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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. 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, 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 cerebral palsy. New Zealand Journal of Occupational Therapy 53(1), 24-29

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Occupational therapists 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 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 (ICF) to highlight the activities and participation of individuals with disabilities in addition to levels of impairment. The ICF guidelines are also congruent with the inclusion of special populations of children in regular classrooms. Children with spastic hemiplegic cerebral palsy, one group qualifying for school therapy services, often demonstrate neurological 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, 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 (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 that children with left hemisphere impairments (right hemiplegia) may also experience a negative effect on right-hemisphere, nonverbal 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 reorganisation. Through MRI studies, Mercuri et.al (1996) computed visual acuity 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 and verbal intelligence 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, 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 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 (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, athetoisis and ataxia. 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 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 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 for children with hemiplegia were:

1) no known diagnoses of neurosensory deficits (deafness, visual impairment not corrected by lenses)

2) regular classroom placement with no identified cognitive or learning disabilities identified by the Woodcock-Johnson Complete Battery (Woodcock, McGrew & Mather, 2001) or the Wechsler Preschool and Primary Scale of Intelligence-Revised (Wechsler, 1990)

3) no other neurological diagnoses (such as seizure disorder). 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 (Q) and age equivalent (AE) scores for General Visual Perception (GVP), Motor Reduced Visual Perception (MRP) and Visual Motor Integration (VMI). The authors report high inter-rater (.95-.98) and test-retest reliability (.92-.95) in the manual (Hammill et al.). Concurrent validity studies with the Motor-Free Visual Perceptual Test (Colarusso & Hammill, 1972) and the Developmental Test of Visual-Motor Integration (Beery, 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 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 has been established for construct validity (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 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 (Cronbach's Alpha coeficients from .92-.98) and test-retest reliability (Pearson r and intraclass correlation coeficients from .80-.99). The test is divided into subtests with raw scores converted to criterion cut-off 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, 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 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. 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 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) to better understand and compare CP subgroups with the control children. Post hoc 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 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 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 multivariate 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 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. 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 (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 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 OTR/L, Mikaela Pierce OTR/L, Amy Carnes OTR/L, Joyce Pomo OTR/L and Robin Davis OTR/L for their assistance in data collection, and Gordon Smith 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 origin. Developmental Medicine and Child Neurology, 36, 503-512.

Colarusso, R. P., & Hammill, D. D. (1972). Motor-free visual perceptual test. Novato, CA: Academic Therapy Publications.

Colarusso, R. P., & Hammill, D. D. (1996). Motor-free visual perceptual test-revised. Novato, CA: Academic Therapy Publications.

Coster, W., Deeney, T., Haltiwanger, J., & Haley, S. M. (1998). School function assessment: User's manual. San Antonio, TX: Therapy Skill Builders.

Dorman, C. (1987). Verbal, perceptual and intellectual factors associated with reading achievement in adolescents with cerebral palsy. Perceptual and Motor Skills, 64, 671-678.

Goodman, R., & Yude, C. (1996). IQ and its predictors in childhood hemiplegia. Developmental Medicine and Child Neurology, 38, 881-890.

Hagberg, B., Hagberg, G., Olow, I., & von Wendt, L. (1989). The changing panorama of cerebral palsy in Sweden. The birth year period 1979-1982. Acta Pediatrica Scandinavica, 78, 664-670.

Hammill, D. D., Pearson, N. A., & Voress, J. K. (1993). Developmental test of visual perception. (2nd ed.). Austin, TX: Pro-Ed.

Hwang, J. L., Davies, P. L., Taylor, M. P., & Gavin, W. J. (2002). Validation of school function assessment with elementary school children. OTJR: Occupation, Participation and Health, 22(2), 48-58.

Law, M., Darrah, J., Pollock, N., King, G., Rosenbaum, P., Russell, D., Palisano, R., Harris, S., Armstrong, R., & Watt, J. (1998). Family-centered functional therapy for children with cerebral palsy: An emerging practice model. Physical & Occupational Therapy in Pediatrics 18, 83-102.

Menken, C., Cermak, S. A. & Fisher A., (1987). Evaluating the visual-perceptual skills of children with cerebral palsy. American Journal of Occupational Therapy, 41, 646-651.

Mercuri, E., Spano, M., Bruccini, G., Frisone, M. F., Trombetta, J. C., Blandino, A., Longo, M., & Guzzetta, F. (1996). Visual outcome in children with congenital hemiplegia: Correlation with MRI findings. Neuropediatrics, 27, 184-188.

Newell, K. M. (1991). Motor skill acquisition. Annual Review of Psychology, 42, 213-217.

Pellegrino, L. (2002). Cerebral palsy. In M. Batshaw (Ed.), Children with disabilities (pp. 443-467). Baltimore: Paul H. Brookes.

Satz, P., Strauss, E., Wada, J., & Orsini. D. L. (1988). Some correlates of intra- and interhemispheric speech organization after left focal brain injury. Neuropsychologia, 26, 245-350.

Scherzer, A L., & Tscharnuter, I. (1990). Early diagnosis and therapy in cerebral palsy: A primer on infant developmental problems (2nd ed.). New York: Marcel Dekker.

Shumway-Cook. A., & Woollacott, M. H. (2001). Motor control: Theory and practical application (2nd ed.). Baltimore: Williams & Wilkins.

Stiers. P., Vanderkelen, R., Coene, S., DeRammelaere, M., & Vandenbussche, E. (2002). Visual-perceptual impairment in a random sample of children with cerebral palsy. Development Medicine and Child Neurology, 44, 370-382.

Stiles-Davis, J., Janowsky, J., Engel, M., & Nass R. (1988). Drawing ability of four young children with congenital unilateral brain lesions. Neuropyschologia, 26, 359-371.

Strauss E., Satz, P., & Wada, J., (1990). An examination of the crowding hypothesis in epileptic patients who have undergone the carotid amytal test. Neuropsychologia, 28, 1221-1227.

Wechsler, D. (1990). Weschler preschool and primary scale of intelligence-revised. San Antonio, TX: Psychological Corp.

Woodcock, R. W., McGrew, K. S., & Mather, N. (2001). Woodcock-Johnson III complete battery. Itasca, IL: Riverside Publishing.

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Patricia Burtner PhD, OTR/L, FAOTA is Associate Professor in the Occupational Therapy Graduate Program, Department of Pediatrics, University of New Mexico.

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 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, New Mexico.

Address all correspondence to Patricia A. Burtner Ph.D., OTR/L, Occupational Therapy Program, HSSB 215, School of Medicine MSC09-5240, 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
Words:5166
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