The role of play in pediatric occupational therapy.

OBJECTIVE: This study examined the roles that play occupies within current occupational therapy practice with preschoolers. METHOD: Two hundred twenty-four pediatric occupational therapists completed mail questionnaires designed to ascertain how they use play in their practice, their knowledge and use of play assessments, and potential constraints on their use of play. RESULTS: Although respondents indicated that play was important in motivating children and frequently used play as a treatment modality or reinforcer, they less frequently assessed play behaviors or wrote treatment goals and objectives related to play. Differences were found between school-based and non-school-based respondents regarding the discipline or model that addresses play in the work setting, the use of play assessments, and constraints that limit the use of play in the work setting. CONCLUSION: The results suggest a need for increasing the emphasis on play in entry-level curricula and continuing education, improving clinician access to valid and reliable play assessments, and completing studies designed to examine the use and efficacy of play in occupational therapy intervention.

The Test of Sensory Functions in Infants: test-retest reliability for infants with developmental delays.

OBJECTIVE: The Test of Sensory Functions in Infants (TSFI) is one tool that occupational therapists use to identify sensory processing disorders among infants. However, data on the reliability of TSFI scores with infants with developmental delays are lacking. METHOD: Test-retest reliabilities for TSFI total test and subtest scores were determined with a sample of 26 infants with developmental delays. All infants were between 10 months and 18 months of age. The test-retest interval ranged from 5 days to 10 days. Magnitudes of difference between test and retest scores and percentages of agreement among the TSFI classification categories (i.e., normal, at-risk, deficient) also were determined to examine relationships between test scores. RESULTS: Reliability for the total test score was borderline, with an intraclass correlation coefficient of .78. Reliability coefficients for the five subtests ranged from .54 to .74. Percentage of agreement for the total test classification categories between test and retest was adequate (81%). Percentages of agreement for subtest classification categories were low, ranging from 58% to 68%. CONCLUSION: TSFI scores should be interpreted cautiously and used only in conjunction with findings from additional developmental assessments and clinical observations for infants with developmental delays.

Test-retest reliability of the test of visual perceptual skills with children with learning disabilities.

This study examined the test-retest reliability of the Test of Visual Perceptual Skills (nonmotor) (TVPS). The sample consisted of 30 first- and second-grade children (aged 6 years through 8 years) with identified learning disabilities. The TVPS was administered on two separate occasions that were 1 to 2 weeks apart. The intraclass correlation coefficient for the total test standard scores was .81. The intraclass correlation coefficients for the subtests ranged from .33 (Sequential Memory) to .78 (Form Constancy). The primary finding from this study is that TVPS scores on the total test show adequate test-retest reliability for use in clinical settings. The scores on the subtests, however, should be used with extreme caution, as the test-retest reliability estimates were low.

Test-retest reliability of two tiltboard tests in children.

BACKGROUND AND PURPOSE: Most clinical evaluations of postural control in children are relatively subjective and have not been tested for reliability of scoring. The purpose of this study was to investigate the test-retest reliability of measurements obtained with two tiltboard tests. SUBJECTS: Subjects were 18 children, aged 53 to 81 months (mean = 64.4, SD = 8.3), who were typically developing (TD group) and 18 children, aged 50 to 79 months (mean = 63.3, SD = 8.4), with developmental delays (DD group). METHODS: Each child was tested using the two tilt-board tests and was then retested using the same tests approximately 1 week later. The maximum angle of tiltboard tilt prior to any postural adjustment by the child was recorded. RESULTS: Intraclass correlation coefficients for test-retest reliability (two-way, random-effects, repeated-measures model) ranged from .49 to .54 for the TD group and from .52 to .82 for the DD group. Angles were higher for both groups for the second test. CONCLUSION AND DISCUSSION: The results suggest that these tiltboard tests do not give stable and reliable measurements across test sessions. Before these tests can be used to document change in postural control abilities across time, further research is warranted.

Attending behavior: a descriptive study of children aged 18 through 23 months.

The purpose of this study was to provide descriptive data on the attending behavior of children aged 18 through 23 months. The method used was designed to be clinically feasible for occupational therapy practitioners. Forty-eight children between the ages of 18 and 24 months were studied through observation of a 15-min session of free play with a standard set of toys. The child's physical contact with objects was used as a guideline for timing. Four factors were examined: total time attending, total number of activities attended to, average attending time per activity, and longest time attending to one activity. The Mann Whitney U statistic revealed that there were no significant differences between boys and girls on any of the four factors. There were, however, statistically significant differences between children aged 18 through 20 months and children aged 21 through 23 months for all of the factors except longest time attending to one activity. The children in this study changed activities frequently (median of 10 activities in 15 min) and attended briefly (median attending time per activity of 81 sec). They were, however, capable of attending to one activity for much longer periods of time (median of 225 sec). With minimal adult intervention, the children spent an average of 12.5 min attending to the toys during a 15-min session. These results may augment other aspects of occupational therapy assessment by offering some insight into whether or not an individual child demonstrates age-appropriate attending behavior. Additionally, this standardized method of observation may offer occupational therapists a clinically feasible means of assessing attending behavior.

Gait parameters of children with spastic diplegia: a comparison of effects of posterior and anterior walkers.

The purpose of this study was to compare the effects of posterior and anterior walkers on the gait parameters of five children with spastic diplegic cerebral palsy. Computer-based kinematic analysis was used to investigate differences in gait. Gait laboratory data indicated that use of the posterior walker (1) facilitated more upright posture in these subjects, as seen in decreased trunk and hip flexion during stance phase; (2) decreased double stance time; and (3) increased walking velocity. According to parent report, both the parents and their children preferred the posterior walker. Most parents also reported that when using the posterior walker, their children walked more normally with increased stability and interacted more easily with other children.

Performance of preschoolers on the Pediatric Clinical Test of Sensory Interaction for Balance.

The purposes of this study were to describe the performance of 40 children aged 4 and 5 years on the Pediatric Clinical Test of Sensory Interaction for Balance (P-CTSIB) and to determine whether age- and gender-related differences were present. The P-CTSIB measures standing balance when sensory input is systematically altered. Kruskal-Wallis one-way analyses of variance by ranks (p less than or equal to .05) were used for comparisons by age and gender. When the 4-year-olds were compared with the 5-year-olds, significant duration differences were found in 4 of the 6 conditions in the heel-toe position of the P-CTSIB. The age-related differences on the remaining 2 heel-toe conditions, as well as on Condition 6 of the feet-together position, approached significance. Gender differences with 4-year-olds and 5-year-olds combined were statistically non-significant in all instances; however, girls performed better on 9 of the 12 conditions of the P-CTSIB. The results indicate that the feet-together position can discriminate between children without balance deficits and children with balance deficits. The heel-toe position is difficult for children aged 4 and 5 years without balance deficits and consequently has limited diagnostic value for this age group.

Carpal tunnel syndrome: objective measures and splint use.

One hundred five adults with carpal tunnel syndrome (CTS) were studied to assess the efficacy of a neutral-angle wrist splint, and to identify criteria for splint referral. Ten observations before and after treatment were analyzed with descriptive and inferential statistics. After splint use, 67% of the subjects reported symptom relief. T-test comparison of sensory latency of values before and after treatment indicated improvement for the total group. Chi-square and t-tests failed to reveal significant differences between relief and no-relief groups for gender, affected hand, presence of concomitant conditions, duration of symptoms before treatment, age, length of time between pretreatment and posttreatment nerve conduction testing, initial nerve latency of motor and sensory fibers, or the difference between pretreatment and posttreatment sensory latencies. A significant difference was found for motor latency; the relief group improved and the no-relief group deteriorated. Data suggest that splinting is most effective if applied within three months of symptom onset. Those with damage to the wrist structures or median nerve were least responsive to splinting.

The Test of Orientation for Rehabilitation Patients: interrater reliability.

The Test of Orientation for Rehabilitation Patients (TORP) (Deitz, Beeman, & Thorn, in press) was developed for use with patients with brain injuries in inpatient rehabilitation settings. It was designed to assess orientation to person and personal situation, place, time, schedule, and temporal continuity. Interrater reliability for the TORP was examined with the use of 34 brain-injured and 35 non-brain-injured patients. Two occupational therapists trained in administering the TORP, as specified in the test manual (Dietz et al., in press), served as the examiners. One therapist administered and scored the test while the second therapist observed and scored the test for the same subject. Intraclass correlation coefficients, used as indexes of reliability for the scoring of the total test and subtests, ranged from .89 to 1.00 for the non-brain-injured group and from .94 to .99 for the brain-injured group. These findings suggest that an occupational therapist can reliably score the TORP for patients both with and without brain injuries.

Interrater and test-retest reliability of two pediatric balance tests.

The purpose of this study was to examine the interrater and test-retest reliability of a one-leg balance test and a tiltboard balance test. Twenty-four normally developing children aged 4 through 9 years participated in the study. Time and quality of balance on one leg and degrees of tilt on a tiltboard prior to postural adjustment were measured. Both tests were completed with eyes open and with eyes closed. Interrater reliability was examined using two raters. Test-retest reliability, with a one-week interval between test and retest, was examined for a subgroup consisting of 12 children. Spearman rank-order correlation coefficients were used as indexes of both interrater and test-retest reliability for time and degrees of tilt. To supplement the correlation coefficients, the magnitudes of difference between raters' scores and between test and retest scores were calculated. Spearman coefficients were moderate to high for one-leg balance when scores for both feet were combined for both eyes-open and eyes-closed conditions. The magnitude of difference between scores was low, indicating good agreement between raters and across time. Interrater and test-retest reliabilities of quality of one-leg standing balance were examined by calculating percentages of agreement and Cohen's Kappa statistics. Results of these analyses revealed the need for further study. The Spearman coefficients for the interrater tiltboard test were high; however, the test-retest coefficients were low. The magnitudes of difference between scores were small for the two raters, but large for test and retest. These results are important to consider when using these tests for initial evaluation or for monitoring patient progress.

Preschool motor skills of children born prematurely and not diagnosed as having cerebral palsy.

To evaluate the preschool motor skills of children born prematurely, we examined 90 children who were participating in a longitudinal follow-up program at 4 1/2 years corrected age. Children with major neurological impairments, such as cerebral palsy, were excluded from this investigation. Study subjects' gestational ages ranged from 24 to 36 weeks. Both gross and fine motor function were assessed with standardized instruments. Overall, the later motor development of these children was reassuringly intact and within the average range on all measures. Nevertheless, extremely low birth weight (less than 1000 g) children as a group displayed significantly inferior skills in all motor functions. Symptomatic intracranial hemorrhage was also associated with significantly poorer motor performance.

A comparison of motor performance of preschoolers enrolled in mental health programs and non-mental health programs.

Recognizing that the etiologies of some major mental illnesses may be in the physical domain, this study described and compared the motor performance of 27 preschool children enrolled in mental health programs with 27 children enrolled in Project Head Start, a non-mental health program. The two groups were matched for age, race, and sex. The Gross and Fine Motor scales of the Peabody Developmental Motor Scales were administered to all subjects. On both measures the children enrolled in mental health programs scored significantly lower than the children enrolled in Project Head Start. In addition their scores were more variable. The results of this study support other findings suggesting that developmental delays may be characteristic of children with emotional disturbances.

The effects of chronic otitis media on motor performance in 5- and 6-year-old children.

Two 16-member groups of 5- and 6-year-old children, one group with a history of chronic otitis media and one without such a history, were tested on three measures of motor performance. These were the Motor Accuracy Test-Revised, the Stott Test of Motor Impairment, and measures of duration of standing balance. These instruments assess, respectively, fine motor coordination, overall motor skills, and balance. On each of these measures, children with a history of chronic otitis media scored lower than children without such a history. However, when these scores were compared statistically, no significant differences were found between the two groups. Because the results of this study were inconclusive, routine motor performance evaluation of children with a history of chronic otitis media is not advocated at this time.

Efficacy of two treatment approaches to reduce tongue protrusion of children with Down syndrome.

Five children with Down syndrome aged between 21 and 31 months, all of whom demonstrated habitual tongue protrusion, were randomly assigned to receive either oral-motor treatment or behavior modification. Tongue posture of all three children who received oral-motor treatment improved. For two of these the improvement leveled off after treatment had ended, but the third continued to show improvement. One of the two children receiving behavior modification showed improved tongue posture during treatment and maintained the improvement, but for the second there were insufficient data points to draw firm conclusions. Both forms of treatment appear to be effective, but further study is needed before definite conclusions can be made.

The relationship between the Bayley Scales of Infant Development and preschool gross motor and cognitive performance.

Early identification of disabilities enables early intervention by occupational therapists and other health professionals. Because the number of children who can be seen in therapy is limited, it is important to be able to identify those infants most likely to have deficits at a later age. Therefore, it is necessary to study and understand the relationship between infants' scores on early developmental assessments and later developmental outcomes. The purpose of this study was to determine the extent to which scores on the Bayley Scales of Infant Development (BSID) during the first 2 years of life are related to motor and cognitive performance at 4 1/2 years for a sample of children identified at birth as biologically high risk. This retrospective study involved 70 children who were evaluated at corrected ages of 4 months, 1 year, 2 years, and 4 1/2 years. The 4-month BSID Mental and Motor Scale scores did not relate significantly to later cognitive motor performance. In contrast, the 12-month BSID Mental Scale scores related significantly to preschool scores on both the motor and cognitive measures. However, the 24-month BSID Mental Scale scores related significantly only to scores on the preschool cognitive measures. Though significant, these correlation coefficients had small magnitudes. Thus, therapists should be cautious about using BSID testing at 4 months, 1 year, and 2 years when attempting to predict later preschool performance.

Relationship between infant neuromotor assessment and preschool motor measures.

The purpose of this retrospective study was to examine the relationship between early neuromotor findings, as assessed by the Movement Assessment of Infants (MAI), and later gross and fine motor outcomes, as measured by the Peabody Developmental Gross Motor Scale and the Frostig Eye-Motor Coordination Subtest. The sample consisted of 77 children who had been identified in infancy as biologically at risk and who had 4-month MAI scores and 4.5-year motor evaluation scores. Spearman's rank correlation coefficients between the MAI scores and the two motor outcome measures yielded no clinically significant relationships. These findings suggest that therapists should use the MAI as a reflection of an infant's performance at the time of testing rather than as an indicator of future potential.

Time use of mothers with preschool children: a pilot study.

This pilot study describes and compares the time use for physical child care of two groups of mothers--those with physically handicapped preschoolers (N = 16) and those with normal preschoolers (N = 21). Each mother completed a questionnaire on the time she spent in three categories of physical child care activities. These activities included feeding, personal care, and transportation for physical care. Investigators collected data on both frequency and duration. They reported descriptive data for all categories separately and combined. The results of the study show that the mothers of the physically handicapped preschoolers spent significantly more time engaged in physical child care activities than did the mothers of normal preschoolers. Results also show a high correlation between frequency and duration data for physical child care. The results strongly suggest that the mothers of physically handicapped preschoolers spend significantly more time in physical child care than do the mothers of normal preschoolers. They also suggest that frequency data alone could be collected in further studies in this area without appreciably reducing the accuracy of the results.

Pilot study of a revised field work performance report rating procedure.

Expressed dissatisfaction with the rating aspect of the Field Work Performance Report (FWPR) led to a study of the following proposed revisions: the present FWPR scale was extended by one point (from 4 to 5), the possible points were redefined quantitatively, and a qualitative factor was added. Both the present form and the revised form of the FWPR were administered to field work students from two schools to determine if these revisions would result in more effective and meaningful distributions of item scores and total scores. To make this determination, statistical analyses were employed and comments from participating clinical supervisors were invited. Findings indicated that the revised form dispersed scores more effectively and meaningfully. However, the analyses also pointed to the need for further revisions.