Clinical and Experimental Optometry

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Visual-perceptual function of children using the

developmental test of visual perception-3

A Valarmathi, Kalpana Suresh, Lakshmi Venkatesh & Santhanam T

To cite this article: A Valarmathi, Kalpana Suresh, Lakshmi Venkatesh & Santhanam T (2021):
Visual-perceptual function of children using the developmental test of visual perception-3, Clinical
and Experimental Optometry, DOI: 10.1080/08164622.2021.1878823

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Published online: 28 Feb 2021.

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CLINICAL AND EXPERIMENTAL OPTOMETRY
https://doi.org/10.1080/08164622.2021.1878823

RESEARCH

Visual-perceptual function of children using the developmental test of visual

perception-3
a
A Valarmathi , Kalpana Sureshb, Lakshmi Venkateshc and Santhanam Td
a
Department of Optometry, Sri Ramachandra Institute of Higher Education and Research, Chennai, India; bKalpana Eye Care, Chennai, India;
c
Department of Speech, Language and Hearing Sciences, Sri Ramachandra Institute of Higher Education and Research, Chennai, India; dSDS
Institute of Behavioral Sciences, Chennai, India

ABSTRACT ARTICLE HISTORY

Received 20 April 2020
Clinical relevance: The development of region-specific norms for the Developmental Test of Visual Revised 29 October 2020
Perception, third edition (DTVP-3), from a group of children from South India will contribute to the Accepted 3 December 2020
assessment of visual-perceptual skills in children.
KEYWORDS
Background: Visual-perceptual skills are crucial for children to understand their environment, per­ Developmental normative
form activities of daily living, and cope with their learning environment. These perceptual skills also values; eye-hand
influence children’s behavioural characteristics. Well-constructed, norm-referenced standardised coordination; visual motor;
tools are vital for assessing visual-perceptual skills. Since ethnicity and cultural background may visual perception; DTVP
influence the performance of perceptual tasks, the proposed norms for any assessment tool need to
be validated for specific populations. Hence, the current study aimed to develop norms in the Indian
context for the Developmental Test of Visual Perception, third edition (DTVP-3), and compare the
obtained norms with the norms established in the United States of America.
Methods: One hundred and thirty-seven healthy children (mean age: 9.5 ± 1.7 years, range:
7-12 years, 67 females) participated in the study. Visual-perceptual functions including eye-hand
coordination, copying, figure-ground, visual closure, and form constancy, were assessed and com­
pared with age-matched norms provided in the test manual. Internal consistency of DTVP-3 was
evaluated using Cronbach’s Alpha correlation coefficients.
Results: Significant differences were observed between the study groups and the given norms for
assessment of the abilities of eye-hand coordination, copying skills and visual figure-ground
(p < 0.05). No significant difference was found for visual closure and form constancy subtests.
Cronbach’s alpha coefficients for the five subtests ranged from 0.70 to 0.91 while the composite
indexes had coefficients from 0.90 to 0.93.
Conclusion: The DTVP-3 showed acceptable limits of internal consistency when tested in a group of
children from South India. Region-specific norms need to be used for each of the subtests.

Introduction assessment of visual-perceptual skills.7–11 These tools enable

Perception is the process by which sensory stimuli can be
recognised and interpreted. Visual perception is the ability to
interpret visual information from the surroundings and make
sense of what is seen. Children with visual-perceptual deficits
may exhibit reduced physical (e.g., ball catching) and aca­
demic performance. They may also display challenging
behaviours.1 Thus, we depend on vision for our day to day
activities. Visual-perceptual skills also vary with different
types of disabilities.2,3 The ability to interpret sensory infor­
mation also depends on the individual’s cognitive processes
and prior knowledge.4,5
Assessing visual-perceptual skills is an integral part of
paediatricthe eye examination, though not routinely followed
in most eye clinics.6 A systematic approach is required to
ascertain visual-perceptual skills,2 and in the absence of
such information, it would be challenging to help children
progress in their activities of daily living or improve perfor­
mance in school.3
Well-constructed, norm-referenced, standardised tools
such as the test of visual-perceptual skills (TVPS), Beery-
Bucktenica visual-motor integration (Beery VMI), and motor-
free visual-perceptual tests (MVPT), are available for
measurement and reporting of visual-perceptual skills with
such confidence that the results can be interpreted mean­
ingfully even when tests are repeated multiple times.
However, these tests independently measure either visual-
motor skills or motor-reduced visual-perceptual skills. A tool
that looks at both these aspects would be ideal for assessing
young children. It is also essential to know that observations
made by an optometrist must withstand critical analyses by
the multidisciplinary team. Therefore, it is vital to identify
deficits accurately using appropriate tools and plan early
interventions to remediate deficits, if any.
The Developmental Test of Visual Perception – third edi­
tion (DTVP-3)12 is one such tool published in 2014. The tool
was developed to identify visual-motor integration and
visual-perceptual skills of children aged 4 to 12 years. DTVP-
3 consists of five subtests that measure both visual-motor
integration and motor-reduced visual perception.12 Eye-hand
coordination and copying subtests measure visual-motor
integration skills; motor-reduced visual perception can be
assessed by the figure-ground, visual closure and form con­
stancy subtests. Development of the tool ensured adequate
standardisation in terms of procedure, the inclusion of

CONTACT A. Valarmathi valarmathiarun@sriramachandra.edu.in Department of Optometry, Sri Ramachandra Institute of Higher Education and Research,
Porur, Chennai, India
© 2021 Optometry Australia
2 A. VALARMATHI ET AL.
participants, reliability, and validity measures. The normative
data were also derived from a sizeable sample that consisted
of at least 100 children in each age interval.13 Further, test
developers evaluated standard error of measurement of the
tool, which ensures that scores obtained are reflections of the
real performance of the participant and not due to chance or
error.13 DTVP-3 was normalised on the American population,
73% of participants being white, 14% black/African American,
and 6% Asian or Pacific Islanders. The remaining 7% of parti­
cipants were from two or more ethnicities or other ethnicities.
The percentages were reported to be representative of the US
population in the age range of four to 12 years.
Since the development of the tool in 2014, the test has
been reliably used in several research investigations aimed at
assessing visual-perceptual skills of specific populations. The
tool has been validated against other tools like the Beery–
Buktenica Developmental Test of Visual-motor Integration
sixth edition (Beery VMI-6) and the Test of visual-perceptual
skills (TVPS-3).14 Apart from determining the severity of
visual-motor integration or visual perception problems, the
tool can successfully capture changes in visual perception
abilities after suitable interventions.12
Visual perception is known to vary based on cultural con­
texts and also for each target being presented.15–17 Cross-
cultural differences in visual-perceptual skills exist among
children from different cultures; when administered to chil­
dren from different regions, these assessment tools can iden­
tify differences and gaps between people from different
cultures.18
The current study was designed to investigate the internal
consistency of DTVP-3 when administered to typically devel­
oping South Indian children aged seven to 12 years of age
and compare the study group’s performance with normed
population scores. We recognise that the data are not truly
comparable; however, a comparison is made in the current
study to show cross-cultural differences, if any, in the data,
and the need to gather culture-specific norms for such assess­
ment tools.
Method
A cross-sectional, non-experimental research design was used
for this study, involving one group of participants completing
the DTVP-3. Based on an earlier study,11 assuming mean and
standard deviation with the absolute precision of 4% and
95% confidence interval, the sample size was calculated to
be 137 samples.
One hundred and thirty-seven healthy children who vis­
ited the paediatric optometry outpatient department of Sri
Ramachandra Institute of Higher Education and Research
(SRIHER) from January 2018—December 2018 were recruited
for the study. The sample comprises 67 females and 70 males.
The age of the participants ranged from seven years, one
month to 12 years, 11 months, the average age of the sample
being 9.5 ± 1.7 years. Table 1 shows the sample by age group.
Only children with no known history of physical, physiologi­
cal, psychosocial, developmental, or neurological disorders or
disabilities were included in the study. Those with visual
acuity better than or equal to 6/9 and N6, for distance and
near vision, respectively, in both eyes were included in the
study. Children with low binocular vision were identified and
excluded from the study after performing a minimum battery
of tests to identify binocular vision anomalies as described in
Table 1. Demographic characteristics as stratified by age in years.
Gender
Female Male
Age n n % n %
7 31 18 58.1 13 41.9
8 23 13 56.5 10 43.5
9 24 14 58.3 10 41.7
10 23 11 47.8 12 52.2
11 16 3 18.8 13 81.3
12 20 8 40.0 12 60.0
Total 137
an earlier study.19 Children who were unable to follow and
perform the test as per instructions were also excluded from
the study.
The study conformed to the Declaration of Helsinki and
was approved by the Institutional Ethics Committee of the
Institute. Informed consent was obtained from the parents,
and verbal assent was taken from the participants. Parents
completed a questionnaire that elicited demographic data
including the child’s date of birth, gender, name of the
school, grade currently attending, and a series of questions
to understand the developmental stages and academic per­
formance of the participants. All the study participants under­
went a detailed ophthalmic examination that included visual
acuity assessment done monocularly using logMAR chart,
refraction, extraocular motility testing, examination of ocular
alignment, anterior and posterior segment evaluation. DTVP-
3 was administered in a quiet room with the children wearing
their best-corrected glasses. An attempt was made to follow
the same procedure for testing as detailed in the test manual
under ‘basic testing procedure’.12 A well-ventilated, well-
illuminated and distraction-free environment was chosen to
administer the DTVP-3. The examiner established rapport
with the child during the preliminary examination. The exam­
iner monitored the level of alertness and fatigue of the child
during the testing and allowed for breaks if the child demon­
strated signs of tiredness or loss of interest in the testing.
Children were reinforced by verbal praise and encourage­
ment. No prompts were provided during the testing. The
order of administration of subtests was the same as in the
original study, in the following order: 1) Eye-hand coordina­
tion, 2) Copying, 3) Figure-ground, 4) Visual closure, and 5)
Form constancy.
Demographic data and the scores of DTVP—3 were ana­
lysed using Statistical Package for the Social Sciences (SPSS
version 16). Independent t-test was done to compare means
of the DTVP—3 subtests of the study population and the
normed population. Cronbach’s alpha correlation coefficients
were used to assess the internal consistency of various subt­
ests of DTVP-3.
Results
Overall raw score mean and standard deviation for the five
subtests and the composite scores are presented in Table
2 and also elaborated for each age group in Table 3. The
values of means of the study population and the normed
population were compared to understand the difference.
Comparison between subtests of visual-motor integration
skills is shown in Table 4 for each age group. Comparison
between subtests of motor-reduced visual perception
skills is shown in Table 5 for each age group. The mean
 CLINICAL AND EXPERIMENTAL OPTOMETRY 3

Table 2. Descriptive statistics for DTVP-3 (n = 137). Discussion

Test Mean SD†
Visual-motor integration skills refer to the ability to receive,
DTVP-3 subscales
Eye–hand coordination 188.49 4.35 recognise, analyse, and elaborate on any given visual
Copying 40.52 7.49 stimulus.9 Average raw score means of visual-motor integra­
Figure-ground 38.50 8.03
tion subtests of the study population were compared with
Visual closure 14.33 3.47
Form constancy 36.13 8.27 the normed data for all age groups. South Indian children
DTVP-3 Composites outperformed their western peers on both the subtests of
Visual-motor integration 229.00 9.48
eye-hand coordination and coping skills.
Motor-reduced visual perception 88.96 16.30
† This result may be attributed to children beginning their
SD: standard deviation
pre-schooling and kindergarten considerably earlier in India
than their peers in western countries. Pre-schooling in India
and standard deviation values have been rounded off, in starts as early as two years of age and kindergarten starts
line with the representation of data in the DTVP-3 manual. around three years of age, where children learn to read and
Children in the study population demonstrate significantly write alphabets and numbers. In contrast, children from wes­
higher scores in comparison to the normed population on tern countries typically enter kindergarten after completing
visual-motor integration skills, both eye-hand coordination five years.20,21 Chinese children were also found to have much
and copying skills (p < 0.05). higher levels of performance in visual-motor abilities than
In contrast, children in the study population per­ children in the United States.16 Chinese children use chop­
formed significantly lower in comparison to the normed sticks to eat as early as four years of age, where they receive
population on motor-reduced visual-perceptual skills of opportunities to develop visual-motor abilities at a much
figure-ground perception. However, the groups did not younger age, influenced by their culture.15
differ on visual closure and form constancy subtests. The Motor reduced visual perception was assessed using three
internal consistency of each subtest of the DTVP-3 and subtests. Figure-ground describes how a visual scene is sim­
among the three composite indices is presented in plified and perceived when children are required to detect
Table 6. figures against confusing backgrounds.12 Children in the

Table 3. Descriptive statistics for DTVP-3 for each age group of the study population (n = 137).
Age in years
Subtests 7 8 9 10 11 12
Eye–hand coordination
Mean 186.35 187.70 188.21 189.35 190.38 190.55
SD† 3.65 5.32 5.55 2.69 3.09 3.44
Range 15 20 25 11 12 14
Quartiles 186,188,189 188,189,191 187,190,191 188,190,192 190,192,192 191,192,192
Copying
Mean 35.87 36.65 41.54 42.65 43.75 45.90
SD 8.24 6.85 6.14 6.97 4.63 4.67
Range 32 26 24 30 15 17
Quartiles 31,37,42 31,37,42 38,41,45 39,44,48 41,45,48 44,48,49
Figure-ground
Mean 32.16 35.04 37.96 40.30 42.75 47.45
SD 4.74 8.16 7.26 5.64 6.23 5.81
Range 16 23 26 23 22 19
Quartiles 30,32,36 27,33,45 33, 38.45 39,41,42 38,45,47 43,47,53
Visual closure
Mean 11.77 13.13 14.25 15.22 16.13 17.30
SD 2.64 2.72 3.33 3.70 2.63 2.54
Range 10 9 12 12 12 8
Quartiles 9,12,14 10,13,16 11,16,17 11,15,18 15,16,17 16,17,20
Form constancy
Mean 30.32 32.13 34.67 38.70 42.06 43.80
SD 4.66 9.03 6.86 7.64 5.63 5.87
Range 16 33 23 34 25 28
Quartiles 25,32,34 25,35,38 31,35,41 35,40,44 40,43,45 42,46,47
†
SD: standard deviation

Table 4. Raw score means and standard deviation with age for visual-motor integration subtests of DTVP-3 between the study population (SP) and normed
population (NP) for the six age intervals (Rounded value).
EHC†_SP EHC_NP CO‡_SP CO_NP
Age in years M(SD) M(SD) t-statistic p-value M(SD) M(SD) t-statistic p-value
7 186(4) 166(19) 6.350 < 0.0001 36(8) 24(6) 9.924 < 0.0001
8 188(5) 174(17) 3.651 0.0004 37(7) 26(6) 7.504 < 0.0001
9 188(6) 177(14) 3.786 0.0002 42(6) 29(6) 9.846 < 0.0001
10 189(3) 179(14) 3.397 0.0009 43(7) 30(6) 9.031 < 0.0001
11 190(3) 183(10) 2.501 0.0138 44(7) 32(5) 7.763 < 0.0001
12 191(3) 184(9) 3.430 0.0008 46(5) 33(6) 9.071 < 0.0001
†
Eye-hand coordination
‡
Copying
4 A. VALARMATHI ET AL.

Table 5. Raw score means and standard deviation with age for motor-reduced visual perception subtests of DTVP-3 between the study population (SP) and
normed population (NP) for the six age intervals (Rounded value).
FG†_SP FG_NP VC‡_SP VC_NP FC§_SP FC_NP
Age (years) M(SD) M(SD) t-statistic p-value M(SD) M(SD) t-statistic p-value M(SD) M(SD) t-statistic p-value
7 32(5) 45(10) 7.629 < 0.0001 12(3) 12(4) 0.000 1.000 30(5) 32(7) 1.623 0.1066
8 35(8) 47(10) 5.131 < 0.0001 13(3) 14(4) 1.074 0.2844 32(9) 33(8) 0.514 0.6076
9 38(7) 50(9) 6.228 < 0.0001 14(3) 15(4) 1.171 0.2431 35(7) 36(8) 0.577 0.5645
10 40(6) 51(10) 5.052 < 0.0001 15(4) 16(4) 1.077 0.2838 39(8) 36(8) −1.615 0.1089
11 43(6) 52(8) 3.912 0.0002 16(3) 17(3) 1.132 0.2601 42(6) 39(7) −1.476 0.1427
12 47(6) 53(8) 3.176 0.0019 17(3) 18(3) 1.361 0.1762 44(6) 44(7) 0.000 1.0000
†
Figure ground
‡
Visual closure
§
Form constancy

Table 6. Internal consistency results of DTVP-3 (n = 137).

# of items Cronbach’s Alpha
DTVP—3 Subscales
Eye–hand coordination 60
Copying 18
Figure-Ground 23
Visual Closure 26
Form Constancy 24
DTVP-3 Composite Index
Visual motor integration 78
Motor reduced visual perception 73
General visual perception 151
study population performed significantly lower in compari­
son to the normed population on figure-ground perception
skills. According to Nisbett and Miyamoto,22 Westerners typi­
cally follow an analytical style, whereas East Asians follow
holistic style. As a result, Westerners are more focused and
place less emphasis on background or context information,
whereas East Asians attend to the relationship between
objects and context information in a visual scene.22 This
difference in processing style may contribute to the differ­
ence in performance on visual figure-ground between the
two groups of children.
The visual closure subtest represents the ability to visualise
a complete target when only part of it is shown, and the form
constancy subtest requires a mental manipulation of the
forms and their outcomes.7 In both these subtests, the
study population and the normed population seemed to
possess similar exposures. In western countries, primary
school education focuses on introducing children to a broad
range of knowledge that includes learning basic
Mathematics, English proficiency, science, social studies, phy­
sical development, and fine arts.21 Similar exposure is pro­
vided in the Indian system of education, and hence
differences in performance were not noted among visual
closure and form constancy subtests.
Internal consistency of the tool was also established by
determining the Cronbach’s alpha correlation coefficients.
In the current study, Cronbach’s alpha coefficients ranged
from 0.702 to 0.913 for the subtests, and alpha ranged
from 0.886 to 0.932 for the composites. Alpha values in
the range of 0.60 to 0.80 were reported in a study where
DTVP-3 was administered on a subgroup of Australian
children.11 Alpha limits of the normed population too
ranged from 0.80 to 0.90 for the subtests and 0.92 to
0.95 for the composites.12 Alpha values from 0.70 to 0.95
are acceptable limits.23,24 Alpha limits of the current study
are in the acceptable to excellent limits of internal con­
sistency. Coefficient alphas for the composites are particu­
larly encouraging as they are indicating near-perfect
reliability.
This study was conducted in only one State of India,
namely, Tamilnadu; hence, the results may be associated
0.846 with geographical bias. Second, the representative sample
0.913 in each age interval is not uniform and in some age intervals,
0.841
0.702 there were fewer participants since children presenting to the
0.900 clinic during the study period, of that particular age interval,
were less. As there were no follow up visits with the children,
0.886
0.914 test–retest reliability was not established in this study. Future
0.932 studies can focus on re-administering the test to the same
population. Further research using multi-centred trials may
include representations from varied geographical areas. The
study should also be extended to children with special needs.
The tool could also be used to determine the effect of an
intervention.
Conclusion
In summary, this study established superior visual-motor inte­
gration skills among children in the age group seven to
12 years, from South India when assessed using DTVP-3.
However, significant differences did not exist in the case of
motor-reduced visual perception between the study popula­
tion and the normed population. Cultural variations influence
these differences; hence, it is necessary to be aware of the
differences to understand or interpret performances. Indeed,
visual-perceptual skills influence an individual’s functional
and academic performance, thus supporting routine use of
these tools in optometric practice. The current study provides
preliminary evidence for the feasibility of administering
DTVP-3 on children from South India.
Acknowledgements
The authors express sincere gratitude to the children and their parents
for their participation in the study.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
A Valarmathi http://orcid.org/0000-0002-1234-5466
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