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Visual perceptual skills and related school functions in children with hemiplegic cerebal palsy.



Abstract

This study investigated differences in visual perception and visual-motor based school functions in children with and without congenital hemiplegia hemiplegia /hemi·ple·gia/ (-ple´jah) paralysis of one side of the body.hemiple´gic

alternate hemiplegia  paralysis of one side of the face and the opposite side of the body.
. Twenty children with hemiplegia (9 right; 11 left) and 37 control children ages 4-10 years were compared using the Developmental Test of Visual Perception, Motor-Free Visual Perceptual Test-Revised and School Function Assessment subtests (Using Materials, Written Work). Children with hemiplegia attained significantly lower scores than controls on all measures by one-way ANOVAs. Children with left hemiplegia scored significantly lower on motor-free visual tests. Regression analyses identified visual measures predictive of school performance. Results will assist school-based therapists working with this population.

Key words

Visual Perception, Cerebral Palsy cerebral palsy (sərē`brəl pôl`zē), disability caused by brain damage before or during birth or in the first years, resulting in a loss of voluntary muscular control and coordination. , Occupational Therapy, School, Functional Skills.

Burtner, P.A., Dukeminier, A., Ben, L., Qualls, C., & Scott, K. Visual perceptual skills and related school functions in children with hemiplegic hem·i·ple·gia  
n.
Paralysis affecting only one side of the body.



[Late Greek hmipl
 cerebral palsy. New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland.  Journal of Occupational Therapy 53(1), 24-29

**********

Occupational therapists occupational therapist A person trained to help people manage daily activities of living–dressing, cooking, etc, and other activities that promote recovery and regaining vocational skills Salary $51K + 4% bonus. See ADL.  are often the team members responsible for assessing the functional skills of children in the school setting. While therapists have long recognised the contributions of multiple systems (motor, cognitive, sensory, environmental) to daily occupations mastered by children, only recently have models of practice emphasised this functional approach (Law et. al, 1998). Likewise, researchers in movement sciences (Newell, 1991; Shumway-Cook & Woollacott, 2001) emphasise the study of development of perception, action and cognition cognition

Act or process of knowing. Cognition includes every mental process that may be described as an experience of knowing (including perceiving, recognizing, conceiving, and reasoning), as distinguished from an experience of feeling or of willing.
 less in isolation and more in the context of functional outcomes in the child's natural environment. In response to this contemporary view of disabilities, the World Health Organisation (2001) recently revised their guidelines in the International Classification of Functioning, Disability and Health International Classification of Functioning, Disability and Health, also known as ICF, is a classification of the health components of functioning and disability.  (ICF (Internet Connection Firewall) The built-in firewall in Windows XP. It provides a stateful inspection of packets which accepts only responses to requests originated by the user. ) to highlight the activities and participation of individuals with disabilities in addition to levels of impairment. The ICF guidelines are also congruent con·gru·ent  
adj.
1. Corresponding; congruous.

2. Mathematics
a. Coinciding exactly when superimposed: congruent triangles.

b.
 with the inclusion of special populations of children in regular classrooms. Children with spastic spastic /spas·tic/ (spas´tik)
1. of the nature of or characterized by spasms.

2. hypertonic, so that the muscles are stiff and movements awkward.


spas·tic
adj.
1.
 hemiplegic cerebral palsy, one group qualifying for school therapy services, often demonstrate neurological neurological, neurologic

pertaining to or emanating from the nervous system or from neurology.


neurological assessment
evaluation of the health status of a patient with a nervous system disorder or dysfunction.
 differences in motor skills and visual perceptual skills that affect school performance not observed in typically developing peers. The aim of this research study was to identify visual perceptual and school functional differences in children with hemiplegic cerebral palsy as compared with typically developing children.

Review of literature

Cerebral palsy (CP) is a neurodevelopmental disorder caused by non-progressive lesions in single or multiple locations in the immature brain in utero in utero (in u´ter-o) [L.] within the uterus.

in u·ter·o
adj.
In the uterus.



in utero adv.
, during or shortly after birth, resulting in motor impairment and often sensory deficits evident in early infancy (Scherzer & Tscharnuter, 1990). Within the diagnostic category of CP, an estimated 36.4% are children with spastic hemiplegia spastic hemiplegia
n.
Hemiplegia accompanied by spasms of the muscles of the affected side.
 (Hagberg, Hagberg, Olow & von Wendt, 1989) and an estimated 40% of these children have accompanying cognitive and learning disabilities. A variety of vision abnormalities have also been identified in children with hemiplegia and the overall population of children with CP (Pellegrino, 2002).

Visual perceptual differences of children with spastic hemiplegia are of interest to researchers due to differences in hemisphere functions (left hemisphere typically processing verbal-language functions vs. right hemisphere processing non-verbal visual spatial functions). In children with congenital spastic hemiplegia, hemisphere processing has not been clear. Carlsson, Uvebrandt, Hugdahl, Arvidsson, Wiklund & von Wendt (1994) reported lower scores on tests of intellectual functioning in children with right or left hemiplegia, with performance scores (visual spatial functions) lower than verbal scores in both groups of children. Similar findings have been reported by other researchers (Goodman & Yude, 1996; Stiers, Vanderkelen, Coene, DeRammelaere & Vandenbussche, 2002).

To better understand low performance scores in both groups of children with unilateral lesions, investigators hypothesise Verb 1. hypothesise - to believe especially on uncertain or tentative grounds; "Scientists supposed that large dinosaurs lived in swamps"
conjecture, hypothesize, speculate, theorise, theorize, hypothecate, suppose
 that children with left hemisphere impairments (right hemiplegia) may also experience a negative effect on right-hemisphere, nonverbal non·ver·bal  
adj.
1. Being other than verbal; not involving words: nonverbal communication.

2. Involving little use of language: a nonverbal intelligence test.
 functions because of the "crowding effect" (Satz, Strrauss, Wada & Orsini, 1988; Strauss, Satz & Wada, 1990). This effect has been described as a developmental change in brain function where the intact right hemisphere will process language at the cost of non-verbal functions (such as visual perceptual skills) during cortical cor·ti·cal
adj.
1. Of, relating to, derived from, or consisting of cortex.

2. Of, relating to, associated with, or depending on the cerebral cortex.
 reorganisation Noun 1. reorganisation - the imposition of a new organization; organizing differently (often involving extensive and drastic changes); "a committee was appointed to oversee the reorganization of the curriculum"; "top officials were forced out in the cabinet . Through MRI 1. (application) MRI - Magnetic Resonance Imaging.
2. MRI - Measurement Requirements and Interface.
 studies, Mercuri et.al (1996) computed visual acuity visual acuity
n.
Sharpness of vision, especially as tested with a Snellen chart. Normal visual acuity based on the Snellen chart is 20/20.


Visual acuity
The ability to distinguish details and shapes of objects.
 and crowding ratio in children with congenital hemiplegic CP and found a high incidence (78%) of visual abnormalities in this population, despite the absence of differences in visual structures on scans.

How do these hemispheric differences affect the academic skills of children with congenital hemiplegia? Few studies have documented the accompanying differences in school related functions in children with hemiplegia with visual perceptual difficulties. In a comprehensive study by Dorman (1987), adolescents with cerebral palsy who scored lower on reading measures had highly correlated (low) scores in auditory perception auditory perception Neurology The ability to identify, interpret, and attach meaning to sound  and verbal intelligence Noun 1. verbal intelligence - intelligence in the use and comprehension of language
intelligence - the ability to comprehend; to understand and profit from experience
 as well as low scores in visual spatial perception. Thus, reading differences could not be solely attributed to visual spatial disorders. In another study, Menken, Cermak & Fisher, (1987) documented significantly lower visual (non-motor) perceptual quotients in children with cerebral palsy than typically developing children, however the children with cerebral palsy did not include those diagnosed with hemiplegia and no related school functions were tested. Pre-academic motor skills of children with hemiplegia were investigated by Stiles-Davis, Janowsky, Engel and Nass (1988). Drawings of four 5-year old children with hemiplegia (2 with left, 2 with right) were compared to the drawings of 20 typically developing children age 3.5-5 years. Results of their study revealed hemispheric differences related to visual motor differences. Children with left hemisphere lesions (right hemiplegia) displayed normal development of their copying and free drawings, while the children with right hemisphere lesions (left hemiplegia) had delayed drawing skills. However, results of this study were limited by the small sample size.

Although occupational therapists in New Zealand school settings address visual perceptual and functional skills related to academic performance, few studies of children with hemiplegia describe the performance of this population of children. With the publication of the School Function Assessment (Coster Cos´ter   

n. 1. One who hawks about fruit, green vegetables, fish, etc.
, Deeney, Haltiwanger, Haley, 1998) in the last decade, school based therapists now have a reliable, valid measure of skills needed by children in this setting. In a recent study by Hwang and associates (2002), a subgroup sub·group  
n.
1. A distinct group within a group; a subdivision of a group.

2. A subordinate group.

3. Mathematics A group that is a subset of a group.

tr.v.
 of children with CP was found to differ in all areas of the School Function Assessment as compared to typically developing children in general education. In addition, they differed from a group of children with learning disabilities on the physical domain of the SFA See sales force automation.

SFA - Sales Force Automation
 (Hwang, Davies, Taylor & Gavin, 2002). However, the group of children with CP was mixed in diagnostic categories that is, children with hemiplegic cerebral palsy were included with children with quadriplegia quadriplegia: see paraplegia. , athetoisis and ataxia ataxia (ətăk`sēə), lack of coordination of the voluntary muscles resulting in irregular movements of the body. Ataxia can be brought on by an injury, infection, or degenerative disease of the central nervous system, e.g. . Thus, further study is warranted specific to children with hemiplegic cerebral palsy investigating visual perceptual skills and related school functions.

The purpose of this study was to describe and compare visual perceptual and school related motor-based functional skills that are affected by visual perception in children with hemiplegic CP and age matched control matched study, matched control

a comparison between groups in which each subject animal is matched by a comparable animal in terms of age and all other measurable parameters. Called also matched or paired control.
 children. Specific hypotheses for the study were:

1) Children with hemiplegic cerebral palsy will score lower on measures of visual perceptual, visual motor skills and measures of school function that require visual motor skills than typically developing children

2) Children with left hemiplegia (right hemisphere involvement) will score lower than children with right hemiplegia (left hemisphere involvement) on measures of visual perception and visual motor skills

3) Children's visual-motor scores will be more predictive of their performance on school function measures than their visual non-motor perceptual scores.

Method

A quantitative approach was used to compare visual perception and school functions in children with, and without, cerebral palsy. The goal was to determine which, if any, visual perceptual scores would best predict school functions in the children.

Participants

Fifty-seven children enrolled in the study; 20 children diagnosed with spastic hemiplegic CP (11 with left hemiplegia, 9 with right hemiplegia) and 37 children with typical development who served as controls. The children ranged in age from 4--10 years of age with gender controlled (boys represented to girls with an approximate ratio of 2:1) similar to incidence ratio of children diagnosed with CP. The mean ages and standard deviations In statistics, the average amount a number varies from the average number in a series of numbers.

(statistics) standard deviation - (SD) A measure of the range of values in a set of numbers.
 in months for the control and CP groups are reported in Table 1. There were no significant differences between the three groups (F =2.24; p =0.12). Control children who met the criteria of grade-level academic progress with no special education services were selected as a convenience sample by psychoeducational diagnosticians employed by the school district and a local preschool. Exclusion criteria exclusion criteria AIDS Donor exclusion criteria, see there  for children with hemiplegia were:

1) no known diagnoses of neurosensory neu·ro·sen·so·ry
adj.
Of or relating to the sensory activity or functions of the nervous system.
 deficits (deafness, visual impairment Visual Impairment Definition

Total blindness is the inability to tell light from dark, or the total inability to see. Visual impairment or low vision is a severe reduction in vision that cannot be corrected with standard glasses or contact lenses and
 not corrected by lenses)

2) regular classroom placement with no identified cognitive or learning disabilities identified by the Woodcock-Johnson Complete Battery (Woodcock woodcock: see snipe.
woodcock

Any of five species (family Scolopacidae) of plump, sharp-billed migratory birds of damp, dense woodlands in North America, Europe, and Asia.
, McGrew & Mather, 2001) or the Wechsler Preschool and Primary Scale of Intelligence-Revised (Wechsler, 1990)

3) no other neurological diagnoses (such as seizure disorder Seizure Disorder Definition

A seizure is a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioral manifestations.
). Both groups of children spoke English as their primary language and had representation of lower to upper middle socioeconomic classes.

Instruments

Developmental Test of Visual Perception 2nd ed. (Hammill, Pearson, & Voress, 1993): The Developmental Test of Visual Perception (DTVP-2) is a norm-referenced standardised test designed to measure visual perception with little motor requirements (motor reduced) and with motor requirements (visual motor integration). The DTVP-2 includes 181 items divided into 8 subtests (4 visual perceptual and 4 visual-motor). Normative data were collected on 1,972 children ages 4 through 10, residing in 12 states. Children with disabilities represented 3% of the sample. Raw scores are converted to standard scores, percentiles, perceptual quotient quotient - The number obtained by dividing one number (the "numerator") by another (the "denominator"). If both numbers are rational then the result will also be rational.  (Q) and age equivalent (AE) scores for General Visual Perception (GVP GVP Genesys Voice Platform
GVP General Voters Party (Fiji)
GVP Gasoline Vapor Pressure
GVP Global Vision for Peace
GVP Global Visualization Process
), Motor Reduced Visual Perception (MRP (Material Requirements Planning) An information system that determines what assemblies must be built and what materials must be procured in order to build a unit of equipment by a certain date. ) and Visual Motor Integration (VMI VMI Virginia Military Institute
VMI Vendor Managed Inventory
VMI Vertical Motion Index
VMI Valtakunnan Metsien Inventointi (Finnish: National Forest Inventory)
VMI Video Module Interface
). The authors report high inter-rater (.95-.98) and test-retest reliability test-retest reliability Psychology A measure of the ability of a psychologic testing instrument to yield the same result for a single Pt at 2 different test periods, which are closely spaced so that any variation detected reflects reliability of the instrument  (.92-.95) in the manual (Hammill et al.). Concurrent validity concurrent validity,
n the degree to which results from one test agree with results from other, different tests.
 studies with the Motor-Free Visual Perceptual Test (Colarusso & Hammill, 1972) and the Developmental Test of Visual-Motor Integration (Beery beer·y  
adj. beer·i·er, beer·i·est
1. Smelling or tasting of beer: beery breath.

2. Affected or produced by beer: beery humor.
, 1989) resulted in a high correlation with subtest scores of the DTVP-2. (Hammill et al.).

Motor-Free Visual Perceptual Test Revised (Colarusso & Hammill, 1996): The purpose of the Motor-Free Visual Perceptual Test Revised (MVPT-R) is to measure visual processing Visual processing is the sequence of steps that information takes as it flows from visual sensors to cognitive processing. The sensors may be zoological eyes or they may be cameras or sensor arrays that sense various portions of the electromagnetic spectrum.  with minimal motor responses required. The MVPT-R is a norm-referenced standardised test of 40 items measuring non-motor abilities in children. The test was standardised on 912 children aged 4 through 11 years with no motor, sensory, or learning disabilities, with equal representation of genders, but limited in geographic representation. Raw scores are converted to perceptual quotients (PQ) and perceptual ages (PA). A recent reliability study has shown high inter-rater and test-retest reliability quotients (Burtner, Qualls, Ortega, Morris & Scott, 2002). Concurrent validity with the DTVP-2 are high, and age differentiation and internal consistency In statistics and research, internal consistency is a measure based on the correlations between different items on the same test (or the same subscale on a larger test). It measures whether several items that propose to measure the same general construct produce similar scores.  has been established for construct validity construct validity,
n the degree to which an experimentally-determined definition matches the theoretical definition.
 (Colarusso & Hammill).

School Function Assessment (Coster et al., 1998): The School Function Assessment (SFA) is standardised test of 198 items designed to measure the wide spectrum of school-related functional skills in elementary school elementary school: see school.  children. The normative sample included 678 children (363 with disabilities and 315 typically developing) from 112 different urban and rural sites in 40 states (Coster et al.). The SFA manual reports high internal validity Internal validity is a form of experimental validity [1]. An experiment is said to possess internal validity if it properly demonstrates a causal relation between two variables [2] [3].  (Cronbach's Alpha Cronbach's (alpha) has an important use as a measure of the reliability of a psychometric instrument. It was first named as alpha by Cronbach (1951), as he had intended to continue with further instruments.  coeficients from .92-.98) and test-retest reliability (Pearson r and intraclass correlation In statistics, the intraclass correlation (or the intraclass correlation coefficient[1]) is a measure of correlation, consistency or conformity for a data set when it has multiple groups.  coeficients from .80-.99). The test is divided into subtests with raw scores converted to criterion cut-off cut-off Anesthesiology The point at which elongation of the carbon chain of the 1-alkanol family of anesthetics results in a precipitous drop in the anesthetic potential of these agents–eg, at > 12 carbons in length, there is little anesthetic activity,  scores by the school grade level of the child. Although the entire SFA battery is recommended for use, each subtest is statistically sound to be used independently. For the purposes of this study, two subtests of Activity Performance (Part III) related to visual perceptual functions were administered: 1) Using Materials subtest to measure a child's use of classroom tools (pencils, erasers, markers, scissors scissors

Cutting instrument or tool consisting of a pair of opposed metal blades that meet and cut when the handles at their ends are brought together. Modern scissors are of two types: the more usual pivoted blades have a rivet or screw connection between the cutting ends
, tape, glue) and the ability to manipulate books, paper and small objects and 2) Written Work subtest to measure a child's ability to produce written work of acceptable quality by copying from text and blackboard (1) See Blackboard Learning System.

(2) The traditional classroom presentation board that is written on with chalk and erased with a felt pad. Although originally black, "white" boards and colored chalks are also used.
 with sustained effort and speed to keep up with peers.

Procedure

After obtaining approval from the Institutional Review Boards of the university and local school district, all parents and the participating children over age 7 signed a written consent form. Prior to data collection, 3 researchers and 5 assistants established inter-scorer agreement on 30 volunteer children (each of the research team members administered the tests to 5 children with 1-2 on the team members scoring simultaneously), The percentage of agreement for the research team was .99 on the MVPT-R and .96 on the DTVP-2.

One researcher administered both visual perceptual tests to an individual participant in a quiet, well-lit room in the child's school or therapy setting, with rest breaks given as needed as needed prn. See prn order. . Raw scores were computed and converted to standard scores for the visual perceptual tests and criterion scores for the SFA. Either the child's teacher or a school district therapist familiar with the child rated each participant's performance on the two SFA subtests. As is described in the manual for the SFA, no inter-rater reliability Inter-rater reliability, Inter-rater agreement, or Concordance is the degree of agreement among raters. It gives a score of how much , or consensus, there is in the ratings given by judges.  was completed since the authors of the test recommend scoring by only one individual who know the child's performance in a specific area of function. The Written Work subtest of the SFA was not rated for four-year old children due to their age.

Statistical analysis

Mean scores of the 3 groups (control, children with right hemiplegia, children with left hemiplegia) on the MVPT-R, DTVP-2, and SFA subtests were compared using a one-way analysis of variance (ANOVA anova

see analysis of variance.

ANOVA Analysis of variance, see there
) to better understand and compare CP subgroups with the control children. Post hoc post hoc  
adv. & adj.
In or of the form of an argument in which one event is asserted to be the cause of a later event simply by virtue of having happened earlier:
 test using the Fisher's Least Significant Difference methods were completed to determine what the differences were between specific subgroups of children with right vs. left hemiplegia.

Regression analyses were completed to determine the visual perceptual scores that predicted children's performance on their functional academic skills as measured by subtests of performance on the SFA. Stepwise regression In statistics, stepwise regression includes regression models in which the choice of predictive variables is carried out by an automatic procedure.[1][2][3]  was also completed to determine the best predictive measure for SFA subtests. Significance level was set at the .05 level for all analyses.

Results

This study investigated the differences in visual perception and related school functions between children with hemiplegic cerebral palsy and typically developing children. Results for the first hypothesis using one-way analysis of variance (ANOVA) of mean scores of the three groups (control children and subgroups of children with left and right hemiplegia and Total CP group) are displayed in Table 2. On all measures of visual perceptual skills (MVPT-R, DTVP-2) and functional skills (SFA), all children with CP (Total CP) scored significantly lower (p [less than or equal to] .05) than control children.

Post hoc t-tests using Fisher's Least Significant Difference method comparing the subgroups of children with CP (right and left hemiplegia) to control children are also displayed in Table 2. Results on visual perception test scores revealed differences in the children with right vs. left hemiplegia according to according to
prep.
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

3.
 the motor requirements of the test given. That is, both groups of children with hemiplegia scored significantly lower than control children (ANOVA, p < 001) when the test required the child to use more complex fine motor control to draw figures (DTVP-2 Visual Motor Integration scores). However, on tests that required the child only to point to correct answers (MVPT-R, DTVP-2 MRP), the children with left hemiplegia scored significantly lower (all p [less than or equal to] .04) than control children while the children with right hemiplegia showed no significant differences as compared to control children on these non-motor visual perceptual measures (see Table 2). General visual perception scores (GVP) that combined motor reduced (MRP) and motor enhanced scores (VMI) were significantly lower in both groups of children with hemiplegia as compared to the control children (all p [less than or equal to] .001).

Both groups of children with right and left hemiplegia scored significantly lower on the SFA subtests of Using Materials and Written Work than control children (ANOVA, p<.001). Post hoc analysis between the children with right and left hemiplegia using Fisher's least significant tests however demonstrated no significant differences between the children with right and left hemiplegia on the SFA subtests.

The last hypothesis was to identify which visual perceptual tests may be used by therapists as predictive measures of how a child may perform school functions requiring use of materials or written work. Additional analysis independent of group influences (all children combined) were conducted by univariate regression and stepwise stepwise

incremental; additional information is added at each step.


stepwise multiple regression
used when a large number of possible explanatory variables are available and there is difficulty interpreting the partial regression
 multivariate The use of multiple variables in a forecasting model.  regression analyses to determine if the visual perceptual tests were predictors of functional skills (SFA Using Materials and Written Work). These results are shown in Table 3. When each visual perceptual score was considered separately as a predictor of SFA scores on Using Materials and Written Work by regression analyses, most scores were significant predictors. (p [less than or equal to] .05) except the DTVP-2 Motor Reduced Perception scores (p=.06). To determine which of the visual perceptual variables was the best predictor of school function motor based skills, a stepwise multiple regression Multiple regression

The estimated relationship between a dependent variable and more than one explanatory variable.
 analysis for the two SFA subtests was used. The VMI quotient score of the DTVP-2 emerged as the best predictor of scores on the Using Materials and Written Work SFA subtests.

Discussion

The first hypothesis that children with hemiplegic cerebral palsy will score lower on visual perceptual tests and on specific school function measures (written work, using materials) that require visual motor skills than typically developing children was supported. Results are similar to Hwang and colleagues (2002) who reported lower scores for children with CP on the SFA physical domain subtests as compared to children with no diagnoses of multiple handicapping conditions. However, this study identified these differences specifically in children with spastic hemiplegia with no cognitive deficits Cognitive deficit is an inclusive term to describe any characteristic that acts as a barrier to cognitive performance. The term may describe deficits in global intellectual performance, such as mental retardation, or it may describe specific deficits in cognitive abilities . While the motor differences found in children with CP would explain the lower scores, the hypothesis that visual perceptual demands of these tasks also appears to contribute to a child's performance differences. When scores of all children with CP were compared to typically developing peers, significantly lower scores were noted in the children with spastic hemiplegia on non-motor and visual motor tests. Similar results were reported using a non-motor visual perceptual test, the Test of Visual-Perceptual Skills Visual-perceptual skills
The capacity of the mind and the eye to "see" something as it objectively exists.

Mentioned in: Bender-Gestalt Test
 (TVPS), by Menken, Cermak and Fisher (1987). These results suggest that school therapists should consider the presence of visual perceptual difficulties (in addition to motor difficulties) in children with hemiplegia who may be referred for occupational therapy services.

Results of this study further revealed differences in children with right versus left hemiplegia on non-motor tests, thus supporting our second hypothesis. Only children with left hemiplegia significantly scored lower than control children on non-motor perceptual tests (MVPT-R, DTVP-2 MRP) and significant differences were noted on the MVPT-R quotient scores between the two groups of children with hemiplegia. Children with left hemiplegia (predominantly right hemisphere brain lesions) scored lower on one non-motor visual perception test (MVPT-R) but subgroup differences were not found on the other non-motor visual perceptual tests (DTVP-2 MRP). Previous studies by other researchers suggest that both groups of children with hemiplegia score low on visual spatial functions as measured by performance scores on intelligent tests (Carlsson et al., 1994; Goodman & Yude, 1996; Stiers et al., 2002).

In addition, results of this study demonstrated some differences in the two subgroups of children with hemiplegia. These results support findings of Stiles-Davis et al. (1988) who described delayed visual motor skills in children with right hemisphere lesions (left hemiplegia) in copying and free drawing skills, and normal development of these skills in children with left hemisphere lesions (right hemiplegia). Further research with larger numbers of children is warranted to more clearly delineate possible differences between these subgroups of children with hemiplegia. Since intelligence tests performance subtests combine non-motor and visual motor tasks, further research on right versus left hemiplegia with the two domains of visual perception (non-motor and visual motor) investigated separately are needed. Using MRI results to delineate the site and extent of brain lesions in the children would be bene.cial to better understand these neural mechanisms. Results do suggest that children with left hemiplegia who are referred for school based services may be more likely to have visual perceptual difficulties, however screening both subgroups of children with hemiplegia would be recommended.

The final hypothesis that children's scores on measures of visual motor skills best predicts children's scores on measures of school function was also supported in part. Results of the stepwise regression identified the DTVP-2 VMI quotients as the best predictor of children's scores on School Function Assessment Using Material and Written Work subtests. Such results are not surprising since the diagnosis of cerebral palsy suggests motor impairment. However, it should be noted that all test quotients were found to be predictive of differences in the motor-based school functions. Thus, practicing therapists may use the MVPT-R perceptual quotient score, the DVPT-R General Visual Perception quotient, Motor Reduced quotient or the Visual Motor Integration quotient to ascertain how children may perform when using materials or completing written work during daily school performance.

Limitations of this study should be considered by therapists working in New Zealand schools and school settings in other countries. While this investigation focused on visual perceptual abilities of children and the relationship of these skills to school occupations, one should not overlook the complexity of these school activities. Assessment and intervention of multiple systems (somatoesensory, fine motor, motor planning, attention, cognition, motivation, environmental factors) contributing to the child's occupational performance are recommended for best practice and service provision for the individual child. The convenience sample is also a limitation of this study. A controlled randomised Adj. 1. randomised - set up or distributed in a deliberately random way
randomized

irregular - contrary to rule or accepted order or general practice; "irregular hiring practices"
 sample using the complete SFA may provide more in depth information about the school performance of children with hemiplegia. However, the results of this study do suggest that the SFA and visual perceptual tests may assist therapists practicing in school settings to identify specific areas of school occupation for intervention and underlying functions that affect the successful completion of school tasks.

Conclusions

The results of this study indicate that there are significant visual perceptual differences between typically developing children and children with hemiplegic cerebral palsy who are enrolled in schools with regular classroom placement. Although teachers and therapists identified significant differences between the two groups of children in motor-based school functions such as using classroom materials and completing written work, the difficulties identified were related not only to the motor deficits inherent in the diagnosis of cerebral palsy, but also to visual perceptual differences. Results suggest that visual perceptual and visual motor assessments are helpful to further understand the underlying mechanisms that may require intervention to maximise the participation of children with hemiplegia in the classroom.

Acknowledgments

The authors wish to thank the families and children who agreed to participate in the study. The authors also thank Alice Gourd gourd (gôrd, grd), common name for some members of the Cucurbitaceae, a family of plants whose range includes all tropical and subtropical areas and extends into the temperate zones.  OTR/L OTR/L Occupational Therapist, Registered, Licensed , Mikaela Pierce OTR/L, Amy Carnes OTR/L, Joyce Pomo Pomo, Native Americans of N California, belonging to the Hokan branch of the Hokan-Siouan linguistic stock (see Native American languages). The Pomo were the most southerly Native Americans on the California coast not brought under the mission influence of the  OTR/L and Robin Davis OTR/L for their assistance in data collection, and Gordon Smith
For other people by this name see Gordon Smith (disambiguation)


Gordon Harold Smith (born May 25, 1952) is Oregon's junior United States Senator, currently serving his second term. He is a member of the Republican Party.
 for his assistance with preparation of research materials.

References

Beery, K. (1989). Developmental test of visual motor integration. Cleveland: Modern Curriculum Press.

Burtner, P. A., Qualls, C., Ortega, S. G., Morris, C. G., & Scott, K. (2002). Test-retest reliability of the motor-free visual perceptual test-revised. Physical and Occupational Therapy in Pediatrics, 22(3/4), 23-36.

Carlsson, G., Uvebrant, P., Jugdahl, K., Arvidsson, J., Wiklund, L. M., & vonWendt, L. (1994). Verbal and non-verbal function of children with right-versus left-hemiplegic cerebral palsy of pre-and perinatal perinatal /peri·na·tal/ (-na´t'l) relating to the period shortly before and after birth; from the twentieth to twenty-ninth week of gestation to one to four weeks after birth.

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: Author.

Patricia Burtner PhD, OTR/L, FAOTA FAOTA Fellow of the American Occupational Therapy Association  is Associate Professor in the Occupational Therapy Graduate Program, Department of Pediatrics, University of New Mexico The University of New Mexico (UNM) is a public university in Albuquerque, New Mexico. It was founded in 1889. It also offers multiple bachelor's, master's, doctoral, and professional degree programs in all areas of the arts, sciences, and engineering. .

Aimee Dukeminier and Lynette Ben were students in the Occupational Therapy Program at the time of this research project.

Clifford Qualls PhD is a Professor Emeritus e·mer·i·tus  
adj.
Retired but retaining an honorary title corresponding to that held immediately before retirement: a professor emeritus.

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 in the Department of Mathematics and Statistics, University of New Mexico

Keri Scott MS, OTR/L is Neuromotor Liaison for Special Education Services, Albuquerque Public Schools Albuquerque Public Schools is a school district based in Albuquerque, New Mexico.

In 2005 it had a total of 127 schools with some 86,560 students. It had 80 elementary, 26 middle and 12 high schools, as well as 10 alternative schools.
, Albuquerque, New Mexico “Albuquerque” redirects here. For other uses, see Albuquerque (disambiguation).
Albuquerque (pronounced [ˈæl.bə.kɚ.kiː], Spanish: [al.βu.
.

Address all correspondence to Patricia A. Burtner Ph.D., OTR/L, Occupational Therapy Program, HSSB HSSB High Speed Serial Bus (Harris Corp.)
HSSB Harmonic Single Side-Band
 215, School of Medicine MSC (1) (MSC.Software Corporation, Santa Ana, CA, www.mscsoftware.com) Founded in 1963 by Richard H. MacNeal and Robert G. Schwendler, MSC is the world's largest provider of mechanical computer aided engineering (MCAE) strategies, simulation software and services. 09-5240, University of New Mexico, Email for correspondence pburtner@unm.edu
Table 1: Means and Standard Deviations of Age for Each
Group

Means and Standard Deviations of Age for Each Group

Group                       n     Mean      SD

Control                     37    90.6     24.8
Cerebal Palsy Total         20    82.4     22.4
        Right Hemiplegia     9    72.4     19.7
        Left Hemiplegia     11    90.5     21.8

All groups include children at each level 4-10 years

Table 2: Group Mean Differences of Perceptual Quotient and Criterion
Scores by One Way ANOVA

                                          Control
Test                                      (n = 37)

MVPT-R       PQ         Mean (SD)       100.4 (15.5)
                          Range            64-120

DTVP-2    General Visual Perception
          Quotient      Mean (SD)       104.5 (11.2)
                          Range            86-124

          Motor Reduced Visual Perception
          Quotient      Mean (SD)       101.2 (14.9)
                          Range            68-128

          Visual Motor Integration
          Quotient      Mean (SD)       107.3 (10.8)
                          Range            75-125

SFA       Using Materials
          Criterion     Mean (SD)       94.2 (10.5)
                          Range            64-100
                      Ages 6-10 only      (n = 27)

          Written Work
          Criterion     Mean (SD)       93.3 (10.4)
                          Range            67-100

                                            Groups

                                          Total CP
Test                                      (n = 20)

MVPT-R       PQ         Mean (SD)       89.7 (21) *
                          Range            55-122

DTVP-2    General Visual Perception
          Quotient      Mean (SD)      87.7 (10.7) *
                          Range            65-106

          Motor Reduced Visual Perception
          Quotient      Mean (SD)       90.3(11.9) *
                          Range            67-113

          Visual Motor Integration
          Quotient      Mean (SD)      86.4 (12.1) *
                          Range            56-106

SFA       Using Materials
          Criterion     Mean (SD)      67.5 (13.9) *
                          Range            52-100
                      Ages 6-10 only      (n = 14)

          Written Work
          Criterion     Mean (SD)      65.4 (20.3) *
                          Range            24-100

                                       Groups

                                         R Hemi CP
Test                                      (n = 9)

MVPT-R       PQ         Mean (SD)        101 (15.5)
                          Range            68-122

DTVP-2    General Visual Perception
          Quotient      Mean (SD)      91.8 (12.6) *
                          Range            65-106

          Motor Reduced Visual Perception
          Quotient      Mean (SD)        96. (9.9)
                          Range            78.107

          Visual Motor Integration
          Quotient      Mean (SD)      88.7 (16.9) *
                          Range            56-106

SFA       Using Materials
          Criterion     Mean (SD)      68.3 (15.1) *
                          Range            53-100
                      Ages 6-10 only      (n = 6)

          Written Work
          Criterion     Mean (SD)      60.8 (27.5) *
                          Range            24-100

                                          Groups

                                         L Hemi CP
Test                                      (n = 11)

MVPT-R       PQ         Mean (SD)      80.4 (20.8) *#
                          Range            55-112

DTVP-2    General Visual Perception
          Quotient      Mean (SD)       84.3 (7.8) *
                          Range            77-105

          Motor Reduced Visual Perception
          Quotient      Mean (SD)       85.6(11.9) *
                          Range            67-113

          Visual Motor Integration
          Quotient      Mean (SD)       84.5 (6.4) *
                          Range            73.97

SFA       Using Materials
          Criterion     Mean (SD)      66.9 (12.3) *
                          Range            52-95
                      Ages 6-10 only      (n = 8)

          Written Work
          Criterion     Mean (SD)      68.3 (15.7) *
                          Range            52-94

                                          Groups

                                           ANOVA
Test                                      p value

MVPT-R       PQ         Mean (SD)         p = .003
                          Range

DTVP-2    General Visual Perception
          Quotient      Mean (SD)         p <.001
                          Range

          Motor Reduced Visual Perception
          Quotient      Mean (SD)          p=.007
                          Range

          Visual Motor Integration
          Quotient      Mean (SD)         p <.001
                          Range

SFA       Using Materials
          Criterion     Mean (SD)         p <. 001
                          Range
                      Ages 6-10 only

          Written Work
          Criterion     Mean (SD)         p <. 001
                          Range

CP = Children with Cerebal Palsy; R Hemi = Right Hemiplegia;
L Hemi = Left Hemiplegia

MVPT R = Motor Free Visual Perception Test Revised; PQ =
perceptual quotient

DVPT2 = Development Test of Visual Perception; SFA = School
Function Assessment

* = significant vs. Control children by Post hoc t-tests using
Fisher's Least Significant Difference Method

# = significant vs. Children with Right Hemiplegia

Table 3: Regression Prediction of Functional Skills with Visual
Perceptual Quotients

                      Outcome of SFA Using Materials Subtest
                      (n = 57)

Predictor Variables   Regression     Standard
                      Coefficient    Error
MVPT
           PQ         0.35           0.12
DTVP-2
           GVP Q      0.62           0.15
           MRP Q      0.3            0.15
           * VMI Q    0.68           0.12

                      Outcome of SFA Written Work Subtest
MVPT                  (n = 41)

           PQ         0.34           0.16
           GVP Q      0.57           0.19
           MRP Q      0.41           0.19
           * VMI Q    0.53           0.18

                      Outcome of SFA Using Materials Subtest
                      (n = 57)

Predictor Variables   t-value        p-value

MVPT
           PQ         2.98           p = 0.004
DTVP-2
           GVP Q      4.2            p <.001
           MRP Q      1.96           p = 0.06
           * VMI Q    5.44           p <.001

                      Outcome of SFA Using Materials Subtest
MVPT                  (n = 41)

           PQ         2.16           p = 0.004
           GVP Q      2.87           p = 0.007
           MRP Q      2.07           p = 0.05
           * VMI Q    2.97           p = 0.006

SFA--School Function Assessment (Criterion Scores);
MVPT-R-Motor Free Visual Perception Test Revised;

PQ = perceptual quotient; DVPT2--Development Test of
Visual Perception;

GVP = General Visual Perception; Q = Quotient;
MRP = Motor Reduced Perception;

VMI = Visual Motor Integration

* Stepwise regression identified VMI of the DVPT-2 as the
best predictor of SFA subtest scores
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Author:Burtner, Patricia A.; Dukeminier, Aimee; Ben, Lynette; Qualls, Clifford; Scott, Keri
Publication:New Zealand Journal of Occupational Therapy
Geographic Code:8NEWZ
Date:Mar 1, 2006
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