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PART

III

Tools for Assessment

208

CHAPTER

8

Assessment of Sensory

Integration Functions Using

the Sensory Integration

and Praxis Tests

 Shelley Mulligan , PhD, OTR/L, FAOTA

 Chapter 8

 The Sensory Integration and Praxis Tests (SIPT) help us to understand why

some children have diffi culty learning or behaving as we expected . . . they

. . . evaluate some important abilities needed to get along in the world.

 —A. Jean Ayres

Upon completion of this chapter, the reader will be able to:

✔ Describe the utility of the Sensory Integration

and Praxis Tests (SIPT) for clinical practice.

✔ Explain the fi ndings of factor and cluster

analyses completed on the SIPT and how this

information supports the assessment process.

✔ Defi ne the role of the SIPT as part of a

comprehensive assessment for children with

suspected sensory integrative diffi culties.

LEARNING OUTCOMES

Purpose and Scope

 The Sensory Integration and Praxis Tests (SIPT)

are designed primarily to examine aspects of

sensory discrimination and praxis. They are

intended to be used as part of an overall evaluation process for school-aged children who

experience diffi culties in these areas that impact

occupational performance and participation.

This chapter offers a brief introduction to this

test battery and guides readers to understand the

various factor and cluster analyses that form the

foundation for identifying sensory integrative

strengths and weaknesses in children. A great

deal more detail on the SIPT can be found in

the test manual ( Ayres, 2005 ), and that information is not repeated in this chapter. Because it is

crucial that the SIPT not be used in isolation, discussion is included here regarding integration of

this tool with other assessments and observations

that complete the picture. We present an analysis

model that has been used in certifi cation courses

as a way to organize the assessment process. To

illustrate this assessment process, a case study is

presented.

Description and Purpose

of the Sensory Integration

and Praxis Tests

 Standardized assessment tools specifi cally

designed to evaluate sensory processing and

CHAPTER 8 Assessment of Sensory Integration Functions Using the Sensory Integration and Praxis Tests ■ 209

integration are important for identifying whether

sensory processing problems are present and

interfering with a child ’ s occupational performance. Such tools provide objective data for

determining the types or patterns of sensory

integration (SI) dysfunction that exist as well as

the extent or severity of the dysfunction. This

information is integral for guiding the intervention planning process, and it is helpful for justifying the need for occupational therapy services

using an SI approach. Such standardized testing

may also be used to evaluate the effectiveness of

intervention programs designed to improve SI

functions in children.

 The most psychometrically sound, standardized, performance-based assessment tool available to measure SI functions is the SIPT ( Ayres,

 2005 ). Therefore, this section of the chapter is

devoted to content describing the SIPT and how

the test is used in the context of comprehensive

occupational therapy evaluations of children following an SI approach.

 The SIPT is comprised of 17 tests, is normreferenced, and was designed for children from

4 years 0 months of age to 8 years 11 months of

age who are suspected of having a sensory integrative disorder. Each of the tests is individually

administered, and the entire battery takes approximately 1.5 to 2 hours to administer. Completion

of advanced training through the Comprehensive

Training and Certifi cation Program offered by

Western P s ychological Services/University of

Southern California (see http://chan.usc.edu/academics/usc-wps-certifi cation ) has been expected

for therapists wishing to learn and use the SIPT.

The SI functions measured by the SIPT can be

categorized into four overlapping areas:

 1. Visual form and space perception

 2. Tactile discrimination

 3. Praxis (various forms)

 4. Vestibular and proprioceptive processing

 A brief description of each test by group is

shown in Table 8-1 . In consideration of the

model of SI dysfunction presented in Figure 1-6 ,

it is important to recognize the facets of the

model that are and are not addressed by the

SIPT. Indicators of poor SI and praxis are well

captured by the SIPT including some aspects of

postural-ocular control, visual-motor control,

and, to a lesser extent, body percept or kinesthesia. These defi cits may result in either (or both) of

two common patterns of dysfunction: VestibularBilateral Integration and Sequencing (VBIS) disorder, and Somatopraxis, which is dyspraxia with

an underlying somatosensory basis. Processing

and sensory discrimination functions related to

the visual, tactile, proprioceptive, and vestibular

systems are addressed by the SIPT, although the

test does not address the processing of auditory,

olfactory, and gustatory sensory input. Sensory

modulation including sensory responsivity is also

not directly measured by the SIPT. It is, however,

important to note that clinical observations made

during the administration of the SIPT are very

useful for capturing aspects of sensory modulation, as well as for identifying some functional

or occupational performance challenges and

behavioral consequences of sensory processing

defi ciencies that might exist.

 The SIPT provides z-scores for each of the

17 tests, and scores falling within 1 standard

deviation from the mean are interpreted as being

within the normal range ( Ayres, 2005 ). Each of

the 17 tests was shown to discriminate between

children with SI problems and those without,

using 1 standard deviation below the mean as

the criteria for performance that would be considered below average ( Ayres, 2005 ). The SIPT

was normed using approximately 2,000 North

American children who were representative at

the time of U.S. population characteristics and

distribution in terms of race, gender, and geographic location, as well as urban and rural representation. There are separate norms for boys

and girls, and there are 12 age groups. Children

4 to 5 years of age are divided by 4-month intervals, whereas children 6 through 8 years of age

are divided by 6-month intervals.

 In addition to using the SIPT z-scores from

each of the tests to interpret a child ’ s SI performance and dysfunction, a number of other

data sources are available and should be used to

assist in the interpretation process. The SIPT is

a well-researched tool, and many multivariate

factor analytic studies and cluster analyses have

been completed with its tests ( Davies & Tucker,

 2010 ). These studies have contributed to the

establishment of construct validity of the SIPT

(discussed in more detail next) and are useful

in the interpretation process for identifying

specifi c patterns of SI dysfunction seen in individual children. The test manual ( Ayres, 2005 )

describes many of the factor analyses that were

210 ■ PART III Tools for Assessment

TABLE 8-1 Functions Measured by SIPT

PRIMARY DOMAIN TEST DESCRIPTION

Visual Form and

Space, Visual-Motor

Coordination;

Visuopraxis

Space Visualization (SV)

Figure Ground (FG)

Design Copying (DC)

Constructional Praxis (CPr)

Motor Accuracy (MA)

Motor-free visual form and motor coordination; mental

manipulation of objects

Perception and location of fi gures on a rival background

Copying simple and complex two-dimensional designs;

approach for copying

Block construction; ability to relate objects to one

another in three-dimensional space

Eye-hand coordination, tracing, motor control

Tactile Perception

and Discrimination

Finger Identifi cation (FI)

Localization of Tactile Stimuli

(LTS)

Graphesthesia (GRA)

Manual Form Perception

(MFP)

Discrimination of touch to individual fi ngers

Perception of location of tactile stimuli applied to the

forearm and hand

Perception and replication of designs drawn on the back

of the hands

Stereognosis; matching a shape held in one hand with

a visual counterpart or with another shape felt by the

other hand

Praxis Bilateral Motor Coordination

(BMC)

Sequencing Praxis (SPr)

Postural Praxis (PPr)

Oral Praxis (OPr)

Praxis on Verbal Command

(PrVC)

Sequencing and moving both hands and both feet in

smooth patterns

Imitating motor sequences of hands and fi ngers

Imitating, planning, and executing static body postures

Imitating, planning, and executing oral motor

movements of the lip, tongue, and jaw

Planning and executing static body postures from verbal

directions

Vestibular and

Proprioceptive

Processing

Kinesthesia (KIN)

Standing and Walking

Balance (SWB)

Post-Rotary Nystagmus (PRN)

Perception of passive hand and arm movements

Static and dynamic balance on one or both feet, with

eyes open and closed

Duration of the vestibular-ocular refl ex following rotation

done during the development of SIPT as well as

much later ( Mulligan, 1998 ); the manual also

details how this research can be used to assist

in the interpretation process. The SIPT report

also generates a statistic called a D-squared

index value that indicates how closely the child ’ s

scores fi t each of six cluster groupings. The

cluster groupings represent patterns of SI functioning that were found during the development

of the test. Therefore, interpreting SIPT scores is

a complex process using multiple data sources

from the test itself as well as considering other

sources of evaluation data, such as information

from occupation-based assessments, parent interviews, and clinical observations. Further information on how SIPT data is synthesized with

other data sources to complete comprehensive

evaluations of children is provided later in this

chapter, following a review of the validity and

reliability of the SIPT. It is also touched on in

 Chapter 11 (Interpreting and Explaining Evaluation Data), relative to the interpretation of evaluation fi ndings.

HERE ’ S THE POINT

• Aside from the SIPT ( Ayres, 1989, 2005 ),

there are few objective standardized

assessment tools for measuring SI functions

in children.

• The SIPT is especially useful for identifying

deficits with visual form and space perception,

tactile discrimination and praxis, and for

identifying specifi c patterns of SI dysfunction.

CHAPTER 8 Assessment of Sensory Integration Functions Using the Sensory Integration and Praxis Tests ■ 211

• Administration of the SIPT, in conjunction

with data gathered from caregiver interviews,

informal and structured clinical observations,

and inventories or questionnaires for

quantifying behaviors associated with

sensory processing and modulation, provide

comprehensive evaluations of sensory

processing and integration.

Validity and Reliability

of the Sensory Integration

and Praxis Tests

 Validity

Validity is the ability to draw meaningful inferences from test scores for an intended purpose,

and it refl ects the extent to which a test measures

the construct(s) it intends to measure. SI functioning is a complex, multidimensional construct

that can be inferred only by behaviors that can

be observed, which makes validity evidence for

the SIPT especially important. The test manual

( Ayres, 2005 ) provides an abundance of research

supporting the tests’ validity, which will be summarized only briefl y here.

 The SIPT evolved through decades, and it was

the result of a revision of an earlier, 12-subtest

version of the test battery, titled the Southern

California Sensory Integration Test (SCSIT;

 Ayres, 1972 ). Content included in the SIPT was

based on a review of test items by experts in the

fi eld, with consideration of literature supporting

the neurological basis for SI processes, as well

as by data-driven methods, such as factor and

cluster analyses. Whereas factor analyses group

tests together, cluster analyses group individuals

with similar patterns of scores. Factor analyses

conducted from the mid-1960s through 2011

used subsets of the tests as well as the entire

battery (both the SIPT and its earlier version);

results revealed several fairly consistent factors

representing patterns of SI dysfunction. These

patterns have included:

• Somatodyspraxia, a pattern with low

performance on measures of tactile and

proprioceptive functions and low praxis or

motor planning scores ( Ayres, 1969, 1977,

1989 ; Mailloux et al., 2011 )

• Visual form and space pattern with low

scores on visual perceptual, visual-motor, and

visual construction tasks ( Ayres, 1969, 1972,

1977, 1989 ; Mailloux et al., 2011 ; Mulligan,

 1998 )

• Sensory modulation defi cits include underand over-responsivity to sensory stimuli and

fl uctuating responses. These responses are

often also seen with challenges regulating

behavior. The challenges are refl ected in

behaviors such as hyperactivity, sensory

craving or seeking, avoidance behaviors,

and distractibility. ( Ayres, 1969, 1972, 1977 ;

 Mailloux et al., 2011 )

• Vestibular processing, with postural-ocular

problems, and bilateral integration and

sequencing (BIS) defi cits ( Ayres 1969, 1972,

1977, 1989 ; Mailloux et al., 2011 ; Mulligan,

 1998 )

 Three studies using factor analysis conducted during the development of the SIPT are

described in detail in the SIPT manual ( Ayres,

 1989, 2005 ). One study used a sample of children who were developing typically, one used a

sample of children with learning or sensory integrative dysfunction, and the third study used a

combined sample of children with and without

learning or SI dysfunction. Scores from the children who were developing typically suggested

four factors—somatopraxis, visuopraxis, vestibular processing, and somatosensory processing—

and a kinesthetic-motor factor. When SIPT

scores from a sample of children with learning

and SI disorders were considered, fi ve factors

emerged, including somatopraxis, somatosensory, and visuopraxis, as was seen with the

normative sample. In addition, a pattern of

BIS emerged, along with a pattern of Praxis on

Verbal Command (very low scores on the Praxis

on Verbal Command test with moderately high

scores for Post-Rotary Nystagmus). Mulligan

 ( 1998 ) conducted factor analyses on a sample of

more than 10,000 children tested with SIPT. She

found similar patterns of SI dysfunction, including BIS defi cits, somatosensory processing problems, visual perception issues, and dyspraxia. In

addition, Mulligan ’ s results showed that the four

patterns of dysfunction were highly correlated,

suggesting an underlying encompassing disorder, perhaps representing sensory integrative

disorder. Most recently, Mailloux and colleagues

 ( 2011 ) conducted a factor analysis with a clinical sample of 425 children using SIPT scores

212 ■ PART III Tools for Assessment

as well as a measure of sensory modulation,

including attention and tactile defensiveness.

The four factors or patterns emerging from this

study were quite consistent with the fi ndings of

previous studies, and they included the following

patterns: Dyspraxia; Vestibular/Proprioceptive

Bilateral Integration and Sequencing; Tactile and

Visual Discrimination; and Tactile Defensiveness

and Inattention. The research studies conducted

on patterns of sensory integrative function and

dysfunction provide solid evidence that SI processes are multidimensional and that the SIPT is

a useful tool for uncovering specifi c patterns of

dysfunction.

 Another multivariate statistical technique that

has been used to support the construct validity of

the SIPT is cluster analysis. Using a combined

sample of about 300 children with and without

learning and SI defi cits, data from SIPT scores

generated a total of six cluster groupings ( Ayres,

 2005 ). Ayres interpreted two of the clusters as

representing normal functioning: High-Average

Sensory Integration and Praxis, and Low-Average

Sensory Integration and Praxis. One cluster

grouping characterized by very low scores on

the Praxis on Verbal Command test, and moderately high scores on Post-Rotary Nystagmus,

was interpreted as representing a problem other

than an SI defi cit (Praxis on Verbal Command).

This pattern was hypothesized by Ayres ( 2005 )

to be associated with defi ciencies with attention, learning, and auditory processing. The

other three cluster groupings were interpreted as

being associated with patterns of SI dysfunction.

Low Average BIS was the most common cluster

grouping, and it was characterized by children

with the lowest scores on tests identifi ed with a

BIS component and with typical scores on the

rest of the SIPT. The Generalized Sensory Integrative Dysfunction cluster included children

with very low scores on almost all 17 tests, and,

fi nally, the Visuo- and Somatodyspraxia cluster

included children with below-average scores primarily on measures of tactile processing, praxis,

and tests of form and space perception. Mulligan

 ( 2000 ) also conducted a cluster analysis with a

larger data set, and she found similar diagnostic

patterns, including:

• BIS

• Generalized Sensory Integration and

Dyspraxia-Severe

• Generalized Sensory Integration and

Dyspraxia-Moderate

• Dyspraxia

• Average Sensory Integration and Praxis

 The research using cluster analyses assists in the

interpretation of SIPT scores of children and the

level of severity of dysfunction when it occurs.

Furthermore, cluster analyses have supported

much of the data obtained by the factor analytic studies regarding subtypes of SI disorder,

the underlying sensory basis of disorders such

as praxis, and relations among facets of sensory

processing.

 Other forms of validity evidence were also

obtained during the development of SIPT, and

the evidence has been augmented during the

past 25 years ( Mulligan, 2011 ). Ayres demonstrated that the SIPT has discriminate validity

such that children with known disabilities score

more poorly on the SIPT than do children who

are developing typically ( Ayres, 2005 ). Subsequently, studies have shown the kind of SI dysfunction associated with specifi c disabilities or

populations, such as autism ( Ben-Sasson et al.,

 2008 ; Roley et al., 2015 ) and attention disorders

( Mulligan, 1996 ; Parush, Sohmer, Steinberg, &

Kaitz, 1997 ). Murray, Cermak, and O’Brien

 ( 1990 ) found children with learning disabilities

scored signifi cantly lower on four out of six tests

measuring form and space perception as well as

tests of visual construction, also supporting the

idea that there is a relation among visual perception, motor coordination, and praxis functions.

Developmental trends have been shown by the

test such that older children demonstrate more

skilled performance than do younger children,

supporting the idea of SI functioning as a developmental construct.

 A limited amount of data regarding criterionrelated validity is available. For example, correlations of SIPT scores with Kaufman-ABC

scores supported the aspects of the SIPT for measuring sequential processes, as the SIPT items

correlated highly with the K-ABC items known

to measure sequential processing ( Ayres, 2005 ).

 Cermak and Murray ( 1991 ) found moderately

high correlations between the constructional

praxis tests of the SIPT (Design Copying [DC]

and Constructional Praxis [CPr]) and other tests

known to assess similar aspects of constructional

praxis, the Beery-Buktenica Developmental

CHAPTER 8 Assessment of Sensory Integration Functions Using the Sensory Integration and Praxis Tests ■ 213

Tests of Visual Motor Integration, and the Block

Design of the Wechsler Intelligence Scale for

Children. Predictive criterion-related validity

was addressed by Parham ( 1998 ) who demonstrated that sensory integrative functioning as

measured by the SIPT was able to predict later

academic achievement in school-aged children.

 Reliability

 Evidence of the reliability of the SIPT is presented in the manual ( Ayres, 1989, 2005 ). Stability across trained administrators is very strong,

with correlation coeffi cients of inter-rater reliability ranging from 0.94 to 0.99. The stability

of the SIPT through time is also acceptable, with

especially high test-retest reliability for the tests

of praxis with coeffi cients ranging from 0.70 to

0.93 for a combined sample of children developing typically and children with known learning

or SI problems ( Ayres, 2005 ). Four of the tests

(Kinesthesia, Figure Ground, Localization of

Tactile Stimuli, and Post-Rotary Nystagmus)

demonstrated relatively low stability through

time, with reliability coeffi cients ranging from

0.48 to 0.56.

Analyses of SIPT Scores

with Other Assessment Data

for Completing Comprehensive

Evaluations of Children

 The SIPT ’ s contribution to a comprehensive

evaluation of children identifi ed with, or suspected of having, SI disorders is in providing

a standardized, rigorous, objective measure of

many forms of praxis, tactile discrimination, nonmotor visual perception including form and space

perception, aspects of vestibular and proprioceptive functioning, visual-motor skills, and bilateral motor coordination. The combination of the

17 tests of the SIPT has been well-researched so

that they also yield useful information regarding

specifi c patterns of SI dysfunction, most notably

somatopraxis, visuo-praxis, BIS disorder, and

postural-motor disorder, as well as a more generalized sensory integrative disorder. Throughout

this section of the book, it has been emphasized

that comprehensive occupational therapy evaluations of children using an SI approach consider

not only the underlying body function defi cits

that the SIPT is designed to measure but also

the way that defi cits that are discovered impact

a child ’ s ability to perform his or her desired and

required daily occupations.

 The evaluation process, therefore, begins by

gathering information about a child ’ s concerns,

occupational and medical history, strengths,

and priorities, and this is usually accomplished

through conducting interviews with the caregiver, teacher, and child. Assessment of the

child ’ s occupational performance in context of

the many roles the child assumes in his or her

daily life (e.g., social partner and player, student,

worker) and during the completion of necessary

self-care tasks, such as eating, bathing, and toileting, should be completed before SIPT administration. Also, occupational performance is often

evaluated through interviews using standardized

evaluations of occupational performance, such

HERE ’ S THE EVIDENCE

It is important that professionals who use standardized assessment tools in their practice are

aware of ongoing research that is being done on

the tools that they routinely use and how such

research might impact how those professionals

might apply these tools in their practice. For

example, Mailloux and colleagues ( 2011 ) examined the construct validity of the SIPT in their

study titled, “Verifi cation and Clarifi cation of Patterns of Sensory Integration Dysfunction.” In this

study, evaluation data (SIPT scores, along with

two variables related to sensory modulationmeasure of attention, a tactile defensiveness

score) were analyzed using a clinical sample of

273 children. The results supported four main

factors: (1) Dyspraxia; (2) Vestibular/Proprioceptive Bilateral Integration and Sequencing;

(3) Tactile and Visual Discrimination; and

(4) Tactile Defensiveness and Inattention. These

patterns support earlier factor analyses done

by Mulligan ( 1998 ) and Ayres ( 1989 ), which

strengthens our confi dence in the clinical application of these patterns of SI dysfunction. In

addition, for the fi rst time, two SIPT subtests that

were always thought to fi t theoretically within a

pattern of vestibular-proprioceptive processing,

Post-Rotary Nystagmus and Kinesthesia, did load

on the Vestibular/Proprioceptive Bilateral Integration and Sequencing as would be expected.

214 ■ PART III Tools for Assessment

as the Assessment of Motor and Process Skills

( Fisher, 2003 ) or the Canadian Occupational Performance Measure ( Law et al., 2005 ). Therapists

also should conduct observations of children in

the context of their daily activities in the home,

during play, or at school. Early in the evaluation

process, therapists begin to hypothesize how

potential SI defi cits might be infl uencing occupational performance, and this theorizing often

results in a strong rationale for further testing

with the SIPT.

 In the next phase of the evaluation process,

limitations of the SIPT as a measure of processing and integration of sensory information by

the central nervous system should be considered

so that appropriate additional evaluation activities are included. For instance, assessment of

sensory modulation should be considered as the

SIPT does not include formal measures of modulation. This can be completed through the administration of standardized caregiver questionnaires,

such as the Sensory Profi le-2 ( Dunn, 2014 ) or the

Sensory Processing Measure (SPM)-Home form

( Parham & Ecker, 2007 ). Modulation also can

be examined by doing interviews with relevant

people regarding the children ’ s sensory history

as well as their usual responses to types of

sensory stimuli in the contexts of daily routines

and activities. Common types of sensory modulation disorders that have been identifi ed in the

literature include sensory over-responsivity (e.g.,

tactile and auditory defensiveness, gravitational

insecurity) or under-responsivity, which may be

refl ected in poor sensory registration. Clinical

observations and procedures to evaluate vestibular, proprioceptive, and postural-ocular functions should also be administered, as test items

measuring these aspects of SI and processing on

the SIPT are limited (see Chapter 9 , Using Clinical Observations within the Evaluation Process,

for more information on clinical observations).

Finally, when diagnostic judgments are being

made, consideration of other explanations for

atypical behavior or occupational performance

problems (other than sensory integrative defi cits)

often need to be considered and explored further.

This might include cognitive functioning, emotional and mental health concerns, and orthopedic concerns, as well as any sociocultural or

environmental factors that might be infl uencing

the child ’ s functioning. It is often just as important in an evaluation to rule out the presence of

a sensory integrative disorder as it is to discover

a disorder exists. Finally, depending on the referring concerns, additional assessments might be

warranted to gather more detailed information on

specifi c functions, such as fi ne and gross motor

skills, handwriting performance, or social skills.

Synthesis of Evaluation Data

 Once all the necessary evaluation information

has been gathered, the next step in the evaluation process is to organize and synthesize all the

information so that a determination can be made

regarding the nature of any SI problems that are

uncovered as well as how they are impacting the

child ’ s occupational performance. Occupational

therapists engage in a process of clinical reasoning (or, more simply put, therapists’ thinking) to

examine, organize, synthesize, and interpret all

the data that has been collected. An interpretation worksheet was created by the authors of

the Comprehensive Training and Certifi cation

Program in Sensory Integration, Course 3 for this

purpose, and it is presented in Figure 8-1 ( Roley,

 2012 ). This worksheet considers data gathered

from the SIPT, as well as other related clinical

observations and data sources.

 The top section of the worksheet leads the

therapist to consider basic processing within

sensory systems fi rst. The processing of information by the visual, vestibular, and somatosensory (tactile and proprioceptive) systems

is emphasized, along with the modulation of

sensory information from all sensory domains,

with consideration given to the multiple types of

modulation disorders. Within these sections on

the worksheet, the therapist has an opportunity

to record and analyze scores from the individual tests of the SIPT with relevant observational

or other data refl ecting performance within that

sensory domain or pattern of dysfunction. It is

important to note that the specifi c SIPT tests

included within each section were placed strategically and thoughtfully to represent the relationships among the tests that have been validated

through the many previous studies using factor

and cluster analyses discussed in the previous

section. Moreover, the tests are listed in order of

importance for defi ning a problem in that area, as

determined by the number of studies that identifi ed the relationship as well as the size of factor

loading values derived by the research.

CHAPTER 8 Assessment of Sensory Integration Functions Using the Sensory Integration and Praxis Tests ■ 215

FIGURE 8-1 Sensory Integration and Praxis Test (SIPT) analysis worksheet. SPM: Sensory Processing Measure;

SP: Sensory Profi le; SVCU: Space Visualization Crossing Midline; PHU: prefered hand use; R/L: right/left;

IQ: intelligence quotient.

 The middle section in Figure 8-1 , including

BIS and Praxis, is placed as such, based on the

assumption that these patterns of SI dysfunction

are largely the result of underlying defi cits with

vestibular, proprioceptive, or tactile processing.

During the clinical reasoning process, the therapist considers the contributions of basic sensory

system functioning to problems associated

with BIS or dyspraxia. The potential relations

between problems with BIS and dyspraxia (and

vice versa) are also considered, as well as how

such problems relate to the child ’ s motor and

other skills.

 The bottom section of the worksheet suggests

that some problems that appear as though they

are defi cits with sensory processing and integration may instead be linked with a higher level,

cortical problem rather than be the result of a

sensory processing problem. Information may be

obtained that suggests a right or left hemisphere

defi cit, learning or cognitive impairment, or a

neuro-motor defi cit, such as seizures or cerebral

palsy. These potential factors assist in differential diagnoses, and those factors are important

for understanding how such neurological irregularities might co-exist with, affect, or rule out a

defi cit in sensory modulation or processing.

 Using the worksheet is effective for applying

the abundance of research on the patterns of SI

dysfunction and for organizing and interpreting

SIPT scores. The child ’ s D-squared index values

for each of the SIPT ’ s six cluster groupings are

also data that can be used to assist in clarifying

whether a child has an SI problem and, if so, the

nature of the dysfunction. When a child is identifi ed as fi tting within a particular cluster grouping, the common characteristics of children from

the matching cluster grouping can be applied to

assist in describing that child ’ s SI defi cits.

 The fi nal step in the evaluation process is to

consider how a child ’ s SI problems based on

standardized testing with the SIPT contribute

to the child ’ s challenges with occupational performance and other skill defi cits. Such careful

Score Score Score Score

Score Score Score

Score Score

Score

DC

CPR

MAC

MFP

GRA

Observations

Haptic Form

and Space

Visual Praxis

SV

FG

Visual Spatial

Visual

Bilateral Integration

 BMC

 SPr

 OPr

 GRA

 MFPII

 MAC

 Observations

 (e.g., skipping, jump jacks)

Low PRN

Ocular stability

Head/neck/eye

coordination

Observations

Vestibular-Ocular

SWB

Prone extension

Stability

Righting

Equilibrium

Vestibular

Postural Control

Low performance

High verbal

Poor visual spatial

SV, FG, FI, DC

Significantly lower

left-sided scores

Low frustration toler.

Right Hemisphere

IQ

PPr

OPr

PRVC

(SPr)

(BMC)

Flexion

Observations

 (e.g., play)

Praxis

PRVC (LOW)

PRN (average to high)

Poor sequencing

Possible low scores on:

OPr, SPr, BMC, SWB,

DC

Praxis on

Verbal Command

Tactile

LTS

GRA

FI

MFP

Observations

KIN

SWB

Poor body scheme

Observations,

 e.g., finger/nose,

 thumb/finger touching,

 diadokokinesis

Proprioception

Somatosensory

SVCU

PHU

R/L differences

Poor scores on

directionality, reversals,

inversions, jogs

Observations

Laterality

Interoception/

Sensory Modulation

Sensory responses

 Over/Under

 Fluctuating

SPM results

 Visual

 Hearing

 Touch (LTS)

 Body awareness

 Balance and motion

SP results

 Hypersensitive

 Sensory avoiding

 Hypo-response

 Sensory seeking

 Observations

 Arousal

 Affect

 Activity level

 Attention

High performance

Low verbal

Poor sequencing

Left Hemisphere

IQ

Irregular Neurological Signs circle if present: hyper- or hypotonia, associated movements, clonus, increased PRN, tremors,

tics, choreoathetosis, hypersensitivity to movement, seizures, other specify…

216 ■ PART III Tools for Assessment

thought assists in developing strategies to reduce

the impact of a child ’ s SI dysfunction on his or

her daily life, and it provides direction for the

development of effective intervention for remediating the SI defi cits that are impacting the

child ’ s occupational performance.

HERE ’ S THE POINT

• The synthesis of data from multiple sources,

including the SIPT, is a complex process, and

tools such as the interpretation worksheet

provided in this chapter are useful for helping

therapists organize and analyze their evaluation

data.

• It is vital that therapists are aware of the

strengths and weaknesses of the standardized

measures that they are using. Therapists must

administer and interpret scores from those

tools in ways that are consistent with the

research that has been done and with the

authors’ recommendations for how the test is

intended to be used.

Her mother was concerned that Lilly ’ s fi ne

and gross motor skills were below average and

that she had trouble getting along with peers.

Her mother also reported that Lilly had a lot

of anxiety, that she was a very picky eater,

and that she was very sensitive to sensory

stimuli such as loud noises. In order to get a

full picture of Lilly ’ s strengths and needs, the

therapist planned her evaluation as follows:

an unstructured parent interview with Lilly ’ s

mother; completion of the SPM-Home form

by her mother; clinical observations of Lilly ’ s

sensory and motor functions, fi ne and gross

motor skills, and play behaviors; and administration of the SIPT ( Ayres, 2005 ).

 Information gathered from the parent interview revealed Lilly is an only child who lives

with her parents in a rural neighborhood. Early

developmental motor milestones were achieved

within the age-appropriate ranges; Lilly walked

by 13 months of age and said her fi rst words

before 14 months. Despite an unremarkable

medical history, Lilly was described by her

mother as an emotionally sensitive child who

frustrates easily and who has trouble following through with simple requests at home. She

actively participates but requires some assistance with most aspects of her self-care, such

as grooming, bathing, and dressing, and there

were very few foods that she would eat. Her

mother reported that activities outside the home

are limited because Lilly becomes overstimulated easily, especially when there is a lot of

noise, or if there are other people around. Her

mother said that she is doing average school

work with reading and math for a child of her

age, although her pencil skills are poor. Lilly

prefers sedentary play such as playing with

dolls, and although she interacts quite well

with adults, she tends to be very withdrawn and

more of an observer when with children her

own age. She does not enjoy playing on playground equipment and cannot pump a swing.

Lilly wants to learn to ride her two-wheeled

bike with training wheels, but, thus far, she had

been too fearful to get on it.

 Lilly ’ s scores on the SPM-Home form based

on her mother ’ s ratings of behaviors believed to

refl ect sensory processing abilities are reported

in Table 8-2 .

 Lilly ’ s scores on the SPM suggest that

she processes information from her sensory

PRACTICE WISDOM

We are recommending that you use multiple

data sources for your evaluations. However,

sometimes you will be faced with a dilemma

when data that you obtain from two (or more)

different sources about the same function reveal

different results. For example, what should

you do if your clinical observations lead you to

hypothesize that a child ’ s kinesthetic awareness

is poor, but the score on the Kinesthesia test of

the SIPT fell within the average range? To resolve

such dilemmas, use your clinical judgment; consider the standard error of measure of the test

that you administered and how confi dent you

are the child performed the test or the behaviors that were observed to his or her true ability.

Considering these and other contextual factors

and knowledge about how the child typically

performs will help you to resolve confl icting

assessment data when this happens.

CASE STUDY ■ USING THE SIPT

IN THE EVALUATION PROCESS: LILLY

 Lilly was a 5-year-old girl who was evaluated

by an occupational therapist at a private clinic

specializing in working with children with SI

and processing disorders and their families.

CHAPTER 8 Assessment of Sensory Integration Functions Using the Sensory Integration and Praxis Tests ■ 217

systems in many atypical ways. With respect to

her visual system, Lilly is sensitive to light, and

often she lacks awareness of objects or activity in her environment. She focuses adequately

using her vision and discriminates between

objects, such as puzzle pieces, without diffi -

culty. With respect to auditory processing, Lilly

often needs directions to be repeated, and often

it requires more effort than would be typical to

get her attention; however, she is overly sensitive to loud noises. In the tactile area, her mom

reported that she is overly sensitive to touch

during grooming and dressing activities. Her

play is somewhat rigid, and she lacks creativity,

suggesting some motor planning problems. Her

score on the social participation scale indicated

some challenges, noted more with her peers

than when interacting with adults. Overall,

Lilly has a tendency to be overly sensitive to

auditory and tactile sensory input, and she can

become overwhelmed easily in environments

that provide a great deal of sensory stimuli.

Diffi culties with processing proprioceptive and

vestibular sensory information were also noted,

which may be impacting her body awareness,

comfort with movement activities, balance, and

motor coordination.

 Observations of gross motor skills indicated

that Lilly moves about her environment without

diffi culty and is able to easily run and walk.

She was able to walk upstairs through alternating her feet without the use of the railing

(although she preferred to hold the railing), and

when descending the stairs, she placed both

feet on each step. She was able to gallop but

not skip, and she was able to jump by clearing both feet from the fl oor at the same time.

Ball play, including consistency with catching

as well as accuracy of tossing and kicking, was

below average. She was nervous when asked

to lie prone over the therapy ball, to sit and

bounce on the therapy ball, and when sitting on

the platform swing even when supported by the

therapist. Lilly ’ s muscle tone was assessed to

be within the average range. Her gross motor

movements were often poorly graded. She was

able to stand on one foot for 5 seconds and hop

on one foot for three consecutive times, but she

had diffi culty coordinating both sides of her

body during attempts to skip and do jumping

jacks. In the fi ne motor area, Lilly was able to

put together Lego ® blocks as well as a simple

12-piece wooden puzzle with pieces that set

into a board. She enjoyed drawing on the white

board, and she was able to hold the marker

using an immature fi nger grasp. She was able

to print her fi rst name but not her last name.

 Other observations revealed that Lilly was

friendly and able to warm up easily with an

unfamiliar adult. She tended to give up very

quickly when challenged by a task and often

would refuse politely even to try a task. She

was quick to notice subtle background noises,

and she was uncomfortable with movement that

challenged her balance or when her feet were

raised from the fl oor, such as when sitting on

the platform swing and the therapy ball.

 Results from the 17 individual tests of

the SIPT generated the z-scores presented in

 Table 8-3 .

 Visual form and space perception were

a relative strength for Lilly, although, when

combined with motor demands such as when

copying designs or doing construction tasks,

she experienced diffi culty. Lilly performed

poorly on most tests of praxis, suggesting

dyspraxia resulting from underlying problems

with somatosensory and vestibular processing.

Lilly ’ s pattern of SIPT scores resulted in a

D-squared index value (.58) that likened her

to the visuo-somatodyspraxia cluster grouping. Children such as Lilly who fall within that

cluster grouping tend to present with signifi cant

SI dysfunction in the areas of somatosensory

TABLE 8-2 Lilly ’ s Scores from the Sensory

Processing Measure

SENSORY

AREA

 * T-SCORE (MEAN

= 50, SD = 10) INTERPRETATION

Social

Participation

67 Some Differences

Visual 71 Dysfunction

Hearing 76 Dysfunction

Touch 74 Dysfunction

Body

Awareness

74 Dysfunction

Balance and

Motion

75 Dysfunction

Planning

and Ideas

63 Some Differences

 * Higher scores represent more dysfunction.

218 ■ PART III Tools for Assessment

TABLE 8-3 SIPT Z-Scores for Lilly

Space Visualization: –0.8 Figure–Ground: –0.2

Manual Form Perception:

0.4

Kinesthesia: –1.5

Finger Identifi cation: –0.6 Graphesthesia –0.9

Localization of Tactile Stim.

–0.6

Praxis on Verbal

Command: –1.4

Design Copying: –1.9 Constructional Praxis:

–1.6

Postural Praxis: –2.0 Oral Praxis –1.6

Sequencing Praxis: –2.0 Bilateral Motor

Coordination: –0.7

Standing & Walking

Balance: –1.4

Motor Accuracy: –0.3

Post-Rotary Nystagmus: –0.5

friendly, and eager to please. She moves about

her environment adequately, and she has developed many motor, academic, and self-help

skills typical of children her age. She would be

an excellent candidate to receive occupational

therapy using an SI approach.

 Lilly would benefi t from intervention to

address the SI defi cits that are impacting her

development of social-emotional skills, play

behaviors, self-help, and motor skills. Intervention recommendations included two 1-hour

occupational therapy sessions for 3 to 4 months

using the Ayres’ Sensory Integration (ASI)

approach, combined with some specifi c skills

training for developing her pencil skills and

ability to ride her bike. Sensory-based activities

were implemented to promote social skills and

motor planning, to reduce tactile hypersensitivities, especially to help expand the repertoire

of what she is willing to eat, and to increase

her comfort level with grooming and dressing

tasks. Intervention also included parent and

child education about sensory integrative disorders along with problem-solving strategies

and solutions to minimize the negative impact

that her sensory differences were having in

the context of her daily life activities at home

and in the community. Intervention strategies

are discussed in more detail in later chapters;

however, some other suggestions to address

her sensory integrative concerns and maximize

her ability to perform her desired occupations

might include the following:

• During tabletop activities, such as puzzles,

looking at books, drawing, or prewriting,

minimize distractions, such as noise,

and provide occasional verbal cues for

encouragement and to help her keep

focused.

• Engage in prewriting activities and simple

craft activities and play with construction

toys and dolls (including accessories such

as clothing) to build visual motor skills,

motor planning, and dexterity.

• Play activities that are very physical in

nature, including the use of playground

equipment, ball play, riding a bike, and

running and jumping games, would be

good for Lilly. Presenting Lilly with novel

activities to try, such as jumping rope,

skiing, swimming, or playing tennis, would

and vestibular processing as well as dyspraxia,

with some visual-spatial challenges.

 The interpretation worksheet was completed

for Lilly to assist in interpreting and synthesizing all the assessment data that was gathered,

and it is presented in Table 8-4 . As illustrated,

Lilly exhibits more than one area or pattern of

SI dysfunction. Most notably, she has a sensory

modulation disorder, with over-responsivity

being the main subtype, and dyspraxia, a

sensory-based motor disorder that appears to be

related to underlying challenges in processing

somatosensory and vestibular sensory information. It is hypothesized that these sensory

processing disorders are contributing to her

challenges in developing fi ne and gross motor

skills as well as in her ability to demonstrate

age-appropriate social play behaviors. These

defi cits also impact her comfort level and ability

to perform in typical, day-to-day situations that

inherently involve a great deal of sensory input

such as going to the mall or playground, as

well as completing many self-care tasks. Situations that require her to be fl exible or adapt

to change, learn new skills or problem-solve

to meet the demands of novel situations when

playing with peers, or complete a self-care task

such as taking a shower are also challenging.

 It is important to acknowledge that Lilly

has many strengths. As noted previously, when

interacting with adults, she is comfortable,

CHAPTER 8 Assessment of Sensory Integration Functions Using the Sensory Integration and Praxis Tests ■ 219

TABLE 8-4 Lilly ’ s Completed Interpretation Worksheet

SENSORY INTEGRATION AND PRAXIS ANALYSIS WORKSHEET

 Visual Score Vestibular Score Somatosensory Score

 Interoception/

**Sensory

Modulation Score

Visual Spatial

 SV

 FG

*Visual Praxis

 DC

 CPR

 MAC

Haptic Form

and Space

MFP part 1

 GRA

 Observations:

Able to do

puzzles,

prints fi rst

name

 –0.8

 –0.2

 –1.9

 –1.6

 –0.3

 –0.6

 –0.9

** Postural

Control

 SWB

 Prone

extension

 Postural

stability

 Righting

 Equilibrium

 VestibularOcular

Low PRN

Ocular stability

 Head/neck/eye

coordination

 Bilateral

coordination

 –1.4

 Weak

 Fair

 Fair

 Poor

 –0.5

 OK

 OK

 Poor

** Proprioception

 KIN

 SWB

Poor body

scheme

 Observations

(e.g., fi nger/

nose) Thumb/

fi nger

touching

* Tactile

LTS

 GRA

 FI

 MFP

 –1.5

 –1.4

Yes

 Poor

 –0.6

 –0.9

 –1.6

 –0.6

Sensory

responses

Over (tactile,

vestibular)

 Under

(auditory)

 Fluctuating

SPM results

 Visual

 Hearing

Touch (LTS)

 Body

awareness

Balance and

motion

SP results

 Hypersensitive

 Sensory

avoiding

 Hypo-response

 Sensory

seeking

 Observations:

 Arousal

 Affect

Activity Level

 Attention

Low frustration

tolerance,

mild anxiety

Yes

Yes

 >1SD

 >2SD

 >2SD

 >2SD

 >2SD

 >1SD

 OK

 OK

 Low

 OK

High at

times

 n/a

 Good

 Possible

concern

Yes

 No

 * Bilateral

Integration Score ** Praxis Score

BMC

 SPr

 OPr

 GRA

MFP part 2

 MAC

 Observations:

skipping

–.07

 –2.0

 –1.6

 –0.9

 –0.5

 –0.3

 Poor

PPr

 OPr

 PrVC

 (SPr)

 (BMC)

 Flexion

Observations: play,

rigid, sedentary

–2.0

–1.6

 –1.4

 –2.0

 –0.7

 OK

 Fair

 Right

Hemisphere Data Laterality Data

Praxis on

Verbal Demand Data

 Left

Hemisphere Data

Low

performance

IQ

High verbal IQ

Poor visual

spatial

Lower left-sided

scores

n/a SVCU

 PHU

R/L differences

Poor scores on

directionality,

reversals,

inversions, jogs

n/a PrVC (LOW)

PRN (average to

high)

Poor sequencing

Possible low scores

on: OPr, SPr,

BMC, SWB, DC

n/a High performance

IQ

Low verbal IQ

Poor sequencing

n/a

Irregular Neurological Signs Circle if present: Hyper- or hypotonia, associated movements, clonus, increased PRN,

tremors, tics, choreoathetosis, hypersensitivity to movement, seizures, other (specify . . . ).

 *means important to your clinical reasoning

 **means very important to your clinical reasoning

n/a: not assessed

220 ■ PART III Tools for Assessment

also be helpful, provided the activities

are enjoyable. However, it is important

to acknowledge that Lilly may need

more time than other children her age

to feel comfortable and learn new skills.

Exercising patience and providing lots of

opportunity for repetition and practice will

assist with the pace of her learning.

• Heavy work activities that provide

Lilly ’ s body with proprioceptive sensory

information would assist in developing

body awareness and increase Lilly ’ s level

of comfort with movement and motor

planning skills. Tug of war, pulling and

pushing heavy objects, pedaling a bike,

and bouncing on a trampoline are examples

of heavy work activities. Imitation games,

such as Simon Says and Follow the Leader,

and setting up or going through obstacle

courses are also good ways to work on

motor planning skills.

• As an only child who is home-schooled,

Lilly needs to be provided with

opportunities to play with other children,

and interacting with small groups of

children (two or three others) would be

ideal. Providing her with some parent or

adult support should be considered to assist

her in following the play of others and

to help her successfully engage and feel

comfortable in cooperative, social play

situations.

Summary and Conclusions

 This chapter discussed the use of the SIPT when

conducting comprehensive evaluations of children using a sensory integrative approach. The

chapter presented an overview of the test, its

purpose, and its psychometric properties. Also

presented was the interpretation of SIPT scores

in combination with other sources of evaluation data for making clinical decisions regarding

diagnosis and for guiding intervention. A case

study illustrated how the principles presented

throughout the chapter can be applied in practice.

Where Can I Find More?

 Training in SI evaluation techniques is available

from several sources:

 • University of Southern California: http://

chan.usc.edu/academics/sensory-integration/

continuing-education

 • STAR Institute, Denver, CO: https://www

.spdstar.org/

 • The Spiral Foundation: http://thespiralfoundation.org

 • The Collaborative for Leadership in Ayres

Sensory Integration (CLASI): https://www

.cl-asi.org/

 • Thomas Jefferson University, Advanced Certifi cate in Sensory Integration: http://www

.jefferson.edu/university/health-professions/

departments/occupational-therapy

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dysfunction among disabled learners. American

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Praxis Tests manual . Los Angeles, CA : Western

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 Ben-Sasson , A. , Hen , L. , Fluss , R. , Cermak , S. A. ,

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CHAPTER 8 Assessment of Sensory Integration Functions Using the Sensory Integration and Praxis Tests ■ 221

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.2015.012476

222

CHAPTER

9

Using Clinical Observations

within the Evaluation Process

 Erna Imperatore Blanche , PhD, FAOTA, OTR/L ■ Gustavo Reinoso , PhD, OTR/L ■

 Dominique Blanche Kiefer , OTD, OTR/L

 Chapter 9

 If you make listening and observation your occupation

you will gain much more than you can by talk.

 —Robert Baden-Powell

Upon completion of this chapter, the reader will be able to:

✔ Explain the link between sensory integration (SI)

theory and the skills evaluated through clinical

observations.

✔ Describe the role of clinical observations in

the evaluation process for detecting sensory

processing and praxis diffi culties in children.

✔ Compare different methods for gathering

information through observation.

✔ Describe and interpret specifi c clinical

observations for assessing postural tone and

control, motor planning and sequencing,

bilateral coordination, and reaction to gravity.

LEARNING OUTCOMES

Purpose and Scope

 A comprehensive evaluation process includes

observations of a child ’ s preferred occupations

and the skills required to perform them. These

observations are referred to as skilled observations and may be structured or unstructured.

Clinical observations is a term widely used to

refer to the relatively standard set of structured

observations that complement standardized

assessment of sensory integrative functioning,

often done using the Sensory Integration and

Praxis Tests (SIPT; Ayres, 1989 ). The purpose is

to assist in determining factors that interfere with

a child ’ s participation in daily activities and interactions in the environment. Structured clinical

observations are therapist-directed and involve

specifi c tasks that provide information about

posture and motor planning. Most of the structured, formal clinical observations used in comprehensive sensory integration (SI) evaluations

were fi rst identifi ed by Ayres ( 1972 ; Blanche,

 2002, 2010 ; Bundy & Fisher, 1981 ) and are,

therefore, sometimes referred to as Ayres Clinical

Observations.

 In addition to structured clinical observations,

therapists generally include unstructured, or

informal, observations in assessment. Unstructured observation is a term used in two different

ways: (1) in the context of clinical observations

to capture the qualitative aspects of motor performance and more elusive functions, such as

sensory modulation and regulation, and (2) while

a child is freely interacting in a natural environment. Unstructured observations of the second

type are particularly important with young children, children who do not follow instructions

well, or those who experience diffi culty following the protocols necessary when administering

standardized assessments.

 In this chapter, we describe and illustrate structured clinical observations and the unstructured,

CHAPTER 9 Using Clinical Observations within the Evaluation Process ■ 223

qualitative observations that therapists make,

focusing on postural-ocular control and praxis.

The importance of clinical observations in

the evaluation of SI and praxis lies in the link

between the skill being tested and its relationship

to SI theory. All the observations refl ect a tie—

either theoretical or drawn from basic science

( Agrup, 2008 ; Braswell & Rine, 2006 ; Cohen &

Keshner, 1989 )—between central nervous system

(CNS) functioning and behavior.

 Each clinical observation meets a particular purpose. For example, the vestibular system

contributes to antigravity extension ( Keshner

& Cohen, 1989 ; Markham, 1987 ). In SI theory,

testing antigravity extensor muscle tone is thought

to provide insight into vestibular processing.

Antigravity extension is tested with the child

in the prone position, extending the head, neck,

upper trunk, and limbs against gravity ( Blanche,

 2002, 2010 ; Bundy & Fisher, 1981 ; Fanchiang,

 1989 ; Longo-Kimber, 1984 ; Wilson, Pollock,

Kaplan, & Law, 2000 ; Wilson, Pollock, Kaplan,

Law, & Faris, 1992 ). This chapter describes

several useful observations—both structured and

unstructured—that therapists can do as part of

the evaluation. We link each observation in the

interpretation of performance to a function of

SI. We illustrate those relationships using the

model shown in Figure 9-1 . We also cite existing

research supporting administration procedures.

Readers will fi nd a useful summary of structured

and unstructured clinical observations of postural

control and praxis in Table 9-1 .

 While we focus on standardized clinical

observations for assessing postural-ocular control

and motor planning, a thorough evaluation of SI

also includes informal observation of a child ’ s

responses to tactile, proprioceptive, and vestibular input. For example, an examiner can identify

tactile defensiveness, a diffi culty with sensory

modulation, by watching a child ’ s response to

incidental touch. Such observations often can be

conducted in the context of typical play activities or during other activities of daily living

(ADLs). Most data from clinical observations

are drawn from two types of sources. First, there

are protocols that are commercially available,

such as the Clinical Observations of Motor and

Postural Skills (COMPS; Wilson et al., 1992;

2000 ), which include normative data. Others

have described specifi c methods for administration, through video, and support interpretation

FIGURE 9-1 Relationship of clinical observations to sensory integration theory.

Indicators of poor

sensory modulation

Inadequate CNS

integration and

processing of

sensation

Indicators of poor sensory integration

and praxis

Sensory reactivity

Sensory perception

Poor postural-ocular

control

Poor sensory

discrimination

VBIS

• Prone extension

• Balance, eyes

 closed

• Dynamic reach

• Jumping jacks

• Stride jumps

• Ball play

• Diadochokinesia

• Sequential finger-

 thumb touching

• Skipping

• Schilder’s Arm

 Extension Test

• VBIS observations

• Supine flexion

• Motor imitation

 during supine

 flexion

Somatodyspraxia

• Prone extension

• Postural reactions

• Extensor tone

• Head and neck in

 supine

• Supine flexion

• Dynamic reach (kneel)

• Ramp movements

• Ball play

• Jumping jacks/stride

 jumps

• Movement into

 backward space

• Jumping from a chair

• Touch applied to back

 of neck

• Response to touch

 during administration of

 postural tests

Poor registration

Same as above

Under-responsivity

Same as above

Fluctuating

responsivity

Over-responsivity

Aversive and defensive

reactions Visual

Vestibular

Tactile

[lnteroception]

Auditory

Olfactory

Gustatory

Proprioception

224 ■ PART III Tools for Assessment

TABLE 9-1 Structured and Unstructured Clinical Observations for Assessing Postural Control

and Motor Planning

AREA INTERPRETATION

I. Axial Postural Control Impacted by Sensory Processing

Prone

Extension

Structured Observations

Prone extension

Child assumes a whole

body extended posture as

indicated and demonstrated

by the examiner.

Diffi culties relate to

decreased aspects of

vestibular proprioceptive

processing and its effect on

extensor tone

Unstructured Observations

 a. Swinging in prone

Child is observed during

free play on equipment that

supports swinging in a prone

position (e.g., frog swing).

Same as above

 b. Standing postureChild ’ s upper trunk position. Rounded upper back and

decreased scapula adduction

may be related to decreased

antigravity extension

Flexion

Against

Gravity

Structured Observation

Supine fl exion

Child assumes a whole body

fl exed posture as indicated

and demonstrated by the

examiner.

Somatosensory processing

and its relationship to praxis

diffi culties

Unstructured Observation

 a. Holding on a trapeze while

lifting lower extremities

Child is observed during

free play (e.g., playground

structure).

 b. Standing posture Poor abdominal activation

observed during quiet

stance.

 c. Raising from the fl oor

(supine position)

Child ’ s overall control and

abdominal activation is

observed and noted.

Postural

Control in

Standing

Structured Observations

Standing under different

conditions

 Ability to assume and

maintain standing postures

with feet together, heel-totoe, or standing on one foot

with eyes open and eyes

closed, and using fi rm and

soft surfaces.

Visual, vestibular, and

somatosensory contributions

to postural control abilities

Unstructured Observations

Play and games in which the

child needs to navigate different

surfaces and terrains (sand,

pillows)

Ability to stabilize his/

her body to perform

and participate in play in

comparison with children of

the same age and gender.

Postural

Control in

High Kneeling

Structured Observations

Reaching for an object while on

a high kneeling position

Ability to utilize anticipatory

postural control during a

weight-shifting task.

Anticipatory postural control

CHAPTER 9 Using Clinical Observations within the Evaluation Process ■ 225

AREA INTERPRETATION

II. Motor Planning

Feedback

Related

Structured Observations

Slow ramp movements

Child is observed performing

slow movements. His/her

ability to control speed and

quality are noted.

Contribution of

proprioceptive processing

to slow and controlled

movements

Unstructured Observations

 a. Paper-and-pencil tasks or

other tasks requiring the

use of tools (eraser, pencil

sharpener, folding papers)

The child ’ s ability to stabilize,

dissociate, and grade

speed and pressure of fi ne

movements is observed and

noted.

 b. Child ’ s ability to organize

himself/herself to

imitate the positions

demonstrated by the

examiner

Note performance during

all structured clinical

observations.

Imitation skills and their

relationship to praxis

 c. Play situations or games,

such as Simon Says, or

at school when a child

is expected to imitate or

copy the actions of others.

Overall performance in

comparison with other

children of the same age

and gender

Naturalistic observation.

Timing,

Feedforward,

or Projected

Actions in

Time and

Space

Structured Observations

Ball play:

 Child ’ s ability to anticipate the

movement and trajectory of

objects

Child ’ s ability to orient his/

her body and position

himself/herself in preparation

for catching, hitting, or

making contact.

Feedforward or projected

actions in time and space

Sequencing Structured Observations

 a. Alternating forearm

movements

 b. Sequential fi nger touching

Smoothness, fl uidity, and

isolation of discrete and

rhythmic movements.

Presence or absence of

associated movements.

Movement planning and

execution that relates to

adequate sensory processing

Bilateral Motor

Coordination

Structured Observations

 a. Skipping

 b. Series of jumps

Use of bilateral strategy and

fl uidity of movements.

Continuous movements vs.

interruptions in between

jumps.

Ability to motor plan

movements and bilateral

motor coordination

Additional Observations of Sensory Processing

Modifi ed

Schilder ’ s Arm

Extension Test

Ability to maintain arms outstretched as demonstrated and indicated by the

examiner.

Ability to dissociate movements of the trunk and upper extremity during

head rotations.

Proprioceptive

processing

Gravitational

Insecurity

Child ’ s comfort during different tasks that challenge his or her relationship

to gravity.

Reaction to a

variety of sensory

experiences

TABLE 9-1 Structured and Unstructured Clinical Observations for Assessing Postural Control

and Motor Planning—cont’d

226 ■ PART III Tools for Assessment

through case analysis, such as Observations

Based on Sensory Integration Theory ( Blanche,

 2002, 2010 ). Second, there are some published

research reports that describe a particular observation or group of observations. For example, the

prone extension posture has been examined in

children with and without reported motor diffi -

culties ( Fanchiang, 1989 ; Longo-Kimber, 1984 ).

Assessment and Interpretation

 Children with SI dysfunction often have diffi culty with postural-ocular control. Several

authors ( Blanche, 2002, 2010 ; Bundy, 2002 ;

 Longo-Kimber, 1984 ; Wilson et al., 1992, 2000 )

have suggested assessment procedures. In this

section, we outline clinical observations of

(1) prone extension; (2) fl exion against gravity

(i.e., supine fl exion); (3) postural control in

standing with eyes open and closed, on one foot,

and on soft vs. fi rm surfaces; and (4) dynamic

reach in high kneeling.

HERE ’ S THE POINT

• All assessments (including standardized

testing) should include data from observations

(structured and unstructured).

• There are specifi c procedures or protocols

used to administer several of the structured

clinical observations used during SI evaluations.

It is vital that interpretation of performance

and analysis of data be based on information

obtained from the specifi c protocol utilized.

• Information collected through the

administration of clinical observations can be

easily grouped using three categories: postural

control [infl uenced by sensory processing],

motor planning, and sensory processing.

Postural-Ocular Control

Postural-ocular control is defi ned as those

functions necessary to maintain proximal stability, postural orientation, and a stable visual

fi eld. Proximal stability comprises generalized muscle tone and alterations to tone that

allow postural reactions in response to the pull

of gravity and maintenance of body alignment.

Postural orientation refers to an appropriate

relationship among body segments, the task, and

the environment ( Shumway-Cook & Woollacott,

 2012 ). It involves our ability to orient body segments to each other and a task. A stable visual

fi eld means that while moving the head, the

visual fi eld remains still. In this section, we focus

on the maintenance of postures.

 Postural-ocular control is infl uenced by

anticipatory (feedforward) mechanisms and by

adaptive (feedback) mechanisms. Anticipatory mechanisms refer to activation of postural

muscles in preparation for skilled action. Adaptive mechanisms occur when body position is

perturbed, necessitating a response to maintain

the position ( Shumway-Cook & Woollacott,

 2012 ). Evaluating postural control involves the

ability to maintain stable positions (quiet stance)

as well as the ability to make adaptive postural

adjustments during movement.

Prone Extension

 Processing of vestibular and proprioceptive sensations is closely linked with the ability to assume

and maintain prone extension ( Ayres, 1972 ;

 Quirós & Schrager, 1978 ). During this structured

observation, the examiner observes quantitative

and qualitative behaviors related to assuming and

maintaining the posture. The examiner demonstrates ( Fig. 9-2 ) and then instructs the child to

assume and maintain the position for as long as

possible. The therapist notes both quantitative

information (the number of seconds the child can

maintain the position) and qualitative information (how easily the child assumes and maintains

the position). Asking a child to copy the position

introduces an element of motor planning.

 Length of time children are expected to

maintain the position differs according to the

source. Longo-Kimber ( 1984 ) indicated that the

FIGURE 9-2 Examiner demonstrating the prone

extension position. Copyright Dominique Kiefer.

CHAPTER 9 Using Clinical Observations within the Evaluation Process ■ 227

mean length of time that 5-year-olds can maintain prone extension is 63.2 seconds (males)

and 48.3 seconds (females), although variability

was very high, with a standard deviation ( SD )

of 30.7. Dunn ( 1981 ) reported shorter durations

for both girls and boys (15 to 20 seconds). Some

differences may have been because of sampling

characteristics.

 More recently, data collected on 90 Caucasian

middle-class children between 5 years of age and

7 years, 11 months of age from a metropolitan

city in Chile revealed that 5-year-olds maintained prone extension with adequate quality

for a mean of 16 seconds ( SD = 10) ( Blanche,

Reinoso, & Kiefer, 2015 ; Imperatore Blanche,

Reinoso, Blanche-Kiefer, & Barros, 2016 ).

On the best of two attempts, 6-year-olds maintained the position for 20 seconds ( SD = 11), and

7-year-olds for 21 seconds ( SD = 11). These data

support previous studies ( Harris, 1981 ; Wilson

et al., 2000 ) in which children 6 years of age and

older were able to assume and maintain prone

extension without excessive effort.

 Qualitative observations of testing provide

information about motor planning, muscle tone,

and postural control. Qualitative observations

include the ability to:

• Assume the position nonsegmentally (lifting

arms and legs up simultaneously)

• Hold the head steady and within 45 degrees

of vertical

• Lift the upper chest and shoulders off the

supporting surface

• Raise the distal one-third of both thighs off

the fl oor

• Maintain the knees in less than 45 degrees

of fl exion

• Assume and maintain without excessive

effort ( Blanche et al., 2015 ; Harris, 1981 ;

 Imperatore Blanche et al., 2016 ; Wilson

et al., 2000 )

 Researchers ( Blanche et al., 2015 ; Harris,

 1981 ; Longo-Kimber, 1984 ; Wilson et al., 1992,

2000 ) have shown that both quality of assumption and time maintained differ signifi cantly

between typical children and children with

known diffi culties. Figures 9-3 and 9-4 demonstrate the desired posture and a common incorrect posture, respectively.

 Extension against gravity also can be observed

informally during free play or when the child

FIGURE 9-3 Child assuming a correct position of

prone extension. Copyright Dominique Kiefer.

FIGURE 9-4 Child assuming an incorrect position of

prone extension. Copyright Dominique Kiefer.

utilizes equipment in the clinic, for example,

while lying prone on a scooter board or platform

swing. Movement provides vestibular input,

which should increase extensor tone and help

the child assume antigravity extension. Extensor

tone can be observed in standing or sitting at a

table. In this situation, a rounded upper back,

leaning on the whole forearm, laying the head on

the table, or excessive scapular abduction may

indicate decreased extensor tone and consequent

proximal stability.

Flexion Against Gravity

 The ability to assume and maintain fl exion

against gravity is critical to postural control and

has been linked to somatosensory processing

and praxis ( Dunn, 1981 ; Wilson et al., 1992,

2000 ). Supine fl exion includes crossing arms

(hands to opposite shoulder) and simultaneous

lifting of the upper extremity, head, and legs (see

 Fig. 9-5 ). The examiner demonstrates (or gives

verbal instruction), and then the child assumes

and maintains the position for as long as possible.

228 ■ PART III Tools for Assessment

 Researchers have reported substantial variability in typical samples, even within a single

age group. Fraser ( 1983 ) reported that children from 5 years, 5 months of age to 5 years,

9 months of age held supine fl exion for a mean

of 39 seconds ( SD = 32.77; range = 0–120;

median = 34), whereas Dunn ( 1981 ) found that

5-year-olds maintained for 11 to 20 seconds.

 More recent data indicate that on the best

of two attempts, 5-year-olds maintained supine

fl exion for a mean of 24 seconds ( SD = 20),

6-year-olds for 33 seconds ( SD = 20), and

7-year-olds for 44 seconds ( SD = 18; Imperatore Blanche et al., 2016 ). Preliminary studies

of inter-rater reliability using four raters scoring

four children by video indicated acceptable

agreement on both quantitative and qualitative

parameters ( Blanche et al., 2015 ). Even considering the substantial variability across sources and

given the mean of 24 ± 20 seconds, 5-year-olds

can be expected to assume and maintain supine

fl exion for a minimum of 4 seconds.

 Qualitative observations include the ability to:

• Lift upper and lower extremities

simultaneously

• Maintain head in midline with the chin

tucked

• Keep shoulders and arms off the supporting

surface

• Maintain ankles and knees in fl exion

• Keep hands relatively relaxed (i.e., not

holding self tightly)

• Maintain without effort

Figure 9-6 demonstrates a child assuming and

maintaining the correct position, whereas the

children in Figures 9-7 and 9-8 demonstrate

diffi culty with supine fl exion and an inability

to assume the position. Antigravity fl exion also

can be observed during play when the child is

hanging from a trapeze and attempts to bring the

FIGURE 9-5 Examiner demonstrating the supine

fl exion position. Copyright Dominique Kiefer. FIGURE 9-6 Child assumes and maintains supine

fl exion correctly. Copyright Dominique Kiefer.

FIGURE 9-7 Child assuming supine fl exion incorrectly.

Copyright Dominique Kiefer.

FIGURE 9-8 Child showing signifi cant diffi culty

assuming supine fl exion. Copyright Dominique Kiefer.

CHAPTER 9 Using Clinical Observations within the Evaluation Process ■ 229

legs up against gravity, or in standing by observing abdominal control. In most children, an anterior pelvic tilt is absent.

Postural Control in Standing

 Observing postural reactions while standing with

eyes open and closed provides information about

balance defi cits ( Richardson, Atwater, Crowe, &

Deitz, 1992 ) and the contributions of the vestibular, proprioceptive, and visual systems. Structured observations include standing on one and

both feet, fi rm and soft surfaces, and with eyes

open and closed. According to Deitz, Richardson, Atwater, and Crowe ( 1991 ), in the Sensory

Interaction for Balance Test, the specifi c contribution of each sensory system can be isolated.

For example, if a child maintains a standing

position on a soft surface with eyes open but

falls when standing with eyes closed, the examiner can assume that the child ’ s vestibular system

is under-reactive. On the other hand, if having

the eyes open or closed makes no difference on

maintaining a standing position, the examiner

can assume that the child ’ s balance diffi culties

are of a neuromotor nature. The contributions of

the varying systems are presented in Table 9-2 .

 When using structured observations, the

examiner demonstrates and then encourages the

child to maintain the position as long as possible. Also, the examiner should note if the child

requires physical assistance. Recent data indicate increasing ability with age. Five-year-olds

( N = 90) maintained standing with feet together

and eyes open on a fi rm surface for a mean of

23 seconds ( SD = 2) whereas 6- and 7-year-olds

maintained for a mean of 25 seconds ( SD = 1).

Inter-rater reliability was good (K = .62), and

for the total score, based on intraclass correlation, was very strong (ICC = .91) ( Blanche et al.,

 2015 ).

 Unstructured observations of the ability to

assume and maintain a standing position under

various conditions provide information about

proximal joint stability, muscle tone, and postural strategies. The following can be observed:

• Ankle strategies to maintain equilibrium.

Ankle strategies are reactions that are

observed in the feet in response to weight

shifting when balance is challenged

( Runge, Shupert, Horak, & Zajac, 1999 ).

Proprioceptive processing is pivotal to these

responses.

• Alignment of knees and hips, which depends

on proximal joint stability.

 Figures 9-9 and 9-10 illustrate adequate alignment on fi rm and soft surfaces. Figure 9-11

TABLE 9-2 Sensory Contribution to Postural

Control while Standing on a Firm and Soft

Surface with Eyes Open and Closed

SENSORY

CONTRIBUTION

FIRM SURFACE SOFT SURFACE

Eyes

Open

Eyes

Closed

Eyes

Open

Eyes

Closed

Visual X X

Vestibular X X X X

Somatosensory

(proprioception

and tactile)

X X FIGURE 9-9 Child displaying adequate postural

control on a fi rm surface with eyes open. Observe

adequate alignment. Copyright Dominique Kiefer.

230 ■ PART III Tools for Assessment

FIGURE 9-10 Child displaying adequate postural

control on a soft surface with eyes open. Observe

adequate alignment. Copyright Dominique Kiefer.

FIGURE 9-11 Child displaying inadequate postural

control and alignment when standing on one foot

on a soft surface with eyes open. Observe his use of

compensatory strategies, such as his left foot pressing

against his right leg, hyperextension of the distal

joints of his hands, and hiking of the left shoulder in

an attempt to stabilize. Copyright Dominique Kiefer.

shows a child who is unable to maintain equilibrium on a soft surface.

 Observe the individual ’ s use of compensatory

strategies such as the left foot pressing against

the right leg, hyperextension of distal joints of

the hands, and hiking of the left shoulder in an

attempt to stabilize.

Dynamic Reach in Standing

and High Kneeling

 Observations of dynamic reach are based on The

Pediatric Functional Reach Test. This test was

originally described by Duncan and colleagues

 ( 1990 ) and then adapted for a pediatric population

( Donahoe, Turner, & Worrell, 1994 ). Donahoe

and colleagues ( 1994 ) defi ned functional reach

as the maximal greatest distance of reach,

beyond arms’ length, while remaining standing

over a base of support. Donahoe and colleagues

reported that 5-year-olds reached forward a mean

distance of 15.5 cm ( SD = 4.4). Similar tests were

reported by Fisher ( 1991 ) for measuring balance

while standing on a stable surface or tilt board

and reaching. Imperatore Blanche and colleagues

 ( 2016 ) adapted this test for high kneeling with a

sample of children between 5 years of age and

7 years, 11 months of age. Recent data indicate

that children without reported diffi culties reached

15 to 20 cm diagonally without diffi culty and that

the observation could be scored reliably among

independent raters ( Imperatore Blanche et al.,

 2016 ). Figure 9-12 shows an occupational therapist assessing dynamic reach in a high kneeling

position. Note that this child has reached so far

forward that she needs to compensate by moving

her head backward.

CHAPTER 9 Using Clinical Observations within the Evaluation Process ■ 231

FIGURE 9-12 Child using postural control skills

during a high kneeling reach task. Copyright

Dominique Kiefer.

HERE ’ S THE POINT

• Postural-ocular control is reliant on proximal

(trunk) stability, knowledge of the relationship

between body segments, and a stable visual

fi eld.

• Prone extension and supine fl exion can be

assessed to support an understanding of

postural control.

• Balance can be examined through observation

of postural reactions using soft and fi rm

surfaces and by looking at balance on both

feet and each separately. The role of vision

in balance reactions can be determined by

considering the child ’ s ability to balance with

his or her eyes open and closed.

• Dynamic reach offers another way to examine

active postural-ocular control.

Motor Planning

 Assessment of motor planning is another major

area in which structured clinical observations

can be helpful. These observations include tasks

that are relatively feedback- and feedforwarddependent as well as those that involve sequencing and bilateral motor coordination. Examples

of clinical observations targeting feedbackdependent movements include slow ramp movements and informal observations of motor

HERE ’ S THE EVIDENCE

Kooistra and colleagues ( 2009 ) examined children with fetal alcohol spectrum disorder (FASD)

and children with attention defi cit-hyperactivity

disorder (ADHD) to determine if different motor

profi les could be established to refl ect the two

diagnostic groups and typical children. They

included 116 children, 7 to 10 years of age, in

this study, and the researchers assessed them

using, among other tools, the Movement Assessment Battery for Children (M-ABC; Henderson &

Sugden, 2007 ), COMPS ( Wilson et al., 2000 ),

and clinical measures of balance. Included on

the COMPS are the following observations: slow

(ramp) movements, rapid forearm rotation (dysdiadochokinesis), fi nger–nose touching, prone

extension posture, asymmetrical tonic neck

refl ex, and supine fl exion. Although the M-ABC

failed to distinguish between groups, performance on the COMPS differed among groups.

Children with ADHD performed less well than

the children in the typical comparison group,

and those children had motor and postural defi -

cits that were within the clinical range. The performance of children with FASD was more likely

to be typical on these basic motor functions.

Both diagnostic groups showed balance defi cits,

which suggests that basic motor performance

skills may help differentiate between these diagnostic groups; children with ADHD showed diffi culty with both complex and basic motor skills,

whereas children with FASD showed defi cits primarily in complex skills.

Summarized from Kooistra, L., Ramage, B., Crawford, S., Cantell,

M., Wormsbecker, S., Gibbard, B., & Kaplan, B.J. (2009). Can

attention defi cit hyperactivity disorder and fetal alcohol spectrum

disorder be differentiated by motor and balance defi cits? Human

Movement Science, 28(4), 529–542.

imitation. Feedforward-dependent tasks include

ball play or anticipating an interaction with a

moving object. Sequenced actions include alternating forearm movements (diadochokinesis)

and sequential thumb-to-fi nger touching. Bilateral coordination is assessed during jumping

jacks, skipping, and stride jumps.

Feedback-Dependent Tasks

Feedback-dependent tasks involve ongoing

modifi cation because of sensory feedback

( Seidler, Noll, & Thiers, 2004 ). Feedback control

is inherently slow because of the high degree

of accuracy and the need for error correction

232 ■ PART III Tools for Assessment

( Seidler et al., 2004 ). Therefore, only some movements can be performed using feedback-control.

Clinical observations of feedback-dependent

movements include slow ramp movements and

imitation of body positions demonstrated by the

examiner. When observing a child imitating a

position, the clinician should attend to the strategies the child uses and to the nature of any errors.

Slow Ramp Movements

 Slow ramp movement tests involve mirroring

the smooth, fl uid, slow movements of the examiner. The examiner begins with shoulders and

arms abducted, elbows extended, forearms supinated, wrists in a neutral position, and fi ngers

extended. The examiner then moves his or her

hands to the shoulders and returns to the starting

position using controlled, smooth, fl uid motions.

Movement in each direction should take about

5 seconds or 10 seconds total ( Fig. 9-13 ). The

child faces the examiner and copies the examiner ’ s movements at exactly the same speed. The

examiner observes:

• Speed of movement (i.e., Does the child

complete the movements at the same time?

Within 2 to 3 seconds? More than 3 seconds

difference?)

• Symmetry of movements (right and left)

• Fluidity of movements

• Ability to perform movements without visual

feedback

 Recent data indicate that children between

5 and 7 years of age are able to perform this task

with ease, matching the speed of the examiner ’ s

movements within a mean of 1.5 seconds ( Imperatore Blanche et al., 2016 ). Dunn ( 1981 ) reported

similar results in 5-year-olds. The ability to

imitate following a visual presentation or demonstration without verbal directions is easier than

performing following verbal commands ( Zoia,

Pelamatti, Cuttini, Casotto, & Scabar, 2002 ).

 Figures 9-14 and 9-15 show examples of poor

performance of this task, where children were

unable to move their arms simultaneously and

unable to match the speed of movement with the

examiner.

FIGURE 9-13 Slow ramp movements. Note the

symmetry and simultaneous performance. Copyright

Dominique Kiefer.

FIGURE 9-14 Failure to move simultaneously.

Copyright Dominique Kiefer.

FIGURE 9-15 Failure to move simultaneously.

Copyright Dominique Kiefer.

CHAPTER 9 Using Clinical Observations within the Evaluation Process ■ 233

Motor Imitation: Copying Postures

 Imitation of Postures is one of the standardized tests of praxis included in the SIPT ( Ayres,

 1989 ). Imitation also can be observed when a

child copies an examiner assuming prone extension or supine fl exion postures. Both the strategies used by the child and the outcome of a

child ’ s attempts can be noted. Children with

motor planning diffi culties may verbally direct

their movements or assume the position segmentally or incorrectly.

Feedforward-Dependent Actions, Including

Projected Actions Sequences

 Fisher ( 1991 ) related the ability to perform anticipatory movements that depend on feedforward

control to vestibular and proprioceptive processing. Feedforward-control (i.e., the ability to

initiate an action before feedback is available)

is required when either a child is moving or the

target that the child is acting on is moving, or

both ( Fig. 9-16 ). Feedforward control is particularly important in actions where timing and

sequencing of movements are crucial. Successful completion of feedforward-dependent tasks

involves sequences of actions that enable one to

get the whole body or the hands or feet to the

place where the action is to occur at the time

when the action needs to occur. If a child waits

too long to move his hands toward an oncoming

ball, the child will fail to catch the ball. Observing feedforward-dependent actions, which by

defi nition require timing and sequencing, is an

integral component of an evaluation of praxis.

In everyday life, feedforward control is required

during activities such as playing ball games,

jumping rope, crossing the street, walking

through a crowded space, or avoiding obstacles

while riding a bicycle.

Ball Play

 The ability to perform feedforward-dependent

anticipatory movements effectively is often

observed in clinical observations in the context

of catching or kicking a ball. Standardized

tests of motor profi ciency, such as the M-ABC

(Henderson & Sudgen, 2007) and the BruininksOseretsky Test of Motor Profi ciency, Second

Edition (BOT-2) ( Bruininks & Bruininks, 2005 ),

can also be used to assess these skills and provide

normative information about the speed and accuracy of performance. However, such tests only

indirectly consider qualitative performance.

 Gubbay ( Gubbay, 1975 ; Gubbay, Ellis,

Walton, & Court, 1965 ) developed a test in which

children repeatedly throw a tennis ball in the air,

clap, and then catch the ball as many times as

possible in 30 seconds. In a variation of this task,

a child throws a tennis or medium-size ball in the

air, claps up to three times, and then catches the

ball (see Fig. 9-16 ). Children identifi ed as having

sensory integrative dysfunction often are unable

to perform this task ( Imperatore Blanche et al.,

 2016 ). On the best of two attempts, 5-year-olds

clapped a mean of 1.25 times ( SD = 0.4) before

catching the ball; 6-year-olds clapped twice

( SD = 0.8); and 7-year-olds clapped 2.5 times

( SD = 0.9). Inter-rater reliability as noted with

the other clinical observations was within acceptable standards ( Blanche et al., 2015 ).

 Sequencing

 Sequencing is integral to motor planning. All

feedforward-dependent tasks involve sequencing

actions. Some clinical observations, however,

involve repeated sequences of movements. These

provide opportunities for evaluating fl uidity and

sequencing of movements. To that end, we assess

FIGURE 9-16 Child throwing a medium-size ball

up in the air and clapping before catching the ball.

Copyright Dominique Kiefer.

234 ■ PART III Tools for Assessment

rapidly alternating forearm movements (diadochokinesis) and sequential fi nger touching.

Rapidly Alternating Forearm Movements

 Clinical observation of diadochokinesis involves

performing rapid forearm pronation and supination with each arm separately and then the

two simultaneously. Quality of movement is

important; it should be fl uid, rhythmic, and performed without excessive shoulder movement

(i.e., internal rotation or abduction). Poor performance or associated (i.e., mirroring) movements

in the other hand during unilateral performance

refl ect a high degree of effort and suggest diffi -

culty. Figure 9-17 shows an examiner assessing

alternating forearm movements, and Figure 9-18

shows a child with excessive shoulder rotation

and abduction.

 Recent data collected with typically developing children indicated that on the best of

two attempts, 5-year-olds performed a mean of

4.8 sequences in 5 seconds ( SD = 1.0), 6-year-olds

completed 5.3 sequences ( SD = 1.1), and 7-yearolds did 6.1 sequences ( SD = 1.0). Left, right, and

bilateral scores were similar. Measures of reliability indicate substantial agreement among independent raters ( Imperatore Blanche et al., 2016 ).

 Researchers ( Denckla, 1973 ; Wolf, Gunnoe, &

Cohen, 1985 ) have found that children who have

diffi culty with diadochokinesia also have poor

academic performance. The ability to perform

diadochokinesia also discriminates between children with and without disabilities. The reason

for this link is unclear except that it may refl ect

common neurological underpinnings.

Sequential Finger Touching

 Sequential Finger Touching (SFT) involves

moving fl uidly when touching the thumb to the

tip of each digit, fi rst with one hand and then the

other. The child begins by touching the index

fi nger to the thumb. When he reaches the fi fth

digit, he reverses direction, touching the fi fth digit

only once. He touches each fi nger again, ending

with the index fi nger. Six-year-olds can easily

perform SFT, and girls generally perform better

than boys ( Denckla, 1973 ; Grant, Boelsche, &

Zin, 1973 ). Skillful performance of SFT relies

on proprioceptive feedback. The examiner fi rst

demonstrates the desired movement and then

prevents the child from using visual feedback

by placing a screen between the child ’ s head and

hand (see Figs. 9-19 and 9-20 ). Evaluation of the

quality of SFT includes observation of: FIGURE 9-17 Child demonstrating symmetrical

movements without shoulder rotation. Copyright

Dominique Kiefer.

FIGURE 9-18 Excessive shoulder rotation and

abduction during alternating forearm rotation.

Copyright Dominique Kiefer.

FIGURE 9-19 Examiner demonstrating correct

placement of screen when assessing sequential fi nger

touching. Copyright Dominique Kiefer.

CHAPTER 9 Using Clinical Observations within the Evaluation Process ■ 235

• Fluidity of movement

• Uniform pressure

• No associated (or mirror) movements in the

opposite (resting) hand

Recent data indicate that values for the right hand

are similar to the left. Five-year-olds had a mean

score of 4.9 touches in 5 seconds ( SD = 2.3),

6-year-olds had 5.3 touches ( SD = 2.3), and

7-year-olds had 7.4 touches ( SD = 2.1). Interrater reliability for the counting number of

touches was moderate but for evaluation of fl uidity was very high ( Imperatore Blanche et al.,

 2016 ).

Bilateral Motor Coordination

 Bilateral motor coordination is evaluated with

some subtests of the SIPT ( Ayres, 1989 ) and also

can be observed with structured and unstructured

clinical observations. Unstructured observations

of bilateral motor coordination include observation of tasks that require both hands, such as

using one hand to hold the paper while writing

with the other, opening a jar, and zipping pants

or a jacket. Many tasks that require bilateral

motor coordination, such as riding a bike or a

scooter, also require timing and anticipatory

movements. Structured clinical observations of

bilateral motor coordination include observing

the quality of performance of skipping, jumping

jacks, symmetrical stride jumps, and reciprocal

stride jumps ( Magalhaes, Koomar, & Cermak,

 1989 ). The examiner demonstrates all skills and

should take care to do so fl uidly.

 Skipping

 Most children have learned to skip by the time

they enter kindergarten. To evaluate skipping,

the examiner demonstrates a fl uid, continuous

sequence for approximately 5 seconds. Skipping

requires bilateral motor coordination and fl uid

movements. Children with poor praxis often

“stop” between skips or have diffi culty bouncing from one foot to the other. Data indicate that

typically developing 5-year-olds skipped a mean

of 5.6 times in 5 seconds ( SD = 4.1), whereas

6-year-olds skipped 5.3 times in 5 seconds

( SD = 4.5), and 7-year-olds performed 7.5 skips

in 5 seconds ( SD = 4.6) ( Imperatore Blanche et

al., 2016 ). Inter-rater reliability for both qualitative and quantitative parameters was assessed to

be acceptable ( Blanche, Bodison, et al., 2012 ).

Jumping Jacks and Stride Jumps

Jumping Jacks. Beginning with arms at

the sides and feet together, the examiner does

a series of jumps in place. On the fi rst jump,

the examiner simultaneously abducts legs and

arms until hands clap overhead. Immediately,

the examiner jumps up again, returning arms

and legs to the starting position. The examiner

repeats these jumps a few times continuously and

fl uidly. Having seen the demonstration, the child

performs the same movements, and the examiner

evaluates the quality of the jumping jacks. See

 Figures 9-21 and 9-22 for correct and incorrect

performance of jumping jacks.

Symmetrical Stride Jumps. The examiner

begins with the arm and leg on the same side

forward (e.g., right arm and right foot forward).

The examiner jumps rhythmically in place,

moving the arm and leg that were forward to

the back and bringing the other arm and leg

forward. The ipsilateral arm and leg move

together throughout the sequence. Having seen

the demonstration, the child performs the same

movements, and the examiner evaluates the

quality of the symmetrical stride jumps.

Reciprocal Stride Jumps. The examiner

begins with the contralateral arm and leg forward

(e.g., right hand and left foot). The examiner

jumps rhythmically in place, moving the arm and

leg that were forward to the back and bringing the

other arm and leg forward. The contralateral arm

and leg move together throughout the sequence.

Having seen the demonstration, the child

FIGURE 9-20 Child displaying associated (mirror)

movements in opposite hand. Copyright Dominique

Kiefer.

236 ■ PART III Tools for Assessment

FIGURE 9-22 Jumping jacks: Incorrect position.

Copyright Dominique Kiefer.

FIGURE 9-21 Jumping jacks: Correct position. Child

completes movement by clapping hands overhead.

Copyright Dominique Kiefer.

performs the same movements, and the examiner evaluates the quality of the reciprocal stride

jumps. Figures 9-23 and 9-24 illustrate symmetrical and reciprocal stride jumps, respectively.

 Several qualitative observations can be made

during this task:

• Need for assistance to assume the position

• Fluidity and rhythmicity of movements

• Simultaneous movement of correct (i.e.,

ipsilateral or contralateral) extremities

 The ability to perform jumping jacks appears

to mature by the time a child is 7 years of age.

Stride jumps are more diffi cult and should not be

expected in children younger than 8 or 9 years

old ( Magalhaes et al., 1989 ). Bilateral jumps

involving both arms and legs are included in the

Bruininks-Oseretsky Test of Motor Profi ciency,

Second Edition ( Bruininks & Bruininks, 2005 ).

Recent data indicate that 5- and 6-year-olds have

diffi culty with these jumping tasks and there is a

lot of variability of performance. Seven-year-olds

had a mean score of 6.2 jumping jacks ( SD = 4.5),

6.2 symmetrical stride jumps ( SD = 4.7), and

4.4 reciprocal stride jumps ( SD = 4.4) ( Blanche

et al., 2015 ).

HERE ’ S THE POINT

• The use of feedback (proprioceptive, visual)

in support of the production of action can be

observed in slower movements that allow for

error correction.

• Feedforward control (vestibular, proprioceptive)

is used for movements requiring anticipation,

and it is dependent on time and sequencing.

• Bilateral motor coordination should take into

account quality in the performance of tasks

requiring use of both sides of the body.

Additional Observations

of Sensory Processing

 When evaluating sensory processing in children, the therapist needs to have multiple data

points that indicate a defi cit. Diffi culty with one

observation may or may not be indicative of a

problem. Therefore, it is important to include

CHAPTER 9 Using Clinical Observations within the Evaluation Process ■ 237

FIGURE 9-23 Child demonstrating symmetrical stride

jumps. Copyright Dominique Kiefer.

FIGURE 9-24 Child demonstrates reciprocal stride

jumps. Copyright Dominique Kiefer.

other measures to establish a clear pattern of dysfunction. Three additional observations addressing primarily proprioceptive, vestibular, and

tactile diffi culties are described next.

 Modifi ed Schilder ’ s Arm Extension Test

 To administer the Modifi ed Schilder ’ s Arm Extension Test ( Blanche, 2002, 2010 ; Dunn, 1981 ), the

examiner stands behind the child and instructs

the child to maintain the arms in 90 degrees of

shoulder fl exion, with elbows fully extended and

forearms pronated. The examiner then places her

hands on the sides of the child ’ s face, covering

the child ’ s eyes with her fi ngers. Reminding the

child to maintain the position of the body and

arms, the examiner rotates the child ’ s head. The

following observations can be made:

• Ability to maintain position of upper

extremities

• Ability to allow the head to be moved

without also rotating the trunk (record:

0 degrees of rotation, 0–45 degrees of

rotation, 45–90 degrees of rotation, or

90 + degrees of rotation)

• Ability to keep upper extremities in the

starting position

• Ability to maintain equilibrium

• Freedom of movement of the head

• Fingers and hands kept still

 According to Dunn ( 1981 ), 5-year-olds should

rotate the trunk no more than 45 degrees when

the examiner turns the head 90 degrees. Younger

children are less likely to be able to hold the

body position, but older children should fi nd it

easier. Diffi culties with maintaining the head and

upper extremities in position suggest diffi culties

with proprioceptive processing. Loss of equilibrium suggests vestibular and proprioceptive diffi -

culties. Choreoathetoid movements in the fi ngers

may indicate neuromotor involvement ( Ayres,

 1977 ). Figures 9-25 and 9-26 illustrate some

of the qualitative observations just mentioned.

238 ■ PART III Tools for Assessment

FIGURE 9-25 Examiner demonstrates administration

of Modifi ed Schilder ’ s Arm Extension Test. Copyright

Dominique Kiefer.

FIGURE 9-26 Child has poor ability to maintain trunk

and arm position. Copyright Dominique Kiefer.

For example, the girl ’ s body positioning in Figure 9-25 illustrates an asymmetrical slight drop

of upper extremities; the boy in Figure 9-26

seems to have considerable diffi culty with proprioceptive processing. In response to head turn,

he rotates his trunk more than 90 degrees, fl exes

his elbows, and supinates in the left forearm.

Gravitational Insecurity

 Recall from Chapter 3 (Composing a Theory: An

Historical Perspective) that gravitational insecurity is defi ned as fear of changing body position, having the feet off the ground, or moving

into backward space ( Blanche, 2002, 2010 ). The

fear is out of proportion to the challenge and not

caused by poor postural control. Gravitational

insecurity has been linked to poor integration

of proprioceptive, visual, and vestibular input.

 May-Benson and Koomar ( 2007 ) described two

tests to measure gravitational insecurity. The fi rst

involves tilting the child backward in space, and

the second asks the child to jump off a chair with

eyes closed. Qualitative observations that can be

made during these tests include the following:

• How comfortable is the child with being

tilted backward?

• Does the child resist tilting or show negative

emotions, such as anxiety, fear, or distress?

• Does the child fi rmly grasp the therapist ’ s

arms?

 When performing these tests, the examiner also

should observe postural control. Figures 9-27

FIGURE 9-27 Child demonstrates no resistance to

backward tilting. Copyright Dominique Kiefer.

CHAPTER 9 Using Clinical Observations within the Evaluation Process ■ 239

FIGURE 9-28 Child seems to enjoy moving into

backward space. Copyright Dominique Kiefer.

FIGURE 9-29 Child grasps the therapist ’ s arms,

suggesting fear of being tipped backward. Copyright

Dominique Kiefer.

FIGURE 9-30 Child with postural control diffi culties,

but no resistance to gravitational challenges.

Copyright Dominique Kiefer.

and 9-28 show children with no resistance to, or

fear of, being tipped backward. In contrast, the

child in Figure 9-29 shows signs of fear, whereas

the reaction of the child in Figure 9-30 suggests

poor postural control but no fear or resistance.

Under- and Over-Responsivity

to Tactile Sensations

 Reactivity to tactile sensations can be observed

in a variety of ways during the administration

of clinical observations. Under-reactivity can be

determined if the child fails to orient to light touch

applied to the back of the neck ( Ayres & Tickle,

 1980 ). Over-responsivity may be observed when

providing hands-on physical assistance during

the administration of the postural measures or the

Modifi ed Schilder ’ s Arm Extension Test, when

handling the child on a ball, or when providing

the opportunity to play with tactile media, such

as sand and shaving cream. Tactile reactivity can

limit a child ’ s ability to engage in situations that

can be socially and motorically demanding.

HERE ’ S THE POINT

• Using the Modifi ed Schilder ’ s Arm Extension

Test provides an additional way to examine

vestibular and proprioceptive processing.

This observation also provides insight into

neuromotor control.

• Assessing gravitational insecurity provides

a means of looking at the modulation of

vestibular inputs.

• Observation of the child ’ s response to touch

during clinical observations and standardized

assessments provides insights into tactile overand under-responsivity.

Interpretation of Results

 Two points are particularly relevant with regard

to interpretation. First, any interpretation depends

on a high-quality assessment. A high-quality

assessment means that structured observations

were administered properly and that normative

data were applied when available. We have presented some normative data from a variety of

sources, including performance expectations of

typically developing children at varying ages,

although some of the normative data presented

240 ■ PART III Tools for Assessment

is outdated. When norms are not available, therapists must rely on a solid understanding of

normal development. Second, accurate interpretation depends on in-depth understanding of SI

theory, including the ways in which these clinical observations refl ect the theory. Readers are

encouraged to understand the relationships of

the clinical observations to the constructs associated with SI. See Figure 9-1 , and refer back to

 Figure 1-1 .

observations. There are many reasons why clinical observations are important, but the most

important may be that many postural control

functions that are thought to refl ect vestibularproprioceptive functioning are not well captured

in standardized tests, such as the SIPT. In addition, many young children or children with diagnoses such as autism or ADHD may be unable

to complete the SIPT in a valid way. Thus, the

identifi cation of sensory integrative defi cits must

be made largely based upon skilled clinical

observations and parent report. Information collected using clinical observations was described

in this chapter as it related to postural control,

motor planning or praxis, and reaction to sensory

information.

 Researchers have developed standard procedures for administering many of the structured

clinical observations used during SI evaluations.

Those researchers also have provided preliminary normative data for those observations. It is

vital that interpretation of data based on clinical

observations be used and interpreted judiciously

as there is great variability in the performance of

many of these observable behaviors, particularly

among young children.

Where Can I Find More?

 Until now, clinical observation has been used as

a diagnostic tool, but its use can be expanded to

its application as an outcome measure for postural control and motor planning. In such a case,

caution is necessary as studies utilizing clinical

observations as outcome measures have had mixed

results. In administering clinical observations, the

following resources may be of assistance.

Videos:

 Observations Based on Sensory Integration

Theory

 Author: Erna Blanche, PhD, FAOTA, OTR/L

 Skilled observations of sensory integrative dysfunction allow therapists to discreetly analyze

a child ’ s behavior and skills and, in turn,

develop more effective intervention plans.

This DVD set provides guidelines for clinical observation and nonstandardized assessment. Dr. Erna Blanche shows therapists how

to observe and interpret children ’ s behavior

from an SI perspective. The DVD and accompanying workbook show, step-by-step, how

to administer specifi c observations, including

PRACTICE WISDOM

Clinical observations should be included in all

assessments ( Asher, Parham, & Knox, 2008 ) as

the use of observations (structured and unstructured) provides a clinician with information that

cannot be gathered any other way. Clinical

observations in SI are incorporated into professional practice by using commercially available

protocols with normative data, such as the

COMPS ( Wilson et al., 2000 ), or by applying

resources that guide therapist clinical reasoning and analysis, such as educational videos,

in-depth observation protocols, and case analysis

( Blanche, 2002, 2010 ). Evidence-based information also can be used from research reports, such

as those that have been written by researchers

who have investigated a particular observation

or group of observations. Finally, the value of

augmenting assessment data with naturalistic,

unstructured observations for intervention planning cannot be overestimated. Determining how

a child ’ s underlying sensory processing and integration abilities are supporting or limiting his or

her ability to perform in the natural context, to

play, and to succeed at school is key to designing effective programs.

Summary and Conclusions

 This chapter reviewed the administration and

interpretation of clinical observations, focusing

on postural control, motor planning, and sensory

reactivity as they relate to sensory processing

diffi culties. Structured and unstructured clinical observations are part of any evaluation of

sensory processing. Observations become essential when standardized data is not available, specifi cally with young children and children with

autism spectrum disorders (ASD). Assessments

of SI generally include standardized testing as

well as both structured and unstructured clinical

CHAPTER 9 Using Clinical Observations within the Evaluation Process ■ 241

those originally defi ned by Dr. A. Jean Ayres.

These are specifi c tasks, postural responses,

and signs of nervous system integrity associated with sensory integrative functioning.

Children ’ s skills are compared using splitscreen images and in-depth discussion. The

workbook provides a table of observations,

normative information, a glossary, references,

and worksheets that support the learning

process. The observations demonstrated can

be used with children of varying ages and

skill levels.

Written Materials:

 Clinical Observations of Motor and Postural

Skills: Second Edition (COMPS)

 Author: Brenda Wilson, MS, OT (C); Bonnie

Kaplan, PhD; Nancy Pollock, MSc, OT (C);

and Mary Law, PhD, OT (C)

 A screening tool based on six of the clinical observations developed by Dr. A. Jean

Ayres. It generates a score to help identify

several subtle motor coordination problems

in children. This revision now includes children from 5 years of age to 15 years of age.

COMPS offer standardized administration

procedures and objective criteria for scoring.

Easy-to-follow instructions and illustrations

help therapists to administer the test quickly

and reliably in fewer than 15 minutes. It

includes the Scoremaker software to assist

with scoring.

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use of functional reach as a measure of balance

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242 ■ PART III Tools for Assessment

defi cits . In A. G. Fisher , E. A. Murray , &

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243

CHAPTER

10

Assessing Sensory Integrative

Dysfunction without the SIPT

 Anita C. Bundy , ScD, OT/L, FAOTA

 Chapter 10

 True genius resides in the capacity for evaluation of

uncertain, hazardous, and confl icting information.

 —Winston Churchill

Upon completion of this chapter, the reader will be able to:

✔ Identify aspects of the Bruininks-Oseretsky Test

of Motor Profi ciency-2, and the Movement

ABC-2, and Clinical Observations that can

be used to assist in detecting dyspraxia,

somatosensory processing problems, and

postural and ocular-motor dysfunction in

children.

✔ Describe the limitations of conducting

comprehensive evaluations of sensory

integration (SI) without the administration of

the Sensory Integration and Praxis Tests (SIPT).

✔ Describe how caregiver questionnaires, such

as the Sensory Profi le and Sensory Processing

Measure, can be used to attain important

information regarding a child ’ s sensory

processing abilities and challenges.

LEARNING OUTCOMES

Purpose and Scope

 Although the Sensory Integration and Praxis Tests

(SIPT) ( Ayres, 1989 ) remains the most comprehensive and psychometrically sound means to

assess sensory integration (SI) and praxis in children, their use is not always possible or practical.

The purpose of this chapter is to consider other

tools that might offer insight into aspects of SI

and processing, and the relationship between

sensory integrative dysfunction, occupation, and

participation. It is not our intent to present all

possible assessment tools; that would be a formidable task for this chapter. Instead, we touch on

some of the tools typically used to obtain insight

into diffi culties with sensory modulation, sensory

discrimination, and dyspraxia and then provide

our thoughts on their strengths and weaknesses

relative to understanding sensory integrative

dysfunction. Throughout the chapter, we apply

some of the tools described and then explain our

clinical reasoning with a case, Lenard.

Introduction

 There may be multiple reasons for not choosing

to use the SIPT to assess sensory integrative dysfunction. One important reason is that the level

of detail provided by the SIPT often far exceeds

what is necessary for providing the type of intervention that would be most benefi cial for a particular child. For example, if a therapist wishes

to consult with a teacher to minimize diffi culties

the teacher is experiencing while instructing a

child, most likely it would not be necessary to

know the child ’ s scores on the SIPT. The expense

associated with administering, scoring, and

244 ■ PART III Tools for Assessment

interpreting the SIPT is another reason that its

use is sometimes impractical or impossible. This

may be particularly true outside North America,

where there is little, if any, local normative data.

This situation would require that scores be interpreted very cautiously, as the potential effects of

culture on performance are largely unknown. The

idea of using an expensive SIPT without being

certain how well the norms apply may be incomprehensible to many. Finally, even within North

America, we also must use caution in applying

normative data from the SIPT, as the norms are

quite old and may no longer refl ect child performance accurately.

 Almost two decades have passed since we

published the second edition of Sensory Integration: Theory and Practice ( Bundy, Lane, &

Murray, 2002 ). Evaluation of some aspects of SI

without the SIPT has gotten easier in that time

because of new assessments. These include the

family of tools that comprise the Sensory Profi le2 (SP2; Dunn, 2014 ) and the Sensory Processing Measure (SPM; Parham, Ecker, Kuhaneck,

Henry, & Glennon, 2010 ) . These parent- and

teacher-report assessments address sensory processing and modulation, body awareness and

praxis, and the functional sequelae of diffi culties

with each. Because the cost to administer these

tools is less prohibitive than for the SIPT, many

therapists seem to have adopted parent- and

teacher-report measures in lieu of the favored

SIPT. However, sensory items from the SP2 and

the SPM are organized by system rather than in

a way that makes it easy to distinguish diffi culties with modulation, sensory discrimination, and

praxis. Therefore, examiners must take particular

care when interpreting fi ndings. Similar to the

SIPT, the norms from both refl ect primarily the

performance of children from North America,

meaning that examiners also must be aware of

potential cultural differences. Finally, the results

of proxy-reporting are likely to be different

from those derived through observation ( Lane,

Reynolds, & Dumenci, 2012 ).

 Even in the absence of standardized test

scores that are readily available and easily interpretable, therapists often wish to feel assured

whether sensory integrative dysfunction is a

factor in a child ’ s diffi culties and, if so, the

nature of the dysfunction. In this chapter, we

return to the heart of the model of SI presented

in Chapter 1 (Sensory Integration: A. Jean Ayres’

Theory Revisited) to suggest ways for therapists

to supplement parent- and teacher-reporting with

observations. Reliable use of these observations

depends on well-honed observation skills and a

thorough understanding of normal development.

Many of the observations are drawn from Clinical Observations, described in detail in Chapter 9

(Using Clinical Observations within the Evaluation Process). It is also important to be reminded

that assessment of the performance of everyday

occupations should always accompany examination of SI. These are included, to a degree, in the

SPM and SP2 tools, but we also refer readers to

 Law, Baum, and Dunn ( 2005 ) for a review of

additional assessments.

Sensory Integration

Theory Revisited

 In Chapter 1 (Sensory Integration: A. Jean Ayres’

Theory Revisited), we proposed a model of

sensory integrative dysfunction comprising two

major types of dysfunction: dyspraxia and poor

modulation of sensation; either can have a basis

in poor processing of vestibular, proprioceptive, or tactile sensations. Dyspraxia is manifest

in poor bilateral integration and sequencing or

somatodyspraxia. Modulation problems can be

seen as over-responsivity (i.e., defensiveness or

aversive responses), under-responsivity, or fl uctuating responsivity (see Fig. 1-6 ). If the theory

of SI is sound, then the results of any valid, reliable measures of the constructs described (e.g.,

posture, tactile discrimination, bilateral integration) should provide information about one or

more aspects of sensory integrative functioning.

Of course, assessments are valid and reliable

only within their intrinsic limitations. Information related to assessment reliability and validity is generally available in test manuals and in

reports of research examining the test ’ s measurement properties.

 To say that individuals have sensory integrative dysfunction, we must fi nd meaningful clusters that relate a particular problem with motor

coordination, attention, or behavior to poor

processing of sensation. Thus, for example, it is

not enough to identify a problem with bilateral

coordination (e.g., diffi culty manipulating paper

CHAPTER 10 Assessing Sensory Integrative Dysfunction without the SIPT ■ 245

and scissors to cut out a shape, diffi culty coordinating the two sides of the body in skipping)

and assume sensory integrative dysfunction.

If the problem is sensory integrative in nature,

there also will be evidence of poor processing

of vestibular or proprioceptive information (e.g.,

low muscle tone, poor prone extension). If a

problem with distractibility is an end-product of

sensory integrative dysfunction, then there will

be evidence of poor modulation of tactile, vestibular, or proprioceptive sensation. In Figure 10-1 ,

we embellish the model of SI by proposing

assessments that might be used to examine the

constructs. Table 10-1 contains a key to the

assessments appearing in Figure 10-1 as well as

supplementary detail.

CASE STUDY ■ LENARD

 Lenard, age 6, is a quiet child; he gets along

with most of his peers and relates well to the

caregivers at preschool. He seems a bit immature for his age in terms of the play activities

in which he engages. Lenard attained his milestones generally on time, although most at the

later end of typical development. He was quite

content to sit and play quietly at home, exploring his environment minimally. His mother

enrolled him in preschool at age 3, hoping his

motor and interaction skills would improve by

being around peers. Generally, Lenard seems

clumsy with movement; he runs rarely and

often trips over the legs of chairs and other

TABLE 10-1 Tests for Identifying Aspects of Sensory Integrative Dysfunction in the Absence

of the SIPT

TEST

CONTRIBUTOR TO SI

ASSESSMENT MOD POSTURE

SOMATO

DISCRIM VBIS SD

BOT2 Bruininks-Oseretsky

Test of Motor

Profi ciency

(2nd ed.)

 • Bruininks and

Bruininks, 2013

 • Strength and Agility

 • Body Coordination

 • Manual Coordination

 • Fine Manual Control

✓

( ✓ )

✓

✓

( ✓ )

✓

✓

✓

MABC-2 Movement ABC-2

 • Henderson,

Sugden, and

Barnett, 2007

 • Static and Dynamic Balance

 • Ball Skills

 • Manual Dexterity

✓

✓ ✓

✓

MABC

Checklist

MABC Checklist

 • Henderson and

Sugden, 1992

Parent perceptions of child

motor skills

✓ ✓

NIH

Toolbox

NIH Toolbox

Somatosensory

Items

Somatosensory discrimination ✓

M-FUN Miller Function and

Participation Scales

 • Gross motor

 • Fine motor

 • Visual motor

✓

SPM Sensory Processing

Measure

 • Parham, Ecker,

Kuhaneck,

Henry, and

Glennon, 2010

 • Vision

 • Hearing

 • Touch

 • Taste and Smell

 • Body Awareness

 • Balance and Motion

 • Planning and Ideas

✓

✓

✓

✓

✓

✓

( ✓ )

 ( ✓ )

✓

 ( ✓ )

( ✓ )

 ( ✓ )

( ✓ )

 ( ✓ )

Continued

246 ■ PART III Tools for Assessment

TEST

CONTRIBUTOR TO SI

ASSESSMENT MOD POSTURE

SOMATO

DISCRIM VBIS SD

SP2 Sensory Profi le 2

 • Dunn, 2014

 • Seeking/Seeker

 • Avoiding/Avoider

 • Sensitivity/Sensor

 • Registration/Bystander

Measures senses separately;

posture and movement items

interspersed

✓

✓

✓

✓

( ✓ ) ( ✓) ( ✓ )

SP (AA) Adolescent/Adult

Sensory Profi le

 • Brown and

Dunn, 2002

 • Poor registration

 • Sensitivity to stimuli

 • Sensation seeking

 • Sensation avoiding

✓

✓

✓

✓

COs Clinical

Observations

 • Chapter 9 ,

Using Clinical

Observations

within the

Evaluation

Process

 • Prone extension

 • Postural reactions

 • Extensor tone

 • Head and neck in supine

 • Supine fl exion

 • Dynamic reach (kneel)

 • RAMP movements

 • Ball play

 • Jumping jacks/stride jumps

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

COMPS Clinical

Observations of

Motor and Postural

Skills

 • Slow movements

 • Diadokokinesia

 • Finger-nose touching

 • Prone extension

 • Supine fl exion

 • Asymmetrical tonic neck

refl ex

✓

✓

✓

✓

✓

✓

✓

SCSIT

(SD)

Southern California

Sensory Integration

Tests of Sensory

Discrimination

 • Ayres, 1980

 • Localization of tactile stimuli

 • Finger identifi cation

 • Graphesthesia

 • Manual form perception

 • Kinesthesia 1

✓

✓

✓

✓

✓

1

Conceptually, the Kinesthesia test refl ects somatosensory discrimination, which Ayres felt was an important contributor to body

scheme. However, the reliability of this test is quite low. Thus, it should not be used as a sole indicator and it should be used with

caution.

TABLE 10-1 Tests for Identifying Aspects of Sensory Integrative Dysfunction in the Absence

of the SIPT—cont’d

things left on the fl oor. He does not enjoy

climbing, and he will not jump off things such

as curbs. He can manage a spoon and fork for

eating, but he has diffi culty using scissors and

writing his name. As he is preparing to enter

kindergarten, both the preschool caregivers and

his parents have concerns.

 Lenard ’ s behavior at home is not a problem

(he is an only child); in preschool, he has had

diffi culty sharing toys and space as well as

cooperating with other children during free

play. Lenard shows a preference for playing

with a single peer at a time, seeming to become

anxious when others join in. Not understanding

the rules at school about sharing and including

interested friends, when the group becomes too

large, Lenard moves away and fi nds something

else to play. He does well interacting with the

caregivers at preschool, and often they can help

him play with others, especially if the games

and play themes are familiar to him. Lenard

repeats common play themes and activities

and seems lost when other children or adults

suggest changing the game. For instance, he

CHAPTER 10 Assessing Sensory Integrative Dysfunction without the SIPT ■ 247

FIGURE 10-1 Relationship of tests to sensory integration theory.

Indicators of poor

sensory modulation

Indicators of poor sensory integration

and praxis

Poor postural-ocular

control

Poor sensory

discrimination

Poor body scheme

VBIS

BOT-2

MABC-2

BOT-2

MABC-2

Somatodyspraxia

BOT-2

MABC-2

M-FUN

Clinical observations

COMPS

SCSIT (SD)

NIH toolbox

SPM, SP2

SPM, SP2

SPM, SP2

Poor registration

Under-responsivity

Fluctuating

responsivity

Over-responsivity

Aversive and defensive

reactions

Inadequate

CNS integration

and processing

of sensation

Visual

Vestibular

Tactile

[lnteroception]

Auditory

Olfactory

Gustatory

Proprioception

Sensory reactivity

Sensory perception

likes to build trucks with blocks, but he always

builds a fi re truck and likes to put out pretend

fi res. When other boys wanted to change to

dump trucks and play a construction game,

Lenard seemed lost and uncertain how to make

it fun. Rather than join in with this game,

Lenard stood back and watched them play.

 Dyspraxia

 In the evaluation of dyspraxia, we rely most

heavily on two assessments: the BruininksOseretsky Test of Motor Profi ciency, Second

Edition (BOT2) and the Movement Assessment Battery for Children-2 (MABC-2), which

includes both a performance test and an accompanying proxy-report checklist. The BOT2

comprises four motor composites, each of which

includes subtests. Many of these provide normative data for observations that therapists make

as structured or unstructured observations in the

context of assessment of SI dysfunction. Hypothesized relationships between BOT2 subtests and

SI dysfunction are shown in Table 10-1 and

 Figure 10-1 . The BOT2 yields standard scores

for children, adolescents, and young adults from

4 through 21 years of age. The test manual ( Bruininks & Bruininks, 2013 ) and authors of a review

article ( Deitz, Kartin, & Kopp, 2007 ) provide

reasonable evidence for reliability and validity

of data gathered with the BOT2. However, Deitz

and colleagues noted that not all subtests are

reliable at all ages and that very young children

(4- and 5-year-olds), especially those with motor

delays, fi nd some items very challenging.

 Based on research with predecessors to both

the BOT2 (i.e., the Bruininks-Oseretsky Test

of Motor Performance [BOTMP], Bruininks,

 1978 ) and the SIPT (i.e., the Southern California

Sensory Integration Tests [SCSIT]; Ayres, 1980 ),

there is some support for including the BOT2 in

an evaluation of praxis. Relating composite or

total (fi ne motor composite, gross motor composite, total composite) BOTMP scores with individual tests from the SCSIT, Ziviani and colleagues

 ( 1982 ) found several statistically signifi cant

( p < 0.01) correlations between SCSIT scores

and BOTMP fi ne, gross, and battery composites.

Further, Wilson and colleagues ( 1995 ) found

that four BOTMP subtests were particularly

good for identifying children with mild motor

diffi culties:

248 ■ PART III Tools for Assessment

• Running Speed and Agility

• Balance

• Visual-Motor Coordination

• Upper Limb Speed and Dexterity

 However, it is important to note that the BOT2

is a substantially different test from the BOTMP,

and more work will need to be done to establish

it as a proxy for evaluating praxis ( Bruininks &

Bruininks, 2013 ; Deitz, Kartin, & Kopp, 2007 ).

 The MABC ( Henderson & Sugden, 1992 ),

predecessor to the Movement ABC-2, was

standardized on children in the United States,

Canada, and the United Kingdom (UK). Some

researchers ( Rosblad & Gard, 1998 ; SmitsEngelsman, Henderson, & Michels, 1998 ) have

found generalizability of the norms adequate

in Europe, but others ( Livesey, Coleman, &

Piek, 2007 ) have suggested there are cultural

differences in Australia and, possibly, in Asia.

The Performance Test of the MABC-2 includes

items designed to assess manual dexterity, ball

skills, and balance. Similar to the BOT-2, many

MABC-2 items provide normative data for

observations that therapists would make as structured or unstructured observations in the context

of assessment of sensory integrative dysfunction.

Hypothesized relationships between MABC-2

subtests and sensory integrative dysfunction are

shown in Table 10-1 and Figure 10-1 .

 The MABC-2 yields standard scores for children and adolescents from 3 through 16 years

of age. However, in a review article, Brown and

Lalor ( 2009 ) pointed out that, although a fair

amount of research has addressed the psychometric properties of the MABC, there is very

little evidence for reliability or validity of data

gathered with the MABC-2. Brown and Lalor

reminded us that there are substantial differences between the MABC and the MABC-2.

Thus, normative data drawn from the MABC-2,

although likely better than most examiners’

knowledge of how well children at varying

ages should perform, still should be used cautiously. In the case at the end of this chapter

about Lenard, the MABC-2 has been used in

this manner.

 The checklist included in the MABC-2 yields

ratings from parents on a variety of everyday

activities. In developing this checklist, Henderson and Sugden ( 1992 ) applied the hierarchy

of diffi culty of movement tasks described by

 Gentile and colleagues ( 1975 ) and Keogh and

Sugden ( 1985 ). This hierarchy is based on both

the amount of movement of a target object and

the amount of movement required of the individual to act on the object, and that hierarchy

refl ects the construct of praxis as a continuum

(see Chapter 5 , Praxis and Dyspraxia, for more

detailed discussion of praxis). For instance,

donning a shoe while sitting on the fl oor involves

little movement of the target (shoe) and little

movement of the individual to act on the target.

In contrast, donning the shoe while standing up

may involve a great deal of movement of both

the target (shoe) and individual if the person is

hopping about trying to put the shoe on! Therefore, information on the potential impact of problems with praxis on a child ’ s ability to perform

many activities of daily living may be derived

from interpretations made from the scores on the

MABC-2 Checklist.

 An older tool that therapists may use to gain

insight into motor coordination is the Clinical Observations of Motor and Postural SkillsSecond Edition (COMPS-2; Wilson, Pollock,

Kaplan, & Law, 2000 ). The COMPS-2 is a standardized and norm-referenced screening tool for

children from 5 to 15 years of age, and it refl ects

a refi nement of Ayres’ Clinical Observation

( Ayres, 1976 ), based on the items that could be

reliably administered and scored. It is intended

to be a useful supplement to standardized testing.

Items on the COMPS-2 include slow movements, diadokokinesia, fi nger-nose touching,

prone extension, supine fl exion, and the asymmetrical tonic neck refl ex. No research could be

found on this second edition, but good 2-week

test–retest and inter-rater reliability and internal

consistency were noted in the fi rst edition when

testing children with and without developmental

coordination disorder ( Wilson, Pollock, Kaplan,

Law, & Faris, 1992 ). Changes to the second

edition involved expanding the age range from

5 years of age and 9 years 11 months of age,

to 5 years of age and 15 years of age; as such,

applying these psychometrics to testing older

children must be done cautiously.

 Other tools are available to assess gross and

fi ne motor function. For instance, the Miller

Function & Participation Scales (M-FUN; Miller,

 2006 ) has assessment items for gross, fi ne, and

CHAPTER 10 Assessing Sensory Integrative Dysfunction without the SIPT ■ 249

visual motor performance and ties motor performance to participation. The usefulness of tools,

such as the M-FUN, for assessing aspects of

sensory integrative function comes from using

observational skills to examine the quality of

motor performance, giving thought to how each

task was conceptualized, planned, and executed.

As such, the M-FUN and other similar tools can

offer insights into end products commonly associated with SI dysfunction (fi ne, gross, and visual

motor, and participation) but, alone, do not allow

us to conclude that sensory integrative concerns

are at the root of any problem.

CASE STUDY ■ LOOKING AT LENARD ’ S

PRAXIS

 Lenard was referred for an occupational therapy

evaluation to investigate his motor skills and

clumsiness, hesitancy to play in groups, and

preference for sameness in play. Our background in SI theory guides us in the evaluation

process, but we decided not to use the SIPT.

Instead, we used a combination of assessments

to address the concerns. In considering his

motor skills, we recognized that Lenard appears

clumsy, leading us to be concerned about vestibular and proprioceptive processing, posturalocular control, and praxis. We decided to use

the MABC-2, the checklist for the MABC,

and Clinical Observations to examine these

areas. Results from the MABC-2 indicated that

Lenard had diffi culty with static and dynamic

balance and ball skills, with percentile ranks of

3 for balance and 5 for ball skills. His manual

dexterity percentile was 7, indicating borderline

performance. The checklist, completed by his

mother, put him clearly in the red zone. Also,

Lenard was identifi ed by his mother as being

somewhat timid and anxious, which could

infl uence his movement scores.

 On the model shown in Figure 10-2 , we have

“plotted” our interpretations of these fi ndings

and show a “plus” ( + ) for areas of concern and

a “minus” (–) for areas where we do not have

concern. You can see that we have hypothesized that Lenard ’ s MABC-2 suggests diffi culty

with postural-ocular control and implicates

diffi culty with vestibular and proprioceptive

processing.

HERE ’ S THE POINT

• Sometimes it is impractical and not feasible or

necessary to administer the SIPT.

• Clinical Observations, and the administration

of other assessments, such as the SP2, SPM,

BOT2, MABC-2, the COMPS, and the M-FUN,

may be used to gather important information

about a child ’ s praxis abilities and how

dyspraxia may be impacting a child ’ s ability to

perform his or her daily occupations.

Assessment of Somatosensory

Discrimination

 Few standardized tests of somatosensory discrimination exist. If they are available, several

tests from the SCSIT ( Ayres, 1980 ), which

have published norms for children between

4 and 9 years of age, offer a structure to observing

discrimination that may be useful. Similar to the

SIPT, these tests examined stereognosis, localization of touch, fi nger identifi cation, graphesthesia, visual-tactile integration, and kinesthesia.

Caution is needed, however; these tactile tests

are known to ceiling early, several are associated

with large errors and relatively poor test–retest

reliability, and the SCSIT was standardized more

than 40 years ago. They are no longer available

commercially. Because of these shortcomings,

readers are urged not to report standard scores

in documentation. Rather, consider scores above

1 standard deviation below the mean (> –1.0) to

refl ect typical functioning, and scores below that

to be indicative of performance markedly below

that of most children of a given age. These tests

become a way to structure observation of performance and provide guidelines for interpretation

if used cautiously.

 Recently, the National Institutes of Health

(NIH) developed a Toolbox of assessments

designed to be short, simple, and usable across

the life span ( Gershon et al., 2013 ). The whole

Toolbox includes assessments of cognition,

emotion, motor, and sensory functions; individual items may be useful for individuals from 3 to

85 years of age with a variety of adaptations

based on age. Measures of sensation include auditory “word-in-noise,” visual acuity, odor identifi cation, taste perception, and pain scales for

250 ■ PART III Tools for Assessment

FIGURE 10-2 Categorizing Lenard ’ s performance on assessments. Sensory reactivity Sensory perception

Visual

Vestibular

Tactile

Auditory

Olfactory

Gustatory

Indicators of poor

sensory modulation

Inadequate CNS

integration and

processing of

sensation

Indicators of poor sensory integration

and praxis

Poor postural-ocular

control

Poor sensory

discrimination

Poor body scheme

VBIS

MABC-2

Somatodyspraxia

MABC-2

Clinical observations

SPM

Poor registration

SPM

/

Under-responsivity

SPM, SP2

Fluctuating

responsivity

Over-responsivity

Aversive and defensive

reactions

Proprioception

? ?

?

adults ( http://www.healthmeasures.net/exploremeasurement-systems/nih-toolbox/intro-to-nihtoolbox/sensation ). Although these sensory items

are not intended to provide detailed information

on sensory discrimination, they may be useful as

a screening tool. For instance, the NIH Toolbox

items related to somatosensory discrimination

include the Brief Kinesthesia Test, based on the

Kinesthesia test of the SCSIT and the SIPT; a

Wrist Position Sense Test, a Tactile Discrimination Test based on texture discrimination; a localization of touch tool using Semmes-Weinstein

monofi laments; and a Brief Manual Form Perception Test, based on the manual form subtests

of the SCSIT and the SIPT ( Dunn et al., 2015 ).

Performance ranges are offered based on initial

life-span testing. The Toolbox sensory items offer

an accessible, quick, and inexpensive means of

screening people for sensory and proprioceptive

perception.

HERE ’ S THE POINT

• There is no single, standardized assessment of

children ’ s sensory discrimination abilities.

• Use of the somatosensory subtests from the

SCSIT may provide guidance for understanding

tactile and proprioceptive processing in

children.

• The NIH Toolbox somatosensory items provide

a useful screening tool for these functions in

children.

Assessment of Postural

and Ocular Control

 Postural and ocular control are thought to be

important outward indicators of vestibularproprioceptive perception. To assess them, we

include:

• The balance subtest from the BOT2 and

items from the MABC-2

• Other standard Clinical Observations of

neuromotor performance (see the previous

information on the COMPS and Chapter 9 ,

Using Clinical Observations within the

Evaluation Process, for more information on

assessing Clinical Observations)

 Standard Clinical Observations are very useful

when assessing SI, with or without the SIPT. 

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