) tonic neck reflex, (b) co
contraction, (c) forearm rotation, (d) eye pursuits, (e) prone extension, (f) supine flexion,
(g) usage of the non-preferred hand, (h) standing balance, eyes open, (i) standing balance,
eyes closed, (j) postrotary nystagmus, (k) protective or parachute reactions, and (1) neck
co-contraction.
Although Ayres’s original clinical observations continue to be utilized in clinical
practice (B.N. Wilson et al., 1994; 2000), a number o f contemporaneous studies have
examined the role of different observations in children with sensory integration deficits.
Contemporaneous Research on Structured Observations
The expansion o f the sensory integrative frame o f reference to the assessment and
treatment o f diverse populations has challenged pediatric occupational therapists to
design valid and reliable assessment tools, screening, and measuring devices. Thus,
parent questionnaires, sensory histories, standardized testing, and structured observations
have been described to some extent (Blanche, 2002; Blanche et al., 1995; Carrasco, 1993;
Dunn, 1981, 1997; Dunn & Bennett, 2002; Dunn & Brown, 1997; Fisher et al., 1991,
2002; Gregory-Flock & Yerza, 1984; Haak et al., 1993; Harris, 1981; Izraelevitz et al.,
50
1985; Johnson-Ecker & Parham, 2000; Kay, 2001; LaCroix et al., 1997; Magalhaes et al.,
1989; Rife, 2000; Silver & Hagin, 1960; B.N. Wilson et al., 1994).
At least three clinical protocols that include observations o f neuromotor behaviors
have been used in the field o f occupational therapy to assess different sensory processing
deficits in children (Dunn, 1981; Imperatore Blanche, 2002; B.N. Wilson et al., 1994,
2000). Earlier versions of structured observations included several items that represented
different domains o f function such as two-point discrimination, writing hand,
handwriting, sighting eye, choreoathetosis, crossing the mid-line o f the body, and
two-point tactile discrimination among others (Ayres, 1963, 1965). More recent clinical
observations have concentrated on items testing postural stability; coordination, rate and
quality o f movement; ability to inhibit primitive reflexes (B.N. Wilson et al., 1994, 2000);
classic neurological, motor coordination; and motor learning based observations as well
as observations that included free play and play experiences; reactions to sensations and
praxis (Imperatore Blanche, 2002); and classic observations o f postural stability,
coordination, co-contraction, reflexes, motor planning, equilibrium, and eye movements
(Dunn, 1981).
Most publications about structured observations have focused on three separate
aspects: objectivity by examining research reliability and validity and other aspects of
their standardization, their developmental characteristics by determining the responses of
typical and atypical children, and their interpretation by elaboration o f different
observations as they related to different disorders in sensory integration.
51
Measurement Considerations
The notion o f measurement has been involved in all aspects o f validity and
reliability assessment. According to Carmines and Zeller (1979) measurement is most
usefully viewed as the “process o f linking abstract concepts to empirical indicants”
(p. 18). When examining the desirable qualities o f a measurement device such as different
structured observations, reliability concerns the extent to which they yielded the same
result on repeated trials. On the other hand, validity dealt with what the structured
observations were intended to do, in other words, to measure what they are intended to
measure; therefore it referred to the relationship between concept and indicator
(Carmines & Zeller, 1979).
Information on several structured observations and the responses o f typical children
has been published in the literature contributing to their validity and reliability (Ayres
1972; Deitz, Richarson, Atwater, Crowe, & Odiome, 1991; Denckla, 1973; Dunn, 1981;
Fraser, 1983; Grant, Boelsche, & Zin, 1973; Gregory-Flock & Yerxa, 1984; Harris 1981;
Imperatore Blanche, 2002; Kaufman, 1983; Longo-Kimber, 1984; Magalhanes et al.,
1989; Shumway-Cook & Horak, 1996; Silver, 1952; Silver & Hagin, 1952; and B.N.
Wilson et al., 1994) and they were often part o f the assessment process in pediatric
occupational therapy.
A compilation o f different structured observations have been collected from the
literature and organized in a protocol for the purpose o f easy administration and data
collection. The selection of different observations for the present study was based on the
following considerations: (a) studies that included a large sample size as reported in the
original research study, (b) observations that provided an individual rather than a
52
composite score, (c) observations that provided norms or criterion references to typically
developing children, (d) observations that could be administered with ease by clinicians
and that did not impose major challenges to children under testing conditions, and (e)
observations that did not include sophisticated administration procedures or equipment,
and therefore, were impractical for clinical applications.
The following was the group of nine structured observations that were selected to be
utilized in the present study: (a) heel-to-toe (Deitz et al. 1991), (b) prone extension
(Dunn, 1981; Gregory-Flock & Yerxa, 1984; Harris, 1981; Longo-Kimber, 1984), (c)
supine flexion postural test (Fraser, 1983), (d) slow motions (Dunn, 1981), (e) jumping
jacks (Magalhaes et al., 1989), (f) finger to nose (Dunn, 1981; Touwen & Prechtl, 1970),
(g) diadokokinesis (Grant, Boelsche & Zin, 1973), (h) finger-to-thumb opposition (Grant
et al., 1973), (i) modified Schilder’s arm extension test (Dunn, 1981; Silver, 1952; Silver
& Hagin, 1952). In addition the Southern California postrotary nystagmus test (Ayres,
1975) was also utilized.
Objectivity.
Reliability of different measures has usually been reported using several methods
such as retest method, split halves method, and internal consistency method. Validity has
usually been reported as criterion-related (or predictive), content, and construct (or
congruent) validity. Other procedures that were taken to ensure objectivity o f structured
observations as a method o f assessment have included standard instructions, position of
the child, additional equipment needed, and a uniform recording system. All observations
utilized in this study had acceptable criterion-related evidence supporting their concurrent
53
validity as they were tested in normal and dysfunctional children. Given the similarities
between the structured observations selected for the present study and other observations
reported in the literature, validity was assured. In terms o f reliability, most o f the
structured observations selected for this study reported adequate inter-rater reliability.
Although no studies have compared structured observations to the SIPT, some
observations have been correlated to well known measures o f performance. B.N. Wilson,
et al. (1994) studied the relationship between children’s performance in structured
observations and the Bruininks Otzerezki Tests o f Motor Proficency Standard Score (n =
251; r = .561, p <.0001); Bruininks Otzerezki Tests o f Motor Proficency, Subtest: Upper
Limb Coordination (n = 252; r = .331 ,p <.0001); Bruininks Otzerezki Tests o f Motor
Proficency Subtest Visual Motor Control (n = 252; r = .344,/? <.0001); and the
Developmental Coordination Disorder Questionnaire (n = 202; r = .403,/? <.0001). Other
studies (Parush, Yochman, Cohen & Gerhon, 1998) have correlated structured
observations with the Developmental Test o f Visual Motor Integration (t = 5.39,/?< 001)
and the Test o f Visual Perceptual Skills (t = 7.43, p<.001).
Structured Observations in this Study
The following is a description o f the selected group o f structured observations
selected for the purpose o f this study.
Supine flexion postural test.
This observation consisted o f having the child hold his head, arms, and legs flexed
and off the surface on which the back rests. The supine flexion posture appears in an
54
ontogenetic sequence as the first pattern in a series o f motor control patterns. In this study
the length o f time that a child was able to hold this posture against gravity was noted
(Fraser, 1983).
It has been proposed that the child’s ability to assume and maintain a supine flexion
posture is related to somatodyspraxia (Fraser, 1983), the processing o f somatosensory
information (Imperatore Blanche, 2002), and postural ocular movement disorder when
the child has difficulty flexing the neck while assuming the supine flexion position
(Fisher et al., 1991, 2002). Stockmeyer (1969) discussed Rood’s view o f the supine
flexion posture as a significant step in motor development when elaborating on the
withdrawal supine, a position o f supine flexion. In this postural mechanism the upper
extremities cross the chest and the backs o f the hands touch the face, ready to shield the
face or to ward off danger. Neck and shoulder flexion provide protection for the front of
the neck. The lower extremities assume a position o f hip and knee flexion. The
withdrawal pattern is a reciprocal pattern in which flexors are activated and extensors
inhibited.
The supine flexion posture requires muscle activation of the trunk, neck, and
proximal limb muscles. Integration o f the tonic labyrinthine reflex (TLR) occurs as the
withdrawal supine position is held. Voluntary contractions leading to flexion are utilized
in spite o f the reflex facilitation towards extension. Since TLR facilitates extension in the
supine position, flexion achieved while in this position indicates that the reflex is under
higher control (Stockmeyer, 1969). Ayres (1977) demonstrated that children with
dyspraxia often show signs o f poorly integrated primitive postural reflexes, particularly
o f the supine flexion posture. In this investigation, the supine flexion observation was
55
administered following the recommendations and procedures described by Fraser in
1983.
Reliability measures were reported by Fraser (1983) by utilizing the different raters
who concurrently rated 10 selected subjects. The extent o f the relationship between
corresponding scores obtained on each subject by the two raters was reflected by the r
statistics of .99, p = .001. Test-retest reliability was .96, p = .001. The time between the
two administrations was 1 week (Fraser).
Prone extension.
This observation required the child to raise his head, arms, upper trunk, and legs into
an extended pattern. The ability to assume and maintain a totally extended posture against
gravity has been hypothesized to require adequate processing o f gravity information via
the vestibular nuclei (particularly Deiters’s nucleus) down to the lateral vestibular spinal
tract and medial longitudinal fasciculus tracts to extensor motor neurons (Montgomery,
1985) that send impulses to the head, neck, and back; the head and eyes are lifted for a
horizontal visual orientation (Gregory-Flock & Yerxa, 1984).
Interpretations o f this observation have been related to the child’s ability to process
vestibular information from gravity receptors and neck proprioceptors (Ayres, 1972;
Fisher, 1984; Ottenbacher, 1978, 1982) and has also been linked to motor planning ability
(Imperatore Blanche, 2002), and as one indicator o f a postural ocular movement disorder
(Ayres, 1979; Fisher, 1991, 2002). In addition, this posture has been considered,
developmentally, to be one o f the first stability postures eliciting extensor control
(Stockmeyer, 1969). In the present study, the prone extension observation was
56
administered following the recommendations and procedures described by Harris (1981),
Longo-Kimber (1984), Dunn, (1981), and Gregory-Flock and Yerxa (1984).
Construct or congruent validity o f this observation has been established when in one
of Ayres factor analytic studies (Ayres, 1965) the prone extension measure loaded with
other measures of vestibular function. In addition, Ottenbacher (1978) demonstrated that
the prone extension observation was able to predict a score on the postrotary nystagmus
test. The postrotary nystagmus test has been considered an accepted measure of
vestibular function (Gregory-Flock & Yerxa, 1984).
The reliability o f this observation has been reported to be adequate for clinical use as
the interrater reliability coefficient on duration and quality scores to be r = 1.00; test-
retest reliability coefficients on the duration score was r =.79, and on the quality score
was r = .77 (Gregory-Flock & Yerxa, 1984).
Significant differences among age groups were evident in all studies that included the
prone extension observation. Thus, Gregory-Flock & Yerxa (1984) reported that 5 year
olds were significantly different from all other age groups. Six year olds performed
significantly different in both duration and quality from all age groups. Seven and eight
year olds performed similarly in both duration and quality. Similar results were reported
by Harris (1981) for quality scores in children 4 year olds, 6 year olds, and 8 year olds.
Longo-Kimber (1982) reported similar findings in children ages 5 and 7 years o f age.
Postrotary nystagmus.
Nystagmus is an involuntary, rapid, back-and-forth movement o f the eyeballs. This
reflex movement results from one o f the following conditions: stimulation o f the
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semicircular canals o f the vestibular system, a certain type of visual input, or, in some
cases, brain disorder (Ayres, 1977). Although the interpretation o f this structured
observation or test has been related to processing o f some aspects o f vestibular
information (Ayres, 1989); its precise association with other CNS functions remains
controversial.
The vestibular ocular reflex functions to help maintain a stable retinal image during
head movements (D. Clark, 1985). In the primate this appears to be primarily a function
of the semicircular canals. The generation of control o f the eye movements by canal input
is a complex task that uses several CNS pathways. The semicircular canals, and to much
lesser extent, the otoliths, detect head movements and through the vestibular ocular
reflex, reflexively move the eyes in the orbit at the same velocity as the head, but in the
opposite direction, in order to compensate for the head movement.
Several types o f nystagmus have been described in the literature. Thus, types o f
nystagmus are usually described as spontaneous, congenital, positional, optokinetic, and
caloric nystagmus. In the present study, the word nystagmus refers to nystagmus of
vestibular origin and as it is observed after rotation.
It would appear that sensitive measures o f nystagmus require highly sophisticated
equipment, not available in clinical settings. However, Keating (1979) compared the
duration o f postrotary nystagmus by means o f the Southern California Post-Rotary
Nystagmus Test and electronystagmography in normal individuals and found a high
correlation o f .899 (p <.01).
Research studies that have correlated a depressed nystagmus and other observations
continue to be controversial and reported subsequently. Thus, depressed nystagmus
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duration and poor postural mechanisms (i.e., hypotonia, poor prone extension, poor
equilibrium reactions) (Clyse & Short, 1983; Ottenbacher, 1978) have been found to be
common in children with learning disabilities (Ayres, 1969a; Morrison, Hinshaw, &
Carte, 1985; Ottenbacher, 1978); adults with mental retardation (Shuer, Clark, & Azen,
1980); children with Down’s syndrome (Zee-Chen & Hardman, 1983); articulation,
speech, and language disorder (Stilwell, Crowe, & McCallum, 1978), and adolescents
with idiopathic scoliosis (Jensen & Wilson, 1979); children who were at high risk at birth
(Deitz & Crowe, 1985); and deaf children (Potter & Silverman, 1984) have been
reported. Short, Watson, Ottenbacher, and Rogers, (1983) reported that in children with
depressed scores in the postrotary nystagmus test were associated with muscle co
contraction, standing balance, supine flexion, asymmetrical tonic neck reflex, muscle
tone and prone extension as they accounted for 50% o f the variance.
In addition, several studies have been conducted and linked to decreased scores in the
postrotary nystagmus test with different skills such as visual skills (Haack, Short-
DeGraff, & Hanzlik, 1993); oculomotor skills (Ottenbacher, 1978); walking with eyes
open and closed, standing balance with eyes open and closed, muscle tone, and prone
extension (Clyse & Short, 1983; Ottenbacher, 1978); visuomotor skills and practic
management of two dimensional space (Ayres, 1989); and reading difficulties (deQuiros
and Schrager, 1979; Levinson, 1980).
In addition, normal nystagmus values have been obtained from various age groups o f
children. Eviatar and Eviatar (1979) tested vestibular responses in 121 newborn infants
and reported normative data from 0-24 months o f age that could be used to differentiate
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normal from abnormal responses. Tibbling (1969) findings suggested a tendency for
nystagmus parameters to decrease with increasing age.
There have been several explanations in terms o f what vestibular nystagmus means. It
is important to note that nystagmus following rotation is a normal adaptive response
designed to re-establish the original fixation on a visual field. Therefore, the significance
o f reduced nystagmus or abnormally prolonged nystagmus has been hypothesized not to
implicate the mechanisms to produce a stable visual field (Ayres, 1977). Normal
nystagmus has not been equated in any way to normal functioning o f the vestibular
system. Several explanations have been provided to explain the mechanisms that produce
an abnormal duration o f vestibular nystagmus followed by rotation. They have included
too much or too little cortical inhibition acting on the vestibular nuclei (Shimazu, 1971
cited in Ayres, 1977); over-inhibition o f the cerebellum could account for reduced
nystagmus and its under-activity or inadequate modulation could enter into
hyperresponsivity, or nystagmus o f prolonged duration (Wylie & Felpel, 1971). Other
factors such as excessive excitation or inadequate modulation from sensory systems in
children with autism; general arousability (Clark as cited in Ayres, 1977); deficiency in
muscle proprioception of the extraocular muscles (Bach-Y-Rita, 1971 as cited in Ayres,
1977); normal adaptive capacity to inhibit nystagmus such as those observed in athletes
(Dowd & Cramer, 1971); or photic stimulation or input producing optokinetic nystagmus
in the opposite direction have also been proposed because o f their potential to strongly
inhibit labyrinthine nystagmus (Bergman & Costin, 1970). Punward (1982) reported that
the duration of nystagmus from 3 to 10 years remained relatively constant, and the
duration is longer in adults (Keating, 1979).
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Some studies have reported the normative data for children o f various ages using the
SCPNT (Crowe, Deitz, & Siegner, 1984). Others have reported norms for younger
children as part o f a sensory functions assessment (DeGangi & Greenspan, 1982).
It should be noted that correlation o f postrotary nystagmus with other tests o f the
SIPT were known. In the normative sample PRN was not correlated with any tests o f the
SIPT. However, in a sample o f children with learning disabilities, postrotary nystagmus
had a significant negative correlation with praxis on verbal command and bilateral motor
coordination. In the matched sample o f dysfunctional and normal children, postrotary
nystagmus had significant positive correlations with design copying (visual space
management); and also with finger identification, graphesthesia, oral praxis, and
sequencing praxis (Ayres, 1989).
For the purpose of this study, postrotary nystagmus was tested twice, first as part of
the SIPT and second by means o f the Southern California Postrotary Nystagmus Test
(Ayres, 1975). The reason behind this procedure was that PRN scores as part of the
SCPNT could be scored inexpensively. This was done to eliminate the financial
constraints that this test may pose when administered as part o f the SIPT.
In this observation the child is asked to sit on a nystagmus board with the head flexed
30 degrees forward from the right, vertical position (Ayres, 1975). The child is turned
around to the left and to the right 10 times in 20 seconds. The child is then stopped while
the examiner observes and measures the duration o f vestibular nystagmus. Either
excessive depression or excessive responsiveness is atypical and is suggestive of
dysfunction (Ayres, 1975). It has been reported that the average child did not lose his
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balance following the 40 seconds o f rotation, nor did his head balance show loss of
control (Ayres, 1977).
Reliability studies have demonstrated that the SCPNT was reliable when scores were
obtained by computing a correlation between two tests. Thus, Ayres (1975) reported r =
0.834; the standard error o f measurement for boys was 3 seconds and for girls was 2.6
seconds for the total score (sum o f seconds following rotation to the left and seconds
following rotation to the right). Kimball (1981) reported similar results.
Finger-to-nose.
This observation has been included in the examination of children ages 4 and older
but has been reported not to be reliable in younger children (Touwen & Prechtl, 1970).
Also, the sample examined by Dunn (1981) revealed that normal children ages 5 though
6.6 years o f age were expected to touch the tip o f their nose within 1.5 centimeters or
correct themselves if they were not accurate. Touwen and Prechtl reported that this
observation was appropriate for children as young as 4 years o f age. They found that even
slight difficulties in performing this observation (indicated by a high score) reflected
proprioceptive rather than cerebellar functions. However, they warned clinicians as high
scores could possibly reflect the first manifestation o f a progressive cerebellar disease.
B.N. Wilson et al. (1994; 2000) used this observation and provided norms for
children 5 through 15 years of age. The task involved touching the nose and then the
finger of the other hand, which was extended as far as possible away from the face. These
authors developed this observation based on the Jones and Monkhouse protocol
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developed in 1981. The recent version of the clinical observations o f motor and postural
skills requires the child to perform the tasks continuously and without stopping between
the eyes open and eyes closed conditions to facilitate the activation o f proprioceptive
mechanisms (Wilson, Pollock, Kaplan, Law, 2000).
Based on the research conducted by Dunn (1981) and Touwen and Prechtl (1970) it
was expected that children in this study performed the test without difficulties, as the
sample of this study included children 5-8 years o f age but did not provide separate
scores for the observations.
In this observation the child sits with extended arms abducted at 90 degrees and then
is asked to touch the tip o f his nose with his index finger with eyes closed. This
observation is believed to measure aspects o f cerebellar integrity or coordination
(Imperatore Blanche, 2002; B.N.Wilson et al. 2000); proprioceptive mechanisms (Wilson
et al., 2000); and the ability to process somatosensory information and to copy simple
actions that involve motor planning (Imperatore Blanche, 2002). In this study the finger
to nose observation is administered following the recommendations and procedures
described by Dunn in 1981.
Slow motions.
This observation was described by Dunn in 1981. B.N. Wilson et al. (2000) adapted
the administration o f slow movements by incorporating duration o f 6 seconds and scoring
symmetry, quality o f performance, and speed. In this observation the child was asked to
bring his/her arms toward his/her shoulders moving them slowly. It is possible that this
observation provides information related to the child’s ability to process proprioceptive
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information as this task requires slow, controlled, and calibrated movements of the upper
extremities which are functions often attributed to this system. Other interpretations have
included integrity o f cerebellar mechanisms (B.N. Wilson et al., 2000). Deficits in this
observation have been associated with somatodyspraxia (Fraser, 1983). In addition, it is
possible that this observation provided information regarding practic skills as it requires
decoding verbal information into motor actions. In this study the observation as it was
first described by Dunn in 1981 was favored because B.N. Wilson et al., (2000) did not
provide a way to score this item individually.
Diadochokinesis.
This observation has been extensively used in neurology and neuromotor testing.
Diadochokinesis consists of quickly pronating and supinating the hand and forearm.
Touwen and Prechtl (1970) tested children in a standing position at a speed o f 4
movements per second and noted associated movements in the contralateral extremity
and abduction-adduction of the arm in centimeters. They described abduction of 5-15
centimeters for diadochokinetic movements and marked mirror movements with/without
flexion o f the elbow in children younger than 5 years. At the age o f 6 and 7 they
described abduction o f 5-15 centimeters and marked associated movements. At age eight
they described smooth movements and decreased amount of associated movements. They
warned clinicians about associated movements in the legs and feet if the child was tested
seated.
Wolf, Gunnoe, and Cohen (1985) included diadochokinetic movements as one o f the
timed maneuvers and compared this and other neuromotor measures to psychological
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performance. They found that mirror movements accounted for a significant percentage
o f unique variance in reading achievement, verbal memory, and automatized naming
speed among young normal children. Speed o f timed maneuvers accounted for a
significant percentage o f unique variance in naming speed, verbal memory and reading
comprehension in first grade children. Denhoff and Siqueland (1968) have suggested that
a positive relationship exists between the child’s ability to perform diadochokinetic tasks
and her school performance. Grant, Boelsche, and Zin (1973) were the first to study and
delineate by age and sex the developmental pattern o f diadochokinesis. They included
four skill components: ability, uncontrolled slapping movements, hand elevation, and
symmetry of movements under two conditions, non-stress and stress. The slope o f the
curve for the development o f diadochokinesis showed a plateau between the ages o f 5
and 6 years. Additionally, the scores for ages 7 and 8 are identical and near the perfect
score of 8, suggesting that this function matures around the age o f 7 years.
In this observation the child is asked to rotate both forearms on his thighs
simultaneously. This observation may provide occupational therapists with information
related to how a child processes somatosensory information, cerebellar integrity and
motor planning (Imperatore Blanche, 2002), school performance (Denhoff & Siqueland,
1968), and is often included in measures o f coordination as part o f neurological
examinations o f children (Denckla, 1973). This observation is administered following the
recommendations and procedures described by Grant et al. in 1973.
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Finger-to-thumb opposition.
Finger-to-thumb opposition consists o f rapidly and smoothly touching the tip o f each
finger to the tip o f the thumb in sequence, beginning with the fifth finger. The hand that
was not tested was kept palm upward on the child’s lap so overflow movements could be
easily observed.
Hertzig (1981) reported norms for the finger-to-thumb opposition in children ages 9
yrs. 5 months though 15 years 6 months using a sample o f 198 children identified as
learning disabled or neurologically impaired and 36 age matched children. The
observation utilized in the Hertzig study differed from other studies as she tested
imitating the examiner in the opposition o f the thumb to fingers in the following
sequence: index, fourth, middle, pinky, pinky, middle, fourth, index. The child was asked
to repeat each movement before the next was illustrated. This study reported that
sequential finger-to thumb opposition was not stable across different examinations.
However, other studies using a basically similar examination reported that although the
overall number o f signs found in two examinations conducted on young adults 24-48
hours apart did not differ significantly, findings with respect to speech, finger-thumb
opposition, and graphesthesia were reliably replicated (Quitkin, Rifkin, & Klein, 1976).
Touwen and Prechtl (1970) examined children using this observation and starting
with the index finger in the sequence: 2, 3, 4, 5, 4, 3, 2, 3, 4, 5, etc. The child was asked
to complete five sequences to and fro. The test was carried out at a rate o f approximately
3-4 seconds for one complete sequence. These authors described three skill components:
smoothness of movement, finger-to finger transition, and mirror movements; and
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reported that the skill was easily achieved by age 6 with girls performing better than
boys.
This observation provides information related to cerebellar integrity as well as the
child’s ability to process somatosensory information and motor planning skills; manual
coordination and decreased maturation o f the nervous system if mirror movements are
present (Touwen & Prechtl, 1970). It has also been related to mental age (Strauss &
Carrison, 1942).
Denckla (1973) studied successive finger-movement in 237 children in order to
provide normative data. She found sex differences with girls performing better than boys
at all age levels, differences between the right and the left hands, and differences by age
level with this skill getting faster with increased age.
In this study finger-to-thumb opposition was administered following the
recommendations and procedures described by Grant et al. in 1973. These authors
described five skill components: able-unable, clumping o f fingers, contralateral overflow
movements, timing, and sequence under two conditions, non-stress and stress. Grant et al.
reported significant changes in this observation between the years o f 4 and 5, 6 and 7 and
7, and 8 but were not significant between years 5 and 6. Grant et al. reported descriptive
statistics for fmger-to-thumb opposition with standard deviations that were smaller than
for those in diadochokinetic movements which indicated greater complexity when
scoring diadochokinetic movements.
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Extension o f the arms or modified Schilder’s arm extension test.
In this observation the child is asked to stand with his/her feet together and his/her
head centered, and then to stretch out his/her arms, palms downward, for twenty seconds
with eyes closed (Touwen & Prechtl, 1970). The head is passively rotated to one side and
then the other side without discomfort to the patient (Dunn, 1981; Silver, 1952). The
amount o f trunk and upper extremity rotation to the sides when the head is passively
moved is noted.
Slight modifications o f this observation have been made by different authors. Touwen
and Prechtl (1970) repeated the test with the palms turned upwards (in supination) and
established scoring for the following parameters: deviation from the horizontal line,
deviation from the median line, spooning/forking or when the wrist was somewhat flexed
and the fingers hyperextended in the metacarpal phalangeal joints, and pronation.
It has been hypothesized that this observation measures aspects o f cerebellar
integration (Imperatore Blanche, 2002); upper extremity muscle tone; the integration of
the tonic neck and neck righting responses (Silver, 1952); sensoriomotor innervation
disturbances, unilateral coordination disorders, local disorders (muscle or joint diseases,
strong hand dominance (Touwen & Prechtl, 1970); and the presence or absence of
choreoatethoid movements, (Dunn, 1981). It has also been correlated to reading disability
(Silver, 1952; Silver & Hagin, 1952). Children ages 6 and older did not present with
deviations from the horizontal line or median line. They, however, presented with some
degree o f spooning, especially if they were slender, and pronation over 30 to 60 degrees.
It was noted by Schilder (1931) that in the absence o f peripheral orthopedic or
neurologic defects, the elevated extremity was the one with greater muscle tone and
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hence an indication of the dominant cerebral hemisphere. Because it has been commonly
reported that children exhibited “choreathetosis” in the fingers during this test, the
following distinction was made. Choreiform movements or choreatiform movements are
small and jerky movements which occur irregularly and arhytmically in different
muscles. The examiner was recommended to look for choreiform movements in fingers
and wrist joints and in the arms and shoulders. Athetotiform movements or athetoid-like
movements are small, slow movements, somewhat writhing in appearance, which occur
quite irregularly and arhythmically in different muscles and were better observed in the
muscles of the fingers and tongue. Choreatic movements or movements o f chorea consist
of rather gross jerky movements occurring irregularly and arhythmically in different
muscles. The patient usually has difficulty in keeping his/her balance because o f the
amplitude and intensity o f the choreatic movements (Prechtl and Stemmer, 1962).
In a very early study that began in 1949, one hundred and fifty children ages 8 years 6
months to 14 years diagnosed as having reading disability were examined using a variety
of neurological and perceptual integrative measures (Silver & Hagin, 1960). While the
neurophysiological nature o f this maneuver was unknown, it appears to have an
ontogenetic sequence o f maturation and is theoretically related to the postural orientation
o f the organism with respect to stimuli from the muscles of the neck and from the
labyrinth. All but seven o f the children with reading disability had abnormal response in
this test.
It was an interesting finding that the test described as Schilder’s arm extension test
elsewhere (Dunn, 1981; Fisher et al., 1991, 2002) was described as part o f several
postural responses and was originally described by Silver in 1952 and not by Schilder.
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Silver described the extension o f the arms test to observe a divergence o f the parallel
arms while the other arm was usually held higher than the other. When proceeding to the
passive movement o f the head in both directions, this test was called the “neck righting
response” and its main purpose was to observe if there was rotation of the shoulders and
hips on their longitudinal axis that followed the movements of the head (Silver, 1952).
This author described this test and its potential to bring out fine abnormalities in postural
control while revealing tonic-neck and neck righting responses. Clinically this test had a
maximum value in the child above the age of 5 years.
In this study this observation was administered and scored following the
recommendations and procedures described by Dunn, 1981; Silver, 1952; and Silver and
Hagin, 1952.
Heel-to-toe.
The assessment of balance and postural control is essential when assessing the motor
development o f children because o f its impact on the child’s functional tasks such as
play, dressing, and other common activities. When considering performance across
different age levels Clark and Waltkins (1984) found no significant differences in a group
o f 154 normal children between 6 and 9 years old on a test examining balance under four
different conditions: body position, size o f the base o f support, availability o f visual cues,
and leg used for support. Similar findings were reported by Morris, Williams, Atwater,
and Wilmore (1982) in 269 children between 3 and 6 years o f age. Ayres (1982) reported
significant differences between girls and boys in one foot standing balance in the 6.5 to
6.11 year ranges and 8.0 to 8.5 for eyes open and for eyes closed. She did not find any
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significant gender differences in standing balance with eyes open and closed for children
between 4.0 to 8.11 years.
Nasher and collegues were the first to report information regarding balance under
different sensory conditions (Horak and Nashner, 1986; Nashner, 1983; Nashner, Black,
& Wall, 1982). They tested balance under six conditions: (a) standing on a platform with
eyes open -a ll sensory cues available, (b) standing on a platform, eyes closed -visual
system eliminated, somatosensory and vestibular cues available, (c) standing on a
platform with eyes open and visual surround moving in synchrony with the subject’s
movements -visual cues in conflict with accurate somatosensory and vestibular cues, (d)
standing on the platform which moved in synchrony with the subject’s movement with
eyes open -somatosensory cues inaccurate, visual and vestibular cues available, (e)
standing on a platform, which moves in synchrony with the subject’s movement, eyes
closed - somatosensory cues inaccurate, visual cues eliminated, vestibular cues available
and (f) standing on a platform with eyes open, platform and visual surround moved in
synchrony with the subject’s movement - somatosensory and visual cues inaccurate,
vestibular cues available.
This measurement assisted clinicians in determining which sensory systems were
functioning appropriately and which systems were unable to trigger a balance reaction at
appropriate times (Deitz et al., 1991). Shumway-Cook and Horak (1996) introduced a
similar method to the one described by Nashner (1983). Visual conditions included eyes
open, eyes closed, and inaccurate visual input. The support surfaces included a flat floor
and a firm, high density foam that reduced the accuracy of orientation information. This
test was called the Clinical Test o f Sensory Interaction for Balance. In collaboration with
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Shumway-Cook and Horak; Deitz et al. developed a pediatric version o f the clinical test
o f sensory interaction for balance in order to assist clinicians to systematically assess
balance in children and to design appropriate treatment programs.
For the purpose o f this study only the heel-to-toe portion o f the pediatric version of
the clinical test of sensory interaction for balance was administered following the
recommendations of Deitz et al. (1991). These authors have also reported adequate
reliability between two independent raters and all raters participating in the normative
studies reached procedural reliability (Richarson, Atwater, Crowe, & Deitz, 1992).
The heel-to-toe test was administered under four conditions: (a) normal surface, eye
open; which provided the child with vision, somatosensory, and vestibular information,
(b) normal surface, eyes closed; which provided the child with somatosensory and
vestibular information and eliminated visual information, (c) foam, eyes open; which
provided the child with visual and vestibular information and compromised the
somatosensory information (inaccurate), and (d) foam, eyes closed; which provided the
child with vestibular information and compromised the somatosensory information while
vision was absent.
Jumping jacks.
Jumping jacks and similar motor tasks involve sequential and rhythmic changes in
limb posture that require complex levels o f bilateral motor coordination and motor
planning (Magalhaes et al., 1989). Different patterns o f jumps have been used to assess
bilateral motor coordination, motor skills, and perceptual motor dysfunctions (Bruininks,
1978; Hugues & Riley, 1981; Roach & Kephart, 1966).
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Ayres (1972) proposed that the process o f integration of vestibular and proprioceptive
sensations and the efficiency o f interhemispheral connections are the basis for good
bilateral integration of both sides o f the body. According to Kauffman (1983), good
performance on alternate foot tapping and on jumping jacks should be expected at the age
o f 7 years.
It appears that the acquisition o f motor control over the use o f the extremities follows
a developmental sequence that usually starts with control over bilateral, symmetrical
movements, then moves to homolateral or unilateral movements and finally proceeds to
reciprocal movements of the extremities and skilled bilateral function (Williams, 1983).
Magalhaes et al., (1989) suggested that after the postural abilities improve, elements of
this development recur during the acquisition o f new and more complex bilateral skills.
Interpretations of this observation have included motor planning or praxis (Ayres, 1972)
with low scores contributing to the profiles o f developmental dyspraxia and vestibular-
bilateral integration disorders (Ayres, 1972, 1979).
For the purposes of this study it was required that the subjects perform a series of
jumping jacks. This observation had two sections; one which emphasizes the child’s
ability to respond to the instructions given by the examiner and a second phase in which
the child’s performance was measured. This observation is administered following the
recommendations and procedures described by Magalhaes et al. 1989. These authors
have reported intraclass correlation index o f r = .99 for jumping jacks and test-retest by
using the Pearson correlation coefficient for the total scores which was r = .82 for the
jumping jacks scale.
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The Sensory Integration and Praxis Tests (SIPT)
The SIPT are a commercially available group o f tests that provide diagnostic and
descriptive information related to sensory integration and praxis in children aged 4-8
years old. It consists o f 17 tests designed to assess sensory perception, sensory
processing, and aspects o f praxis. The tests are scored initially by the examiner, with
standard scores being computer generated (Spitzer et al., 1996). The SIPT include
measures of organization o f inputs from the sensory systems and also practic behaviors
associated with them, which allow the individual to engage in adaptive interaction with
the physical world (Ayres, 1989). The SIPT are the standardized assessments considered
the “gold standard” (Windsor et al., 2001) when assessing children with suspected
sensory processing deficits within the field o f occupational therapy.
Construct validity o f the SIPT has been extensively established by a series o f factor
analytic studies prior to its publication. In addition, the construct measured by the SIPT
has been further studied by analyzing scores from different populations. A principal
component analysis o f the 17 major SIPT scores from a national sample (n = 1,750; M =
6.92, SD = 1.13) yielded 4 factors as follows: (a) visuopraxis, (b) somatopraxis, (c)
vestibular and somatosensory, and (d) kinesthesia/motor accuracy.
There is some resemblance between these results and the factor structure from
previous factor analysis studies. The first factor to emerge was designated bilateral
integration and sequencing factor. Factor 2 was labeled praxis on verbal command;
Factor 3 somatosensory processing and oral praxis; Factor 4 visuopraxis; and Factor 5
somatopraxis. Factors 4 and 5 were quite similar in the normative and learning disabled
sample. Factor 3 was found in both groups but its composition was different; in the
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normative group the factor was associated with vestibular function and in the learning-
disabled group with praxis on verbal command.
Another factor analysis including a sample of children with learning disabilities
matched on age, grade, gender, geographic region, and parental education and occupation
(n = 176) with a group o f 176 normal children (incomplete data for 59 children) resulting
in a final sample o f n = 293 (117 children with learning disabilities and 176 children from
the standardization sample (M = 7 years, 4 months; SD 1 year, 0 months). This study
identified the following factors: (a) somatopraxis, (b) visuopraxis, (c) vestibular
functioning, and (d) somatosensory processing.
The SIPT have also been studied by means o f cluster analysis, specifically by using
agglomeration or joining techniques using the Ward method. This type o f analysis
answers the question o f whether or not the SIPT can accurately identify groups of
children in need o f different kinds o f remediation and services (Ayres, 1989). The same
sample that was used for factor analysis was utilized for cluster analysis. The results are
described to a great extent in the SIPT manual (Ayres, 1989) with the main clusters
being: (a) low average bilateral integration and sequencing, (b) generalized sensory
integrative dysfunction, (c) visuo- and somatodyspraxia, (d) low average sensory
integration and praxis, (e) dyspraxia on verbal command and, (f) high average sensory
integration and praxis.
Concurrent validity is usually established by comparing a test with another well
known or accepted measure. This process was determined inappropriate for the SIPT as
there are no comparable tests (Ayres, 1989). Therefore, the SIPT were used to collect
information on children with many known and different previously determined diagnoses
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such as learning disability and minimal brain dysfunction, language disorders, sensory
integrative disorders, reading disorders, mental retardation, traumatic brain injury, spina
bifida and meningomyelocele, cerebral palsy, emotional disturbance, orofacial cleft, and
exposure to Agent Orange.
The SIPT were also compared to scores on alternative measures. In a study by
Kaufman and Kaufman, (1983) both the SIPT and the Kaufman Assessment Battery for
Children were administered to a combined sample of normal (n = 47), learning disabled
(n = 35), and sensory integrative disordered (n = 9) children. In this study, the SIPT tests
that measured sequencing skills showed high correlations with the tests o f the Kaufman
Assessment Battery for Children that measured similar domains o f function. Another
study (Parham, 1998) compared a sample of children with and without learning
disabilities using the SIPT and the Kaufman Assessment Battery for Children and found
that SI factors were strongly related to arithmetic achievement at early ages, but the
strength o f the relationship decreased with time. The opposite pattern was found between
praxis and arithmetic achievement (K.F. Walker, 2004).
The SIPT are the gold standard for measuring sensory integrative dysfunctions in
children. These tests have evolved as the result o f many years o f research that has
included several factor analysis and cluster analysis studies. The SIPT have been
compared to other tests, mostly tests related to educational achievement and they have
demonstrated adequate correlations with tests or subtests that measure similar domains of
function. However, this area o f research is still controversial because there are no other
tests that measure the same domain.
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Contribution of this Study to the Literature
The present study contributes to the literature in providing information regarding
how structured observations correlate with a known and accepted measure o f sensory
integration, the SIPT. In addition, how different structured observations correlate to each
other provides a solid foundation for selecting observations that measure the same
domain o f function when screening children for sensory processing deficits.
There is an existing gap in the literature as no studies have been conducted in
which structured observations were compared to the SIPT. The present study may help by
providing some answers to the current state o f knowledge. In addition, this information
provides useful data contributing to the evolving concurrent validity o f different
structured observations in measuring neuromotor and motor coordination skills in
children with sensory integration dysfunction.
No one has ever researched the relationship between structured observations and
the SIPT, a standardized assessment considered the “gold standard” (Windsor et al.,
2001) when assessing children with suspected sensory processing deficits. Whether
structured observations and the different tests o f the SIPT that measure a similar domain
of function are correlated is not known. A significant contribution could be made to the
existing literature if the correlational analysis does show high correlations between those
structured observations that are assumed to represent a similar domain o f function as
those in the SIPT. Conversely, if low correlations between both measures are found, this
could indicate different domains o f function. In this case, the complementary use o f these
measures could provide valuable information.
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The use o f a simple and inexpensive protocol o f structured observations with
quick access to normative scores for different age groups will be o f most use to
clinicians. This information is of most benefit for the purposes o f screening children with
possible neuromotor or sensory integration dysfunction and could utilize reliable standard
scores as a preliminary base for further and more extensive testing.
Elucidating specific deficits in motor control or coordination and their relations to
poor sensory processing as they directly impact the performance o f specific task
performance is o f most importance to clinicians. Determining specific deficits o f children
and the ability to compare deficits to standard performance will assist therapists in
designing accurate treatment protocols that target children’s occupational performance at
home, school, and in the community.
Summary
This literature review has described what is known about observations utilized by
clinicians as a way o f measuring dysfunction in children. Structured observations and
their correlates, neurological soft signs, have been presented in the context of populations
affected by different diagnoses including adults, adolescents, and children with several
diagnoses. Research has consistently shown associations between neurological soft signs
and difficulties in functional performance. Insights from adult studies have been mostly
considered neurological soft signs or structured observations as influencing factors that
determine a dysfunction or diagnosis in motor coordination or integration o f sensations or
cognitive domains. Adult studies emphasize how different neurological soft signs refer to
a particular area or loci of the central nervous system. Adult patients diagnosed as having
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schizophrenia have been studied in depth. Different disciplines are starting to examine
neurological soft signs in different diagnoses such as patients diagnosed as having OCD
and bipolar disorder among others. It appears that the neurological soft signs examined in
the adult literature have different clinical presentation, loci, stability, and prognosis.
However, they appear to equally affect the individual’s ability to perform functional
tasks. Although studies involving more advanced imaging techniques are increasing as
well as their ability to detect CNS changes, it appears that carefully administered
structured observations are sensitive to detecting deficits that correlate highly with more
sophisticated examination techniques.
The literature on adolescents is very scarce with more concentration of
individuals affected by conduct disorders, attention deficits, and schizophrenia. These
studies have shown that greater incidence o f neurological soft signs that correlate highly
with lower cognitive functioning, impulsivity, and right hemisphere dysfunction,
negatively impact functional performance. The opposite is true in children with different
diagnoses. The most common areas o f structured observations or neurological soft signs
include descriptions o f clumsiness (Gubbay et al., 1965); visuomotor and visual
perceptual difficulties (M. Walker, 1965); delayed maturation (Illingworth, 1968);
increased amount o f associated movements (Abercrombie and Tyson, 1964) and more
recently sensory integration and sensory processing difficulties (Smith Roley et al.,
2001). Other groups o f studies include structured observations or neurological soft signs
that are specific to a diagnostic group and those that are capable o f discriminating
between healthy and dysfunctional individuals.
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A brief description o f sensory integration theory and its evolution was presented.
This included Ayres’s original view o f the sensory systems and their contribution to a
variety of occupations as well as current conceptualizations in sensory integration theory.
In addition, the review o f the literature presented here shows how these
observations have been part of the assessment process that helps clinicians to identify
different disorders in their clinical practice since their inception when they were first
included as part o f factor analytic studies. These structured observations appear not to
have evolved significantly from their first inclusion in different studies; their
interpretation however, appears to be becoming clearer. Instead o f the loci or site
assumed to represent the basis for a particular disorder, sensory integration theory
appears to be more interested in their interpretation as representing deficits in sensory
processing, motor coordination, or as being related to a neuromotor component.
The gold standard in sensory integration measurement, the SIPT, was described in
terms o f its ability to discriminate among individuals with different profiles. This
measure has never been compared to structured observations that are commonly used in
clinical practice.
Part o f this review has also included three protocols that include clinical
observations and that are currently being utilized in clinical practice. None o f these
protocols has ever been compared to the SIPT. A protocol has been designed for the
purpose o f this study, this protocol includes nine structured observations including, (a)
heel-to-toe, (b) prone extension, (c) the supine flexion postural test, (d) slow motions, (e)
jumping jacks, (f) finger- to-nose, (g) diadochokinesis, (h) finger-to-thumb opposition,
and (i) arm extension test. In addition the Southern California Postrotary Nystagmus Test
(Ayres, 1975) was also utilized. These structured observations which are to be correlated
to the SIPT and to each other, will be used to answer the proposed research questions of
this study.
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CHAPTER III: RESEARCH DESIGN AND METHODOLOGY
The purpose o f this chapter is to describe research designs and the methods
utilized answer the proposed research questions. The present study questioned whether a
relationship among a group o f selected structured observations and individual tests o f the
SIPT exists and proposed to determine if structured observations explained single or a
group o f scores in the SIPT profiles. The design and methods o f this study attempted to
answer these research questions while proposing that there were no significant
relationships between scores in a protocol o f structured observations and scores in the
SIPT, and that a group o f scores on different structured observations could describe SIPT
profiles.
The first part describes research design as well as the specific methods and
rationale, the threats to internal and external validity and how they were addressed. The
second portion o f this chapter describes the subjects that composed the study sample,
inclusion and exclusion criteria, recruitment process, and ethical considerations. Lastly, a
description o f the setting, equipment, instruments, data collection, and analysis
procedures employed was included; the emphasis is on the measurement psychometric
properties.
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Specific Methods and Rationale
The proposed study utilized a descriptive, correlational, and tentative theoretical
factor analytic study as described by Portney and Watkins, 1993; Sapnas and Zeller,
2002; Stein and Cutler, 1991; and Thorndike, 1978. In addition, forward linear regression
was utilized to determine if different structured observations entered and remained in the
forward regression at 5% significance level and that explained the variability in the
different tests of the SIPT. This course o f action was taken because o f the nature o f the
research questions, the hypotheses proposed, and because the specific aim o f this study
was to identify significant relationships and groups o f similar variables. Table 1 and
Table 2 (see Appendix C) show each dependent variable, its type and level of
measurement. In order to answer the proposed research questions and because of the
suitability o f the dependent variables, correlational and exploratory theoretical factor
analytic techniques were utilized.
Specific Procedures
The families attending the treatment center where the study took place and staff
therapists were invited to participate via two advertisement flyers (see Appendix A).
Participating families provided additional information by phone or informal
conversations, when requested. The procedures o f the study were explained in detail
including aspects of confidentiality and Institutional Review Board procedures. Once a
family agreed to participate, the informed consent form that was part o f the research
protocol No. HPD-CAHN06130508Exp. was given for parents to review. After the
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informed consent and assent forms were discussed and signed, appointments were
scheduled so as not to disrupt treatment times.
Administration o f the SIPT and structured observation measures were completed
in two to three sessions. Parents were allowed to be present during testing. Additional
information was collected from the client’s chart and included: a) date o f birth, b) date at
which child began occupational therapy services, c) SIPT scores, if available, d)
structured observation scores, if available, e) medical/educational diagnosis, if available,
and f) reason for referral (Appendix B). This protected health information was part o f the
informed consent signed by the families participating in the study.
Threats to Internal Validity
Internal validity refers to the degree o f rigor in an experiment in controlling for
extraneous variables and error variance (Stein and Cutler, 1991). The most common
sources o f threats to internal validity in research studies have been described as
maturation, instrumentation, and lack o f random sampling (Carmines & Zeller, 1979).
Therefore, these threats were addressed individually.
Maturation Effect
Maturation effect threatened internal validity in this study because the subjects
o f this study were receiving occupational therapy treatment. Therefore, there was
potential for change in the subject’s status as measured by the data collection instruments.
Measures to minimize maturational effects were taken by decreasing the time
period between measurements during the data collection process. Total testing time of
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both instruments was 2.45 to 3.00 hours. All testing procedures were designed to take
between one and no more than three sessions which were conducted in a period o f 3-4
weeks. As it was described in the review o f the literature, structured observations and
neurological soft signs are stable in nature for periods o f up to a year (Pine, et al.,1997).
Although studies examining the stability o f different structured observations over time
are very limited, some evidence has demonstrated very high reliability between testers at
different time periods such as one week (Fraser, 1983). The SIPT have been reported to
be stable over long periods of time as these tests are diagnostic, descriptive, and
explanatory in nature (Ayres, 1989). In addition, data were also collected, altering the
order o f administration (i.e., structured observations were administered before and/or
after the SIPT and at random order).
It was concluded that in the sample selected for this study the maturational
effects were minimal. The selected subjects were tested using the SIPT; parents were
allowed to be present during the SIPT administration and some chose to do so. The
administration o f the SIPT usually took two hours but in some cases testing was broken
into two or three sessions depending on subject comfort with testing procedures. The
subjects were also tested with different structured observations. As with the SIPT
administration, parents were allowed to be present during the administration o f the
structured observations and some chose to do so. Structured observations were usually
administered within 30 to 45 minutes depending on subject comfort with the testing
procedures. Structured observations did not need to be broken into different sessions as
children tolerated them well and some o f them even reported them to be funny or silly.
Lastly, information on some children was available from clinical records and therefore
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data on these subjects was collected without involving testing procedures, to minimize
personal discomfort and treatment disruption.
Instrumentation
Two instruments were used to collect data for this study, the SIPT (Ayres, 1989)
and nine different specific structured observations that were assembled for the purpose of
this study. The Southern California postrotary nystagmus test (Ayres, 1975) was included
in the protocol of structured observations. The SIPT are commercially available tests that
provide diagnostic and descriptive information related to sensory integration and praxis
in children aged 4-8 years of age. They are a group o f 17 tests designed to assess sensory
perception, sensory processing, and aspects o f praxis. The tests are scored initially by the
examiner, with standard scores being computer generated (Spitzer et al., 1996). The
structured observations consisted o f a group o f measures assembled together on a
recording sheet and are commonly used in clinical settings for which some norms or
reference criterion were available. Structured observations were scored with tables
generated by the principal investigator and derived from scores reported in peer-review
literature. Structured observations: These are a group o f observations collected by the
principal investigator that are commonly used in clinical settings and for which some
norms or reference criterion are available and were drawn from the professional
literature. They are usually non-standardized and are composed o f a different level of
measurements. The following is a brief description o f the structured observation utilized
in the present research study
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The heel-to-toe observation is related to the child’s ability to maintain a heel-to-
toe position and is used in clinical settings to assess balance and postural control,
(Shumway-Cook & Horak, 1986). The heel-to-toe measure relates to the child’s ability to
process visual, somatosensory and vestibular information and how they contribute to
balance (Shumway-Cook & Horak). This observation is administered following the
recommendations and procedures described by Deitz et al. in 1991.
The prone extension observation requires the child to raise his head, arms, upper
trunk, and legs into an extended pattern and the length o f time this can be sustained is
noted. It is believed to be related to the child’s ability to process vestibular information
(Ayres, 1972; Ottenbacher, 1978, 1982). This observation is administered following the
recommendations and procedures described by Harris (1981), Longo-Kimber (1984),
Dunn, (1981), and Gregory-Flock and Yerxa, (1984).
The supine flexion observation consists o f having the child hold his head, arms,
and legs flexed and off the surface on which the back rests. The length o f time that a
child can hold this posture against gravity is noted (Fraser, 1983). It has been proposed
that the child’s ability to assume and maintain a supine flexion posture is related to
somatodyspraxia (Fraser) and postural ocular movement disorder when the child has
difficulty flexing the neck while assuming the supine flexion position (Fisher, 1991). This
observation is administered following the recommendations and procedures described by
Fraser in 1983.
The slow motions observation consists o f the child being asked to bring his/her
arms in, moving them slowly toward his shoulders. It is possible that this observation
provides information related to the child’s ability to process proprioceptive information
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as this task requires slow, controlled and calibrated movements o f the upper extremity
which are functions often attributed to the proprioceptive system. Deficits in this
observation have been associated with somatodyspraxia (Fraser, 1983). This observation
is administered following the recommendations and procedures described by Dunn in
1981.
The jumping jacks observation requires the child to perform a series o f jumping
jacks. This observation has two sections; one which emphasizes the child’s ability to
respond to the instructions given by the examiner and a second phase in which the child’s
performance is measured. Observing children performing jumping jacks may provide
information related to their bilateral motor coordination (Kauffman, 1983), integration o f
body parts and motor planning/praxis abilities (Magalhaes et al., 1989). This observation
is administered following the recommendations and procedures described by Magalhaes,
Koomar, and Cermark in 1989.
The finger-to-nose observation requires the child to sit with extended arms
abducted at 90 degrees and then to touch the tip o f his nose with his index finger with
eyes closed. This observation is believed to measure aspects o f cerebellar integrity
(Imperatore Blanche, 2002). This observation is administered following the
recommendations and procedures described by Dunn in 1981.
In the diadokokinesis observation, the child is asked to rotate both forearms on his
thighs simultaneously. This observation may provide occupational therapists with
information related to how a child processes somatosensory information, cerebellar
integrity and motor planning (Imperatore Blanche, 2002), school performance (Denhoff
& Siqueland, 1968), and is often included in measures o f coordination as part of
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neurological examinations o f children (Denckla, 1973). This observation is administered
following the recommendations and procedures described by Grant et al. in 1973.
In the finger-to-thumb opposition observation the child is asked to rapidly touch
the tip of each finger to the tip o f the thumb in sequence, beginning with the V finger
(Denkla, 1973). This observation provides information related to cerebellar integrity as
well as the child’s ability to process somatosensory information and motor planning skills
(Exner, 2001 cited in Imperatore Blanche, 2002). This observation is administered
following the recommendations and procedures described by Grant, Boelsche, and Zin in
1973.
During the modified postural Schilder’s arm extension test, the child is asked to
stand with his arms extended, feet together, and eyes closed. The head is passively
rotated to one side and then the other side without discomfort to the patient (Dunn, 1981;
Silver, 1952;). It has been hypothesized that this observation measures aspects of
cerebellar integration (Imperatore Blanche, 2002), upper extremity muscle tone (Schilder,
1952), reading disability (Silver, 1952; Silver and Hagin, 1952) the integration of the
tonic neck and neck righting responses (Silver, 1952), and the presence or absence o f
choreoatethoid movements, (Dunn, 1981). This observation is administered following the
recommendations and procedures described by Dunn, 1981; Silver, 1952; and Silver &
Hagin, 1952).
The postrotary nystagmus test requires that the child be seated on the nystagmus
board with the head flexed 30 degrees forward from the upright, vertical position.
(Ayres, 1975). The child is turned around to the left 10 times in 20 seconds. The child is
then stopped while the examiner observes and measures the duration o f vestibular
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nystagmus. Either excessive depression or excessive responsiveness is atypical and is
suggestive o f dysfunction (Ayres, 1975).
Threats to internal validity by means of instrumentation were minimized by strict
adherence to the standardized procedures of the SIPT by a certified therapist and the
individual structured observations that comprised the protocol used in this study. In
addition, the primary researcher has extensive experience in testing children by means of
structured observations and is certified in the theory, administration, interpretation and
treatment using the SIPT as well as the sensory integration frame o f reference.
Random Sampling
The following study was not able to control internal validity threats by means of
utilizing a sample extracted from a target population using random procedures. However,
all information used in this study was examined to ensure it matched the inclusion and
exclusion criteria. Subjects in this study were selected using a sample o f convenience.
Threats to External Validity
Threats to external validity include the representativeness o f a sample and the
rigor o f an experiment for the purposes o f replication (Stein & Cutler, 1991). Although it
was not possible to include a random sample due to time and available resource
constraints, the specific steps for replication by other researchers have been outlined. The
external validity o f the findings o f this research study could increase by carefully
designed replication with a larger random sample, or cumulative effects. Correlational
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research external validity greatly improves by replication as it increases the power and
significance o f association between the variables under investigation.
Study Design
The proposed study utilized descriptive, correlational, and tentative theoretical
factor analytic study as described by Portney and Watkins, 1993; Sapnas and Zeller,
2002; Stein and Cutler, 1991. In addition, a forward linear regression model was used to
explain the variability o f the SIPT measures. The design of the present study, therefore,
combined several approaches.
Correlational Research
Correlational research allowed for relationship between variables to be compared
by measuring their differences (Stein & Cutler, 1991). The scores o f the subjects on the
structured observations and the SIPT were analyzed to determine their specific
correlations. Table 1 and Table 2 (see Appendix C) show each dependent variable and its
type and level of measurement. Comparisons were done by using the Spearman Rho
correlation coefficient formula and the corresponding p values using a 2 tailed test of
significance. The section on data collection procedures and data analysis describes in
detail the statistical tests utilized in this study.
Tentative Factor Model
A tentative theoretical factor analysis attempted to identify the underlying
variables, or factors, that explained the pattern o f correlations within the researched
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variables. Factor analysis has been used in data reduction to identify a small number of
factors that explain most of the variance observed in a much larger number of manifest
variables (SPSS, 1999). In this study, a tentative theoretical exploratory factor analysis or
grouping o f the variables under study was used to determine if a factor structure
underlying the structured observations used in this study shared similarities.
Forward Linear Regression Model
This statistical model o f analysis was utilized to determine if different structured
observations could predict the variability in the different measures o f the SIPT. In this
analysis all structured observations were used individually and as representing groups
that could account for the variability to single tests of the SIPT.
Subjects
A total o f 27 families contacted the principal investigator to participate in the
study. A total o f 6 children did not qualify for the study because o f their chronological
age. A sample of convenience o f 21 subjects o f 5-8 years of age and receiving
occupational therapy services with a sensory integration frame o f reference was selected
based on specific inclusion and exclusion criteria. In addition, records were utilized to
collect information, when available and as part o f the informed consent signed by the
families participating in the study. Table 3 (see Appendix D) presents the participant’s
main characteristics.
There is great disagreement in the literature regarding the number subjects
needed for a correlational or factor analysis study (Cattell, 1978; DeVellis, 1991;
Kerlinger, 1986; Kline, 1994, 1998; Nunally 1978; Thorndike, 1982). Researchers do
agree, however, that a researcher should have an adequate but not excessive number of
respondents to evaluate their findings. It has been further proposed that at some point,
additional respondents do not improve the evaluation o f the measures and waste precious
research resources (Sapnas & Zeller, 2002). Twenty one subjects was judged to be an
adequate number, as similar sample sizes for correlational analysis have been described
in the literature Arrindel & Van der Ende, 1985; Kauffman, 1983; Kimball, 1977).
Inclusion Criteria
The following inclusion criteria were followed to ensure internal validity and
objectivity o f all data collected.
1. The subjects were undergoing pediatric occupational therapy treatment with a sensory
integration frame o f reference.
2. The subjects were between the ages o f 5 and 8 years o f age.
3. The subjects demonstrated willingness to participate in the proposed research study.
4. Parent consent and child assent forms were signed agreeing to participation in the
proposed study.
5. A clinical record with the information necessary for the present study could qualify.
Exclusion Criteria
A child who met all inclusion criteria but because o f no cooperation, extraneous
distractions, anxiety, fatigue, and any other factors that would threaten the validity o f the
findings in this study, was excluded. If a child refused to perform a test of the SIPT or
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any o f the structured observations he or she was removed from the study as described in
the Institutional Review Board (IRB) consent and assent forms. Nine children were
excluded from this study for the abovementioned reasons.
Characteristics
Families and children who participated in the study were familiar with testing
procedures and comfortable providing the necessary information for the purpose o f this
study. Most children were accustomed to testing procedures o f some sort, even if some of
them were never assessed with the SIPT. Most children knew the performance of
structured observations as they are commonly used at the treatment center where the
study took place. It appeared that children were aware o f their deficits to a certain extent
as they would often explain that some testing items were hard for them.
Recruitment Procedures
The recruitment was done by advertising the study by means o f two fliers. One of
the flyers, the family flyer, was displayed in all waiting rooms and administrative offices
of Therapy West, Inc. (please refer to Appendix A). Some parents chose to call the
primary investigator and asked for detailed information regarding the purpose o f the
research study and testing procedures involved.
Another flyer, the therapist flyer, was placed in the mailbox o f the therapists
working at Therapy West, Inc. (please refer to Appendix A). Additional information was
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provided when requested by means o f informal conversations. A brief description o f the
purpose o f the study was presented at a Therapy West, Inc. staff meeting.
Ethical Considerations
Informed consent was sought for all subjects participating in this study. In
addition, children and parents signed the assent form prepared for this study and
according to the Nova Southeastern University (NSU) and the Institutional Review Board
(IRB) (http://www.nova.edu/irb/index.html). The informed consent and assent forms
were signed before testing took place. Data collection was done using a string of numbers
to protect the confidentiality o f all participants. Thus, only the principal investigator
maintained a list o f all participants in a locked cabinet and in a computer file protected by
a password. The master list containing the names o f all participants was destroyed at the
end of the research project. However, informed consent and testing result copies were
included in the client’s charts following the requirements of the IRB. A brief description
of the test results was given to the parents and questions were answered when the parents
sought additional information.
The Research Setting
Therapy West, Inc. is a state o f the art facility providing occupational therapy,
physical therapy, speech and language pathology, early intervention, and consultation
services. Therapy West, Inc. specializes in the assessment and treatment of children with
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a variety o f disabilities as well as in the teaching and training o f professionals in several
methodologies, including sensory integration. This facility is located on the west side of
Los Angeles, California. Patients treated at this facility have a variety o f diagnoses such
as learning disabilities, autism, cerebral palsy, developmental delays, and genetic
disorders, among others. Therapeutic services are funded through a variety o f sources
including private pay, regional centers, California Children Services, unified school
districts, and health insurances.
Equipment
The equipment utilized by this study included the materials that are part o f the
SIPT which included: (a) space visualization placement card, form board, blocks, and
pegs; (b) figure-ground perception tests plates; (c) standing and walking balance half-
round wood dowel; (d) design copying test booklets and scoring guide; (e) constructional
praxis preassembled model, blocks, and angle guide card; (f) postrotary nystagmus angle
guide card; (g) motor accuracy test sheets and line measure; (h) manual form perception
bases, forms o f various shapes, response card; (i) kinesthesia test sheet; (j) localization of
tactile stimuli pen; (k) shield; (1) centimeter/inches ruler; (m) two red nylon-tipped pens;
(n) masking tape; (o) test manual; (p) nystagmus rotation board; (q) stopwatch capable of
recording 1/10 seconds; (s) soft (No. 2) black-leaded pencil.
In addition, a centimeter ruler and a piece o f high density, firm foam was used to
measure the distance in centimeters during the scoring o f finger-to-nose and the heel-to-
toe observations, respectively. No other additional equipment was utilized during the
study.
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Independent and Dependent Variables Operationalized
Sensory integration is operationally defined as the organization o f sensory
integration information in the central nervous system and its use guiding the adaptive
motor behaviors that make up occupational performance (Kielhofner, 1991). Sensory
integration can also be defined as a therapeutic approach to ameliorate sensory
integration dysfunction or difficulties in the process o f organizing sensation for its
functional use during the performance o f daily occupations. Sensory integration
dysfunction is operationally defined as a cluster o f meaningful and marked deficits in the
SIPT and in a group o f structured observations selected for the purpose o f this study.
Currently, pediatric occupational therapists use a sensory integrative frame o f reference
with diverse populations (Smith Roley et al. 2001). Some examples are children
diagnosed with autism (Ayres & Tickle, 1980); cerebral palsy (Blanche et al., 1995;
Imperatore Blanche & Nakasuji, 2001); Fragile X syndrome (Stackhouse, 1994); hearing
impairment (Schaffer-Pullan et al., 1991); mental retardation (F.A. Clark et al.,1978;
Kielhofner & Miyake, 1981; Sowers & Powers, 1995; Storey et al. 1984); premature birth
(Anderson, 1986); prenatal drug exposure (Stallings-Sahler, 1993); and visual
impairments (Smith Roley & Schneck, 2001). Studies on children with sensory
integrative dysfunction have included the SIPT as well as their performance in different
observations to measure the nature and extent o f their deficits. Dependent variables are
composed o f the different measures o f the SIPT and structured observations. All
dependent variables are described in Tables 1 and 2.
Instruments
The assessment instruments were composed of the SIPT (Ayres, 1989) and nine
specific structured observations designed for the purpose of this study (please refer to
Appendix B). The administration o f these measures was altered in random order so
different subjects received the SIPT or the structured observations first.
Data Collection
Once consent was obtained, data collection procedures took place. Data collection
was done first, using a Microsoft Excel spread sheet to collect general information on the
subjects as follows: (a) date o f birth; (b) date o f onset o f treatment; (c) SIPT scores and
date o f administration, if available; (d) structured observation scores and date of
administration, if available; (e) medical and/or educational diagnosis, if available; and (f)
reason for referral.
Based on the information collected from records it was decided whether
additional information needed to be collected. After this process, an appointment was set
up with the family and testing took place. All testing procedures were completed in 1-3
sessions within a total time of 3-4 weeks.
Data Analysis
All data collected were kept confidential in the front office o f Therapy West, Inc.
The HIPPA officer was informed o f the location o f testing materials and a disc containing
a file with the master list o f the subjects participating in the study. All remaining data
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were numeric in nature and was handled using the Statistical Package for the Social
Sciences in a computer with a personal password only known by the principal
investigator. The master list and the other files containing personal information were
destroyed at the end o f the research study. Data were inputted on a SPSS file using the
data editor for the following variable attributes: (a) name, (b) type, (c) width, (d)
decimals, (e) label, (f) value, (g) variables missing, and (h) variable’s level of
measurement. Once the data was collected on all the subjects available for the study, data
analysis followed. Data analysis proceeded according to the following steps.
Statistical Package for the Social Sciences (SPSS)
Spearman rho correlation coefficients were calculated using SPSS bivariate
correlations to compute pairwise associations between the different structured
observations and the different measures o f the SIPT. The results were reported and
interpretation o f correlation coefficients were made following parameters that are widely
accepted in health science studies (Portney & Watkins, 1993).
It was necessary to submit the correlation coefficients to a test o f significance.
This was done to determine if the observed values could have occurred by chance. Values
were located on statistical tables, and checked against those reported by SPSS for two-
tailed tests o f significance with n - 2 degrees o f freedom. The observed value needed to
be greater than or equal to the tabled value to be significant (Portney & Watkins, 1993),
so that value was not to be expected if the hypothesis that stated that no relation between
variables was true.
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Following the calculation o f correlation coefficients, a forward linear regression
model was run using all individual structured observations and the different tests o f the
SIPT. Next, a theoretical and tentative factor analysis by means o f principal component
analysis was performed on the scores o f children’s structured observations. This was
done to determine if observations that shared a common theoretical ground tended to
associate together. Factor extraction was performed based on the considerations made by
Thorndike (1978) and Cattell (1978) as to retaining factors with eigen values greater than
1.0 or by observing the plot o f eigen values and finding where they broke in the curve;
respectively. Construction o f a factor matrix containing the factor loadings for each
variable on each factor ranging from 0.00 to ± 1.00 was done. Visual inspection and
consideration o f the nature o f the variables to determine if factor rotation was necessary,
was performed. Factor rotation utilizing different rotation methods was performed to
maximize the orientation o f variables near the axes (Portney & Watkins, 1993).
Reliability and Validity
Considerable information on several structured observations and the response of
typical children has been published in the literature contributing to their validity and
reliability (Ayres 1975, 1989; Deitz et al., 1991; Denckla, 1973; Dunn, 1981; Fraser,
1983; Grant et al., 1973; Gregory-Flock and Yerxa, 1984; Harris 1981; Imperatore
Blanche, 2002; Kauffman, 1983; Longo-Kimber, 1984; Magalhaes et al., Shumway-Cook
1986; Silver, 1952; Silver and Hagin, 1952; and B.N. Wilson et al., 1994)
In this study reliability was ensured by following strict procedures in
administration and scoring o f the different clinical observations and the standardization
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o f the SIPT as they have been reported in research studies and test manuals (Ayres, 1975,
1989; Deitz et al., 1991; Dunn, 1981; Fraser, 1983; Grant et al., 1973; Gregory-Flock &
Yerxa, 1984; Harris, 1981; Longo-Kimber, 1984; Magalhaes et al., 1989).
The validity o f the findings in this study was warranted by years o f research in the
field of pediatric occupational therapy and sensory integration. Construct validity, or the
ability o f a measure to determine a specific theoretical construct o f the SIPT has been
extensively documented as related to the efficiency o f some o f the neural substrates of
learning and behavior (Ayres, 1989). Criterion-related validity, or the ability to predict
future performance based on the results of a particular measure are not applicable to this
measure as this test was designed for the detection, description, and explanation of
current dysfunction rather than the prediction o f other later criterion (Ayres, 1989).
Extensive concurrent validity data has been documented on the SIPT in different
populations based on the testing o f children with many known and different diagnoses
(Ayres, 1989). The sample selected for this study consisted o f children that were referred
for occupational therapy services using a sensory integration frame o f reference because
of problems with learning, behavior, motor coordination, or general development.
Therefore, the concurrent validity reported in the SIPT manual was considered valid for
the present study. Similar findings have been reported by Ayres, 1975, 1989; Deitz et al.,
1991; Dunn, 1981; Fraser, 1983; Grant et al., 1973; Gregory-Flock & Yerxa, 1984;
Harris, 1981; Longo-Kimber, 1984; Magalhaes et al., 1989 when examining the validity
properties o f the different structured observations utilized in this study.
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Summary
This chapter presented the methodology utilized for correlating the scores o f a
sample o f children with sensory integration dysfunction in different structured
observations and the SIPT. The threats to internal validity in terms o f maturational
effects, instrumentation, and lack o f random sampling as well as the measures taken to
decrease them have been outlined. They were dealt with by keeping testing periods to a
minimum for maturation and treatment effects as well as discussing the adequacy o f the
validity and reliability o f the measures used in this study. Threats to external validity
were discussed and identified as related to the lack o f a random sample. In addition,
measures to overcome these threats were discussed as related to establishing clear
guidelines for replications as well as the value o f replication in increasing the
significance o f correlational and factor analysis studies.
The study utilized a design that included descriptive, correlational, and tentative
theoretical factor analytic elements. A forward linear regression model was utilized to
determine if different structured observations could predict the scores o f the SIPT
individual measures. A sample o f convenience was utilized and composed o f 21 children
5-8 years o f age. These children were referred to occupational therapy services with a
sensory integration frame o f reference because o f their difficulties in learning, behavior,
or motor coordination. The specific inclusion and exclusion criteria as well as the general
characteristics o f the sample and recruitment procedures for the study were discussed.
The clinical setting in which the study took place was a state o f the art facility that
provides occupational therapy, physical therapy, speech and language pathology, early
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intervention and consultation services for children and their families. The equipment,
assessment instruments, and systematic data collection procedures were described.
Data analysis and the format o f reporting results were described in detail for the
purpose o f clarity and potential replication. More information regarding statistical
analysis will be provided in chapter 4. Analysis included classic methods for the
treatment o f variables submitted to correlational and tentative theoretical factor analysis
model. Mainly, they included a correlation coefficient matrix with control for outliyers, a
forward linear regression model, and a principal component analysis with a varimax
rotation to adjust for a better fit between the scores obtained. Finally, the psychometric
properties o f the measurement instruments as discussed in the literature was examined
and judged to be adequate for the present study.
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Chapter 4: RESULTS
The following chapter will present the results o f the statistical data analysis. The
present study questioned whether a relationship among a group o f selected structured
observations and individual tests o f the SIPT exists and proposed to determine if
structured observations explained single or a group o f scores in the SIPT profiles. The
statistical analysis performed in the present study was conducted using the Statistical
Package for the Social Sciences software version 10.0. Results are presented and
described according to each o f the research questions. First, data analysis is presented to
determine all different degrees o f associations between scores on the SIPT and different
structured observations. Second, SIPT scores were separated and two subgroups were
formed based on the subject’s proximity to the prototypic groups a) low average bilateral
integration and sequencing and b) visuo- and somatodyspraxia as described by the SIPT
manual. Intercorrelations between different structured observations and these two groups
were explored. Third, two factor analyses attempted data reduction and established a
group fit for different structured observations. Last, a forward linear regression model
was utilized to determine if different structured observations could predict score profile
on the SIPT.
All statistically significant correlations at 0.01 levels (2-tailed) will be presented,
followed by those which reached significance at 0.05 levels (2-tailed). Chapter 5 will
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discuss these statistical findings in light o f what has been described in the literature of
neurological soft signs and structured observations and will provide recommendations for
further research.
The dependent variables were treated separately to include all sub-variables.
Thus, all variables were computed individually with the exception of the variables: a)
heel-to-toe, b) prone extension, c) finger to nose, d) diadochokinesis, e) fmger-to-thumb
opposition, and f) jumping jacks that included their sub-variables. These variables are
described in detail in Table 1 and 2 (see Appendix C). Bivariate correlations using the
Spearman Rho Correlation Coefficient were calculated for all variables; significant
correlations at 0.01 and 0.05 levels were flagged. Table 3 describes the main sample
characteristics.
Table 3
Sample characteristics
Number Mean Age Measurement Reason for Referral

Interval
21 6.7 yrs. 3.5 weeks 01a, 02b, 03°, 04d, 05e,

06f, 07s
aFine motor coordination & handwriting. bDisruptive behavior. cGross motor coordination & sports.
dLanguage. eAttention. fHigh motor activity. gSchool performance.
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Research Question 1
What is the relationship among a group o f selected structured observations and
individual tests o f the SIPT?
SPSS was set to correlate all dependent variables using the Spearman Rho
correlation coefficient formula. This was done because the sample size o f this study was
small and it was not possible to assume normal distribution. All possible correlation
coefficient computations are described in Table 4 (see Appendix E). In order to determine
the specific degree o f relationship between both measures, a closer look at all statistically
significant correlation coefficients follows. These associations were organized following
the individual tests o f the SIPT that reached significance when related to different
structured observations and are now described.
Space Visualization
This test o f the SIPT significantly correlated with the following structured
observation: a) slow motions. The space visualization test of the SIPT also correlated
significantly with the Southern California Postrotary Nystagmus Test. The extent o f the
relationship between these scores is reflected in the obtained values reported in Table 5.
Subjects who had difficulties with the space visualization test included 43% of the total
sample. Some children in this group presented with decreased scores in the space
visualization contralateral hand use, but average scores in the preferred hand use. A
shared reason for referral for all these children was a degree o f difficulty performing
tasks that require fine motor coordination and handwriting skills. The most common
activities named by parents in their reasons for attending therapy sessions included a)
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copying and using writing/art instruments, b) managing buttons and zippers, c) using
scissors, and d) opening food/snack containers.
Table 5
Space Visualization (SV) and its correlations with the Slow Motions (SM) structured
observation and the Southern California Postrotary Nystagmus Test (SCPNT).
Variable SV
SM 0.43*
SCPNT 0.51**
* p < .05., ** p <.01. (two-tailed)
Figure Ground Perception
observations: a) prone extension, b) finger-to-nose, right and c) finger to thumb
opposition -total score. The extent o f the relationship between these scores is reflected in
the obtained values reported in Table 6. Only 25% of the subjects that comprised the
sample in this study had difficulty with this test. From behavioral observations it is
possible that some o f these children performed poorly because o f unrelated factors such
as impulsivity, distractibility, or decreased organization of behavior. A shared reason for
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referral o f all these children was a degree o f difficulty performing tasks that require fine
motor coordination and handwriting skills as well as gross motor coordination and
sporting activities. The most common gross motor and sporting activities named by
parents as their reasons for attending therapy sessions included: a) climbing, b) safety
during playground activities, c) group sports, and d) playing sports that require ball skills.
Table 6
Figure Ground (FG) and its correlations with the Prone Extension (PE), Finger-to-Nose,
right (FN-R); Finger-to-thumb Opposition, Total Score (FTO-TS) Structured
Observations
Variable FG
PE -0.48**
FN-R 0.45**
FTO-TS 0.45**
** p <.01. (two-tailed)
Finger Identification
observation: a) slow motions. This test o f the SIPT also significantly correlated with the
Southern California Postrotary Nystagmus test. The extent of the relationship between
these scores is reflected in the obtained values reported in Table 7. Subjects who had
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difficulties with this test included 24% of the total sample. A common reason for referral
of all these children, was a degree o f difficulty with general school performance.
Table 7
Finger Identification (FI) and its correlations with the Slow Motions (SM) Structured
Observation and the Southern California Postrotary Nystagmus Test (SCPNT)
Variable FI
SM 0.44**
SCPNT 0.70**
** p < .01. (two-tailed)
Localization o f Tactile Stimuli
observation: a) finger-to-nose, right. The extent o f the relationship between these scores
is reflected in the obtained values reported in Table 8. Subjects who had difficulties with
this test included 43% o f the sample. A common reason for referral for all these children
included difficulties with tasks that require fine motor coordination and handwriting
skills.
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Table 8
Localization o f Tactile Stimuli and its correlation with the Finger-to-Nose, Right (FN-R)
Structured Observation
Variable LTS
FN-R -0.52**
Design Copying
observation: a) prone extension quality. The extent o f the relationship between these
scores is reflected in the obtained value reported in Table 9. Subjects who had difficulties
with this test included 43% o f the total sample. A common reason for referral o f all these
children included difficulties with tasks that require fine motor coordination and
handwriting skills.
Oral Praxis
observations: a) finger to nose -right, d) finger to nose -left, and e) diadochokinesis -total
score. The extent of the relationship between these scores is reflected in the obtained
values reported in Table 10.
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Table 9
Design Copying (DC) and its correlation with the Prone extension quality (PEQ)
structured observation
Variable DC
PEQ 0.047**
Subjects who had difficulties with this test included 52% of the sample. There was not a
common reason for referral for the children who had difficulties performing these tests.
Ill
Table 10
Oral Praxis (OPR) and its correlations with the Finger-to-Nose, right (FN-R); Finger-to-
Nose, left (FN-L); and Diadochokinesis, Total Score (DIA) Structured Observations
Variable OPR
FN-R 0.61**
FN-L 0.68**
DIA 0.50**
Sequencing Praxis
observations: a) slow motions, b) finger-to-nose left, c) the modified Schilder’s arm
extension test, and d) the jumping jacks -total score. The extent o f the relationship
between these scores is reflected in the obtained values reported in Table 11. Subjects
who had difficulties with this test included 24% o f the total sample. A common reason
for referral o f all these children included difficulties with tasks that require fine motor
coordination and handwriting skills.
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Table 11
Sequencing Praxis (SP) and its Correlations with the Slow Motions (SM); Finger-to-
Nose, Left; the Modified Schilder’s Arm Extension Test (SAT); and the Jumping Jacks,
Total Score (JJ-TS) Structured Observations
Variable SP
SM 0.64**
FN-L -0.52**
SAT 0.45**
JJ-TS 0.44**
Bilateral Motor Coordination
This test o f the SIPT significantly correlated with the Southern California
Postrotary Nystagmus Test. The extent o f the relationship between these scores is
reflected in the obtained value reported in Table 12. Subjects who had difficulties with
this test included 29% of the total sample. A common reason for referral o f all these
handwriting skills
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Table 12
Bilateral Motor Coordination and its Correlations with the Southern California
Postrotary Nystagmus Test (SCPNT)
Variable BMC
SCPNT 0.51**
Standing and Walking Balance
observations: a) fmger-to-thumb opposition, non stress. The extent o f the relationship
between these scores is reflected in the obtained values reported in Table 13. Subjects
who had difficulties with this test included 81% o f the total sample. A common reason
for referral o f all these children included difficulties with tasks that require fine motor
coordination and handwriting skills.
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Table 13
Standing and Walking Balance (SWB) and its Correlation with the Finger-to-Thumb
Opposition, Non Stress Condition (FTO-NS)
Variable SWB
FTO-NS 0.44**
** p < . 01 . (two-tailed)
Postrotary Nystagmus
This test o f the SIPT significantly correlated with the Southern California
Postrotary Nystagmus Test. The extent o f the relationship between these scores is
reflected in the obtained value reported in Table 14. Subjects who had difficulties with
this test included 29% o f the total sample. A common reason for referral o f all these
handwriting skills.
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Table 14
The Postrotary Nystagmus (PRN) and its Correlation with the Southern California
Postroatry Nystagmus Test (SCPNT)
Variable PRN
SCPNT 0.62**
Relationship between different structured observations and the SIPT
When all correlations were computed a matrix o f 17X22 was generated and 374
correlations were obtained. Out o f these 374 correlation coefficients 20 reached statistical
significance and were flagged as *p < .05. and **p < .01. This indicates a very low
degree o f overlapping between both measures which approaches 5%. This degree o f
relationship indicates a complementary function as both measures seemed to be tapping
into different domains o f functions or theoretical constructs.
The degree o f different associations between the structured observations and the
different tests o f the SIPT showed in this study offers only partial support for the first
generated hypothesis. This hypothesis stated that there were not expected significant
relationships between both measures.
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Research Question 2
How do scores on a group of selected structured observations explain single or a
group o f scores in the SIPT profiles?
Domains o f Function
To obtain a better fit of representations the sample of this study was divided into
two small groups based on their proximity to the six prototypic groups as described by
the SIPT manual. This was done by taking into consideration the D-squared values
reported in the SIPT computerized report. Following this procedure 2 groups that
included 17 children of the sample were formed as follows: a) a first group composed o f
children with a small value or one close to 1 D-square value indicating a close fit to the
prototypic group o f low average bilateral integration and sequencing, b) a second group
o f children with a small, or close to 1 D-square value, indicating a close fit to the
prototypic group visuo- and somatodyspraxia. Eleven and six children comprised the
groups a and b respectively. Followed is a detailed description o f which structured
observations were particularly relevant in each o f the abovementioned groups.
Close fit to the Low Bilateral Integration and Sequencing Prototypic Group
This group o f children presented with average SIPT scores but had low Z scores
on standing and walking balance, bilateral motor coordination, oral praxis, sequencing
praxis, and graphesthesia. Children with a close fit to the bilateral integration and
sequencing prototypic group presented with significant difficulties in different structured
observations. In decreasing order o f importance:
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a) none of these children were able to receive an average score in the prone extension
qualitative observation, b) all but one child received significantly poor scores on the
prone extension and diadochokinesis observation, c) significant difficulties in the heel-to-
toe observation and its sub-variables, d) significant difficulties in the jumping jacks
observation and its sub-variables, e) all but two children received very below average
scores in the finger to thumb opposition and the Southern California Postrotary
Nystagmus test, and f) all but three children received below average scores for their
chronological age in the supine flexion observation.
Close fit to the Visuo- and Somatodyspraxia Prototypic Group
This group o f children presented with low Z scores on the design copying, finger
identification, graphesthesia, postural praxis, sequencing praxis, bilateral motor
coordination, standing and walking balance, motor accuracy, and kinesthesia tests o f the
SIPT. Children with a close fit to the visuo- and somatodyspraxia prototypic group
presented with significant difficulties in several structured observations and they were
characterized by: a) inconsistent scores in the heel-to-toe observation and its sub
variables with a different pattern o f scores than all other children. This pattern was easily
recognizable as these children oftentimes scored poorly on an easy sub-variable and
better on a more challenging one, b) all children in this group presented with below
average scores in the prone extension observation. Similarly, all but one child scored
below average on the prone extension quality observation, c) all but two children
received below average scores on the supine flexion observation. The other two children
received borderline scores in this observation, d) all but one child received below average
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scores on the finger to nose and diadochokinesis scores, e) all these children received
below average scores in the finger to thumb observation and the Southern California
postrotary nystagmus test, and f) children in this group received inconsistent scores on
the jumping jacks observation and its sub-variables.
Theoretical and Tentative Data Reduction Model
Data reduction among the scores o f children with sensory integration dysfunction
on a selected group o f structured observations was inconclusive and unclear. However, a
tentative and theoretical data reduction using rotated factors was run in SPSS for
illustrative purposes and in order to assist in answering research question 2. The
structured observation scores o f children in the first prototypic group o f the SIPT were
submitted to this analysis.
Two or three rotated factors better described the group o f children with a close fit
to the bilateral integration and sequencing prototypic group and accounted for 40.45%
and 56.15% o f the cumulative variance as illustrated in Table 15. The first factor was
composed o f the jumping jacks observation and its three sub-variables together with the
supine flexion observation.
The second factor consisted o f the heel-to-toe eyes closed -so ft surface, prone
extension and slow motion observations. The third was composed o f the finger to nose
and diadochokinesis observations. This grouping o f variables, although theoretical and
tentative, closely resembles the individual observation score findings with the children of
Table 15
Total variance explained
c Initial Eigenvalues
Total % a2 Cumulative
1 5.565 25.297 25.297
2 5.078 23.083 48.380
3 3.244 14.746 63.126
4 2.544 11.566 74.692
5 1.917 8.713 83.404
6 1.643 7.467 90.872
7 .831 3.779 94.650
8 .535 2.431 97.081
9 .438 1.989 99.070
10 .205 .930 100.000
Note. Extraction Method: Principal Component Analysis; C=Components.
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Table 15
Total variance explained (Cont.)
C Rotation Sum o f Squared Loadings
Total % a2 Cumulative
1 4.922 22.373 22.373
2 3.978 18.082 40.454
3 3.455 15.702 56.157
4 2.777 12.625 68.781
5 2.579 11.723 80.505
6 2.281 10.367 90.872
Note. Extraction Method: Principal Component Analysis; C=Components.
this group. Table 16 delineates rotated factors and their specific loadings.
Structured Observation as Predictors
The tentative factor analyses and their specific loading partially explained how
these measures tended to group together and how they were related to subjects with a
closer fit to the low average bilateral integration and sequencing and visuo-
somatodyspraxia. In order to determine if individual or groups o f structured observations
could predict individual scores o f the SIPT individual tests, a forward linear regression
model was created as this could further clarify the second research question proposed by
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Table 16
Rotated Component Matrix
Variable Component
1 2 3 4 5 6
H TT-0
-.132 .010 .115 .955 .132 .146
HTT-C
-.080 .632 .546 .304 -.363 .120
HTT-O-S
.197 -.054 -.303 -.023 -.248 -.823
HTT-C-S
-.292 .869 .117 .089 -.127 .080
PE
-.422 .780 .025 .079 .013 .376
PEQ
-.166 -.822 .091 -.090 -.333 -.100
SF
.768 .320 .133 -.180 -.429 .053
SM
.364 .835 -.240 .256 .054 -.127
FN-R
.268 -.145 .794 .016 .209 -.118
FN-L
-.185 -.127 .925 -.132 -.034 -.031
DIA
.394 .334 .731 .338 -.218 -.010
DIA-NS
.339 .294 .697 .357 -.374 .134
DIA-S
-.085 .229 -.202 .732 .054 .534
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Table 16
Rotated Component Matrix (Cont.)
Variable Component
1 2 3 4 5 6
FTO-TS
.553 -.355 .421 .038 .257 -.170
FTO-NS
.183 .203 -.021 .292 .844 .195
FTO-S
.019 -.025 -.010 .094 .982 -.057
SAT
-.102 .352 .150 .807 -.049 -.269
SCPRN
.037 .195 -.369 .071 -.175 .852
JJ-L
.891 -.275 .165 .141 .181 .022
JJ-P
.916 .020 .085 .064 .033 -.246
JJ-10
.871 .107 .083 .142 .069 -.172
JJ-T
.847 -.179 -.164 .244 .066 .339
Note: Extraction Method: Principal Com ponent Analysis, Rotation Method; V arim ax; 1, 2, 3, 4, 5, 6 = Components; H T T -0 = Heel-
to-toe, eyes open, firm surface; HTT-C = Heel-to-toe, eyes closed, firm surface; HTT-O-S = Heel-to-toe, eyes open, soft surface;
HTT-C-S = Heel-to-toe, eyes closed, soft surface; PE = Prone extension; PEQ = Prone extension quality; SF = Supine flexion; SM =
Slow motions; FN-R = Finger-to-nose, right; FN-L = Finger-to-nose -le ft; DIA = Diadochokinesis total score; DIA -N S =
D iadochokinesis, no stress condition; DIA-S = Diadochokinesis -stre ss condition; FTO-TS = Finger-to-thum b opposition, total score;
FTO-NS = Finger-to-thum b opposition, non stress condition; FTO-S = Finger-to-thumb opposition, stress condition; SAT = Modified
Schilder’s arm extension test; SCPNT = Southern California Postrotary Nystagm us test; JJ-L = Jum ping jacks, learning phase score;
JJ-P = Jum ping jacks -perform ance phase score; JJ-10 = Num ber o f jum ping jacks in 10 seconds; JJ-T = Jum ping jacks, total score;
SV = Space visualization; FG = Figure ground perception; MFP = Manual form perception; KIN = Kinesthesia; FI = Finger
identification; GRA = G raphesthesia; LTS = Localization o f Tactile Stimuli; PVC = Praxis on verbal com m and; OPR = Oral praxis;
SPR = Sequencing praxis; BM C = Bilateral m otor coordination; SWB = Standing and walking balance; MAC = M otor accuracy;
PRN = Postrotary nystagmus.
*p < .05. = *Correlation is significant at the 0.05 level (2 -tailed); ** p < .01. = Correlation is significant at the 0.01 level (2 -tailed).
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this study. This research question asked if a group o f structured observations could
explain individual or group SIPT profile scores. It was hypothesized that different
structured observations have that clinical potential. In order to better explore this research
question a forward linear regression procedure was utilized to determine if structured
observations that entered and remained in the forward regression at 5% significance level
could explain the variability reflected by individual SIPT scores. All these relationships
are detailed in Tables 17-30 (see Appendix F).
When the linear regression model was obtained, the power o f prediction o f the
structured observations was determined and judged to be low. This offers support for the
second hypothesis of this study that postulated that structured observations could not
statistically and significantly describe different SIPT profiles. A range o f prediction
potential was obtained and it was determined to be between 19% and 61% o f the total
variability. These are now described separately and in decreasing order o f importance.
The Southern California Postrotary Nystagmus test and the jumping jacks
performance phase score observation explained 61% o f the variability o f the space
visualization test o f the SIPT. Those parameters were both positive, which indicated the
tendency o f these measures to co-vary together and are displayed in Table 17.
The heel-to-toe, eyes open soft surface together with the prone extension quality
and finger-to-thumb opposition, total score observations explained 56% o f the variability
o f the design copying test o f the SIPT. In this group the heel-to-toe, eyes open soft
surface and the fmger-to-thumb opposition, total score, positively covariate with the
design copying test but the prone extension quality did so negatively. These relationships
are displayed in Table 18.
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The finger-to-nose right and left observations explained 53% o f the variability of
the oral praxis test o f the SIPT. In this group, the parameters were both positive which
indicated the tendency of these measures to co-vary together as they are displayed in
Table 19.
The diadochokinesis, non stress condition observation and the Southern California
Postrotary Nystagmus Test explained 47% o f the variability o f the postrotary nystagmus
test of the SIPT. In this group the Southern California Postrotary Nystagmus Test
parameter was positive and the diadochokinesis, non stress condition parameter was
negative. These relationships are illustrated in Table 20.
The heel-to-toe, eyes closed soft surface and the prone extension observations
explained 46% o f the variability o f the standing and walking balance test o f the SIPT. In
this group the heel-to-toe, eyes closed soft surface parameter was positive and prone
extension parameter was negative and are illustrated in Table 21.
The heel-to-toe eyes open, firm surface and fmger-to-thumb opposition total score
observations explained 45% o f the variability o f the graphesthesia test o f the SIPT. In this
group the heel-to-toe eyes open, firm surface parameter was negative and the finger-to-
thumb opposition total score was positive as displayed in Table 22.
The Southern California Postrotary Nystagmus test explained 38% o f the
variability o f the finger identification o f the SIPT. The Southern California Postrotary
Nystagmus Test parameter was positive and therefore they tended to co-vary together as
illustrated in table 23.
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The slow motion observation explained 30% o f the variability o f the sequencing
praxis test o f the SIPT. The slow motion parameter was positive and therefore they
tended to co-vary together and are displayed in Table 24.
The Southern California postrotary nystagmus test explained 30% o f the
variability of the bilateral motor coordination test o f the SIPT. The Southern California
Postrotary Nystagmus Test parameter was positive and therefore they tended to co-vary
together and are displayed in Table 25.
The finger-to-nose, right observation explained 27% o f the variability of the
finger identification o f the SIPT. The finger-to-nose, right parameter was negative. Those
values are illustrated in Table 26.
The finger-to-thumb opposition, total score observation explained 22% o f the
variability o f the figure ground test o f the SIPT. The finger-to-thumb opposition total
score parameter was positive as displayed in table 27.
The Southern California Postrotary Nystagmus Test explained 20% o f the
variability o f the manual form perception test o f the SIPT. The Southern California
Postrotary Nystagmus Test parameter was positive and these measures tended to co-vary
together as illustrated in Table 28.
The heel-to-toe, eyes open firm surface observation explained 20% o f the
variability o f the motor accuracy test o f the SIPT. The heel-to-toe, eyes open firm surface
parameter was positive and these measures tended to co-vary together as depicted in
Table 29.
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The finger-to-nose, right observation explained 19% of the variability of the
postural praxis test of the SIPT. The finger-to-nose, right parameter was positive and
these measures tended to co-vary together as illustrated in Table 30.
No measures were able to predict at the 5% significance level the kinesthesia,
praxis on verbal command, and constructional praxis tests of the SIPT.
Summary
The data analysis that was presented aided in the answering o f the proposed
research questions. When all the specific dependent variables degree o f relationship was
examined, it was found that the subjects that constituted the sample o f the present study
performed differently in each test o f the SIPT as well as in different structured
observations. Therefore, it was necessary to compare each group o f scores against the
total sample in order to build an argument to answer the question o f how all these
measures were related to each other.
As a group, children with sensory integration dysfunction presented with deficits
in the following SIPT measures: a) 83% o f the total sample had difficulties in the
standing and walking balance; b) 52% o f the total sample had difficulties in the oral
praxis test; c) 43-48% o f the total sample presented with difficulties with postural praxis,
design copying, space visualization, and localization o f tactile stimuli tests; d) 33% o f the
total sample presented with difficulties in manual form perception, praxis on verbal
command, and constructional praxis tests; e) 19% o f the total sample presented with
difficulties in the kinesthesia test; and f) 10 and 14% o f the total sample presented with
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difficulties in the graphesthesia and motor accuracy tests, respectively. A common reason
for referral for 81% o f the children included in this study was difficulty with tasks that
require fine motor coordination and handwriting skills.
A small degree of relationship was detected when exploring the generated
correlation matrix. A degree of overlapping o f approximately 5% between both measures
was found. Twenty significant correlations were found between the structured
observations and the SIPT and were mostly significant at the p < .01. level (two-tailed).
These correlations and their significance will be discussed in chapter 5. Because the
relationship between the SIPT and structured observations share a very small statistical
area they are assumed to be complementary as they measure different although related
constructs. However, the evidence found in this study was not sufficient to accept the first
hypothesis that proposed no degree o f relationship between both measures.
To further the analysis, and in order to answer the second research question, the
sample was divided in two separate groups which represent prototypic clusters in the
computerized report o f the SIPT. Children with a close fit to the low average bilateral
integration and sequencing group were best represented by deficits in the following
structured observations: a) prone extension, b) heel-to-toe, c) jumping jacks, d) finger to
thumb opposition, e) the Southern California Postrotary Nystagmus Test and f) and
deficits in the supine flexion observation. In contrast, children with a close fit to the
visuo- and somatodyspraxia prototypic group were best represented by deficits in the
following structured observations: a) prone extension, b) supine flexion, c) finger to nose,
d) inconsistent scores in the heel-to-toe and jumping jacks observations and e) the
Southern California Postrotary Nystagmus Test.
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Data reduction among the scores o f children with sensory integration dysfunction
on different structured observations was inconclusive and unclear. However, tentative
and theoretical data reduction using rotated factors was attempted and yielded a clearer
structure. Three theoretical factors emerged after statistical rotation and were best
represented by the following observations; a) the jumping jacks and supine flexion
observation, b) heel-to-toe, prone extension, and slow motions; and c) finger-to-nose and
diadochokinesis.
To finalize the data analysis, a forward linear regression model at 5% significance
level was only able to explain 61% o f the variability o f a single SIPT measure at its best,
with 20% representation at the lowest level. Three tests o f the SIPT, the kinesthesia, the
praxis on verbal command, and the constructional praxis were not predicted by any
structured observation when using a forward linear regression model at 5% significance.
Sufficient evidence was provided to safely accept the second research hypothesis
that proposed that different groups o f structured observations could not statistically and
significantly describe the SIPT profiles. However, it should be noted that these profiles
found a small degree o f representation in different structured observations, although not
reaching statistical significance.
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Chapter 5: Discussion
The present study raised the question o f whether a relationship among a group of
selected structured observations and individual tests o f the SIPT exists; and proposed to
determine if structured observations explained single or a group o f scores in the SIPT
profiles. According to the results, there is a degree o f relationship between a group of
structured observations and the measures o f the SIPT. Because a number o f statistically
significant correlations were obtained between the SIPT and the structured observations,
the first null hypothesis that established no degree o f relationship was rejected. The
relationship between both measures in a sample o f convenience can not be compared to
other research findings because no other studies comparing structured observations and
the SIPT have been conducted in the past. First, in this chapter the results o f the
significant correlations between the SIPT and different structured observations that was
presented in chapter 4 will be discussed following postulates o f sensory integration
theory and the findings in the literature. Second, the fit o f a group o f structured
observations to two common problems in sensory integration: low average bilateral
integration and sequencing and visuo- somatodyspraxia will be elaborated upon
following the results o f two exploratory factor analyses. Third, different structured
observations sharing potential to describe single SIPT measures will be discussed in light
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o f sensory integration theory. Last, a discussion o f the implication for further research,
clinical practice, and a summary will conclude this chapter.
Individual Relationships Between Both Measures
The degree o f relationship between both measures was presented in chapter 4 and
described as low or approaching a 5%. These associations are now presented in all the
individual SIPT tests. Plausible explanations for these associations in light o f sensory
integration theory, similar underlying constructs, and other study findings are presented
in the following section.
Space Visualization
Almost half o f the sample presented with difficulties in the space visualization
test of the SIPT. Ayres (1989) described this test as one requiring motor free visual
perceptual skills as well as practic ideation and motor planning. This test correlated
significantly with the slow motions observation and Southern California Postrotary
Nystagmus Test. Slow motions, as it was administered in this study, could be described
as a task that requires adequate processing o f somatosensory, visual, and auditory
processing. The Southern California Postrotary Nystagmus test has been described as a
measure o f some aspects o f the vetibulo-ocular reflex which is related to the processing
o f vestibular information (Ayres, 1989). It is possible that the nature and degree o f the
relationship between the space visualization and the slow motions observations was due
to the practic ideation and motor planning aspects that both measures share. However,
this relationship needs to be considered carefully in this study as scores in the slow
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motions observation were extrapolated to older children. Recommendations for future
modifications of this observation by future studies will be provided at the end o f this
chapter. It is interesting that the relationship between space visualization and the
Southern California Postrotary Nystagmus Test occurred in some children who also
presented with decreased contralateral hand use scores. Ayres (1989) documented a
factorial linkage between space visualization contralateral hand use and low scores on the
postrotary nystagmus test which may offer additional support for this association.
Other studies have linked decreased scores in postrotary nystagmus to visual
skills (Haack, et al., 1993); oculomotor skills (Ottenbacher, 1978); visuomotor skills and
practic management o f two dimensional space (Ayres, 1989); and reading difficulties
(deQuiros & Schrager, 1978; Levinson, 1980). Most children who presented with
difficulties in the space visualization tests o f the SIPT also had depressed nystagmus. It is
not possible to ascertain if a relationship between the mechanisms underlying the
nystagmatic response is responsible for higher level space visualization aspects of
performance, however the possibility o f this relationship should not be discarded and
could be explored in further research,
Children who had low scores in the space visualization and slow motions
observation were reported to have similar functional difficulties as explained by their
parents. They included: a) copying and using writing/art instruments, a) managing
buttons and zippers, b) using scissors, and d) opening food/snack containers. There is
evidence to support the notion that difficulty performing these tasks are due to a certain
extent by a shared proprioceptive processing component as measured by the slow
motions observation and a degree o f space management and mental visualization as
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measured by the space visualization test o f the SIPT. The practic management o f a two
dimensional space described by Ayres as being related to aspects o f the vestibular system
could also explain the relationship o f the abovementioned task difficulty and the Southern
California Postrotary Nystagmus Test (Ayres, 1989).
Figure Ground Perception
Few subjects in the sample presented with difficulties in the figure ground
perception test of the SIPT. Ayres (1989) described this test as reflective o f visual
perceptual deficits and warned clinicians about its low reliability as well as its
vulnerability to chance factors. This test correlated significantly with the finger-to-nose
and fmger-to-thumb opposition observations. These observations have usually been
described as measuring aspects o f proprioceptive mechanisms (B.N. Wilson et al., 2000),
proprioceptive and cerebellar functioning (Touwen & Prechtl, 1970), somatosensory
processing and incorporating elements o f copying and sequencing that are typical o f tasks
requiring motor planning (Imperatore Blanche, 2002). There is no clear explanation of
why these scores appeared to covariate. It is possible that children who experience this
association may present with a more generalized dysfunction rather than it being the
result o f a sensory integrative deficit. This alternative explanation has some support in the
fact that the figure ground perception test is one o f the most sensitive measures o f the
SIPT to high level central nervous system integrity (Ayres, 1989). It should also be
considered that two out o f the five children who presented with difficulties in the figure
ground perception test also presented with very low scores on praxis on verbal command,
which further supports the idea o f possible higher level central nervous system
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inefficiency. Perhaps this finding is similar to the functional disturbance o f the
integration o f the temporal lobes, cerebellum, and subcortical structures, related to motor
planning and aspects of cognition described by Guftafsson et al., (2000) in children with
attention deficit hyperactivity disorder.
The third significant correlation with the figure ground perception was found in a
statistically significant negative correlation with the prone extension measure. Although
this negative association was considered carefully it does not seem to represent a
construct that is theoretically or clinically important and may have occurred by chance.
Children with deficits in finger identification in the study sample also presented
with deficits in the slow motions observation and the Southern California Postrotary
Nystagmus Test, specifically with decreased scores. The relationship with the slow
motions observation is not clear. It is possible that inadequate proprioceptive processing
as indicated by the slow motions observation could motivate errors in localizing the
finger being touched during the administration o f the finger identification test o f the
SIPT.
The relationship of finger identification with postrotary nystagmus has been
documented in the past. In a matched sample o f dysfunctional and normal children Ayres
demonstrated that postrotary nystagmus had significant positive correlations with design
copying (visual space management), finger identification, graphesthesia, oral praxis, and
sequencing praxis (Ayres, 1989).
It is interesting that children who had difficulties with the finger identification test
also had difficulties with school performance, specifically a) difficulties adjusting to
school, and b) poor academics. These difficulties could have been better explained by a
correlation o f the finger identification test and the fmger-to-thumb opposition observation
which has been associated with mental age and could possibly explain poor academic
functioning as discussed by Strauss and Carrison in 1942.
Localization o f Tactile Stimuli
This test is commonly interpreted together with other tactile tests due to its low
reliability (Ayres, 1989). This test did not correlate positively with any structured
observations. This was a surprising finding because almost half o f the sample presented
with deficits in this test of the SIPT. A significant negative correlation was found with the
finger-to-nose observation. The reason for this association could not be explained and it
has not been documented before.
Design Copying
This test o f the SIPT has been associated with visuopraxis functioning (Ayres,
1989). It correlated significantly with the quality aspects of the prone extension posture.
The relationship is possibly due to a shared motor planning skill component by both
measures. Most o f these children also had low scores on constructional praxis further
supporting a diagnosis o f visuopraxis impairment. This was also verified by parent’s
report o f their children having difficulties with tasks requiring fine motor coordination
and handwriting skills.
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It was surprising that this test o f the SIPT did not show associations with
observations that tap into more refined motor planning skill components such as the
fmger-to-thumb opposition and the diadochokinesis observations. This may indicate that
difficulties in assuming or maintaining a posture may have an impact on fine motor
planning abilities in children with sensory integration dysfunction. This is consistent with
reports in the sensory integration literature (Blanche et al., 1995; Smith Roley et al.,
2001).
Oral Praxis
This test o f the SIPT was significantly correlated to the finger-to-nose and the
total score o f the diadochokinesis observations. Children with low scores in this test of
the SIPT tended to show low scores in postural praxis, sequencing praxis, and
constructional praxis reflecting the concept o f central practic ability described by Ayres
(Ayres, 1989). Low scores in bilateral motor coordination were also common. H alf o f the
children in this group had low scores in the localization o f tactile stimuli test, indicating
possible poor tactile perception in the oral cavity. It is interesting to note that these
children were reported to have language difficulties, specifically those related to
articulation.
The relationship o f the oral praxis test and the finger-to-nose and diadochokinesis
observations could easily be explained by inadequate cerebellar processing or integrity as
this organ is responsible for the coordination o f fine motor movements including those of
the tongue. The correlation o f these structured observations to oral praxis is most likely
related to decreased tactile and proprioceptive processing. These findings are similar to
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those reported in sensory integration theory as these observations have been related to
sequencing, the processing o f somatosensory information and the ability to copy simple
motor actions that involve motor planning (Imperatore Blanche, 2002).
The performance of diadochokinetic movements has been related to psychological
test performance in the areas o f reading achievement and verbal memory (W olf et al.,
1985). Denhoff and Siqueland (1968) have suggested that a positive relationship exists
between the child’s ability to perform diadochokinetic tasks and his school performance.
These associations have not been explored in this study but appear to be interesting lines
of inquiry for further research.
Sequencing Praxis
This test is often interpreted in light o f the results o f other praxis tests reflecting a
quality central to praxis (Ayres, 1989). Children who presented with deficits in this test
tended to have low scores in oral praxis, graphesthesia, standing and walking balance,
oral praxis, and bilateral motor coordination, therefore approaching the low average
bilateral integration and sequencing prototypic group. This test correlated significantly
with the slow motions, modified Schilder’s arm extension , and the total score o f the
jumping jacks observations. The association o f sequencing praxis with the slow motions
and the jumping jacks total score observation could be explained by the shared
difficulties in the sequencing aspects o f praxis.
The association of sequencing praxis and slow motions is similar to the one
reported by Fisher et al. (1991), Murray, and Bundy in children with somatodyspraxia.
Imperatore Blanche (2002) reported that in sensory integration theory the modified
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Schilder’s arm extension test is related to the ability to dissociate the head from upper
extremities requiring adequate vestibular proprioceptive processing. Perhaps difficulties
in the modified Schilder’s arm extension test were correlated to sequencing praxis in this
study because this relationship was describing the group o f children with a close fit to the
low average bilateral integration and sequencing disorder.
Parents of children that presented with difficulties in the sequencing praxis tests
of the SIPT also reported difficulties with tasks requiring fine motor coordination and
handwriting skills. It would be interesting to determine if these deficits are related to the
poor sequencing aspects of praxis or are found to be related to poor proprioceptive
processing as evidenced by their relationship to the slow motions structured observation.
The jumping jacks observation involves sequential and rhythmic changes in limb
posture that require complex levels of bilateral motor coordination and motor planning
(Magalhaes et al., 1989). This is consistent with the findings o f the present study as
explained by the correlation o f this observation with the sequencing praxis test of the
SIPT. Ayres (1972) proposed that the process o f integration o f vestibular and
proprioceptive sensations and the efficiency o f interhemispheral connections are the basis
for good bilateral integration o f both sides o f the body. This further supports the notion o f
the jumping jacks observation being a good indicator o f sequencing praxis and
integration o f vestibular and proprioceptive sensations.
Items related to sequencing o f complex motor acts, which closely resemble those
of the sequencing praxis test o f the SIPT, differentiate between healthy individuals and
patients diagnosed with bipolar disorder (Negash et al., 2004). An innovative line of
inquiry could attempt to determine if children and adolescents diagnosed with bipolar
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disorder present with sensory processing deficits and if they are responsive to treatment
techniques utilizing a sensory integration frame o f reference.
The statistically significant negative correlation of the finger-to-nose left hand
with the sequencing praxis tests of the SIPT could not be accounted for and probably is
not clinically significant. Future research should determine if this association has any
theoretical or clinical relevance in children with sensory integration dysfunction.
Low scores on this test o f the SIPT were most commonly accompanied with
deficits in oral praxis, graphesthesia, postrotary nystagmus, and sequencing praxis
reflecting a profile of close resemblance to the prototypic group o f low average bilateral
integration and sequencing. This test significantly correlated with low scores in the
Southern California Postrotary Nystagmus Test. Ayres described this relationship to be
common as performance in bilateral motor coordination may be negatively impacted by
the conditions that contribute to low and high scores in the postrotary nystagmus test
(Ayres, 1989).
It was expected that there would be a significant degree o f relationship between
bilateral motor coordination and the jumping jacks observation, but this association was
not revealed in this study. It is possible that this relationship was not evident because
most o f the sub-items of the bilateral motor coordination test o f the SIPT require the
execution o f asymmetrical movement while the jumping jacks observation requires
reciprocal and symmetrical patterns. A future research study that includes a sample of
older children and incorporates the symmetrical and reciprocal stride jumps could clarify
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this relationship. These measures have been described by Magalhaes et ah, as maturing at
the age o f nine.
The findings o f the present study differ from those reported in the literature as low
scores in postrotary nystagmus have not been correlated with the bilateral motor
coordination test o f the SIPT in a dysfunctional sample. However, this relationship has
been assumed in theory (Ayres, 1989).
Standing and Walking Balance
This test was greatly affected in the sample of this study as most children received
below age expectancy scores. This test o f the SIPT significantly correlated with the
finger-to-thumb opposition, non stress condition observations. This association may be
explained by the shared somatosensory aspects o f both measures.
It was surprising that the standing and walking balance test o f the SIPT did not
correlate with the heel-to-toe observation and its different conditions. The findings
reported in the literature differ greatly in terms o f typical parameters according to
chronological age (Clark & Walkins, 1984; Morris et al., 1982); sex (Ayres, 1980), and
testing under different sensory conditions (Horak & Nashner, 1986; Nashner, 1983;
Nashner et al., 1982). It is possible that no correlation was found among these measures
because the heel-to-toe observation was not able to capture all aspects o f the construct of
balance.
Although the heel-to-toe observations tested under different conditions may assist
clinicians in determining which sensory systems are functioning appropriately and which
are unable to trigger a balance reaction at the appropriate time (Deitz et al., 1991),
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additional measures o f balance and postural control should be utilized. It appears that the
construct o f balance would be better captured using a variety o f structured observations
that represent this domain.
Postrotary Nystagmus
This test of the SIPT correlated significantly with the Southern California
Postrotary Nystagmus Test. The association with the Southern California Postrotary
Nystagmus Test may support the notion o f stability o f this observation over time, as both
tests were separated by a mean time interval of 3.5 weeks. These findings are in
opposition to those reported by Ottenbacher (1978) who demonstrated that the prone
extension observation was able to predict a score on the postrotary nystagmus test.
Similar to data reported by Fisher and Bundy (1991) the present study did not find
significant associations between decreased postrotary nystagmus and the prone extension
position.
Ottenbacher and Rogers (1983) reported that in children, depressed scores in the
postrotary nystagmus test were associated with supine flexion. This association was not
found in this study as supine flexion and postrotary nystagmus correlation coefficients
did not reach statistical significance. Depressed scores in this test have also been
correlated with poor visuomotor skill, practic management o f two dimensional space
(Ayres, 1989), and reading difficulties (deQuiros and Schrager, 1978; Levinson, 1980).
Similarly, all parents o f the children participating in this study that presented with
decreased scores in the postrotary nystagmus test of the SIPT, reported difficulties in fine
motor coordination and handwriting skills.
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Association with Prototypic Groups
As discussed above, different degrees o f relationships do exist among the SIPT
and the different structured observations utilized in this study. To further the
understanding o f these relationships, clusters o f observations and different groups o f tests
o f the SIPT have been outlined in chapter 4. However, in order to make more meaningful
interpretations, the associations o f positive correlations with the two prototypic groups,
low average bilateral integration and sequencing and visuo- and somatodyspraxia using
rotated factors was explored.
The low average bilateral integration and sequencing prototypic group.
By means o f Q-factor analytic techniques Ayres (1969a) described low academic
functioning as being associated with deficits in postural and bilateral integration. She
described this group o f children as presenting with poorly integrated postural and ocular
mechanisms, difficulties with bilateral integration, and a non-specific visual perceptual
deficit (Ayres, 1972). More recently these children have been described in terms o f their
scores on the SIPT as presenting with difficulties in oral praxis, sequencing praxis,
bilateral motor coordination, standing and walking balance, and graphesthesia (Ayres,
1989). In the present study, when children with this cluster were separated from the total
sample they presented with specific deficits in different structured observations. As a
group, these children were best represented by deficits in prone extension, heel-to-toe,
jumping jacks, finger-to-thumb opposition, and the Southern California Postrotary
Nystagmus Test. In addition, some children presented with deficits in the supine flexion
observation.
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This association appears to be meaningful as these structured observations reflect
the processing o f vestibular-proprioceptive inputs and motor planning components. It is
unfortunate that none of these observations tapped into the feedforward mechanisms that
have been reported to be common among children with bilateral integration and
sequencing disorder (Fisher et al., 1991; 2000). Future research could attempt to establish
this relationship.
The visuo- and somatodyspraxia prototypic group.
This prototypic group was best represented by deficits in prone extension, supine
flexion, fmger-to-nose, and the Southern California Postrotary Nystagmus Test and
inconsistent scores in the heel-to-toe and jumping jacks observations. This was not
surprising as some o f these observations share a common ground with the ability to plan
and execute non habitual motor tasks, a concept central to praxis (Ayres, 1969a).
Children with developmental dyspraxia have also been described as having minor
neo-cerebellar disturbances, usually bilateral, and/or o f vermian disturbance (Lesny,
1980). This may have been one o f the reasons for these children presenting with deficits
in the fmger-to-nose observation.
The performance o f these children as a group was difficult to establish on a
quantitative basis. Oftentimes they needed to be re-tested as it was common to get the
impression that they were not performing at their best. This may be consistent with the
description o f these children as emotionally labile and their tendency to present with
behavioral problems (Ayres, 1979). Most of the time testing problems were related to the
child being silly or inconsistent during their performance of an observation which made it
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difficult to ascertain a specific score. This was particularly true during the administration
o f the heel-to-toe observation in which these children tended to have very unstable
performance, varying greatly in different administrations.
Other types o f difficulties often observed in these children was a great degree of
difficulty in achieving the requested testing position. However, some of them were
observed to assume the correct position after the examiner finalized the scoring o f the
requested observation. When examining adults with schizophrenia Krebs et al. (2000)
described performance differences and instability and proposed that the most appropriate
level of measurement when examining neurological soft signs should be on qualitative
rather than all-or-nothing scales. Perhaps, the development of new instruments to
measure structured observations should reflect this line o f thinking to better capture an
unstable level o f performance that appears typical o f children in this group.
Theoretical and Tentative Data Reduction Model
Exploratory factor analysis techniques have long been used in behavioral and
health sciences. Many parameters that are standard in other statistical techniques such as
power, sample size and so forth are still debatable when using factor analysis (Arrindel &
van der Ende, 1985; Cattell, 1978). Therefore this technique has been utilized with as few
as 20 subjects with some degree o f success (Arrindel & van der Ende). When the
structured observations o f children presenting with a close fit to the low average bilateral
integration and sequencing were submitted to exploratory factor analysis for data
reduction, two main results emerged. They were represented by a grouping o f
observations composed of the jumping jacks observation and its three sub-variables
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together with the supine flexion observation. The second factor consisted o f the heel-to-
toe eyes closed -so ft surface, prone extension and slow motion observations. The third
was composed o f the fmger-to-nose and diadochokinesis observations. These factors may
represent three components that describe a) motor planning and aspects o f bilateral
sequencing, b) a vestibulo-proprioceptive, and c) cerebellar aspects o f speed,
acceleration, and trajectory. These findings need to be further explored and considered
with caution, and efforts should be made for their detection in a larger scale study. The
grouping o f children that were a close fit to the visuo-somatodyspraxia was inconclusive
due to sample size and lack o f adequate factor loading.
When the liner regression model was obtained, the power o f prediction of
different structured observations in relationship to different tests o f the SIPT was
determined and judged to be low, as expected. The Southern California Postrotary
Nystagmus Test was the most common predictor o f performance in different tests o f the
SIPT, although most structured observations that entered and remained in the forward
regression model at 5% significance level could only partially explain the variability of
the different measures o f the SIPT. Variability levels varied greatly with different
structured observations and were not superior to 62%. All the other structured
observations that entered and remained in the forward regression model at 5%
significance level explained variability levels in different tests o f the SIPT and ranged
from 19% to 56%. Kinesthesia, praxis on verbal command, and constructional praxis
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tests of the SIPT were not predicted by any structured observation at any level to enter
and remain in the forward regression model at 5% significance level.
Implications for Practice
To further the understanding o f the developmental parameters, deficits, and
common associations among different structured observations, these need to be used
consistently following similar measurement parameters. The use o f structured
observations provides clinicians with a simple and useful evaluation technique for
children with sensory integration deficit and other disorders. The behaviors observed
during the administration o f structured observations in children are particularly intriguing
because they appear to be stable in nature, may guide clinicians in their treatment
approach, and may be relatively unaffected in different social and cultural settings. If this
could be further investigated and demonstrated, this method o f assessment may be useful
for comparative evaluation o f development and deficits across cultures and provide a
relatively cultural and social free basis for the occupational therapy assessment process.
This method o f examination may be o f particular potential value for the screening
of children who present with deficits in fine motor coordination and handwriting who are
often referred to occupational therapy practitioners. These children may be at risk for
later school failure. Structured observations have been related to areas as diverse as
school performance (Denhoff & Siqueland, 1968) and as specific as mental age (Strauss
& Carrison, 1942).
Although it is not possible to ascertain what scores should be expected in the SIPT
given a set o f structured observations, clinicians should be alert to the degree of
146
statistically significant relationships among different measures as well as to how different
observations partially explain scores in the SIPT measures. The same is true for different
structured observations, as the SIPT is not able to predict their specific performance.
Clinicians also need to be aware o f the true nature of correlational research and its
inability to establish causal relationships (Portney & Watkins, 1993). Its value is
accumulative in nature; therefore, future studies could add significant value to and
clarification o f these relationships. Clinicians should pay special attention to both
individual performances as well as to meaningful clusters of these observations.
The simplicity, swiftness, and flexibility o f different structured observations make
them suitable for most settings. However, an important conclusion to keep in mind is
that their interpretation is a very complex process. Errors in clinical reasoning guiding the
interpretation of these observations may result in findings that could be misleading for
further assessment and treatment planning.
A review o f all different structured observations, after their administration and
scoring, appears to warrant different levels o f validity and trustworthiness. At the first
and highest level, clinicians may find some structured observations o f which
administration, scoring, and interpretation have been carefully and systematically revised
in the literature. These observations include prone extension, prone extension quality,
supine flexion (Dunn, 1981; Fraser, 1983; Gregory-Flock & Yerxa, 1984; Harris, 1981;
Longo-Kimber, 1984), jumping jacks (Magalhaes et al., 1989), and postrotary
nystyagmus (Ayres, 1975). A second level is comprised of observations which have been
studied widely by several disciplines but whose scoring and interpretation is still posing a
challenge for clinicians. At this level therapists and other health professionals find
147
balance measures (Deitz et al., 1991), diadochokinesis (Adams et al., 1974; Grant et al.),
and finger -to-thumb opposition (Grant, Boelsche & Zin, 1973). At the third and lowest
level, therapists may find structured observations whose clinical relevance and meaning
have been explored mostly at a theoretical level but no attempts have been made for a
systematic way o f collecting quantitative and/or qualitative information. These
observations include the slow motions, modified Schilder’s arm extension test (Dunn,
1981; Silver, 1952; Silver and Hagin, 1952), and fmger-to-nose observations (Dunn,
1981; Touwen & Prechtl, 1970).
The loci or neuroanatomical basis for most neurological soft signs continues to be
investigated mostly in adult populations affected by psychiatric disorders. Very few
conclusions can be drawn from these studies other than the fact that they appear to be
manifested by a reduction o f grey matter volume o f subcortical structures, particularly the
putamen, globus pallidus, and thalamus (Dazzan et al., 2004; Dazzan & Murray, 2002).
Even though it is possible that the same could be manifested in children, this research is
just emerging. On the other hand, signs o f sensory integration deficits were additionally
associated with volume reduction in the cerebral cortex including the precentral, superior,
and middle temporal lobes, and lingual gyri in adults with psychiatric conditions.
Implications for Further Research and Recommendations
From the findings o f this study it appears that two important lines o f inquiry
should be developed to improve the utilization and reliability o f different structured
observations. These aspects can be categorized as measurement issues, specifically
construct validity, and reliability during repeated measures.
148
Future research efforts should concentrate first and foremost on appropriately
defining the construct validity o f structured observations. There are several problems
with existing protocols and they should be resolved to reflect current trends in the
examination and interpretation process in light o f more recent research findings in several
fields of study. A panel o f experts and pilot studies should carefully screen typically
developing children to ascertain normative performance. Secondly, a series o f studies
dealing with children with different functional deficits should be carefully planned. This
second group o f studies is lacking in the literature. This problem tends to generate
protocols and measures with adequate face validity that may not be reliable when dealing
with children with different types o f dysfunction. The great value that different groups of
observations offer to clinicians, highlights the need for a re-standardization process. This
could greatly assist clinicians in collecting information during the screening or
assessment process in an inexpensive and non-obtrusive manner.
If future research is to use similar procedures to the ones utilized during this
study, several problems need to be carefully thought through. As described earlier, few
issues exist with structured observations that have been described at the first level. Both
prone extension and supine flexion should be carefully reviewed to determine which is
the most adequate testing position. In addition, supine flexion needs a qualitative scale
that may capture different aspects o f performance. Furthermore, several criticisms have
surrounded the administration and scoring o f postrotary nystagmus, the most common
probably being the interference of visual fixation and lighting conditions (Ottenbacher &
Short, 1985). Perhaps the performance should be recorded under light and non light
149
conditions, and a way o f determining a fixed angle to support the head during rotation
should be dealt with to increase the validity o f this measure in children.
Measures o f balance under different sensory conditions are ideal, but the
practicality o f their administration in the clinical setting needs to be further explored.
Perhaps the most valuable way o f utilizing these observations is through a composite
score that takes into account different postures and different conditions. The most salient
problem with these measures seems to be their variability in normal and dysfunctional
children. More refined instruments that incorporate computers or videotaping would be
ideal, but would also severely decrease their flexibility and cost o f administration.
Finger-to-thumb opposition and diadochokinesis have been described at length in
the literature and their protocols appear to be well developed. Adding components that
limit the number o f sensory systems utilized during performance may help to clarify their
interpretation. A non visual condition would be highly desirable.
Observations that have been described as part o f the third and lowest level need
serious revisions. Although there is no doubt that the slow motions, modified Schilder’s
arm extension test, and fmger-to-nose observations may help clinicians to identify the
nature o f a suspected dysfunction, their administration and scoring has not been studied
systematically. There is some uniformity in the belief o f what the underlying domain of
function is for these measures, and future research should carefully determine what
aspects o f these observations are worth measuring, as well as their interpretation. In this
regard, the modified Schilder’s arm extension test is probably the most complex as little
is known about the mechanisms mediating differences in its performance. Indication of
cerebral hemisphere dominance and a high incidence o f reading disability when
150
difficulties in this observation are detected has been suggested (Silver, 1952; Silver &
Hagin, 1952). These, however, have not been the problems reported by the parents of
children who presented with difficulties in this observation in the present study. Sample
size factor interference needs to be considered as the original study included a larger
sample (Silver, 1952; Silver and Hagin, 1952).
Although neuroimaging techniques have not been used in children with sensory
integration dysfunction, the literature reported significant differences in brain structure
when several o f the soft signs were present (Mercuri, Dubowitz, et al., 1995; Nickoloff et
al., 1991). However, these studies have mostly been done in adult populations and have
been disorder specific. If this is the case with children who are treated by occupational
therapists in their daily practice, there is some evidence that well conducted neurological
examinations could match the findings o f imaging techniques (Mercuri, Dubowitz et al.,
Nickoloff et al.)
Clusters o f observations could reflect specific types o f occupational performance
deficits. This is an area o f research that has not been fully explored. Are particular
clusters o f deficits in structured observations more likely to affect different areas o f
activity? Associations between structured observations and activities o f daily living,
specific fine motor tasks, and specific areas o f school performance may assist clinicians
in designing appropriate types o f intervention. If decreased sensory processing is an
underlying cause o f poor performance in structured observations, and these observations
are related to specific task performance outcome measures, then evidence based practice
would be a logical end product.
151
A specific cluster o f observations have been detected in children who presented
with a profile o f close resemblance to low average bilateral integration and sequencing
and visuo and somatodypraxia. These associations should be further explored using
cluster analysis and a sample size which could provide more adequate power. Similarly, a
factor analysis o f greater scale should be conducted to determine if a smaller group of
items are measuring the same domain and to assist in the development o f better scales of
measurement.
Limitations o f the Study
One of the most limiting factors in this study was its sample size, lack of
randomization and especially the fact that all scores were derived from different studies
and samples. Small sample size studies, although suitable for correlational and
exploratory factor analysis studies may provide only tentative results and their strength is
related to cumulative efforts.
Another aspect to take into account is the sample characteristics; children who
present with sensory integration dysfunction may often present with other disorders.
Although there was not evidence o f this in the sample studied, this factor should be kept
in mind. In addition, the children that were part o f this study were undergoing
occupational therapy treatment. Although measures were taken to prevent maturation,
history, and treatment effect, they still could have affected the results. With the exception
o f children who presented with motor planning difficulties or a close fit to the visuo and
somatodyspraxia, subjects were cooperative. This could have also impacted the results of
this study.
152
Limitations should also be considered in the measurement instruments,
particularly with the balance and slow motion measures, as extrapolations needed to be
conducted in order to score older children. For the most part this did not constitute a real
problem as those children in the sample performed well below their age expectancies,
therefore resembling the performance o f a younger child. However, future studies should
take into account that a child may perform at or above his/her chronological age limit,
therefore normative information may not be available.
Last, the results o f the tentative exploratory factor analysis should only be
considered for illustrative purposes as sample size may have negatively affected its
results. Sample size determination in factor analytic studies are subject to a great level of
debate among different authors. Addressing these issues of concern in future research is
highly desirable and perhaps sample size should be determined based on ratio sample to
expected factors.
Summary
Some degree o f significant associations was found between the SIPT and the
utilized structured observations which led to partially rejecting the notion o f no
relationship between both measures, the first hypothesis proposed by this study. This was
proven by reported statistical significant correlation coefficients between both measures
which was an unanticipated outcome. The degree o f overlapping was small and judged to
approximate 5%.
When a linear regression model was obtained, the power o f prediction o f the
structured observations was determined and judged to be low. This offers support for the
153
second hypothesis o f this study that postulated that structured observations could not
statistically and significantly describe different SIPT profiles.
When separated into groups that approached the SIPT prototypic groups, the
observations appeared to assume a construct that theoretically approached the processing
o f vestibular-proprioceptive and motor planning aspects o f performance in the low
average bilateral integration and sequencing disorder and, not so clearly, a praxis
component in the visuo and somatodyspraxia disorder. Structured observations scores of
children with the most common profile o f low average bilateral integration and
sequencing disorder appear to group in three areas defined for illustrative and descriptive
purposes as a) motor planning and aspects o f bilateral sequencing, b) a vestibulo-
proprioceptive, and c) a cerebellar aspects o f speed.
The most important aspect for clinical practice is the flexibility o f the measures
utilized for this study, as they may tap into areas not affected by cultural and
socioeconomic factors. In addition, their utilization is o f great value for screening and
present to the child a non-threatening challenge. Low cost should not be taken lightly as
funding issues usually affect pediatric occupational therapy practice methods.
Important considerations for future research include specific delineation o f the
construct under study and establishing clear parameters for measurement o f qualitative
and quantitative aspects o f performance during the administration and scoring o f different
structured observations. This process and the value held by these inexpensive and flexible
measures calls for a joint effort in re standardization.
Several limitations could be identified in the present study, the most important
being those related to sample size, randomization, and the heterogeneity o f the samples
154
that composed the typical groups from which all different structured observations
standard scores were obtained. Heterogeneity o f children with sensory integration
dysfunction is another important aspect as it affected the sample o f this study.
155
APPENDIX A
Family Flyer
m m
n
A CORRELATION STUDY BETWEEN STRUCTURE!
OBSERVATIONS AND THE SENSORY INTEGRATION
AND PRAXIS TESTS (SIPT).
Research Protocol No. HPD-CAHN06130508EXP.
A research study is being conducted at Therapy West, Inc. This research study is being
conducted by Gustavo Reinoso, OTR/L as part o f his doctoral dissertation research from
Nova Southeastern University (NSU). This study seeks to understand how a group o f
structured observations in a clinical setting correlate with a standardized assessment tool,
the Sensory Integration and Praxis Tests (SIPT).
If your child is receiving occupational therapy services and is between the age o f 5 and 8
yrs. he/she may qualify to participate in this study. If you decide to participate, your child
may receive the Sensory Integration and Praxis Tests (SIPT) and a group o f structured
clinical observations at no cost. Should you have any questions or wish to receive more
information, please do not hesitate to contact me at:
Gustavo Reinoso, OTR/L

Pediatric Occupational Therapist
Therapy West, Inc.
(310) 337-7115 #165
greinoso@therapvwest.org
156
Therapist’s Flyer
A CORRELATION STUDY BETWEEN STRUCTURED

OBSERVATIONS AND THE SENSORY INTEGRATION
AND PRAXIS TESTS (SIPT).
Research Protocol No. HPD-CAHN06130508EXP.
A research study is being conducted at Therapy West, Inc. This research study is
conducted by Gustavo Reinoso, OTR/L as part o f his doctoral dissertation research from
Nova Southeastern University (NSU). This study seeks to understand how a group of
structured observations correlate with the Sensory Integration and Praxis Tests (SIPT).
Are you currently working with a client who is between 5 and 8 yrs. o f age? If so, your
client may qualify for this study and be tested with the Sensory Integration and Praxis
Tests (SIPT) and a group o f structured clinical observations at no cost. If you are
interested or want to receive more information please contact me at:
Gustavo Reinoso, OTR/L

Pediatric Occupational Therapist
Therapy West, Inc.
(310) 337-7115 #165
greinoso@.therapywest.org
157
APPENDIX B
Data Collection Instrument
STRUCTURED CLINICAL OBSERVATIONS: DATA COLLECTION
1. Supine Flexion Postural Test (SFPT)

Item Duration (Sec.)
Flexion in Supine
2. Prone Extension (PE)

Quantitative
Ilem Duration (sec.)
PE
Qualitative
Categories 1 Score
Assumes
(0) Does not assume 0
(1) Segmentally 1
(2) Smoothly and quickly, all body parts simultaneously 2
Head
(0) Face remains on mat 0
(1) Face raises less than 45 and/or position o f head varies 1
(2) Face vertical (>45) and held steady 2
Upper Trunk
(0) Shoulders remain on mat 0
(1) Back minimally arched and/or elbows forward o f shoulders 1
(2) Definite arch and elbows even with back o f shoulders 2
Thighs
(0) Thighs remain on mat 0

(1) Barely off, paper can be slid under knees, but not much above 1
(2) Clearly o ff the mat, from midthigh distally 2
Knees
(0) Knees remain on mat 0
(1) Definitively flexed (50 or more) 1
(2) Slightly bent (45 or less) 2
M aintains
(0) Minimal effort due to knees remaining on mat 0
(1) Considerable effort 1
(2) M oderate exertion expended 2
TOTAL
Based on Gregory-Flock and Yerxa (1984) ©American Occupational Therapy Association
3. Post Rotary Nystagmus (PRN)
Duration Seconds SD
To the LEFT
To the RIGHT
Difference in s between L and R
Lesser duration L R
158
4. Slow Motions (SM)

Item Score
Symmetrical movements 0 1
Hands reach shoulders together 0 1
Performance (smooth , jerky) 0 1
TOTAL
5. Finger to Nose (FN)

Item D istance (to the
n e a re s t 0.5 cm )
R arm
L arm
6. Diadokokinesis (DIA)
F or N o n -S tre ss, u se b e st o f 3 tria ls.
F o r S tr e ss, a sk th e c h ild to “ d o th e ta sk a s fa st as
you can” S k ills L ev el N on stre ss S tress
S k ill C o m p o n e n t ____________ _
A. A b ility ______________________________
Alternates supination and pronation each time
Fails to alternate 5 times per trial
Fails to alternate 5-10 times per trial
N o alternate movement
B. U n c o n tro lle d S la p p in g M o v e m e n ts
N o slapping
5 slaps per trial
5-10 slaps per trial
W ild waving o f hands
C . H a n d E lev a tio n
Smoothly and definitively picks hands up o ff surface
Barely lifts hands from surface
Rolls hands over on lateral edge without picking up
D . S y m m e tr y o f m o v e m e n ts
Perfect symmetry
Slight asymmetry
Gross asymmetry
TOTAL
159
7. Finger-to-thiimb opposition
F o r N o n -S tress, u se b e st o f
3 tria ls. N on stre ss S tress
F o r S tress, a sk th e ch ild to S k ill C o m p o n e n t
S k ills L ev el
“d o th e ta s k as fa st a s y ou
ca n ” R R
A. A b le -U n a b le
Touches thumb with tip o f each finger in functional position
Touches tip o f each fmger flexed near the palm and pressed
together
Touches thumb with other than tip o f finger (based o I
phalanx)___________________________________________
D oes not attempt to touch finger
B. C lu m p in g o f fin g e rs
N o clumping
Clumping o f 2 fingers
C. C o n tr a la te r a l o v e r flo w M o v e m e n ts
N o overflow detected (0)_________
Slight m ovem ent o f 1 or 2 fingers
Movements o f 2 or more fingers or marked m ovements o f 2
or less
Movement o f fingers and hand m uscles
D. T im in g
Very smooth (no hesitation)
Slight hesitation (3 sec.) between fingers
Hesitation o f 3 sec, or opens hand between fingers
“Spastic” m ovements with inability to bring tip o f finger to
thumb
E. S e q u en c e
Touches each finger in order
M isses 2 finger or touches 1 finger tw ice in succession
M isses more than 1 finger or touches more than one finger
tw ice in succession
Touches fingers in random order
TOTAL
i. Modified Schilder’s Arm Extension Test (SAT)

Direction o f Rotation A m ount o f Trunk rotation Score
To the R 0 0
0-45 1
45-90 2
To the L 0 0
0-45 1
45-90 2
TOTAL
160
9. Jumping Jacks (JJ)

Learning Phase
Item Score
.. 5 ... .... \ v 4m 3; L " =v : . - r a - ; .... ..
R esponse to Spontaneous Needs second Needs verbal Needs verbal and Unable to perform
Instruction dem onstration structure physical structure
Initiation o f Sm ooth and Does one to two Hesitates or Performs only with Is unable to perform
sequences uninterrupted; able false starts, but then interrupts between examiner or initiates different
to do five in a row is correct sequences m ovem ent pattern
Coordination o f Rhythm ical, lull Is awkward, Reverses pattern Coordinates only Jum ps in place with
arms and legs pattern incomplete, or slow after two or three arms or only legs no coordination
jumps
Performance Phase
Item Score
5 4 . 3: - 2: - 1
N um ber o f full > 10 9 to 7 6 to 4 3 to 1 <1
patterns in 10 sec.
Quality o f Rhythm ical Is slightly awkward Has two or more Is unable to keep Does only
perform ance uninterrupted full or has one interruptions or pattern; tends to do incomplete
pattern interruption; loses reverses after four incomplete jum ps sequences
or reverses pattern to five jum ps with after two or three
but corrects no correction jumps
Learning Phase Perform ance Phase Total Score
Score Score
Based on Magalhanes, Koomar & Cermark (1989). ©American Occupational Therapy Association
10. Balance: P-CTSI] 3 Heel-to-toe

Surface Normal I II Score
Condition 1
Condition 2
Surface Foam
Condition 3
Condition 4
161
APPENDIX C
Table 1
Structured Observations, their Nomenclature, Name, Type, and Level o f Measurements
Structured Observations
Variable Nomenclature Name Type of Level of

Measurement Measurement
1 SF Supine Flexion Postural Seconds Interval

Test
2 PE Prone Extension Seconds Interval
Prone Extension Raw Score Ratio
PEQ
Quality
3 SCPRN Southern California Seconds Interval
Post-rotary Nystagmus
4 SM Slow Motions Raw Score Ratio
5 FN-R Finger-to-nose (right) Centimeters Interval
FN-L Finger-to-nose
(left)
6 Diadokokinesis Total Raw Score Ratio
DIA
Score
Diadokokinesis Non- Raw Score Ratio
DIA-NS
Stress
DIA-S Diadokokinesis Stress Raw Score Ratio
7 F inger-to-Thumb Raw Score Ratio
FTO-T
Opposition Total Score
Finger-to-Thumb Raw Score Ratio
FTO-NS
Opposition Non-Stress
Finger-to-Thumb Raw Score Ratio
FTO-S
Opposition Stress
8 Schilder’s Arm Raw Score Ratio
Extension Test
SAT
162
Table 1
Structured Observations, their Nomenclature, Name, Type, and Level of Measurements
(Cont.)
Structured Observations
Variable Nomenclature Name Type o f Level of

9 JJ-L Jumping Jacks Raw Score Ratio
Learning Phase Score
JJ-P Jumping Jacks Raw Score Ratio

Performance Phase
Score
JJ-10 Jumping Jacks in 10 Raw Score Ratio
Seconds
JJ-T Jumping Jacks Total Raw Score Ratio
Score
Heel-to-toe, eyes open,

H TT-0
firm surface
Heel-to-toe, eyes
HTT-C
closed, firm surface
10 Heel-to-toe, eyes open, Seconds Interval
HTT-O-S
soft surface
Heel-to-toe, eyes
HTT-C-S closed, soft surface
163
Table 2
The Sensory Integration and Praxis Tests, their Nomenclature, Name, Type, and Level of
Measurements.
Variable Nomenclature Name Type o f Level of

1 SV Space Visualizations Standardized Interval

Figure Ground
2 FG Perception Standardized Interval
Manual Form Perception
3 MFP Standardized Interval
4 KIN Kinesthesia Standardized Interval
5 FI Finger Identification Standardized Interval
6 GRA Graphesthesia Standardized Interval
7 Localization of Tactile Standardized Interval
LTS
Stimuli
8 Praxis on Verbal Standardized Interval
PrVC
Command
9 DC Design Copying Standardized Interval
10 Constructional Praxis Standardized Interval
CPR
11 PPR Postural Praxis Standardized Interval
12 OPR Oral Praxis Standardized Interval
13 SPR Sequencing Praxis Standardized Interval
14 Bilateral Motor Standardized Interval
J D IV IV ^
Coordination
15 Standing and Walking Standardized Interval
SWB
Balance
16 MAC Motor Accuracy Standardized Interval
17 PRN Postrotary Nystagmus Standardized Interval
164
APPENDIX D
Table 3
Sample Characteristics
Number Mean Age Measurement Reason for Referral

Interval
21 6.7 yrs. 3.5 weeks 01a, 02b, 03c, 04d, 05e,

06f, 07g
aFine motor coordination & Handwriting. bDisruptive Behavior. 'Gross Motor
Coordination & Sports. dLanguage. 'Attention. fHigh Motor Activity. gSchool
Performance
165
APPENDIX E
Table 4
Spearman Rho Correlation Coefficients among all dependent variables
Variable SV FG
H TT-0 Correlation Coefficient 0.11 -0.09
Sig. (2 - tailed)
HTT-C Correlation Coefficient -0.21 -0.20
Sig. (2 - tailed)
HTT-O-S Correlation Coefficient 0.24 0.05
Sig. (2 - tailed)
HTT-C-S Correlation Coefficient -0.21 -0.42
Sig. (2 - tailed)
PE Correlation Coefficient -0.28 -0.48
Sig. (2 - tailed) 0.03**
PE-Q Correlation Coefficient 0.27 0.12
Sig. (2 - tailed)
SF Correlation Coefficient 0.15 -0.11
Sig. (2 - tailed)
SM Correlation Coefficient 0.43 -0.22
Sig. (2 - tailed) 0.05*
166
Table 4
Spearman Rho Correlation Coefficients among all dependent variables (Cont.)
Variable SV FG
FN-R Correlation Coefficient -0.09 0.45
Sig. (2 - tailed) 0.04**
FN-L Correlation Coefficient -0.12 0.31
Sig. (2 - tailed)
DIA Correlation Coefficient 0.04 0.28
Sig. (2 - tailed)
DIA-NS Correlation Coefficient -0.08 -0.02
Sig. (2 - tailed)
DIA-S Correlation Coefficient -0.22 -0.21
Sig. (2 - tailed)
FTO-TS Correlation Coefficient 0.21 0.45
Sig. (2 - tailed) 0.04**
FTO-NS Correlation Coefficient 0.35 0.34
Sig. (2 - tailed)
167
Table 4
Variable SV FG
FTO-S Correlation Coefficient 0.25 0.37
Sig. (2 - tailed)
SAT Correlation Coefficient 0.21 0.05
Sig. (2 - tailed)
SCPNT Correlation Coefficient 0.51 0.15
Sig. (2 - tailed) 0.02**
JJ-L Correlation Coefficient 0.18 0.35
Sig. (2 - tailed)
JJ-P Correlation Coefficient 0.31 0.21
Sig. ( 2 -ta ile d )
JJ-10 Correlation Coefficient 0.26 0.24
Sig. (2 - tailed)
JJ-T Correlation Coefficient 0.32 0.23
168
Table 4
Variable MFP KIN
Sig. (2 - tailed)
HTT-C Correlation Coefficient 0.01 0.20
Sig. (2 - tailed)
Sig. (2 - tailed)
HTT-C-S Correlation Coefficient -0.08 -0.05
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
SF Correlation Coefficient -0.08 0.19
Sig. (2 - tailed)
SM Correlation Coefficient 0.34 0.20
Sig. (2 - tailed)
169
Table 4
Variable MFP KIN
FN-R Correlation Coefficient 0.09 0.30
Sig. (2 - tailed)
FN-L Correlation Coefficient 0.30 0.08
Sig. (2 - tailed)
Sig. (2 - tailed)
DIA-NS Correlation Coefficient -0.01 0.17
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
170
Table 4
Variable MFP KIN
Sig. (2 - tailed)
Sig. (2 - tailed)
SCPNT Correlation Coefficient 0.38 -0.11
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
171
Table 4
Variable FI GRA
Sig. (2 - tailed)
HTT-C Correlation Coefficient 0.28 -0.03
Sig. (2 - tailed)
HTT-O-S Correlation Coefficient -0.06 0.01
HTT-C-S Correlation Coefficient 0.30 -0.17
Sig. (2 - tailed)
PE Correlation Coefficient 0.34 -0.25
Sig. (2 - tailed)
PE-Q Correlation Coefficient -0.13 -0.02
Sig. (2 - tailed)
SF Correlation Coefficient -0.002 0.21
Sig. (2 - tailed)
Sig. (2 - tailed) 0.04**
172
Table 4
Variable FI GRA
Sig. (2 - tailed)
FN-L Correlation Coefficient -0.11 -0.04
Sig. (2 - tailed)
DIA Correlation Coefficient -0.14 0.001
Sig. (2 - tailed)
DIA-NS Correlation Coefficient 0.005 0.08
Sig. (2 - tailed)
DIA-S Correlation Coefficient 0.20 -0.17
Sig. (2 - tailed)
FTO-TS Correlation Coefficient -0.15 0.35
Sig. (2 - tailed)
Sig. (2 - tailed)
173
Table 4
Variable FI GRA
Sig. (2 - tailed)
Sig. (2 - tailed)
SCPNT Correlation Coefficient 0.70 -0.16
Sig. (2 - tailed) 0.0004**
JJ-L Correlation Coefficient -0.18 0.25
Sig. (2 - tailed)
JJ-P Correlation Coefficient -0.10 0.33
Sig. (2 - tailed)
JJ-10 Correlation Coefficient -0.05 0.41
Sig. (2 - tailed)
Sig. (2 - tailed)
174
Table 4
Variable LTS PVC
H TT-0 Correlation Coefficient 0.35 0.24
Sig. (2 - tailed)
Sig. (2 - tailed)
HTT-O-S Correlation Coefficient 0.22 -0.14
Sig. (2 - tailed)
HTT-C-S Correlation Coefficient 0.02 0.10
Sig. (2 - tailed)
PE Correlation Coefficient 0.17 0.15
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
175
Table 4
Variable LTS PVC
Sig. (2 - tailed) 0.02**
Sig. (2 - tailed)
DIA Correlation Coefficient -0.17 -0.26
Sig. (2 - tailed)
Sig. (2 - tailed)
DIA-S Correlation Coefficient 0.16 0.07
Sig. (2 - tailed)
FTO-TS Correlation Coefficient -0.39 -0.06
Sig. (2 - tailed)
FTO-NS Correlation Coefficient -0.07 0.24
Sig. (2 - tailed)
176
Table 4
Variable LTS PVC
FTO-S Correlation Coefficient -0.06 -0.13
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
JJ-L Correlation Coefficient 0.04 -0.21
Sig. (2 - tailed)
JJ-P Correlation Coefficient 0.14 -0.20
Sig. (2 - tailed)
JJ-10 Correlation Coefficient 0.07 -0.15
Sig. (2 - tailed)
JJ-T Correlation Coefficient 0.19 -0.02
Sig. (2 - tailed)
177
Table 4
Variable DC CPR
H TT-0 Correlation Coefficient -0.13 -0.13
Sig. (2 - tailed)
Sig. (2 - tailed)
HTT-C-S Correlation Coefficient 0.02 0.12
Sig. (2 - tailed)
PE Correlation Coefficient -0.16 0.02
Sig. (2 - tailed)
Sig. (2 - tailed) 0.047**
SF Correlation Coefficient 0.36 0.05
Sig. (2 - tailed)
Sig. (2 - tailed)
178
Table 4
Variable DC CPR
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
DIA-NS Correlation Coefficient 0.11 -0.04
Sig. (2 - tailed)
DIA-S Correlation Coefficient 0.22 -0.15
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
179
Table 4
Variable DC CPR
Sig. (2 - tailed)
SAT Correlation Coefficient -0.22 0.25
Sig. (2 - tailed)
SCPNT Correlation Coefficient -0.10 0.19
Sig. (2 - tailed)
JJ-L Correlation Coefficient -0.07 -0.21
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
JJ-T Correlation Coefficient -0.13 -0.13
Sig. (2 - tailed)
180
Table 4
Variable PP OPR
H TT-0 Correlation Coefficient -0.03 0.38
Sig. (2 - tailed)
HTT-C Correlation Coefficient -0.36 0.43
Sig. (2 - tailed) 0.05*
Sig. (2 - tailed)
HTT-C-S Correlation Coefficient -0.01 0.21
Sig. (2 - tailed)
PE Correlation Coefficient -0.11 0.19
Sig. (2 - tailed)
PE-Q Correlation Coefficient 0.20 -0.08
Sig. (2 - tailed)
SF Correlation Coefficient 0.001 0.24
Sig. (2 - tailed)
Sig. (2 - tailed)
181
Table 4
Variable PP OPR
Sig. (2 - tailed) 0.004**
Sig. (2 - tailed) 0.0007**
Sig. (2 - tailed) 0.02**
Sig. (2 - tailed)
DIA-S Correlation Coefficient -0.35 0.36
Sig. (2 - tailed)
FTO-TS Correlation Coefficient -0.03 0.27
Sig. (2 - tailed)
Sig. (2 - tailed)
182
Table 4
Variable PP OPR
FTO-S Correlation Coefficient -0.16 0.26
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
JJ-L Correlation Coefficient -0.17 -0.22
Sig. (2 - tailed)
JJ-P Correlation Coefficient -0.18 -0.25
Sig. (2 - tailed)
JJ-10 Correlation Coefficient -0.30 -0.33
Sig. (2 - tailed)
JJ-T Correlation Coefficient -0.19 -0.22
Sig. (2 - tailed)
183
Table 4
Variable SP BMC
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
HTT-C-S Correlation Coefficient 0.06 -0.14
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed) 0.002**
184
Table 4
Variable SP BMC
Sig. (2 - tailed)
Sig. (2 - tailed) 0.02**
DIA Correlation Coefficient -0.23 -0.14
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
185
Table 4
Variable SP BMC
FTO-S Correlation Coefficient 0.08 -0.10
Sig. (2 - tailed)
Sig. (2 - tailed) 0.04**
Sig. (2 - tailed) 0.02**
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed) 0.04**
186
Table 4
Variable SWB MAC
H TT-0 Correlation Coefficient 0.39 0.38
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
HTT-C-S Correlation Coefficient -0.35 0.02
Sig. (2 - tailed)
Sig. (2 - tailed)
PE-Q Correlation Coefficient 0.39 -0.11
Sig. (2 - tailed)
SF Correlation Coefficient -0.28 -0.12
Sig. (2 - tailed)
Sig. (2 - tailed)
Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.
187
Table 4
Variable SWB MAC
FN-R Correlation Coefficient 0.08 -0.06
Sig. (2 - tailed)
Sig. (2 - tailed)
DIA Correlation Coefficient -0.02 0.25
Sig. (2 - tailed)
Sig. (2 - tailed)
DIA-S Correlation Coefficient -0.24 0.11
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed) 0.048**
188
Table 4
Variable SWB MAC
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
JJ-L Correlation Coefficient 0.39 -0.19
Sig. (2 - tailed)
Sig. (2 - tailed)
Sig. (2 - tailed)
JJ-T Correlation Coefficient 0.42 -0.08
Sig. (2 - tailed)
189
Table 4
Variable PRN
H TT-0 Correlation Coefficient 0.18
Sig. (2 - tailed)
HTT-C Correlation Coefficient -0.09
Sig. (2 - tailed)
HTT-O-S Correlation Coefficient 0.21
Sig. (2 - tailed)
HTT-C-S Correlation Coefficient -0.10
Sig. (2 - tailed)
PE Correlation Coefficient -0.07
Sig. (2 - tailed)
PE-Q Correlation Coefficient 0.06
Sig. (2 - tailed)
SF Correlation Coefficient 0.17
Sig. (2 - tailed)
SM Correlation Coefficient 0.16
Sig. (2 - tailed)
190
Table 4
Variable PRN
FN-R Correlation Coefficient -0.09
Sig. (2 - tailed)
FN-L Correlation Coefficient 0.30
Sig. (2 - tailed)
DIA Correlation Coefficient 0.07
Sig. (2 - tailed)
DIA-NS Correlation Coefficient -0.18
Sig. (2 - tailed)
DIA-S Correlation Coefficient -0.23
Sig. (2 - tailed)
FTO-TS Correlation Coefficient 0.04
Sig. (2 - tailed)
FTO-NS Correlation Coefficient -0.04
Sig. (2 - tailed)
191
Table 4
Variable PRN
FTO-S Correlation Coefficient 0.28
Sig. (2 - tailed)
SAT Correlation Coefficient 0.08
Sig. (2 - tailed)
SCPNT Correlation Coefficient 0.62
Sig. (2 - tailed) 0.003**
JJ-L Correlation Coefficient -0.03
Sig. (2 - tailed)
JJ-P Correlation Coefficient 0.004
Sig. (2 - tailed)
JJ-10 Correlation Coefficient 0.05
Sig. (2 - tailed)
JJ-T Correlation Coefficient -0.07
Sig. (2 - tailed)
Note: H T T -0 = H eel-to-toe, eyes open, firm surface; HTT-C = Heel-to-toe, eyes closed, firm surface; HTT-O-S = Heel-to-toe, eyes
open, soft surface; HTT-C-S = Heel-to-toe, eyes closed, soft surface; PE = Prone extension; PEQ = Prone extension quality; SF =
Supine flexion; SM = Slow m otions; FN-R = Finger-to-nose, right; FN-L = Finger-to-nose -le ft; DIA = Diadochokinesis total score;
D1A -N S = Diadochokinesis, no stress condition; DIA-S = Diadochokinesis -stress condition; FTO-TS = Finger-to-thum b opposition,
total score; FTO-NS = Finger-to-thum b opposition, non stress condition; FTO-S = Finger-to-thumb opposition, stress condition; SAT
192
= M odified Schilder’s arm extension test; SCPNT = Southern California postrotary nystagmus test; JJ-L = Jum ping jacks, learning
phase score; JJ-P = Jum ping jacks -perform ance phase score; JJ-10 = N um ber o f jum ping jacks in 10 seconds; JJ-T = Jum ping jacks,
total score; SV = Space visualization; FG = Figure ground perception; M FP = Manual form perception; KIN = Kinesthesia; FI =
Finger identification; GRA = Graphesthesia; LTS = Localization o f Tactile Stimuli; PVC = Praxis on verbal com mand; OPR = Oral
praxis; SPR = Sequencing praxis; BM C = Bilateral m otor coordination; SWB = Standing and walking balance; MAC = M otor
accuracy; PRN= Postrotary nystagmus.
*p < .05. = *Correlation is significant at the 0.05 level (2 -tailed); ** p <.01. = Correlation is significant at the 0.01 level (2 -tailed).
193
APPENDIX F
Table 17
Southern California Postrotary Nystagmus Test (SCPN) and Jumping Jacks, Total Score
And the Variability o f Space Visualization (SV)
Source DF Sum Mean F Value PR > F

Squares Square
Model 2 16.31401 8.15700 13.92 0.0002
Error 18 10.54897 0.58605
Table 17 (Cont.)
Southern California Postrotary Nystagmus Test (SCPN) and Jumping Jacks, Total Score
(JJ-T) And the Variability o f Space Visualization (SV)
Variable Parameter Standard Type II SS F Value PR> F

Estimate Error
Intercept 2.11987 0.62962 6.64352 11.34 0.0034
SCPNT 1.42593 0.29732 13.48034 23.00 0.0001
JJ-T 0.54943 0.17081 6.06377 10.35 0.0048
194
Table 18
Heel-to-toe eyes open soft surface (HTT-O-S), Prone Extension Quality (PEQ) and
Finger-to-thumb Opposition Total Score (FTO-TS) And the Variability o f Design
Copying
Source DF Sum Mean F Value PR>F

Squares Square
Model 3 21.06689 7.02230 7.09 0.0027
Error 17 16.84503 0.99088
Corrected 20 37.91191
Total
Table 18 (Cont.)
Heel-to-toe eyes open soft surface (HTT-O-S), Prone Extension Quality (PEQ) and
Finger-to-thumb Opposition Total Score (FTO-TS) And the Variability o f Design
Copying
Variable Parameter Standard Type II SS F Value PR > F

Estimate Error
Intercept -0.59626 0.78159 0.57669 0.58 0.4560
HTT-O-S -0.92183 0.32318 8.06187 8.14 0.0110
PEQ -1.28225 0.30261 17.79121 17.95 0.0006
FTO-TS 0.63193 0.25312 6.17585 6.23 0.231
195
Table 19
Finger-to- nose Right (FTN-R) and Left (FN-L) and the Variability o f Oral Praxis

Squares Square
Model 2 7.46504 3.73252 10.02 0.0012
Error 18 6.70682 0.37260
Total
Table 19 (Cont.)
Finger-to-nose Right (FN-R) and Left (FN-L) And the Variability o f Oral Praxis

Estimate Error
Intercept -0.68854 0.16386 6.57933 17.66 0.0005
FN-R 0.22010 0.09969 1.81613 4.87 0.0405
FN-L 0.28191 0.12114 2.01777 5.42 0.0318
Diadochokinesis Non stress (DIA-NS) the Southern California Postrotary Nystagmus
Test and the Variability o f Postrotary Nystagmus
Source DF Sum Mean F Value PR> F

Squares Square
Model 2 4.71208 2.35604 8.11 0.0031
Error 18 5.22724 0.29040
Total
Table 20 (Cont.)
Diadochokinesis Non stress (DIA-NS) the Southern California Postrotary Nystagmus
Test and the Variability of Postrotary Nystagmus

Estimate Error
Intercept 0.35025 0.42709 0.19531 0.67 0.4229
DIA-NS -0.17010 0.06590 1.93519 6.66 0.0188
SCPNT 0.66331 0.20437 3.05916 10.53 0.0045
197
Table 21
The Heel-to-toe Eyes Closed (HTT-C-S) Soft Surface and the Prone Extension and
The Variability o f Standing and Walking Balance
Source DF Sum Mean F Value PR> F

Squares Square
Model 2 12.26521 6.13261 7.76 0.0037
Error 18 14.22742 0.79041
Total
Table 21 (Cont.)
The Heel-to-toe Eyes Closed (HTT-C-S) Soft Surface and the Prone Extension and
The Variability o f Standing and Walking Balance

Estimate Error
Intercept -1.16648 0.57885 3.20979 4.06 0.0591
HTT-C-S -1.91364 0.52428 10.53039 13.32 0.0018
PE 1.10761 0.46176 4.54766 5.75 0.0275
Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.
198
Table 22
The Heel-to-toe Eyes Open Firm Surface (HTT-O) and the Finger-to-Thumb Opposition
Total Score (FTO-TS) and the Variability of the Graphesthesia

Squares Square
Model 2 11.82779 5.91390 7.24 0.0049
Error 18 14.70621 0.81701
Total
Table 22 (Cont.)
The Heel-to-toe Eyes Open Firm Surface (HTT-O) and the Finger-to-Thumb Opposition
Total Score (FTO-TS) and the Variability of the Graphesthesia

Estimate Error
Intercept 0.17163 0.74815 0.04300 0.05 0.8211
HTT-O -1.33692 0.48819 6.12726 7.50 0.0135
FTO-TS 0.73429 0.23149 8.22030 10.06 0.0053
199
Table 23
The Southern California Postrotary Nystagmus Test (SCPNT) and the Variability o f the

Squares Square
Model 1 12.50013 12.50013 11.65 0.0029
Error 19 20.38827 1.07307
Total
Table 23 (Cont.)

Estimate Error
Intercept 2.30326 0.79553 8.99503 8.38 0.0093
SCPNT 1.33827 0.3921 12.50013 11.65 0.0029
200
Table 24
The Slow Motions (SM) and the Variability o f the Sequencing Praxis

Squares Square
Model 1 5.50671 5.50671 833 0.0095
Error 19 12.56761 0.66145
Total
Table 24 (Cont.)
The Slow Motions (SM) and the Variability o f the Sequencing Praxis

Estimate Error
Intercept -0.27359 0.17797 15318 2.36 0.1407
SM 0.26817 0.09294 5.50671 8.33 0.0095
201
Table 25

Squares Square
Model 1 8.50620 8.50620 83)2 0.0107
Error 19 20.15406 1.06074
Total
Table 25 (Cont.)
The Southern California Postrotary Nystagmus Test (SCPNT )and the Variability o f the

Estimate Error
Intercept 1.91604 079094 6.22485 5.87 0.256
SCPNT 1.10396 0.38984 8.50620 8.02 0.0107
202
Table 26
The Finger-to-Nose and the Variability of the Localization of Tactile Stimuli (LTS)

Squares Square
Model 1 12.91009 12.91009 6.87 0.0168
Error 19 35.70851 1.87940
Total
Table 26 (Cont.)
The Finger-to-Nose Rigth (FN-R) and the Variability o f the Localization o f Tactile
Stimuli (LTS)

Estimate Error
Intercept -1.24404 0.34194 24.87699 13.24 0.0017
FN-R -0.51265 0.19560 12.91009 6.87 0.0168
203
Table 27
The Finger-to-Thumb Opposition Total Score (FTO-TS) and the Variability o f Figure
Ground

Squares Square
Model 1 5.00837 5.00837 5.35 0.0320
Error 19 17.77022 0.93527
Total
Table 27 (Cont.)
The Finger-to-Thumb Opposition Total Score (FTO-TS) and the Variability of Figure
Ground

Estimate Error
Intercept 1.29291 0.62660 3.98193 4.26 0.0530
FTO-TS 0.55954 0.24180 5.00837 5.35 0.0320
204
Table 28
The Southern California Postrotary Nystagmus Test (SCPNT) and the Variability o f '

Squares Square
Model 1 6.63670 6.63670 490 0.0394
Error 19 25.75820 1.35569
Total
Table 28 (Cont.)
The Southern California Postrotary Nystagmus Test (SCPNT) and the Variability of

Estimate Error
Intercept 1.53734 0.89417 4.00735 2.96 0.1018
SCPNT 0.97513 0.44073 6.63670 4.90 0.0394
205
Table 29
The Heel-to-toe Eyes Open Firm Surface (HT-O) and the Variability of Motor Accuracy

Squares Square
Model 1 5.91916 5.91916 4.63 0.0446
Error 19 24.31382 1.27967
Total
Table 29 (Cont.)
The Heel-to-toe Eyes Open Firm Surface (HT-O) and the Variability o f Motor Accuracy

Estimate Error
Intercept 1.91250 0.75955 8.11320 6.34 0.0209
HT-O 1.28282 0.59646 5.91916 4.63 0.0446
206
Table 30
The Finger-to-Nose Right (FN-R) and the Variability o f Postural Praxis

Squares Square
Model 1 4.25816 4.25816 4.49 0.0475
Error 19 18.01822 0.94833
Total
Table 30 (Cont.)
The Finger-to-Nose Right (FN-R) and the Variability o f Postural Praxis

Estimate Error
Intercept -0.85311 0.24289 11.69863 12.34 0.0023
FN-R 0.29442 0.13894 4.25816 4.49 0.0475
207
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A Correlational Study Between Structured Clinical Observations and The Sensory Integration and Praxis Test

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A CORRELATIONAL STUDY BETWEEN STRUCTURED CLINICAL

OBSERVATIONS AND THE SENSORY INTEGRATION AND PRAXIS TEST

Gustavo Alejandro Reinoso

Submitted in partial fulfillment o f the requirements for the degree o f

All rights reserved.

ProQuest Information and Learning Company

Ferol Menks Ludwig, PhD, OTR/L, FAOTA, GCG

Carol Niman Reed, EdD, OTR/L, FAOTA

Em a Imperatore Blanche, PhD, OTR/L, FAOTA

Chapter 2: Selected Review of the Literature.................................................................. 16

High R isk ......................................................................................................... 37

Chapter 3: Research Design and M ethodology................................................................ 81

Copyright Perm ission.............................................................................................................227

Table 3 Sample characteristics (Appendix D) p. 164

Table 4 Spearman Rho Correlation Coefficients among all dependent variables

Table 15 Total variance explained p. 112

Table 16 Rotated Component Matrix p. 114

Table 20 Diadochokinesis Non Stress (DIA-NS) the Southern California Postrotary

Introduction to the Chapter

Occupational therapists working within a sensory integration frame o f reference

often utilize a number o f assessment tools including standardized testing, questionnaires,

in a sample o f 21 children with sensory integration dysfunction.

hypotheses, limitations, definitions of terms, and a summary are presented.

Rationale and Need fo r the Study

In sensory integration, clinical observations are a group o f structured and

unstructured observations o f sensory processing and its effects on movement and

standardized measures were not appropriate.

data collected during an assessment. In contrast, the term “structured observations” is

means o f observations is often used as complementary information in the process of

performing different observations, as well as those with known or suspected dysfunctions

Analysis o f children’s performance on different structured observations is

child’s existing problems. Theorists have described the performance o f children in

different observations with movement components such as balance, postural control,

coordination, and skill development (Gregory-Flock &Yerxa, 1984; Shumway-Cook &

observations allows clinicians to hypothesize the nature o f a child’s problem. Thus,

structured observations may be interpreted according to sensory integration theory. These

interpretations guide further assessment and clinical reasoning during intervention.

pediatric occupational therapy to better understand how a group o f specific structured

The role o f different structured observations in identifying sensory processing

clinical practice to formally assess different sensory processing deficits in children

purposes o f comparison with the sample studied. Thus, a group of 10 structured

observations was selected.

in several studies to unravel the importance o f different structured observations as part of

sensory integrative framework. In addition, structured observations are also

recommended in most standardized pediatric occupational therapy assessments that

functional disorders in sensory processing (Parham & Mailloux, 1996). Sensory

integration takes into account an individual’s neurobiological ability to process and

Jean Ayres’s sensory integration theory is a developmental theory based on

principles o f phylogenetic and ontogenetic development as well as a hypothesized

development o f the sensory integrative process throughout life. Currently, pediatric

occupational therapists use a sensory integrative frame of reference with diverse

Numerous studies have described the increasing recognition and importance of

sensory processing and praxis in children’s performance o f occupations (Baranek et al.,

extent o f sensory processing deficits in children with several diagnoses. Furthermore,

and decreased occupational and functional performance.

as having difficulties related to sensory integration. Some researchers have mentioned 5%

(Mulligan, 1996; 2000).

their utilization recommended. Recent publications have carefully related different

observations to interpretations that guide clinician’s clinical reasoning during the

assessment and treatment of children with sensory integration dysfunction (Imperatore

on standardized testing. This is particularly useful for those situations in which

standardized procedures may not be practical.

Statement o f the Problem