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Prevelance of sensory processing difficulties and the relationship between sensory processing and school function in children in Singapore

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Prevelance of sensory processing difficulties and the relationship between sensory processing and school function in children in Singapore

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PREVELANCE OF SENSORY PROCESSING DIFFICULTIES AND THE
RELATIONSHIP BETWEEN SENSORY PROCESSING AND SCHOOL
FUNCTION IN CHILDREN IN SINGAPORE
by
Peng Chian Tan
A Thesis Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(OCCUPATIONAL THERAPY)
December 2001
Copyright 2001 Peng Chian Tan
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UMI Number: 1411809
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UNIVERSITY O F SO U TH ER N CALIFORNIA
TH E GRADUATE SCH O O L
UNIVERSITY PARK
LOS ANGELES, CA LIFO RN IA S 0 0 0 7
This thesis, written by
TAN, PENG CHIAN
under the direction of h& H Thesis Committee,
and approved by all its members, has been pre
sented to and accepted by the Dean of The
Graduate School, in partial fulfillm ent of the
requirements for the degree of
. .MASIER O F...M TS.
D m m
Date December 17, 2001
THESIS COMMITTEE
Chainm s
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ii
ACKNOWLEDGEMENTS
I wish to thank my committee chairperson, Dr. Diane Parham, for her
patience and generosity in sharing with me her rich knowledge and understanding of
children with sensory processing difficulties. Her guidance and encouragement has
helped me to grow both as a clinician and a researcher and her contribution towards
the successful completion o f this thesis was invaluable. I would also like to extend
my gratitude to my committee members, Dr. Florence Clark and Dr. Diane
Kellegrew. Their valuable advice and support for this thesis have been most
insightful and have made this challenging process ever more interesting.
Most o f all, my deepest appreciation goes to my husband Mr Ian Koh. His
love, care, concern, and support, and his assistance in data collection and proof
reading were of utmost importance. Without him, this thesis would not be possible.
Lastly, I would like to thank and praise God for all the strength and blessing
that He has rendered me over the last two years.
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iii
TABLE OF CONTENTS
ACKNOWLEDGEMENTS....................................................................................... ii
LIST OF TABLES...................................................................................................... v
LIST OF FIGURES................................................................................................... vi
ABSTRACT.............................................................................................................. vii
CHAPTER
I. PROBLEM STATEMENT.................................................................................. 1
Introduction..................................................................................................................1
Rationale and Significance o f the Study....................................................................2
Research Design..........................................................................................................6
Research Questions..................................................................................................... 6
Assumptions................................................................................................................ 6
Limitations...................................................................................................................7
II. LITERATURE REVIEW....................................................................................8
Definition o f Sensory Processing...............................................................................8
Behavioral Presentation o f the Various Types of Sensory Processing Difficulties 9
Identifying Children with Sensory Processing Difficulties....................................11
Prevalence o f Sensory Processing Difficulties........................................................ 13
Demands of School....................................................................................................15
Measurement of School Function.............................................................................16
Effects of Sensory Processing on School Function.................................................17
ID. METHODS........................................................................................................21
Research Design........................................................................................................21
Participants: Part One o f the Study.......................................................................... 21
Participants: Part Two of the Study......................................................................... 30
Instruments................................................................................................................ 33
The Evaluation of Sensory Processing............................................................ 33
Identifying the child with sensory processing difficulties using the ESP 38
The School Function Assessment (SFA)........................................................39
Identifying the child with poor school function using the SFA..................... 42
Procedures................................................................................................................. 44
Data Analysis............................................................................................................. 45
IV. RESULTS..........................................................................................................48
Part One: Prevalence o f Sensory Processing Difficulties...................................... 48
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iv
Prevalence data.............................................................................................. 48vi
Identification of ESP items receiving the lowest scores............................. 50vi
Possibility of response sets............................................................................... 53
Selection of participants for part two of the study.......................................... 54
Part Two: Relationship Between Sensory Processing and School Function 56
Case Analyses of children with Poor Sensory Processing......................................60
Case One............................................................................................................ 63
Case Two...........................................................................................................64
Case Three.........................................................................................................66
Case Four...........................................................................................................67
Case Five...........................................................................................................68
Case Six............................................................................................................. 69
Case Seven.........................................................................................................70
Case Eight..........................................................................................................71
Case Nine........................................................................................................... 72
Case Ten............................................................................................................ 73
DISCUSSION........................................................................................................... 75
Prevalence of Sensory Processing Difficulties........................................................ 75
Limitations of the Prevalence D ata..........................................................................76
Relationship between Sensory Processing and School Function........................... 82
Limitations of School Function Data........................................................................85
Clinical Significance..................................................................................................90
Directions for Future Research................................................................................. 93
REFERENCES..........................................................................................................98
APPENDIX
A. Introductory Letter and Consent Form to School Principals...................102
B. Informed Consent Form for Teachers........................................................106
C. Approval Letter from the Ministry o f Education..................................... 110
D. Letter for Parents and Legal Guardians.................................................... 112
E. Information Sheets for Parents and Legal Guardians...............................115
F. Description of Participating Student Form................................................ 119
G. Evaluation of Sensory Processing Questionnaire (ESP) (Research Version
4) (Modified for Singapore U se)....................................................................121
H. Letter of Notification..................................................................................127
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V
LIST OF TABLES
1. Number of Primary Schools in Various Categories of Schools in Singapore... 22
2. Number of Questionnaires Distributed and Proportion of Valid Returns in Each
School Representing the Different Geographical Regions and School-types... 26
3. Demographic Data o f Subjects Recruited for Part One of the Study (n=324).. 29
4. Demographic Data of Subjects Recruited for the Second Part o f the Study...... 32
5. Changes Made on Four Items o f the ESP Research Version 4 for the Purpose of
This Study..............................................................................................................36
6. ESP Cut-off Scores at the 5th , 10th , and 15th Percentile........................................ 49
7. Percentages of Children who were Reported as Always, Often or Sometimes
Displaying a Certain Behavior.............................................................................. 51
8. Cases in which only One Type of Response was Indicated as the Answer to
Majority of the Questions on the ESP...................................................................54
9. The Lowest 10 Total ESP Scores..........................................................................55
10. Performance in Each Scale o f the SFA of Children with Poor Sensory
Processing Abilities................................................................................................57
11. Relationship between Sensory Processing and Participation............................. 58
12. Relationship between Sensory Processing and Using Material..........................58
13. Relationship between Sensory Processing and Setup and Cleanup................... 58
14. Relationship between Sensory Processing and Written W ork...........................59
15. Relationship between Sensory Processing and Task Behavior/Completion 59
16. Relationship between Sensory Processing and Behavior Regulation................59
17. Significance of Relationship Between Each Scale o f the SFA and Sensory
Processing...............................................................................................................60
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vi
LIST OF FIGURES
1. Mean scores o f each sensory domain in children with poor sensory processing
and school functional difficulties.............................................................................61
2. Mean scores of each sensory domain in children with poor sensory processing
and no school functional difficulties........................................................................62
3. Case One's mean ESP score on each sensory domain.............................................64
4. Case Two's mean ESP score on each sensory domain............................................65
5. Case Three's mean ESP score on each sensory domain...........................................66
6. Case Four’ s mean ESP score on each sensory domain............................................ 67
7. Case Five’ s mean ESP score on each sensory domain............................................68
8. Case Six's mean ESP score on each sensory domain............................................ 69
9. Case Seven’ s mean ESP score on each sensory domain........................................ 70
10. Case Eight's mean ESP score on each sensory domain......................................... 71
11. Case Nine's mean ESP score on each sensory domain.................................... 72
12. Case Ten's mean ESP score on each sensory domain............................................. 74
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ABSTRACT
This study used the Evaluation o f Sensory Processing (ESP), a parent questionnaire,
to estimate the prevalence o f sensory processing difficulties in children in Singapore.
In addition, this study explored the relationship o f sensory processing to school
function, as measured by the School Function Assessment (SFA). O f342 children
(mean age = 7.0 years), 14.5% met the criterion for sensory processing difficulties,
i.e., an ESP total score of less than 277 (derived from existing American data).
Children with the poorest sensory processing (n=10) were found to perform
significantly poorer (p<.05) only on the SFA Setup and Cleanup scale, compared to
children with good sensory processing (n=10). Results are interpreted with caution
due to limitations related to small sample size, instrumentation, as well as language
and cultural influences on parent and teacher questionnaire responses.
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Chapter I
Problem Statement
Introduction
This study consists o f two main purposes. The first part o f this study
described the investigation into the prevalence of sensory processing difficulties
among children who are attending primary one in regular primary schools in
Singapore. Sensory processing difficulties were assessed using the Evaluation of
Sensory Processing (ESP) Research Version 4 (modified for Singapore use). Primary
schools in Singapore are equivalent to elementary schools in the United States of
America and children in primary one are attending their first year in primary school.
The second part o f this research was a pilot study examining the relationship
between sensory processing and children’s level o f functioning in school. After
establishing from part one o f the study that there were more than ten children who
scored below 277 in the total ESP score, two groups o f children were identified. The
first group consisted o f 10 children with the lowest ESP scores and they were
identified as having relatively poor sensory processing; the 10 children with the
highest ESP scores were defined as belonging to the second group who has good
sensory processing. A total ESP score o f277 was determined based on statistical
information derived from previous studies of the ESP on the American population.
The ability o f these two groups o f children to perform in important non-academic
activities that enable them to participate successfully in school was then assessed
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using the School Function Assessment (SFA). The relationship between sensory
processing and school function was subsequently explored.
Rationale and Significance o f Study
Sensory processing is an essential human function. It involves the ability to
register, modulate, integrate, and organize sensory stimulation and subsequent
behavior responses (Ayres, 1979; Miller & Lane, 2000). Children with sensory
processing difficulties may experience difficulty in one, many, or all of the above areas
and this often affects their ability to function in daily activities. For example, a child
who has difficulty modulating tactile stimulation may avoid getting his hands in finger
paint, glue, or sand, hence limiting his play, his learning experiences, and his social
interaction. This child may also dislike being touched unexpectedly and seek
proprioceptive stimulation to help modulate this uncomfortable sensation.
Behaviorally, we may see this child, if asked to line up between two children, pushing
and bumping into the other children in order to seek proprioceptive input; or he may
choose to be the last one in the line to avoid being touched unexpectedly by his peers.
In recent years, research in neuroscience and behavioral science has led to
heightened awareness o f the role o f sensory processing in the performance of children
(Dunn, 1997). Wilbarger and Wilbarger (1991) suggested that about 15% of the
general population experience some form o f sensory processing difficulties. However,
other than a study by Baranek, Foster, and Berkson (1997), it appears that no other
studies have attempted to identify the prevalence o f sensory processing difficulties,
either in the typically developing population or in people with disabilities.
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Estimating the prevalence o f sensory processing is a fundamental step in
understanding the nature o f the problem. It is important for occupational therapists
and other professionals to understand the pervasiveness o f sensory processing
difficulties in children in order to render them adequate and appropriate services.
This is especially so in the so-called “typically developing” population because many
o f these children may be having a difficult time, yet they are very good at hiding
their sensory processing difficulties (Ayres, 1979) and hence they may not be
identified as needing help.
In Singapore, children in primary one are assumed to be o f typical
development, that is, these children have not been identified as unsuitable for “normal”
schooling. However, a number o f these “typically developing” children may be
experiencing sensory processing difficulties. As mentioned earlier, sensory processing
difficulties may present itself in various forms and severity. Two possible groups of
children could be affected by sensory processing difficulties in this “typically
developing” population o f primary one children and yet unidentified as warranting
help.
The first group consists o f children with high intelligence. They are often
able to cope with then difficulties, but due to their increased expenditure o f energy in
coping with their hidden disability, they may not perform as well in school as
expected given their intellectual ability. Identifying these children can help them to
maximize then potential.
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The other group consists of children with mild to severe sensory processing
difficulties who may be struggling and failing in school. However, due to lack of
awareness o f sensory integrative dysfunction, and/or a variety o f other reasons, many
of these children have simply been labeled “slower learners” and they continue to
receive no help from educationally related services such as occupational therapy.
An estimate of the proportion o f children with sensory processing difficulties
would highlight the problem. It might increase recognition o f the problem among
teachers, psychologist, medical practitioners and other related professionals and the
general public and hence, assisting occupational therapists and parents to advocate
for appropriate resources and services for these children.
Sensory integration theory implies that school function o f children might be
affected by sensory processing difficulties. A child's performance in school depends
on his ability to manage both academic and non-academic demands (Coster, Deeney,
Haltiwanger & Haley, 1998). Examples o f non-academic activities include observing
school rules, lining up before and after class, getting along with peers, participating in
self-care tasks such as toileting, buying food, eating, and taking transport to and from
school. Success in school also depends on abilities that support skills such as the
ability to manipulate a pencil, to write and copy legibly, to pay attention in class, and
to understand and follow a series of related instructions. These skills might be affected
in children with sensory processing difficulties, and yet they were usually expected to
be fully developed in children who had just begun formal schooling.
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In addition to a lack of understanding o f the actual prevalence of the problem,
occupational therapists appears to be assuming the above putative relationship between
sensory processing difficulties and the school function of children. A literature review
o f the effects o f sensory processing revealed studies that tend to demonstrate the
effects o f components o f sensory processing (such as tactile defensiveness) on
performance components such as in-hand manipulation, handwriting, attention to
specific tasks, isolated component o f social skills and so on. There appear to be no
studies that have considered the influence o f sensory processing on children’s overall
participation and functional performance in the school context.
The second part o f this study explored the influence o f sensory processing on
the ability o f children to meet the functional demands o f school by utilizing the School
Function Assessment, an instrument that focuses on school function per se. This part
o f the study was important in providing evidence regarding the influence o f sensory
processing on various school functions.
Many children are being helped by occupational therapists to improve their
function in school and in other daily occupations. The additional information from this
pilot part o f the study would help occupational therapists to further understand yet
another possible reason for the difficulties their clients could be experiencing in
schools. The findings o f this study may serve as an important evidence in advocating
for services for children in regular schools. In particular, it is hoped that children in
Singapore would benefit as current occupational therapy services are confined to
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clinical settings and yet to be conceived as necessary or appropriate in the regular
school environment.
Research Design
The first part o f this study was a descriptive study. The second part of the
study was an ex post facto design.
Research Questions
1. What is the estimated percentage of primary one children in Singapore whose
parents report behavioral signs o f sensory processing difficulties?
2. What is the estimated percentage of children with poor sensory processing and
poor school function?
3. Will children with poor sensory processing abilities perform significantly more
poorly in school than children with good sensory processing abilities?
Assumptions
1. The ESP reliably and validly measures children’s sensory processing abilities.
2. The SFA reliably and validly identifies children whom, when compared with
their same grade peers, have limitations in functioning in the school setting.
3. Because the official language in Singapore is English, parents o f children studied
would be able to accurately interpret and complete the ESP.
4. Cultural differences between the American populations for which the ESP and
the SFA were developed, and the population to be studied in Singapore have
minimal effects on the ability o f the instruments to measure what they purport to
measure.
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5. In completing the SFA for a particular student, the teacher who was providing
the information bad observed the student on a variety o f separate occasions in the
school contexts that were assessed by the SFA.
6. Expectations o f teachers o f their students were appropriate and not significantly
different from each other.
Limitations
1. Because the ESP was handed out by the teachers to the children to bring home to
their parents, the actual number o f returned questionnaires may be smaller than
expected, and hence affecting the results o f the study.
2. Parents who have lower educational level may not return the questionnaires due
to an inadequate level o f literacy necessary to complete the questionnaire.
3. Parents’ reports on the ESP may be affected by their understanding of the
questions asked, by cultural practice and socioeconomic status, by their attitude and
expectations towards the child, and by family interactions.
4. The school principals may be biased when recommending class teachers for
participation in the study.
5. Teacher’s report on the SFA may be affected by their experience, attitude and
expectations towards the child, attitude towards the study, cultural practice and
classroom interactions.
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Chapter II
Literature Review
Definition o f Sensory Processing
Since A. Jean Ayres developed the theory and treatment of sensory
integration in the1960s, the term sensory integration has been widely used not only
in the field o f occupational therapy but also in other professions and in the lay press
(Miller & Lane, 2000). Today, the term “sensory integration” can be found to
describe neurophysiological processes, functional behaviors, dysfunctional patterns,
sensory integration theory, or sensory integration treatment (Lane, Miller, & Hanft,
2000). Ayres (1979) defined sensory integration as “ the organization o f sensation
for use” (p. 5). The term when used in this manner refers to the central nervous
system’s capacity to process sensory input in order for the organism to participate in
occupations. This term is sometimes used synonymously with the term sensory
processing (Johnson-Ecker & Parham, 2000; Miller & Lane, 2000). The term
sensory processing broadly encompasses the ability o f the central nervous system
(CNS) to register, modulate, integrate, and organize sensory stimulation, as well as
the individual’s behavioral responses to sensory inputs.
The CNS manages and processes incoming sensory information from seven
peripheral sensory systems (Miller & Lane, 2000). These seven sensory systems
include vestibular, proprioceptive, tactile, visual, auditory, gustatory and olfactory.
Children with sensory processing difficulties may experience difficulties in one or
more o f these systems and in one or more ways (Ayres, 1979). Hence, each child
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with sensory processing difficulties almost always presents a unique set o f symptoms
(Ayres, 1979; Johnson-Ecker & Parham, 2000).
Behavioral Presentation o f the Various Types o f Sensory Processing Difficulties
Sensory processing is an act o f the CNS and does not include the inability to
detect sensory stimuli due to defects o f the peripheral nervous system (such as
blindness and deafness). Sensory integrative dysfunction (DSI) is a dysfunction of
the sensory processing ability o f the CNS. In this study, a child with poor sensory
processing was regarded similarly as a child with DSI.
Ayres (1979) described how sensation from the seven sensory systems,
especially that o f the tactile, proprioceptive, and vestibular systems, need to come
together in order to ensure that a person is able to function happily and successfully
in life. In more recent literature (Hanft, Miller, & Lane, 2000; Lane et al., 2000),
sensory processing difficulties have been perceived as consisting o f dysfunction in
sensory modulation (SMD), dysfunction in sensory discrimination, and dysfunction
in praxis (dyspraxia).
When children have SMD, they have difficulty modulating and regulating the
degree, intensity, duration and nature o f the incoming sensory input. This affects
their ability to further organize the sensory input in order to respond behaviorally in
an adaptive and functional manner. There are three types o f response patterns in
children with SMD: over-responsivity, underresponsivity, and fluctuating
responsivity (Lane et al., 2000).
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Under the same sensory conditions, children who over-response to sensory
stimulation have greater response to the sensory input than children with normal
sensory modulation processes (Lane et al., 2000). They may respond with intense
emotions, increased activity level, distractibility, or other behavioral problems such
as aggression (Blanche, Botticelli, & Hallway, 1995). For example, a child with
tactile defensiveness may perceive a hug from an adult as extremely intrusive and
may throw a temper tantrum when an adult attempts to hug him or her. On the other
hand, most other children welcome a hug from an adult.
Under the same sensory conditions, children who under-response to sensory
stimulation have less response to the sensory input than children with normal sensory
modulation process (Lane et al., 2000). For example, children with under-responsive
vestibular systems may not feel dizzy at all following intensive and prolonged period
of stimulation on roller coaster rides.
Children with fluctuating responsivity have difficulty responding adaptively
to environmental demands because their reactions to sensations rapidly shift between
over-responsiveness and under-responsiveness (Lane et al., 2000). For example, a
child may not respond to the vacuum cleaner going off at one instant; yet at the next
moment, he or she may become extremely irritable with its volume.
As a result o f these different responses to sensory input, children with SMD
may present as sensation seeking or sensation avoiding (Ayres, 1979; Dunn, 1997).
For example, children who have tactile defensiveness may avoid gritty material and
they may seek proprioceptive input (such as pressing down hard on the table or
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1 1
chair) following exposure to such “aversive” material. Children who are under-
responsive to vestibular input may seek intense stimulation on swings and other
moving equipment in order to feed their sensory system. Very often, children with
SMD seek proprioceptive input such as jumping, crashing and pushing in order to
modulate their own experience o f incoming auditory, tactile, gustatory, olfactory,
visual and vestibular input.
Another aspect o f sensory processing is to enable the ability to discriminate
between the temporal and spatial characteristics o f sensory stimuli. Children with
difficulty in sensory discrimination may have a poor body percept (Ayres, 1979) and
have difficulty with feeling where the body is without looking at it or touching it.
Functionally, these children may have difficulties with knowing how much pressure
to exert when writing with a pencil or with reaching into their backpack for their
pencil without looking.
Dysfunction in praxis is another disruption in sensory processing and it often
results from poor discrimination and/or SMD. A child with praxis difficulty has a
hard time planning and performing a novel motor action or a series o f motor actions
(Blanche et al., 1995; Lane et al., 2000). He or she often presents as having
handwriting problems, poor fine and gross motor skills, and/or many other related
social-behavioral issues (Ayres, 1972,1979; Blanche et. al, 1995).
Identifying Children with Sensory Processing Difficulties
Standardized testing (such as using the Sensory Integration and Praxis Tests),
clinical observation o f sensorimotor abilities, observations in clinic and school
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settings, and interviews with parents and teachers are often necessary for a child to
be identified as having sensory processing difficulties (American Occupational
Therapy Association, 1997). The sensory history questionnaires are one o f the most
useful and commonly utilized clinical assessment that occupational therapists apply
to screen children for possible sensory processing difficulties (Johnson-Ecker &
Parham, 2000). Such questionnaires usually require parents to answer a series of
questions about their child’s response to various sensory experiences in the context
o f everyday life (Dunn, 1997).
In order to identify children with sensory processing difficulties, it is
important that sensory questionnaires used accurately reflect a child’s response to the
different types of sensory stimulation. The Evaluation of Sensory Processing (ESP)
Research Version 4 (Parham & Johnson-Ecker, 2000) was used in this study.
The ESP attempts to measure a child’s sensory processing based on his or her
parents' or caregiver’s report. It consists o f items that address behaviors linked with
sensory modulation and sensory discrimination o f the various sensory systems, with
a focus on the tactile, proprioceptive and vestibular system, as according to the
sensory integration theory (Johnson-Ecker & Parham, 2000). This instrument may be
weaker in identifying children with discriminative difficulties as identification of
discriminative and practic abilities usually require much more in-depth testing.
Sensory history questionnaires such as the ESP measures parent’s perception
o f their child’ behavior. Although there are a few items on the ESP that reflects a
child’s behavioral responses in school, most o f the items measure the child’s
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13
response to daily activities in the home or in other environments outside of the
school. Therefore, in using a sensory history questionnaire this way, occupational
therapists are assessing a child's sensory processing ability from a parent’s
perspective. Clinically, many therapists went on to generalize this ability to the
school context. It is hence important to explore if indeed that a child’s sensory
processing ability is influencing his or her school function and this can be best
achieved by utilizing a tool that measures the functional performance o f the child in
the school setting.
Prevalence of Sensory Processing Difficulties
Ayres (1979) proposed that “about five to 10 percent o f the children in this
country today have enough trouble with sensory integration to cause them to be slow
learners or to have behavior problems” (p. 7). Wilbarger and Wilbarger (1991)
claimed that as many as 15% o f the entire population (including both people with
and without disabilities) may be affected with problems o f sensory defensiveness.
However, no research has been reported to support these conjectures.
Baranek, Foster, and Berkson (1997) attempted to describe the relative
prevalence o f various sensory defensive behaviors in persons with developmental
disabilities. Occupational therapists have long speculated that sensory processing
difficulties are more prevalent in special populations. Using only six-items o f a
survey about various kinds o f stereotyped and unusual behaviors, Baranek et al.
estimated that about 3-30% of a total o f 158 adults and 88 children with
developmental disabilities presented with sensory defensiveness behaviors. A closer
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14
examination o f their data revealed that sensory-defensive behaviors were generally
uncommon in their population o f246 persons with developmental disabilities. With
the exception of the item “upset by noise or activity” (indicating sensory
defensiveness in the auditory system) which affected 30% of the children, prevalence
of sensory defensiveness behavior in the other S items range from 2-13% in the 88
children with disabilities. If it is true that sensory processing difficulties are found
primarily in children with disabilities, this result will suggests that the actual
incidence o f sensory processing difficulties in the general population of children is
much lower than the 15%. On the other hand, this result may indicate that, in
addition to the small incidence o f sensory processing difficulties in children with
disabilities, there is a much larger percentage of typically developing population who
are affected by sensory processing difficulties and they make up the 15% o f the
general population who have sensory processing difficulties.
Dunn and colleagues (Dunn, 1997; Dunn & Brown, 1997; Ermer & Dunn,
1998) assessed 1,115 typically developing children with the Sensory Profile, a
sensory questionnaire very similar to the ESP. However, she did not report the
prevalence o f sensory processing difficulties in these children. Instead, her research
was geared towards tool development and identifying items on the sensory profile
that differentiates between typically and non-typically developing children. Several
other studies were similar in nature but with smaller sample sizes (Johnson-Ecker &
Parham, 2000; Royeen & Fortune, 1990).
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Demands o f School
Children construct patterns o f occupational engagement according to both
their abilities and the demands o f their environmental contexts (Coster, 1998). In a
typical school day, a child engages in a large number o f activities, participating
academically and socially, and meeting the demands set forth for them by
themselves, by the personnel in the school, by their parents, and by society in
general.
A primary occupation o f children in school is to engage in academic
activities in order to increase their mastery o f content areas such as language,
mathematics, and science. These academic activities often include classroom and
homework assignments that are set accordingly to a certain curriculum (Coster,
Deeney, Haltiwanger, & Haley, 1998).
In order to perform effectively in school and to benefit from academic
activities, children are also required to perform a variety o f functional tasks that
support or enable them to participate in the academic and social aspects o f the
educational program (Coster et al., 1998). These functional tasks are often referred to
as the non-academic aspects o f a school program and the ability to perform these
non-academic tasks is often assumed to be folly functioning in children attending
regular education. Examples o f non-academic skills necessary to enable a child to
participate folly in curriculum-related activities include manipulating books and tools
for writing, moving around the classroom and school, compliance with rules and
instructions, maintaining adequate attention, and interacting with peers.
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16
Mane ini, Coster, Trombly, and Heeren (2000) found that children need both
physical and cognitive-behavioral skills in order to successfully participate in school.
Important physical skills demanded in the schools include not only the ability to
utilize writing and cutting implements but also maneuvering on playground
equipment and manipulating clothing items such as putting on clothes, buttoning,
tying shoe laces, and so on. Cognitive-behavioral skills demands in addition to
academic work includes social skills such as showing general good manners,
maintaining appropriate social and physical boundaries, asking permission when
required, and general compliance with teacher’s directions and rules (Mancini et al.,
2000).
Measurement o f School Function
In this study, school function referred to children’s ability to perform in non-
academic tasks that require both physical and cognitive-social skills, and that support
their participation in the academic and social aspects o f an elementary school
program. Children’s school function was measured using the School Function
Assessment (SFA) (Coster et al., 1998). The SFA has been designed to describe a
student’s participation, support needs and functional performance across a variety o f
relevant school settings.
The SFA was preferred over adaptive behavior assessments because it
measures a child’s occupational performance in the school setting. It also allows the
teachers completing the assessment to compare the children to their peers, limiting
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17
the influence o f cultural bias due to the differences between the children studied and
the normative sample.
The SFA is criterion referenced. It has a cut o ff point that differentiates
children who has limitations in school function from children without limitations.
This cut-off point was established to identify any child whose school functional
performance foils below the expectation o f 95% o f the rest o f the typically
developing population. This increases the sensitivity o f the instrument and facilitates
the dichotomizing o f children into those with poor school function and those with
good school function, as was necessary as part o f the design o f this study. Being
criterion referenced rather than norm referenced, the SFA enables the researcher to
measure the child’s functional performance relative to the overall continuum o f
function (Coster et al., 1998).
In addition, the SFA examines areas o f school functioning closely related to
sensory processing, such as handling o f various school tools, traveling through
congested areas and in a line, recreational movements (hopping, skipping, throwing
and catching balls and so on), moving while manipulating objects (such as tray o f
food), and behavior regulation (such as acceptance o f unexpected changes in
routine).
Effects o f Sensory Processing on School Function
“Educators often call reading, writing, and arithmetic the ’basics’, but
actually these are extremely complex processes that can develop only upon a strong
foundation o f sensory integration” (Ayres, 1979, p. 9).
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In a position statement regarding “Sensory Integration Evaluation and
Intervention in School-based Occupational Therapy”, the American Occupational
Therapy Association (1997) explained that children with sensory processing
difficulties may present with cognitive delays, motor delays and other related
psychosocial issues such as difficulty socializing or complying with rules. It stated
that “sensory integration enhances the individual’s capacity to perform functional
activities in school such as sitting in a chair to read, paying attention, organizing
school supplies and a desk to begin a task, holding and using a pencil, and translating
verbal instructions into appropriate behaviors” (p. 861).
Many researchers, clinicians, and academicians believe that sensory
processing difficulties affect everyday occupation and school function (Ayres, 1979;
Blanche et. al, 1995; Case-smith, 1997; Dunbar, 1999; Fisher, Murray, & Bundy,
1991; Parham & Mailloux, 1996). Case-Smith (1997) wrote, “therapists reported that
understanding a child’s sensory processing is critical to understanding his or her
functional performance in school” (p. 496). Indeed, clinical experience and logical
deductions from research results in the field o f neuroscience, behavioral science, and
sensory processing seem to strongly indicate that children whose sensory processing
ability are affected may have difficulty functioning and performing in school.
However, a literature review o f research done in the area o f sensory
integration and sensory processing revealed little direct support for the effects o f
sensory processing difficulties on school function o f children. Coster (1998) was
concerned that occupational therapists often utilized “bottom-up” (p. 337) or
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19
developmental approaches when assessing children, identifying more the child’s
“discrete component abilities” rather than the functional problems that the child is
actually experiencing. The potential functional impact o f sensory processing
difficulties on children in school settings is usually inferred but not assessed in great
depth. Such an approach may hinder research from exploring the direct effect o f
sensory processing on school function.
Case-Smith (1991) showed that tactile defensiveness and tactile
discrimination affects in-hand manipulation. Similar studies have also been
conducted to examine the effect o f various aspect o f sensory processing on
performance components required in school, such as attention, social skills, balance,
and motor skills (Ayres, 1964; Case-smith, 1997; Dunn, 1997; Parush, Sohmer,
Steinberg, & Kaitz, 1997; Short, 1985; Shumway-Cook, Horak, & Black, 1987).
Moreover, many studies (Levine, Meltzer, Busch, Palfrey, & Sullivan, 1983;
Mancini et al., 2000; Stine, Saratsiostis, & Mosser, 1975) have indicated that
successful functioning o f children in school are affected by a variety o f skills and
subtle, underlying neurological conditions, in addition to impairments that were
already identified.
Together, these researches provided evidence o f the possibility o f an effect o f
sensory processing on the occupational behavior o f children in school. In order to
provide more concrete support for such a claim, this study had examined the
influence o f sensory processing deficits on the general function and participation o f
children in school. It was the hypothesis o f this study that children with poor sensory
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2 0
processing will perform more poorly in school compared to children with good
sensory processing.
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2 1
Chapter m
Methods
Research Design
This research was a two-part study. The first part was a descriptive study o f
the prevalence o f sensory processing difficulties among primary one students in
regular classrooms in Singapore. The second part o f this research was a pilot study
that involved identifying children with sensory processing difficulties from the
former in order to conduct an ex post facto relational study. Two groups o f children
were identified from the first part o f the study: one group with poor sensory
processing (n=10) and one group with good sensory processing (n=10). The school
function performance o f these two groups o f children was measured and a statistical
analysis performed to attempt to identify a significant relationship between sensory
processing and non-academic school performance.
Participants: Part One o f the Study
The participants in part one o f this study were primary one students randomly
selected from eight primary schools in Singapore. Singapore is a multi-racial country
consisting mainly o f Chinese, Malay, Indian, and many other smaller ethnic groups.
Although cultural practices and mother tongues o f these various groups may differ,
English is the medium o f instruction in schools in Singapore. English is also the
medium o f administration, commerce, and technology (M inistry o f Education, 2000).
However, being an immigrant country, it is inevitable that a minority o f people may
not be fluent in the language.
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2 2
In Singapore, the government categorized primary schools into four
geographical zones: North, South, East, and West. Primary schools are also divided
into government schools and government-aided schools. Government schools are
fully funded by the government while government-aided schools are semi
independent schools that are partially funded by the government. Singapore primary
schools can also be divided by gender into boys-only schools, girls-only schools and
schools where both boys and girls are co-educated (mixed schools). Table 1
describes how primary schools in Singapore were categorized in this study and the
number o f primary schools in each o f the categories.
Table 1
ries o f Schools in I
Government Schools Government-aided
Schools
Total
Mixed Schools
North zone 45*
South zone 26*
East zone 35“
West zone 42*
Total o f all zones 148*
23« b
171
Girls-only Schools 2 14 16*
Boys-only Schools 1 9 10*
Total
a * . ■ ■ • i
155 46
h • a •
197
divided into zones.
As is evident in Table 1, single-sex schools are also mostly government-aided
schools. Children gain entry into primary schools in Singapore based on balloting
results, alumnus ties o f parents, order o f birth, proximity o f home to school and other
factors not apparently related to the socioeconomic status o f the family. However, it
is a popular folk belief that children attending government-aided schools and single-
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23
sex schools are from families with better socioeconomic status. This is despite any
statistical evidence that a relationship exists between socioeconomic status and type
o f primary school attended by children.
Hence, there appeared to be a need to ensure an equal representation o f
students from the various geographical locations, socioeconomic status and types o f
school environments (single-sex versus mixed schools and government versus
government-aided schools). In an attempt to achieve this, the following process was
conducted to select the eight schools involved in this study. Randomization was
achieved through random drawing o f names o f schools.
One school was randomly selected from each o f the North, South, East and
West zone, resulting in a total o f four government mixed schools being selected. The
5* school was randomly selected from a combination o f all the 152 government
mixed schools regardless o f zone (refer to Table 1). Regardless o f whether they are
government schools or government-aided schools, all the girls-only schools were
grouped together and the 6th school was randomly selected from this group. A similar
process was used to select the 7* school from the group o f boys-only schools. The 8th
school was randomly picked from the group o f government-aided mixed schools.
Groups where a school was randomly selected are denoted by superscript (*) in Table
1.
After a school was randomly selected from each group (e.g. North zone), its
school principal was approached and given a package consisting o f (a) an
Introductory Letter and Consent Form to School Principals (Appendix A); (b) an
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24
Informed Consent Form for Teachers (Appendix B); (c) an Approval Letter from the
Ministry o f Education (Appendix C); (d) a Letter for Parents and Legal Guardians
(Appendix D); (e) an Information Sheets for Parents and Legal Guardians (Appendix
E); (f) a Description o f Participating Student Form (Appendix F); (g) an Evaluation
o f Sensory Processing questionnaire (ESP) (Research Version 4) (Modified for
Singapore Use) (Appendix G); (h) a School Function Assessment questionnaire, and
(0 a copy o f the research proposal. If the principal rejected the invitation to take part
in the study, a second school was randomly selected from that group and the
principal approached. If again, the principal declined to take part, a third school
would be selected from that group and its principal approached. This process was
repeated until there was a school representing each o f the eight groups.
Following the permission by the school principals to conduct research in their
schools, the researcher invited each o f the principals o f the eight schools to randomly
recommend two classes from their school for participation in the study. The class
teachers o f the recommended classes must meet the following inclusion criteria: (a)
the teacher must be spending more than 50% o f total weekly school hours with his or
her class, (b) the teacher must have taught the class for more than three months, and
(c) the teacher must agree to complete the SFA if one o f his or her student is selected
to participate in the second part o f the study.
The class teachers were then requested to sign the Informed Consent Form
for Teachers (Appendix B) and given four sets o f documents to distribute to each
child in their class. These documents are (a) Letter for Parents and Legal Guardians
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(Appendix D), (b) Information Sheet for Parents and Legal Guardians (Appendix E),
(c) Description o f Participating Student Form (Appendix F), and (d) ESP Research
Version 4 (modified) (Appendix G). The teachers were to tell the children to give the
documents to their parents and to bring them back to school the next day if their
parents have completed filling in them.
The teachers were to attempt to collect the forms back from the children in
their class everyday for the next one week. For each o f the eight schools except one,
the researcher managed to collect back the returned questionnaires from the teachers
between 7 to 9 days. For the one school, due to the absence o f the teacher from
school, the questionnaires were only collected back by the researcher after 14 days.
Table 2 shows the number o f sets o f questionnaires distributed by the
teachers and the proportion o f valid returns in each school. All teachers were
conscientious with collecting back the questionnaires and the percentages o f return
from each school range from 40% to 65.75%. However, following a chi-square
analysis, a significant difference was found between the rates o f questionnaires
returned from each school (p<.01). This could be due to the larger proportion o f less-
educated parents in government schools who may experience greater difficulty in
understanding the questionnaires and who may also be less involved in their
children’s educational process. This difference in proportion o f return supported our
attempt to collate a sample representative o f the population by ensuring that schools
o f various geographical regions and types are involved in the study.
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Table 2
Number o f Questionnaires Distributed and Proportion o f Valid Returns in Each
School Representing the Different Geographical Regions and School-tvpes
Types o f school Number distributed Percentage o f valid
return
Government North Zone 80 40.00
Government South Zone 73 65.75
Government East Zone 80 40.00
Government West Zone 80 63.75
Government All Zone 80 51.25
Government-aided mixed school 81 46.91
Girls-only school 74 51.35
Boys-only school 79 55.70
A total o f 627 questionnaires were distributed for the first part o f this study in
order to determine the prevalence o f sensory processing difficulties o f children in
primary one in Singapore. Many returns were received, however, not all o f them
were valid returns. A return was considered valid and the subject included in the
study only if the following inclusion criteria were met.
In general, children attending primary one in regular schools in Singapore are
a homogeneous group, usually having an intelligence quotient o f above 75. Most
children with an intelligence quotient o f less than 75 are identified before going to
primary one and they attend special schools. However, occasionally parents o f
children with mild intellectual disability may choose to send their children to regular
schools. Moreover, there may be children with intellectual disability who are placed
in primary one as they have yet to be identified as having a disability.
Children with physical disabilities such as cerebral palsy (CP), spina bifida,
and muscular dystrophy may attend regular education in Singapore, as long as they
are deemed to have the cognitive ability to cope with a regular curriculum without
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extensive adaptations. Similarly, a small number o f children who have been
diagnosed with childhood disorders such as Asperger Syndrome, Pervasive
Developmental Disorder (PDD), and Attention Deficit Hyperactive Disorder
(ADHD) may also be found in regular primary one classrooms. For the purpose o f
the first part o f this study, all students regardless o f disabilities were included. In the
data collection process, parents participating in the study were asked to provide
information regarding developmental and health problems o f their children (see
Appendix F). O f the valid returns, three children were reported as having been
diagnosed with ADHD, one child was diagnosed with developmental delay and one
child was reported to have auditory defensiveness and was receiving “listening
therapy.”
Five parents returned the ESP questionnaire without returning the Description
o f Participating Student form and they were included in the study.
Completed ESP questionnaires were only considered as valid returns if at
least 75% o f the items in each sensory domain were completed. This means that
there should be no more than 2 missing items out o f the 10 auditory items, no more
than 1 missing item out o f the 5 gustatory/olfactory items, no more than 3 missing
items out o f the 12 proprioceptive items, no more than 5 missing items out o f the 21
tactile items, no more than 3 items out o f the 15 vestibular items and no more than 3
missing items out o f the 13 visual items. In total, there should also be no more than
10 missing items out o f all the items. It was the researcher’s decision that any more
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missing items in each o f the domain would not be representative o f the parents’
perception o f the child’s behavior.
Given these inclusion criteria, 14 invalid returns were rejected and a total
number o f 324 valid parent responses on the ESP were recruited and included for
data analysis, constituting a return rate o f 51.67%. According to the Educational
Statistics Digest (2000) published by the Singapore Ministry o f Education, a total o f
50,258 children attended primary one in the year 2000. A sample size o f 300, based
on an estimate that 5.0% o f the total population will have sensory processing
difficulties, will yield a 95% confidence interval o f 5.0%± 7.8%. Hence, with our
current sample size o f 324 subjects, we are 95% confident that if our data indicate
that 5% o f children are reported to have sensory processing difficulties, then the
actual prevalence estimate is between 2.8% and 12.8%. This is the power o f the
sample size o f this study.
The demographic data o f the subjects recruited via the valid returns (N=324)
are summarized in Table 3. These data indicate that the subjects were representative
o f children attending primary one in the year 2000 in Singapore. The Educational
Statistics Digest 2000 published by the Singapore Ministry o f Education reported
that 98.8% o f children are between 6 to 7 years old when they enter primary one.
The age o f the subjects in this part o f the study was found to range from 6.5 years to
8.5 years with 99.4% o f the subjects (n=314) between 6.5 years to 7.5 years. The
mean age was 7.0 years.
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Table 3
Demographic Data o f Subjects Recruited for Part One o f the Study (N=3241
Frequency Percentage
Gender
Male 158 48.8
Female 160 49.4
Missing cases 6 1.9
Ethnicity
Chinese 222 70.5
Malay 55 17.5
Indian 27 8.6
Eurasians 3 1.0
Others 8 2.5
Missing cases 9 2.8
Relationship o f person completing
questionnaire
Father 112 34.6
Mother 191 59.0
Legal Guardians 4 1.2
Others 9 2.8
Missing cases 8 2.5
Highest Level o f education o f person
completing questionnaire
None 2 0.6
Primary 20 6.2
Secondary 179 55.2
Tertiary 91 28.1
Not applicable 15 4.6
Missing cases 17 5.2
Annual Household Income
Less than S$ 12,000 46 14.2
S$12,000 to S$30,000 95 29.3
S$30,000 to S$60,000 84 25.9
More than S$60,000 80 24.7
Missing cases 19 5.9
O f the participants in this part o f the study, 49.4% were female comparing
favorably to the Educational Statistic Digest 2000 report that 48.2% o f children in
primary one were female. The number o f subjects representing the Chinese, Malay,
Indian, Eurasians, and other ethnicity groups were also comparable to the overall
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30
Singapore population. Parents formed the majority o f persons completing the
questionnaires and most o f the people completing the ESP received at least
secondary education. The subjects o f this study were also evenly represented in the
various socioeconomic groups with the least number o f subjects coming from the
lowest income group.
Participants: Part Two o f the Study
Parents who decided to participate in this research completed and returned
the questionnaires to their child’s class teacher. In doing so, they also agreed to
participate in the second part o f this study. The second part o f this study explored the
school function o f certain children recruited from part one o f the study. This pilot
part o f the study recruited two groups o f children according to their total ESP scores:
the first group, representing children with poor sensory processing, consisted o f the
children with the lowest 10 ESP scores while the second group, representing children
with good sensory processing, consisted o f children with the 10 highest ESP scores.
The total ESP scores (based on a total o f 73 items) o f subjects in the poor sensory
processing group ranged from 219 to 249. As for the group with good sensory
processing, eight o f the ten subjects scored 365 (maximum possible score) points
while one subject scored 363 and one subject scored 362.
As the second part o f the study intended to study the effects o f sensory
processing on the school function o f children, children whose school function were
known to be affected as a direct result o f other diagnostic conditions were not to be
included in this part o f the study. This meant that all children with a physical
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31
impairment such as CP, spina bifida, and muscular dystrophy were to be excluded.
However, as no children from the first part o f the study were reported to have these
conditions, no one was excluded from the second part o f the study. Children with
ADHD and PDD have often been found to have difficulties with sensory processing
and many o f the school function difficulties encountered by these children are a
direct result o f their sensory processing problems. Hence, these children were to be
included in the second part o f the study. Despite this, none o f the children who were
reported as having ADHD (n=3), developmental delay (n= l) or auditory
defensiveness (n= l) scored low or high enough on the ESP to be considered for the
second part o f the study. This means that the parents o f all the 20 children who were
recruited for the second part o f the study had reported that their children had no
developmental conditions.
Table 4 shows the demographic data o f the 20 children who participated in
the second part o f the study. There are more males (n=7) than females (n=3) in the
group with poor sensory processing compared to the group with good sensory
processing. Similar ethnic representation was found in the good and poor sensory
processing groups. As for the person completing the questionnaires, the majority o f
the ESPs were completed by mothers o f the poor sensory processing group while the
ESPs o f most o f the children w ith good sensory processing were completed by the
fathers. The socioeconomic status (as measured by annual household income)
between the poor and the good sensory processing groups appeared to be similar
although no statistical analysis was conducted due to the small sample size.
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The mean age for the group with good sensory processing (n=9) was found to
be 6.98 years and the group with poor sensory processing (n-10) had a mean age o f
7.0S years. An independent t-test indicates no significant difference between the ages
o f the subjects from the two groups.
Table 4
Demographic Data o f Subjects Recruited for the Second Part o f the Study
Frequency
Good Sensory
Processing
Poor Sensory
Processing
Gender
Male 5 7
Female 5 3
Ethnicity
Chinese 6 6
Malay 3 3
Indian 0 1
Others 1 0
Relationship o f person
completing questionnaire
Mother 2 7
Father 6 2
Others 1 1
Missing Cases 1 0
Highest level o f education
o f person completing
questionnaire
Primary 2 0
Secondary 6 7
Tertiary 1 1
Not Applicable 0 1
Missing Cases 1 1
Annual household income
Less than S $12,000 1 1
S$12,000 to S$30,000 4 6
S$30,000 to S$60,000 1 2
More than S$60,000 1 0
Missing cases 3 1
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Instruments
The Evaluation o f Sensory Processing (ESP) questionnaire (Appendix G), as
introduced in chapter 2, was used to evaluate the children’s sensory processing
abilities. The School Function Assessment, described briefly in chapter 2 as well,
was used to evaluate children’s non-academic performance in school. A data form
titled “Description o f Participating Student” (Appendix F) was also used to collect
demographic data such as gender, age, socioeconomic status, education level o f
person completing questionnaires and presence o f health and developmental
problems. As can be seen from Table 3, many parents did not fully complete this
form requesting for their demographic details, for example, 6 cases did not complete
the Gender section, 9 cases did not fill out the Ethnicity section, 19 cases did not
complete the Annual Household Income section and so on.
The Evaluation o f Sensory Processing.
The Evaluation o f Sensory Processing (ESP) is a parent questionnaire that
attempts to assess a child’s sensory processing via an inventory o f the child’s
behavioral and sensory history. It was first conceived by LaCroix (1993). LaCroix
performed an exhaustive search for existing sensory questionnaires both in the
literature and from parents and professionals. She compiled 679 items from existing
questionnaires and from the literature on behaviors indicative o f sensory processing
difficulties. Subsequently, a panel o f experts in sensory integration rated the content
validity o f each item. The result was the first research version o f the ESP, a 200-item
sensory history questionnaire.
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Johnson (1996) revised the first version o f the ESP following an in-depth
interview with five parents. In the same study, this second version o f the ESP,
consisting o f 192 questions, was tested for criterion-related validity. The ESP
questionnaire (Research version 2) was completed by parents o f 30 children with
recently diagnosed sensory integrative disorder and 59 typically developing children
(o f which 30 were matched with the 30 children with sensory integrative disorder for
age, gender, ethnicity, and socioeconomic status). The Wilcoxon signed-rank test for
matched pairs was performed for each individual item o f the ESP. The aim was to
determine if the ESP would be able to discriminate between the two groups. Johnson
found that 84 out o f the 192 items indicated a significant difference between the
matched groups (p < .05).
Meanwhile, Parham (1997) analyzed Johnson’s (1996) data to estimate the
internal consistency o f ESP (Research Version 2) items. Using Cronbach’s alpha, all
sensory domains yielded alphas o f more than .80 (indicating strong reliability)
except for the olfactory and gustatory systems. Following the same methods
employed by LaCroix, the olfactory and gustatory domains were combined and
totally new items generated and tested for content validity.
Using the suggestions in Johnson’s (1996) study, some questions in the ESP
(Research Version 2) were eliminated or revised and an ESP Research Version 3 was
generated, consisting o f 185 questions in 6 domains: auditory, gustatory/olfactory,
proprioceptive, tactile, vestibular, and visual.
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VerMaas Lee (1999) continued with the work on establishing validity o f the
ESP Research Version 3 by conducting a study examining the ability o f the ESP
Research Version 3 to differentiate between children with autism and typically
developing children. Her study included 41 children with autism and 41 typically
developing children. A Mann-Whitney U test was applied to each individual hem
and VerMass Lee found that 114 o f 185 (61%) items significantly differentiated
children with autism from typically developing children (p < .OS). These 114 items
were also found to be distributed throughout every sensory domain.
Meanwhile, Chang (1999) explored the inter-rater reliability between parents.
Both fathers and mothers o f 20 typically developing children and IS children with
sensory integrative dysfunction completed the ESP Research Version 3 separately.
When agreement within one level was assessed, Chang found that more than 7S% o f
the parents agree with each other on the rating o f their children on the ESP items.
The results o f this study indicate moderate (>.50) to high (>.75) intraclass correlation
coefficients (ICC) and Spearman correlation coefficients on certain items o f the ESP.
Together with data from Johnson and VerMaas’s studies, this information was used
to eliminate items on the ESP that were found to have poor inter-rater reliability and
validity (L. D. Parham, personal communication, January 11, 2001). Following
further refinement o f wording on a few o f the items, the ESP Research Version 4
(Parham & Johnson-Ecker, 2000) was conceived (see Appendix G).
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Table 5
Study
Item number Item Description
Before Change After Change
Gustatory
/Olfactory System
No. 5
Tactile System
No. 1 1
Vestibular System
No. 1
Visual System
No. 11
Does your child gag when
anticipating an unappealing
food such as cooked spinach?
Does your child avoid or
dislike playing with gritty
things?
Does your child seem
excessively fearful o f
movement, as in going up and
down stairs or riding swings,
teeter totters, slides or other
playground equipment?
Did your child make reversals
in words or letters when
writing or copying or read
words backwards (such as
reading saw for was) after the
first grade?________________
Does your child gag when
anticipating an unappealing
food such as century egg, fish,
or cooked cabbage or green
leafy vegetables?
Does your child avoid or
dislike playing with gritty or
coarse textured things such as
sand?
Does your child seem
excessively fearful o f
movement, as in going up and
down stairs or riding swings,
seesaws, slides or other
playground equipment?
Did your child make reversals
in words or letters when
writing or copying or read
words backwards (such as
reading saw for was) after
kindergarten 2?____________
The ESP was developed based on the cultural practices o f Americans and the
understanding and usage o f the English language in America. It is important that this
factor be considered when using the ESP on another population, as the sensory
questionnaire may be sensitive to cultural and language differences. To minimize the
likelihood that these factors might affect the results o f this study, four items on the
ESP were slightly modified (by changing the types o f examples to more culturally
related items) for this study. These changes were made based on the opinion o f the
author who is from Singapore. Two adults from Singapore who are not occupational
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37
therapists were also consulted to confirm the relevance and appropriateness o f the
change. The four items on the ESP that were changed for the purpose o f this study
are listed in Table 5. This version will hereby be referred to as the ESP Research
Version 4 (Modified for Singapore Use).
There was one other item on this ESP Research Version 4 that was changed
for the purpose o f this study. This item is vestibular item number 3. On the original
ESP Research Version 4, it reads “ Does your child have good balance?’ On this
item, a response o f “Always” would be most desirable and a response o f “Never”
would be most undesirable. This is in reverse to the other items on the ESP and
hence, to score this item, the scores for each response will have to be reversed (i.e.
the score for “Always” will have to be scored as 5 instead o f 1). For the version
modified for the use o f this Singapore study, this item was changed to read as “Does
your child have poor balance?’ This change was to facilitate the scoring o f the ESP
so that the scores o f each response did not have to be reversed (i.e. the score for the
response o f “Always” will remain as 1, and not S and “Often” will be scored as 4 and
not 2).
Existing studies (Chang, 1999; Johnson-Ecker & Parham, 2000; VerMaas
Lee, 1999) o f the reliability and validity o f the ESP have been conducted on children
between the age o f 2 years 0 months and 11 years 11 months. Hence, the ESP was an
appropriate instrument to be used in this study to examine the sensory processing o f
children who were mostly 6-7 years old. However, it should be noted that the mean
age for typically developing children in Chang’s (1999) study was 61.5 months or
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38
5.13 years and for VerMaas Lee’s (1999) study was 4.59 years. As for Johnson-
Ecker and Parham’s (2000) study, the subjects ranged in age from 3 years to 6 years
11 months. This relatively younger sample could affect the validity and reliability o f
the ESP when it is applied to the current older (mean age = 7.0 years) sample. It
could also affect the validity o f comparing the ESP scores o f children in Singapore
against the ESP scores o f the subjects in these previous studies o f the ESP.
Identifying the child with sensory processing difficulties using the ESP.
The ESP Research Version 4 (modified) was the instrument used in this study
to identify children with sensory processing difficulties. It consists o f a total o f 76
items, with 10 in the auditory system, 5 in the gustatory/olfactory system, 12 in the
proprioception system, 21 in the tactile system, 15 in the vestibular system, and 13 in
the visual system. Prior to this study, the author had utilized data from Chang (1999)
and VerMass Lee (1999) to develop a scoring system for the ESP Research Version
4.
Total ESP scores from 52 typically developing children and 56 non-typically
developing children from Chang and VerMaas Lee’s study (which uses the ESP
Research Version 3 consisting o f 185 items) were analyzed. A total ESP score was
calculated for each child by extracting the 73 items on the ESP Research Version 4
from the 185 items and adding the scores o f each o f the 73 items except for item 11,
12, and 13 in the visual system. These last three items in the visual system are meant
to be completed only if the child is 6 years o f age or older and hence, in the previous
studies, there were not enough data from children above 6 years old to validly
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39
include them. As the present research studied primary one children who would all be
above 6 years old, parents were requested to also complete the last three items in the
visual system.
A Receiver Operating Characteristic (ROC) Curve was employed on the total
ESP scores o f these children from Chang and VerMaas L ee's studies. Its purpose
was to find a cut o ff total score that is both sensitive and specific in differentiating
children with sensory processing difficulties from typically developing children. It
was found that a total score o f 277 for 73 items has 80% sensitivity and 90%
specificity in predicting a child with sensory processing difficulties. Hence, for the
purpose o f this study, any child with a total ESP score o f below 277 (on 73 items)
was defined as presenting with sensory processing difficulties.
The School Function Assessment (SFA- ) (Coster. Deenev. Haltiwaneer. &
Halev. 1998).
The SFA is a judgment-based assessment consisting o f a questionnaire that is
to be completed by one or more school professionals who know the student well and
have observed his or her typical performance on school-related tasks and activities.
For this study, the class teacher o f the student was the only professional completing
the SFA.
The SFA has been developed to apply to students with a wide variety o f
disabilities across the full range o f elementary school grades (kindergarten through
grade six). It was standardized on 363 students with disabilities across 112 different
sites in 40 states o fth e United States plus Puerto Rico. In addition, 318 students
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40
without disabilities were also recruited and matched by grade level and school
system to the students with disabilities; data from these students were used to
establish criterion cut-off scores by grade levels for individual scales.
The SFA is comprised o f three parts. Part I is “Participation”. This consists o f
a scale that examined the student’s level o f participation in six major school activity
settings: regular or special education classroom, playground/recess, transportation,
bathroom/toileting, transitions, and mealtime/snack time. Part n is “Task Support”
and it consists o f 4 scales. This part attempts to assess the support currently provided
to the student when he or she performs physical and cognitive/behavioral tasks that
are required to participate effectively in an educational program. Two types o f task
supports are examined separately in each o f these two types o f tasks: assistance
(adult help) and adaptations (modifications to the environment or program, such as
specialized equipment or adapted materials). Part m is “Activity performance”. It
consists o f 21 separate scales examining the student’s performance o f specific
school-related functional activities such as travel, recreational movement, setup and
cleanup, written work, following social conventions and so on.
Coster et al. (1998) reported uniformly high internal consistency o f the SFA
with Cronbach’s alpha ranging from .92 to .98. Two studies were conducted to
determine the test-retest reliability o f the SFA. The first study was conducted during
the tryout edition with a convenience sample o f 23 students (representative o f the
larger sample in characteristics) who were assessed twice in an interval o f 2-4 weeks.
Reliability coefficient ranged between .82 and .98. The second study was conducted
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41
with the standardization version o f the SFA on a sample o f 29 students
(representative ofthe larger sample) who were assessed twice over an interval o f 2-4
weeks by at least two respondents. Both intraclass correlations (.80 to .99) and
Pearson r (.80 to .99) were similarly high.
Two content validity tests were conducted during the development o f the
SFA. In the first study, conducted during the pilot study phase, evaluations from 30
recognized experts representing a variety o f disciplines in education and clinical
services were obtained. Reviewer ratings supported the comprehensiveness and
relevance o f the items on the SFA and the distinctions among the different levels o f
function. Suggestions for revisions to improve clarity or content coverage were
provided by many reviewers and these suggestions were addressed during revision o f
the instrument.
In the second content review, conducted during the try-out edition, 40
teachers and therapists were asked their opinions via questionnaire. The purpose o f
this review was to obtain feedback from potential users o f the instrument as
compared to the earlier panel o f experts, many o f who were in academic settings.
The instrument was perceived to be both comprehensive and relevant for the
population o f students in elementary schools.
The SFA manual also reported studies done to demonstrate the construct
validity o fth e SFA. Results provided support for the following constructs that
formed the theoretical basis o f the SFA: a) functional performance is context
dependent, b) environmental supports make a unique contribution to task
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42
performance, c) participation in each setting is a function o f performing setting
relevant tasks, and d) functional tasks can be meaningfully grouped according to
whether their major demands are physical or cognitive/behavioral in nature.
Identifying the child with poor school function using the SFA.
The scores on the SFA represent the result o f an interaction between the
student and his or her present school context. They describe the student’s current
participation, task support needs, or functional activity performance as compared to
his or her peers. Part I o f the SFA yields one total raw score while parts II and III
yield 4 and 21 individual raw scores respectively. Each o f these raw scores can be
converted to criterion scores according to conversion tables provided in the SFA
user’s manual.
Criterion scores were developed on a population o f students with disabilities.
Each scale on the SFA is unidimensional and hence the criterion score o f that scale
represents a best estimate o f the student’s current position on the continuum o f
function represented by the items o f that scale. A criterion score o f 100 implies that a
child is functioning grade-appropriately in a particular area.
If a child achieves a criterion score o f less than 100, the criterion cut-off
score is used to determine whether this score is below the level o f his or her typically
performing peers. The criterion cut-off scores were derived from the performance o f
students in the regular education population only. Five percent or fewer typically
performing students would be expected to have scores below these cut-off points.
Hence, if a child’s criterion score on a scale fells below cut-off points, this result
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43
indicates limitations in the student’s current school function in that particular area as
compared to his or her peers. For the purpose o f this study, a child with criterion
score o f less than the cut o ff point on a particular scale o f the SFA was considered as
having poor participation in school, or poor functional performance in the school
activity being measured.
As mentioned earlier in Chapter II, sensory processing difficulties can affect
many areas o f a child’s school function. No pilot study is known to have explored
the performance o f children with poor sensory processing on each o f the areas
measured by the SFA and no scales o f the SFA have previously been reported to be
particularly associated with sensory processing difficulties. Part two o f this study
was designed to analyze each participant’s criterion scores on each o f the 26 scales
o f the SFA in order to discover the area o f school function, if any, that is most likely
to be affected by poor sensory processing. Due to the increased time needed to
complete the extensive 26 SFA scales and the increased likelihood o f Type I error as
a result o f repeated testing, this would not be possible to conduct. In this study, the
researcher had selected 6 areas o f function (represented by 6 different scales on the
SFA) that, in her opinion, would most likely be affected in children who have
sensory processing difficulties. These six scales were (a) Participation, (b) Using
Materials, (c) Setup and Cleanup, (d) W ritten Work, (e) Task Behavior and
Completion, and (f) Behavior Regulation.
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In summary, a subject in this study would be identified as having poor school
function in any o f the above six areas if he or she scored below the criterion cut-off
score for that scale.
Procedures
Following clearance by the Institutional Review Board at the University o f
Southern California and approval by the Singapore Ministry o f Education, the
researcher proceeded with the first part o f the study according to the description in
the Participants section o f this chapter.
Returned ESP questionnaires from primary one students participating in the
first part o f the research were analyzed to identify children with sensory processing
difficulties. It was the original intention o f the study that if there were no children
who obtained a total ESP score o f less than 277, then no further study would be
conducted. If there were I to 9 children who scored below 277 in the ESP, then the
researcher would identify these children and assess them using the SFA. It would
then be the aim o f the second part o f the study to estimate the percentage o f children
who have both poor sensory processing and poor school function. No further
statistical analysis was to be carried out.
Analysis o f the total ESP scores from the first part o f the study identified 47
children who scored below 277 on the ESP. The researcher then proceeded to
identify two groups o f children, one group with the 10 highest ESP scores and one
group with the 10 lowest ESP scores, for assessment on the SFA. A research
assistant was employed to match the lowest 10 ESP scores and the highest 10 ESP
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45
scores to the names o f the children and subsequently identify their teachers. The use
o f a research assistant ensured that the researcher was blind to the children’s scores
on the ESP and not biased when she assisted the teachers to complete the SFA.
To assess the children on the SFA, the researcher made an appointment o f
approximately half-hour with their respective class teachers. At the same time, a
letter was also sent to the parents (through the teachers) to notify them o f their
children’s participation in the second part o f the study (see Appendix H). During the
meeting with the teacher, the researcher introduced the SFA to the class teacher by
summarizing page 2 and 3 o f the SFA Rating Scale Guide. The researcher then
instructed the teacher on the completion o f part I in accordance to the instructions o f
the Rating Scale Guide. After the teacher has completed part 1, he or she was
instructed (according to the Rating Scale Guide) on the completion o f Part m .
Subsequently, the teacher completed the selected 5 scales from Part III: (a) Using
Materials, (b) Setup and Cleanup, (c) W ritten Work, (d) Task Behavior/Completion,
and (e) Behavior Regulation. This process ensured that the assessment was
completed accurately and that the teacher followed the guidelines for completion.
The teacher had no prior knowledge o f the child’s score on the ESP. The SFA was
completed and collected from the teachers at the end o f the meeting.
Data Analysis
For the first part o f the study, two total ESP scores were calculated for each
child. The first total score was the sum o f the ratings for each o f the 73 items
excluding the last 3 items on the visual system on the ESP. The second total ESP
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46
score was the sum o f the ratings for all the 76 items on the ESP, including the last 3
items o f the visual system.
If a questionnaire was a valid return and there were missing items, a mean
score was calculated for the particular sensory domain and used to fill in the missing
data point. The total score o f that domain was then the sum o f every item in that
domain. For example, on one o f the questionnaires returned, there was one missing
item on the auditory domain, and the child scored 4 for all the other 9 items on that
domain, the mean score was (4x9)/9 = 4. This mean score was used as the value o f
the missing item and the total score for the 10 items on that domain was 36+4 = 40.
Subsequently, the percentage o f children who have a total ESP score o f less
than 277 was calculated and this was the estimated prevalence rate o f sensory
processing difficulties in primary one school children in Singapore.
Once it was established that there were more than 10 children who scored
less than 277 on the 73 items, the total ESP scores o f all the children were sorted
from highest to lowest and the children with the highest and the lowest 10 scores
were identified.
To analyze the data o f the SFA, the total raw score o f each scale (e.g. Using
Materials) was converted into a criterion score according to the SFA manual. This
score was then compared against the criterion cut-off score. I f a child scored below
the criterion cut off score, his o r her functioning in that scale would be considered as
poor. The Fisher Exact Probability Analysis was then used to analyze the
relationship between sensory processing and each o f the six areas o f school functions
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measured by the SFA. Since this second part o f the study was a pilot study involving
only a small sample size, it is thus important to investigate the individual
characteristics o f the participants. These results are illustrated in the next chapter.
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Chapter IV
Results
This chapter details the data collected on the prevalence o f sensory
processing difficulties in children in Singapore and provides the findings o f the
relationship between sensory processing and school function using statistical
analysis. It also includes a presentation o f the individual profile o f children with poor
sensory processing who were assessed using the School Function Assessment (SFA).
Part One: Prevalence o f Sensory Processing Difficulties
Prevalence data.
In order to establish the prevalence rate o f sensory processing difficulties for
this study, individual scores o f the first 73 items o f the Evaluation o f Sensory
Processing (ESP) were added to obtain the total ESP score. The last 3 items o f the
visual system were not included in order to compare this total score with the cut-off
score o f 277 from previous American studies (Chang, 1999; VerMaas Lee, 1999)
which used only 73 items o f the ESP (see chapter III). Total ESP scores obtained
from adding all 76 items o f the ESP were also calculated since this study used a
version o f the ESP that consisted o f all the 76 items, including the last 3 visual items.
Both sets o f total scores (for 73 items and for 76 items) were then ranked from
lowest to highest and the cumulative percentage calculated.
Table 6 presented the total ESP scores at the 5lh , 10lh , and 15th percentile
obtained from the current study as well as from an analysis o f the data o f earlier
American studies by Chang (1999) and VerMaas Lee (1999).
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Table 6
ESP Cut-off Scores at the 5th . 10th and 15th Percentile for Both Singaporean and
American Data
Cut-off Total Score
Singaporean Study (N=324) American Study
(N=52)
Sum o f 76 items Sum o f 73 items Sum o f 73 items
At 5* percentile 265.36 255.25 269.25
At 1 0 * * * percentile 279.65 269.00 281.10
At 15* percentile 290.00 277.92 288.00
From Table 6, an analysis o f the total ESP scores (based on 73 items) o f the
Singaporean study (N=324) shows that 5%, 10%, and 15% o f our sample scored
equal or less than 255.25, 269 and 277.92 points respectively.
To facilitate comparison between Singaporean and American data, Table 6
also shows the 5th , 10th and 15th percentile total ESP scores obtained from data based
on two American studies (Chang, 1999; VerMaas Lee, 1999). These two American
studies used the ESP Research Version 3 which consisted o f 185 items. To calculate
a total ESP score for each o f the 52 cases in these two studies, the first 73 items o f
the ESP Research Version 4 were extracted from the 185 items and summed. These
total ESP scores obtained were the same data used to determine the criterion score o f
277 for identification o f children with sensory processing difficulties.
Results showed that the scores from the American data at each o f these
percentiles were much higher than those found in our Singaporean study. This
indicates that when using the American data, a child can obtain a much higher score
(269 as compared to 255) and be classified as belonging to the lowest 5% o f the
population.
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In our Singaporean study, 47 children out o f our sample size o f 324 scored
below 277 points. Thus, the prevalence rate o f sensory processing difficulties in
primary one children in Singapore is estimated to be around 14.5%. The American
data by Chang (1999) and VerMaas Lee (1999) had suggested that a total ESP score
o f below 277 (obtained from adding the first 73 ESP items) indicated sensory
processing difficulties. It was found that when this 277 criterion score was applied to
the same American population (N=52) used to derive this score, only 8.9% o f the
American children would be identified as having sensory processing difficulties.
Identification o f ESP items receiving the lowest scores.
Analysis o f the ESP data o f this study found that there were a few items on
the ESP in which a higher percentage o f caregivers tend to report their child as
“sometimes” (obtaining a score o f 3), “often” (score o f 2) or “always” (score o f 1)
displaying the behavior. A score o f 2 or below indicates difficulty in the sensory
processing o f that particular behavior. Hence, further examination o f these items that
were most frequently reported by caregivers as having scores o f 2 or below was
necessary to determine if there were any particular ESP items with which children in
Singapore were having more difficulty.
An item on the ESP which persistently recorded the lowest scores by
caregivers would also have resulted in a lower total score attained and thus increased
the number o f children with low total ESP scores. Identifying these items that
contributed to low total ESP scores will help us in further interpreting the prevalence
data for sensory processing difficulties found in the Singaporean population.
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Table 7 presents the five items o f the ESP that were found to have the lowest
mean scores in this study. A comparison with the American data obtained from
VerMaas Lee’s (1999) study was also made to explore potential differences between
the ways parents from the two populations rate then* children on the ESP.
Table 7
Percentages o f Children who were Reported as Always. Often or Sometimes
Displaying a Certain Behavior______________________________________
Item Description Singaporean Study
(N=324)
American Study*
(n=40)
Mean
Score
A O S A O S
Does your child
like last spinning
carnival rides, such
as merry-go-
rounds?
2.99 17.0 18.5 31.8 31.7 31.7 31.7
Does your child
jump a lot?
3.19 9.3 18.5 32.4 4.9 22.0 26.8
Does your child
dislike eating
messy food with
his/her hands?
3.60 10.5 7.4 28.1 4.9 7.3 9.8
Does your child
become easily
distracted by visual
stimuli?
3.63 2.2 9.0 38.9 0.0 4.9 26.8
Does your child
seem driven to
seek activities such
as pushing,
pulling, dragging,
lifting, and
jumping?
3.65 4.6 9.0 31.2 7.3 17.1 34.1
Note. Items are arranged in descending order with the first item having the lowest
mean hem score and the largest total percentage o f children scoring 3.0 and below.
A = Always = score o f 1.0; O = Often = score o f 2.0; S = Sometimes = score o f 3.0.
"Based on results obtained on typically developing children in VerMaas Lee’s (1999)
study.
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The item with the lowest mean score was a vestibular item: “Does your child
like fast spinning carnival rides?” As Table 7 shows, the American children were
reported to enjoy fast carnival rides much more frequently (63.4% were rated as
always or often) than Singaporean children (35.5% were rated as always or often).
Similarly, the frequency o f children in America who were reported as always or
often driven to seek proprioceptive activities such as pushing and pulling was much
more than the Singapore population (24.4% compared to 13.6%, respectively). The
frequency o f Singaporean parents reporting that their children like to jump (a
proprioceptive item) was found to be comparable to their American counterparts
(27.8% compared to 26.9%, respectively). Since Singaporean children were not
found to be rated much more poorly on these items than American children, these
results suggested that vestibular and proprioceptive seeking behaviors may not be the
cause for lowering the total ESP scores o f children in Singapore.
However, Singaporean parents did give their children ratings o f always and
often more frequently than Americans on two items shown in Table 7. One item is
the visual item: “Does your child become easily distracted by visual stimuli?” On
this item, 11.2% o f parents from Singapore rated their children as always or often
presenting with the behavior as compared to 4.9% o f American parents. The other
item that found children in Singapore receiving lower ratings more frequently from
then: parents as compared to the American children was in the way parents reported
their child as displaying the problem o f disliking messy hands (17.9% compared to
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53
12.2%). These differences could be due to cultural differences and Chapter 5 will
discuss this in detail.
In summary, examination o f the five lowest scored items did not present a
clear picture o f what items may have contributed to the findings that a higher
percentage o f Singaporean children in this study met the criterion score for sensory
processing difficulties compared to American children in previous studies. It could
be that the reason for Singaporean children receiving lower total ESP scores was due
to the cumulative effect o f generally lower scores obtained on many items and that
no particular item was contributing significantly to the lower total ESP scores o f
children in Singapore.
Possibility o f response sets.
Results indicated that a group o f caregivers tend to rate their children by
using only one type o f response. This finding raised the possibility that these parents
were scoring the ESP with a response set. Response sets are a result o f the tendency
for response biases in some respondents, leading to the distortion o f results. These
respondents may consistently provide extreme responses or then responses may be
characterized by a mid-range alternative only (Polit & Hungler, 1995).
The possible cases o f response set are presented in Table 8. All the 10
children who were selected to represent the group o f children with good sensory
processing in the second part o f this study could have been selected due to response
bias on the part o f their caregivers. Eight out o f ten o f these children achieved a score
o f 5 (“always”) on all the 76 items while the other two children achieved a score o f 5
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54
on 74 o f the items and a score o f 4 (“often”) for the remaining 2 items. This rendered
extremely high total ESP scores for these children. One o f the children identified for
the poor sensory processing group might also have been selected due to response
bias, as the parent o f this child scored him with a 3 (“sometimes”) on all 76 items,
yielding a very low total ESP score o f 219.
Table 8
Cases in which only One Type o f Response was Indicated as the Answer to Majority
o f the Questions on the ESP___________________________________________
Type o f Response No o f questions where
response is being used
No o f cases
“Never” - 5 76 8
“Never” - 5 74 3
“Never” - 5 73 2
“Sometimes” - 3 76 1
“Sometimes” - 3 64 1
Selection o f participants for part two o f the study.
From the first part o f this study, children with the 10 lowest and the 10
highest total ESP scores (calculated based on 73 items) were recruited into the
second part o f this study. Children with the 10 highest total ESP scores constituted
the group with good sensory processing abilities. Children with the 10 lowest ESP
scores made up the group with poor sensory processing and they were the lowest
scoring 3.1% on the ESP in the first part o f the study. As noted above, selection o f
these groups may have been affected by response set, particularly for the good
sensory processing group.
Table 9 shows the total ESP scores (based on both 73 and 76 items) o f the 10
children with the lowest scores. As the scores o f children may vary on the last 3
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visual items o f the ESP, the 10 children with the lowest ESP scores calculated based
on 73 items were different from the 10 children with the lowest ESP scores
calculated based on 76 items. Regardless o f using either a total score o f 73 or 76
items, the children with the lowest 10 total scores constituted the lowest 3.1% o f the
sample.
Table 9
The Lowest 10 Total ESP Scores
Lowest 10 total ESP scores (based on
73 ESP items)
Lowest 10 total ESP Scores (based on
76 ESP items)
219.00 228.00
219.00 228.95
220.95 229.00
221.00 230.00
242.00 252.00
242.57 255.00
246.00 256.00
247.00 256.00
247.00 256.00
247.83 256.57
Note. For missing items, the mean score o f items in the same sensory domain was
calculated and used to replace the missing data point. Total ESP scores then were
derived by adding all items across all sensory domains.
It is evident from Table 9 that the total ESP scores o f the children with the 10
lowest scores fell well below the pre-established cut-off score o f 277 for sensory
processing difficulties, ranging from 219 to 248. The total ESP scores o f the children
with the lowest four scores was nearly similar, ranging from 219 to 221 (based on a
total o f 73 items). However, the total ESP scores o f the other six cases range from
242 to 249, there being a difference o f 21 points between the 4d > (221) and the 5th
lowest scores (242).
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Part Two: Relationship between Sensory Processing and School Function
Children who were selected for the second part o f this study were
subsequently assessed by their teachers using six scales o f the School Function
Assessment. These six scales are Participation, Using Materials, Setup and Cleanup,
Written Work, Task Behavior and Completion, and Behavior Regulation.
Table 10 illustrates the school function profile o fth e 10 children that
constituted the poor sensory processing group in the second part o f this study. Each
individual child's performance on each o f the six scales o f the SFA is represented in
Table 10. A “case number” is the identification number given to each child for the
purpose o f this presentation. As shown in this table, children numbered 1, 2, 3, 4, 7,
and 10 demonstrated some form o f school function difficulties while children
numbered 5, 6, 8, and 9 do not show any school function difficulties. A child was
considered as having functional difficulties in a particular scale when his or her SFA
scores on that scale met the criterion for limitations in school function set forth in the
SFA manual.
From Table 10,6 out o f 10 children with poor sensory processing presented
with difficulties on the Participation Scale. O f the 10 children, 4 were assessed by
their teacher as having poor performance in the Using M aterial scale, 4 children
scored poorly on the Setup and Cleanup scale, 2 were poor on the W ritten Work
scale, and 3 were poor on the Task Behavior and Completion scale. Only one child
was reported by the teacher to have difficulties on the Behavior Regulation scale.
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Table 10
Performance in Each Scale o f the SFA o f Children with Poor Sensorv Processing
Abilities
Case number
1 2 3 4 5 6 7 8 9 10
Sex o f Case M M M M F M M M F F
Type o f school
function (different
scales o f the SFA)
Participation P P P P P P
Using Material P P P P
Setup and Cleanup P P P P
Written Work P P
Task Behavior
/completion
P P P
Behavior Regulation P
Note. P indicates poor performance in the particular scale o
Female.
the SFA. M = Male; F =
In our small sample, all children who were reported as having school function
difficulties had all been scored as having poor Participation. Children who reportedly
had difficulties on the Setup and Cleanup scale also had difficulties on the Using
Material Scale. Behavior Regulation appeared to be a scale that was rarely affected
in our children with poor sensory processing.
It should also be noted that 7 out o f the 10 children were male. O f the 3
females, only one girl demonstrated difficulty in school function (and only in the
Participation Scale and Task Behavior and Completion Scale).
When these data were compared to the group o f children with good sensory
processing (children with the 10 highest total ESP scores from the first part o f the
study), it was found that only two children had difficulty on the Participation scale.
A third child had difficulty on the Using M aterial scale only.
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58
Tables 11 to 16 present the 2 X 2 matrices used to illustrate the number o f
subjects who had poor sensory processing and poor/good school functions and also
the number o f subjects who had good sensory processing and poor/good school
function. A matrix was constructed to illustrate the relationship between sensory
processing and each o fth e six scales o f school function.
Table 11
Relationship between Sensory Processing and Participation
Participation
Sensory Processing Good Poor Total
Good 8 2 10
Poor 4 6 10
Total 12 8 20
Table 12
Relationship between Sensorv Pnrocessine and Usine Material
Using Material
Sensory Processing Good Poor Total
Good 9 1 10
Poor 6 4 10
Total 15 5 20
Table 13
Relationship between Sensorv Processine and Setup and Cleanup
Setup and Cleanup
Sensory Processing Good Poor Total
Good 10 0 10
Poor 6 4 10
Total 16 4 20
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Table 14
Relationship between Sensorv Processing and Written Work
59
______________ Written Work______
Sensory Processing Good________ Poor_________ Total
Good 10 0 10
Poor 8 2 10
Total 18 2 20
Table 15
Relationship between Sensorv Processing and Task Behavior/Completion
Task behavior/completion
Sensory Processing Good Poor Total
Good 10 0 10
Poor 7 3 10
Total 17 3 20
Table 16
Relationship between Sensorv Processing and Behavior Retaliation
Behavior Regulation
Sensory Processing Good Poor Total
Good 10 0 10
Poor 9 1 10
Total 19 1 20
The Fisher Exact Probability was used to analyze the relationship between
sensory processing and school function (using the matrices illustrated in Tables 11 to
16). At an alpha level o f .05, this study found no significant relationship between
sensory processing difficulties and five areas o f non-academically related school
functions, namely, Participation, Using Materials, Written Work, Task behavior and
Completion, and Behavior Regulation (see Table 17). In the area o f Setup and
Cleanup, children with poor sensory processing performed significantly more poorly
than children with good sensory processing (p<.05)
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60
The Fisher Exact Probability analysis was repeated for the scale o f
Participation with 2 children from the good sensory processing group omitted. These
two children were removed from the analysis because they were reported by the
same teacher as having poor Participation in class as they have severe constipation
and hence were having trouble managing their bowel movement. Comparisons were
not repeated for other scales as these two children were not reported as having any
difficulties on the other scales o f the SFA except for Participation. This repeated
analysis for the Participation scale (n=8 children with good sensory processing and
n=10 with poor sensory processing) indicated that sensory processing was
significantly related to Participation (p<.05) (see Table 17).
Table 17
Significance o f Relationship Between Each Scale o f the SFA and Sensorv Processing
Scales o f the SFA p-value*
Participation .085
Participation1 1 .011*
Using Material .152
Setup and Cleanup .043*
Written Work .237
Task behavior/completion .105
Behavior regulation .500
"Fisher’s Exact Probability (1-sided). ’ ’ Two children with good sensory processing
and poor participation were excluded.
*g<.05
Case Analyses o f Children with Poor Sensorv Processing
As the second part o f this study was only a pilot study and involved only 10
children with and 10 children without sensory processing difficulties, it is pertinent
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61
that the individual profiles o f sensory processing and school functions o f these
children be examined.
auditory
gustatory/
olfactory
propnoception
CASE
Figure 1. Mean scores o f each sensory domain in children with poor sensory
processing and school functional difficulties.
Figures 1 and 2 provide an overview o f the individual sensory characteristics
o f the 10 children with poor sensory processing abilities. The mean score o f each
sensory domain was obtained by adding the scores o f individual ESP items in a
sensory domain and dividing it by the total number o f items in that domain. It was
used to represent a child’s performance in that sensory domain. Since there were
different number o f items in each sensory domain (e.g. there were 10 auditory items
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62
as compared to 21 tactile items), the mean scores did not contribute equally to the
total ESP scores.
5.0
4.5
4.0 •
3.5 •
3.0
2.5
5 2.0
III
I
■ a u d ito ry
SSSflqustatorv/
olfactory
^|proprioception
tactile
vestibular
I I visual
CASE
Figure 2. Mean scores o f each sensory domain in children with poor sensory
processing and no school functional difficulties.
Figure 1 shows the mean scores obtained in each sensory domain by children
who were assessed on the SFA and found to have poor functioning in at least one o f
the scales o f the SFA (all o f these 6 children had low Participation scores on the
SFA). Figure 2 illustrates the mean sensory domain scores o f the children with
sensory processing difficulties who were not found to have any difficulties in any o f
the scales o f the SFA. An examination o f the sensory characteristics o f the two
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63
groups o f children with poor sensory processing showed no specific patterns that
differentiate between the children with and without school function. As for the
sensory profiles o f children with good sensory processing, eight o f these children
scored 5 on all the ESP items and the other two children scored 5 on 71 items and 4
on the remaining 2 items.
In the remainder o f this section, ESP and SFA data for each o f the 10
children belonging to the poor sensory processing group are examined individually.
Although these case analyses focused on comparing mean scores across sensory
domains, it should be noted that clinical use o f the ESP mandates that individual
items in each domain be examined to discover patterns o f behavior that are
problematic (such as sensory seeking or avoiding).
Case One.
Case One is the child who obtained the lowest total ESP score in the first part
o f the study. He scored 219 on 73 items, with mean sensory domain scores ranging
widely from 2.6 to 3.8 (see Figure 3). His strengths were in the processing o f
gustatory and visual information, where he scored distinctively better than the rest o f
the sensory domains. He performed poorly in all other sensory domains, having
difficulties especially with the auditory domain. On examining his performance on
the SFA, he was found to have difficulties on the Participation, Using Material, and
Setup and Cleanup scales.
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64
5.0 >
4 .5-
4 .0<
auditory proprioception vestibular
gustatory/olfactory tactile visual
Figure 3. Case One’s mean ESP score on each sensory domain.
This child’s performance on the ESP and the SFA suggested that he may be
experiencing some difficulties with auditory processing and with sensory integration
especially in the area o f praxic ability. Further assessment by the occupational
therapist and the speech and language therapist is necessary to determine this and to
assist in planning his treatment needs.
Case Two.
Case Two is a male child who had obtained a total ESP score (based on 73
items) o f 220.95, with mean domain scores ranging from 2.6 to 3.6 (see Figure 4).
His scores were generally low (below 3.0) in most o f the sensory domains, especially
gustatory/olfactory. Proprioception processing was obviously his strength as he
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65
scored much better (3.6) in this domain than the rest o f the sensory domains. His
SFA scores revealed poor performance in the Participation scale only.
5.0 V— --------------------------------------------------------------------------------------------------
4 .5 '
4 .0 '
auditory proprioception vestibular
gustatory/oifactory tactile visual
Figure 4. Case Two’s mean ESP score on each sensory domain.
I f this child is to receive further professional care, it is necessary to consider
other areas o f his school function that may have been limited and to explore the
possible factors, especially gustatory and olfactory processing, which are affecting
his scores on the Participation scale.
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66
Case Three.
5.0 ---------
4.5 '
4 .0'
3.5'
auditory proprioception vestibular
gustatory/offacftvy tactile visual
Figure 5. Case Three's mean ESP score on each sensory domain.
This child scored a total o f 221 on 73 items o f the ESP with mean scores that
differed minimally across sensory domains (scores ranged from 2.8 to 3.1) (see
Figure 5). All o f his mean scores for the sensory domains were low (all 3.1 or
below), suggesting sensory processing difficulties across all domains. He presented
with the same school function profile as Case One, having difficulty on the
Participation, Using Material, and Setup and Cleanup scales. However, their sensory
profiles are entirely different. This indicates that underlying sensory issues may
differentiate children who have similar problems in school functioning. Hence,
treatments for each child should be planned individually.
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67
Case Four.
5.0 ----
4.5 >
4.0 •
3.5-
fe iil
proprioception
gustatoryfolfacfexy tactile visual
Figure 6. Case Four’s mean ESP score on each sensory domain.
Another child who scored the lowest on the ESP in the first part o f the study
is Case Four. His total ESP scores on 73 items was also 219. However, the results
obtained for this boy was dubious as a response set had clearly been used. His
mother, who completed the questionnaire, had provided an answer o f 3
(“sometimes”) for every item o f the ESP (see Figure 6). Nevertheless, this boy was
reported by his teacher as having difficulties on all the six scales o f school function.
This indicates that the boy may truly be having difficulties, or that his mother could
be anxious about reporting her child’s performance or that both explanations are
operative. It is also plausible that the mother may be unsure about the implications o f
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68
completing the ESP as part o f a research study, and therefore chose to take a safe
way out by marking a mid-range alternative as the answer for all the items.
Case Four’s true sensory characteristics thus remain unknown and further
treatment o f this child would require scrutiny o f the difficulties that may be
contributing to his poor school performance.
Case Five.
5.0
4.5-
P I
l » S
isa
s i s
proprioception auditory
guBttayfatfactory tactile visual
Figure 7. Case Five’s mean ESP score on each sensory domain.
The total ESP scores (on 73 items) for Case Five was 242 with mean sensory
domain scores ranging between 3.1 and 4.2 (see Figure 7). This girl apparently has
good gustatory /olfactory processing with this domain having a distinctive score o f
4.2. Although her scores in all other sensory domains were lower, they were not
particularly poor as they all ranged between 3.1 to 3.5. No school function
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69
difficulties were reported using the SFA, it is unclear whether this child will benefit
from further assessment.
Case Six.
5.0 ---------------------------------------------------------------------------------------------------------------------------------
4.5 •
audlory proprioception voctlxilar
gustatory/otfactofy tactile visual
Figure 8. Case Six’s mean ESP score on each sensory domain.
Case Six is a boy who had obtained a total ESP score (on 73 items) o f
242.57. His mean domain scores fluctuated widely between domains, ranging
between 2.6 and 4.0 (see Figure 8). He was strongest in visual processing and
weakest in auditory processing. Both this child and Case One scored a low 2.6 on the
auditory domain, indicating that they both might benefit from some form o f speech
and language evaluation. However, if we consider that Case Six was reported by his
teacher to have no functional difficulties in school, this child might have
compensated for his poor skills by using his slightly better processing ability in other
sensory domains (such as visual processing) o r using strategies such as cognition and
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70
praxis. Hence, there remains a possibility that this child may not need any further
treatment.
Case Seven.
5.0
4.5 •
4.0 •
ian
psa
auditory proprioception vestibular
g u sta to ryAoKackvy tactile visual
Figure 9. Case Seven’s mean ESP score on each sensory domain.
The total ESP scores (on 73 items) obtained by Case Seven was 246. His
mean domain scores ranged from 2.8 to 3.8 (see Figure 9). This boy’s sensory
processing ability was characterized by significantly poorer tactile and visual skills.
Although his total ESP score was higher than that o f Case Four (219) by 27 points,
he also presented with many areas o f school function difficulties, just like Case Four.
His teacher scored him as having limitations on all scales o f the SFA except for
Behavior Regulation.
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71
It is interesting that Case Seven was reported as not having any difficulties on
the Behavior Regulation Scale, as one would expect that with such low tactile scores
(3.0), there would be problems with sensory modulation and behavior regulation.
Perhaps this child has compensated for this difficulty with his good proprioceptive
processing or perhaps the Behavior Regulation scale is not the most sensitive scale to
identify his problem (see discussion in Chapter V).
Case Eight.
5.0 1-------------------------------------------------------------------------------------------------------------------------
4 .5 ■
m s
M
.Bill
auditory proprioception vestibular
gustatory/olfactory tactile visual
Figure 10. Case Eight’s mean ESP score on each sensory domain.
Case Eight is a boy who had obtained a total ESP score (on 73 items) o f 247
on the first part o f the study. His mean sensory domain scores ranged from 3.0 to 4.4
(see Figure 10) with the proprioception domain achieving a score that was much
higher than any other sensory domain. Gustatory/olfactory, vestibular, and visual
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72
processing seemed to be the weakness o f this child. He was reported to have no
school functional difficulties on the SFA. Once again, it is uncertain if further
assessment o f this child will reveal functional difficulties in other areas or if
treatment is at all appropriate.
Case Nine.
5.0
4.5
4.0
3.5
3.0
2.5
c
8
5 2.0
Figure 11. Case Nine’s mean ESP score on each sensory domain.
Case Nine scored a total o f247 on 73 items o f the ESP. Her scores vary
widely from 2.8 from 3.9 (see Figure U ) with vestibular and visual processing being
her strengths. She was especially weak in gustatory/olfactory and proprioception
domains. Her scores on the SFA indicated no functional limitations on all the six
scales.
m&m
piii
& s!ii
auditory propriocaption
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73
This girl had the same total ESP score as Case Eight and both children
experienced no school functional difficulties as measured by the SFA. Yet, a closer
look at the way each child performed on the different sensory domains revealed
dramatically different characteristics. This observation emphasizes the importance of
not generalizing patterns of sensory processing to every child who displays a certain
functional limitation (for example, assuming that children with regulating behavior
in school have tactile defensiveness) or for that matter, no functional limitations (as
illustrated in this case).
Comparison to Case One further underscores the importance o f individual
differences in sensory processing abilities, and the myriad ways that sensory
processing may relate to functional difficulties. Although both Case One and Case
Nine both presents with poor gustatory and olfactory processing, the former was
reported to have limitations in various areas o f school function while the latter
reportedly has no school function difficulties.
Case Ten
The total ESP score (on 73 hems) for Case Ten was 249. Except for the
visual domain, this girl scored between 3.2 and 3.6 for all domains (see Figure 12),
suggesting a generally acceptable level o f auditory, gustatory/olfactory,
proprioception, tactile and vestibular processing ability. However, visual processing
was clearly weaker than these other domains, obtaining a score o f only 2.8. As for
school function, this child was reported to be affected on the scales o f Participation
and Task Behavior and Completion.
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74
It would be interesting to explore other school functioning difficulties that are
experienced by Case Ten and to find out if simply treating this girl’s visual
processing difficulties would help with improving her school function. Further
assessment in the area o f self-esteem, social skills and emotional well-being may
shed light to her poor ability to perform on the Behavior Regulation Scale o f the
SFA.
5.0 1
4.5 '
4 .0 '
IBS
l i i i
hs'.'rAry-
auditory proprioception vestibular
gustatory/olfactory tactile visual
Figure 12. Case Ten’s mean ESP score on each sensory domain.
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75
Chapter V
Discussion
The purpose of this study was to investigate the prevalence o f sensory
processing difficulties in Singaporean children and to explore if sensory processing
is related to children’s ability to perform non-academic related school functions. This
chapter discusses the findings of the current study, their limitations and their
implications. Finally, it relates our findings to contemporary occupational therapy
practices and concludes with suggestions for future research.
Prevalence of Sensory Processing Difficulties
The results o f this study showed that 14.5% of children in primary one in
Singapore met the criterion for sensory processing difficulties using the cutoff score
o f277 established using American data. This ESP score o f277 had earlier been
deemed as both sensitive and specific enough to differentiate between children in the
United States o f America who presented with and without sensory processing
difficulties.
Compared to the 5 to 10% estimation made by Ayres in 1979, the incidence
rate o f 14.5% reported in this study is relatively high. However, this rate is
comparable to the claim made by Wilbarger and Wilbarger (1991) that as many as
15% o f the general population may be affected with problems o f sensory
defensiveness. It is imperative to note that this 14.5% prevalence rate does not
include children who have been diagnosed as having childhood conditions such as
cerebral palsy, attention deficit hyperactive disorder (ADHD), autistic spectrum
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76
disorder (ASD), intellectual disabilities, hearing and visual impairment, and other
developmental disabilities. A significant proportion o f this group o f children may
have sensory processing difficulties (Baranek, Foster, & Berkson, 1997) and hence
would increase the overall prevalence rate o f sensory processing difficulties in the
general population o f Singapore.
Limitations o f the Prevalence Data
The cutoff score o f277 that was used to identify children with sensory
processing difficulties was developed based on applying the Receiver Operating
Characteristic (ROC) curve on the raw data o f two studies (Chang, 1999; VerMaas
Lee, 1999) conducted on an American population. When this 277 score was used as
a criterion cut-off score on the typically developing children (n=52) in these two
American studies, it was found that 8.9% o f the children met the criteria of having
sensory processing difficulties. This is much lower than the prevalence rate found for
the Singaporean population. It is thus important to explore the factors that may
contribute to this difference and to query the validity o f using a criterion score that is
established on an American population.
The subjects o f the two American studies (Chang, 1999; VerMaas Lee, 1999)
were much younger (mean age o f 5.1 years and 4.6 years respectively) than those in
the current study (mean age = 7.0 years). This age difference raises the question of
the validity of using a criterion cut off score derived from the younger American
sample to determine sensory processing difficulties in older Singaporean children.
Children who are younger may be scored differently on individual ESP items
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77
compared to older children as developmentally they behave differently. Although in
Dunn's (1994) study o f the performance of typical children (n = 64, age range
between 3 tolO years) on the Sensory Profile, only one out o f the 99 items on the
Sensory Profile differentiated between age groups, she acknowledged the possibility
that items on a sensory checklists could be affected by age. Moreover, in our study,
we are comparing populations o f two different cultures and also between total ESP
scores (instead o f individual item scores), thus the cumulative effect of age-related
factors on the prevalence results may be more pronounced. Hence, it is important for
future studies to take into consideration that there may be a need to have different
cut-off scores for different age groups when using the ESP to determine sensory
processing difficulties.
The ability to understand the English language may have impaired parents’
understanding o f the ESP, potentially affecting the results of this study. It was the
assumption of this researcher that since the official language o f Singapore is English,
parents o f children would be able to accurately interpret and complete the ESP.
However, it is possible that a substantial number of parents o f primary one children
in Singapore do not speak English fluently. This possibility was suggested by the
approximately fifteen telephone inquiries received from parents o f potential subjects
by the researcher concerning their inability to understand the language used by the
ESP. We do not know whether these parents participated in the study; if they chose
not to participate, their children are not represented in the prevalence data. However,
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78
if they did participate, they may have misinterpreted the ESP items and consequently
biased the results.
Although 6.2% of the parents who completed the ESP had a primary school
education and 55.2% had secondary school education, it was unclear whether this
proportion is comparable to the larger Singaporean population. It was our
assumption that parents with a lower education would have more difficulty in
completing the ESP and hence their children may also not be accurately represented
in our study. If parents with limited ability to comprehend ESP items did in fact took
part in the study, their possible interpretation of ESP items may have biased the
results o f the study.
Some parents, despite their difficulty with the English language, may struggle
to complete the ESP because the questionnaires were from the school and they were
afraid that not participating would place their child at a disadvantage. This was
apparent from the three telephone inquiries received by the researcher whereby the
parents insisted in getting the researcher to help them to translate numerous
questions in order to complete the questionnaire. One parent even commented to the
researcher (via telephone) that if she did not take part in the research, her child
would be extremely disappointed when she saw the other children handing in the
questionnaires to the teacher. This compulsion o f parents to participate in the study
despite their difficulties with understanding the ESP may have resulted in response
bias and inaccurate reporting o f a child’s behavior, thus contributing to an incorrect
estimate o f the prevalence of sensory processing difficulties in Singapore.
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79
In addition to age, language, and parent education factors, cultural differences
may also affect interpretation o f the ESP data obtained in this study. It is conceivable
that cultural differences between Singaporean and American populations would
affect the validity o f using a criterion cut-off score based on American population to
establish a prevalence rate o f sensory processing difficulties in Singapore.
The ESP is designed to gather information about a child’s sensory
characteristics via parental report. Assessments based on parental report of children’s
behavior may be influenced by cultural practices and expectations (Weisz &
McCarty, 1999). For example, responses to ESP items may be affected by the
parents’ upbringing, their perception of appropriate behavior, their expectations of
their children, the opportunities available for children to demonstrate the behaviors
in question, and the effect o f social desirability.
Social desirability response bias (i.e. a tendency to distort results by
answering according to prevailing social mores) (Poiit & Hungler, 1999) may
influence parents’ response in America as well as in Singapore. Due to cultural
differences, the Singaporean and American populations may both be affected to
significantly different degrees by social desirability factors resulting in the need for
separate criteria scores for American versus Singaporean populations.
The presence o f response sets in a study can indicate that its respondents may
have answered the questionnaires under the influence o f social desirability response
bias. They may have answered the questionnaire in accord with what they perceived
as desired by the researcher and the society at large. In this study, there was one
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80
questionnaire where “sometimes” was indicated as the answers to all the questions
(see Chapter IV, Table 8). This yielded a score o f 219, which is less than 277, hence
indicating that the child may have sensory processing difficulty. There were also
eight caregivers who scored their child as “never” on all the 76 items suggesting that
they again may be answering according to their perception o f desirability.
However, in the American data collected by Chang (1999) and VerMaas Lee
(1999), there was no evidence o f response sets. This indicate that there may be a
cultural difference in the perception o f social desirability between Singaporean
parents and American parents, resulting in Singaporean parents having a stronger
tendency to bias their responses on the ESP, thus affecting the results o f this study.
An interesting finding that may be related to cultural differences on parental
report on the ESP pertains to the item “Does your child dislike eating messy food
with his/her hands?” It was found in this study that 17.9% o f parents reported their
child as always or often displaying this behavior. On the other hand, only 12.2% of
parents in the American population reported their child as always or often having this
problem (see Table 7). Cultural considerations present an interesting perspective on
why a difference may have occurred on this item. Chinese in Singapore (constituting
about 65% o f the population) are very particular about using utensils (such as
chopsticks and spoons) to eat their food. Chinese children are taught by their parents
to keep their hands clean when eating and hands with food are often frowned upon.
These children are likely to have learned from a young age not to tolerate messy
hands and this could result in parents later reporting that their children dislike eating
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81
messy food with their hands. On the other hand, it is the cultural practice o f most
Malays and Indians (together constituting about 34% o f the population) to eat solely
with their hands. Thus, interpretation o f findings for this items is difficult, as we are
unable to discern whether children reported to “dislike eating messy food with
hands” are truly experiencing tactile defensiveness, have more opportunities to
express their dislike for messy hands (as in the case o f the Malays and the Indians) or
have simply been taught to dislike messy hands.
It is the author’s belief that parents in Singapore tend to have higher
expectations o f their child’s behavior than parents in America. It is also a cultural
practice in Singapore for parents to refrain from praising their own children in front
o f other people. These two reasons could result in parents in Singapore being more
critical o f their children’s behaviors than parents in America. This may explain why
certain ESP items such as “Does your child dislike eating messy food with his/her
hands?” and “Does your child become easily distracted by visual stimuli?” were
rated much lower for the Singaporean children as compared to children in America.
If parents in Singapore are generally more critical o f their children’s behavior than
parents in America, this could also result in most items on the ESP being scored
lower generally. This cumulative effect from individual items will lower the total
ESP scores o f children in Singapore as compared to American children, and hence
increase the prevalence rate o f sensory processing difficulties in Singapore.
The author also speculated that parents in Singapore might be less tolerant of
certain proprioceptive and vestibular seeking behavior (such as jumping, pulling,
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82
pushing, riding carnival rides, and so on). It was thus thought that, compared to their
counterparts in America, they would perceived their children as displaying such
behaviors much more frequently. However, this assumption did not hold true when
the frequency o f Singaporean parents reporting their children as displaying these
problems were compared to the American parents (see Chapter IV, Table7). In
Ermer and Dunn’s (1998) study using the Sensory Profile, the sensory processing
profiles o f children without disabilities tended to be characterized by high levels of
sensory seeking behaviors while showing no patterns o f inattention, distractibility, or
oral sensory sensitivity. Our study findings suggest that perhaps this tendency of
typically developing children to display sensory seeking behaviors is universal and
not affected by cultural bias.
In summary, many o f the limitations o f the study are related to potential age,
language and cultural differences between the American and Singaporean
populations. It remains difficult to evaluate the extent to which these differences
influenced the validity o f using the ESP as a tool and the score o f277 as a criterion
to determine sensory processing difficulties in Singapore. Therefore, the prevalence
estimate o f 14.5% generated in this study o f Singaporean children, although
plausible, must be considered as highly tentative, and should be examined in future
research.
Relationship between Sensory Processing and School Function
The second part o f this study was a pilot study that explored the relationship
between sensory processing and non-academically related school functions. Chi-
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83
square analyses on a small sample (N=20) showed that children with poor sensory
processing abilities (n=10) performed significantly more poorly than children with
good sensory processing abilities (n=10) on particular non-academic school
functions. Examination o f the individual ESP profiles o f the 10 children identified as
having poor sensory processing was conducted and related to SFA results to explore
the potential implications for using the ESP in clinical practice and for future
research.
In this study, it was found that 4 out o f the 10 children with poor sensory
processing had difficulties on the Setup and Cleanup scale and this was significantly
different (p<.05) from children with good sensory processing who had no difficulties
in Setup and Cleanup. The four children with poor sensory processing who were
affected on the Setup and Cleanup scale were also reported to perform poorly on the
Using Material scale. However, due to the fact that one child with good processing
was also reported to perform poorly on the Using Material scale, the result for this
scale was not significant.
An interesting finding pertained to the Participation scale. Two children
performed poorly on the Participation scale despite good sensory processing abilities.
These two children, who were Malay and in the same classroom, were both scored
low by the same teacher for the toileting item on the Participation scale because they
were constipated and leaked in their pants. Hence their teacher perceived them as
needing more assistance in participating in toileting than their peers. This affected
the analysis o f the Participation scale, which yielded no significant difference
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84
between groups, although 6 out o f 10 children with poor sensory processing were
reported as performing poorly on this scale. When these two children with good
sensory processing were removed from the sample and the statistical analysis
repeated, a significant relationship was found between sensory processing and
Participation (p<.05).
Results of this pilot study showed that children with good sensory processing
may present with poor school function. The results on the Participation scale clearly
illustrated this: two children demonstrated good sensory processing but poor school
participation (these were the two children rated low on Participation due to the
teacher’s concern with their constipation). On the Using Material scale, one child
had good sensory processing but poor school function (this was a child whose ESP
score may have been affected by response set, as all items were rated with a 5).
Although these three children may have had low SFA scores or high ESP score due
to teacher or parent bias, it is conceivable that some children with good sensory
processing actually do have poor school function due to factors such as medical
conditions, emotional problems, family or social problems, or even lower cognitive
ability.
There were no significant relationships found in our study between sensory
processing and the other three scales o f the SFA, namely, Written Work, Task
Behavior and Completion, and Behavior Regulation. Although the differences were
not significant on these three scales, it was consistently found that more children
with poor sensory processing performed poorly in each o f these scales than children
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85
with good sensory processing. This suggests that it is plausible that school function
in children is indeed affected by poor sensory processing.
Limitation o f School Function Data
The most significant limitation o f the second part o f this study was the small
number o f subjects recruited, and hence it was only considered a pilot study. Only 10
children with the lowest total ESP scores were compared with 10 children with the
highest total ESP scores on school function. This result was analyzed using the
Fisher’s Exact Probability as it is the only statistical test that can reliably analyze
such a small sample size. However, the Fisher Exact Probability is very stringent and
detects significance if the difference is extremely distinctive. Hence, the findings o f
this pilot study should be regarded as an exploration of the potential relationship
between sensory processing and school function.
Another limitation o f the study is related to the selection of SFA scales for
the study based on the researcher’s clinical experience and the literature review. It
was assumed that the six scales chosen were representative o f non-academically
related school functioning that are affected in children with poor sensory processing.
Perhaps other areas of school function measured by the SFA would have been more
sensitive in relation to the sensory processing difficulties experienced by this sample
of children.
The Setup and Cleanup scale and the Using Material scale are examples o f
scales on the SFA that have a higher likelihood o f being the "right" scale for
detecting school problems in children with sensory processing difficulties. Four out
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86
o f ten children with poor sensory processing in our study had the expected problems
in these areas o f school functioning. Thus these two scales may be potential areas
that are affected in children with sensory processing difficulties. The Setup and
Cleanup scale assessed the ability o f children to perform activities such as opening o f
sealed bags (e.g., potato chips), obtaining personal items from own bag or pocket and
giving to another (e.g. homework, money), and using sponge or cloth to wipe
dirt/spill from flat surfaces (e.g. desk/table). An analysis of these tasks shows that
they require numerous sensory processing skills such as regulated responses to tactile
sensation, good tactile discrimination, good auditory and proprioceptive processing,
and good praxis and organizational ability. Like the Setup and Cleanup scale, the
Using Material scale assessed items such as cutting with scissors and sharpening
pencil, which require adequate sensory integration and praxis.
On the other hand, the Behavior Regulation scale on the SFA did not appear
to be a good scale to be used to detect school functional difficulties in children with
poor sensory processing. Only one child out o f the entire group o f children, both
with and without sensory processing difficulties, was reported as having difficulty
with this scale. This is surprising considering that literature (DeGangi, Sickel,
Wiener, & Kaplan, 1996; Mangeot et al., 2001; Parham & Mailloux, 2001) and
clinicians have repeatedly suggested that poor behavior regulation is often an issue
for children with poor sensory processing. However, examination o f the items in the
Behavior Regulation scale o f the SFA indicates that this particular scale seems to be
related to impulse control and availability o f cognitive strategies. Some o f the items
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87
on the Behavior Regulation scale includes “hears constructive criticism without
losing temper,” “uses words rather than physical actions to respond when provoked
or angry at others,” and “handles frustration when experiencing difficulties with
school tasks/activities.” DeGangi et al. (1996) stated that "regulatory disorders were
defined as being behaviorally difficult with disturbances in sleep, feeding, state
control, self calming, mood regulation and sensory processing" (p. 457). Items such
as those on the SFA Behavior Regulation scale may not be representative o f all the
aspects of behavior regulation that are relevant to sensory processing problems,
leading to the negative results in the present study, especially with its small sample
size. On the other hand, it is important to consider also that behavior regulation may
really be an area that generally is not affected in children with sensory processing
difficulties.
In this study, detection o f school function difficulties was dependent on the
SFA. However, it is likely that some aspects of school functions that are related to
sensory processing are not adequately measured by the SFA. Consideration o f some
o f the cases in our study serves to highlight this concern. Case Nine in our sample
(see Case Analyses in Chapter IV) received a total ESP score o f 247, resulting in her
having one of the lowest 10 scores from the first part o f the study. An examination of
her mean ESP scores on each sensory domain showed that she had significant
difficulty in responding appropriately to gustatory and olfactory sensations (mean
score o f 2.8). However, Case Nine was not reported to have any school functional
difficulties. Case Two is another child who had low total ESP scores (220.95) and
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88
difficulty with processing gustatory and olfactory information (mean score o f 2.6).
However, he was reported to have difficulties on the Participation scale. Both Case
Nine and Case Two were considered to have poor sensory processing mainly in the
area of gustatory and olfactory. It may be that difficulty in gustatory and olfactory
processing do not result in any difficulties in school functioning. However, it is
impossible to ascertain whether these two children were experiencing difficulties in
areas o f school function that were not measured in this study.
In addition to the fact that areas of school function chosen may not folly
represent the functional difficulties experienced by children with poor sensory
processing, the different sensory characteristics exhibited by each individual child in
our sample probably influenced the results o f our study. Children with certain
patterns o f sensory processing difficulties may not experience any school functional
difficulties. There is also a possibility that children with poor sensory processing
may possess the abilities to compensate for sensory difficulties. Together, these
factors make it difficult to detect the effects o f sensory processing on school function
in a small sample. The below presents a case example to illustrate this.
Case Six scored a low total ESP score o f242.57, putting him in the lowest 3
% of the population in terms o f sensory processing ability. His performance in the
various sensory systems revealed poor auditory processing (mean sensory domain
score o f 2.6), poor proprioceptive processing (2.9) and good visual skill (4.0). We
would expect a child who has this profile to have some form o f difficulties in school,
maybe in the area o f task behavior and completion due to poor auditory processing
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89
and proprioceptive seeking behavior, or in the area of using utensils due to poor
proprioceptive awareness. However, Case Six was not reported by his teacher to
have any difficulties in school function. Various reasons or a combination of these
reasons could explain this: (a) Perhaps tasks required in daily school functioning are
highly structured, repetitive, and practiced; (b) Perhaps Case Six is very smart and
hence is able to use visual, cognitive, and various other strategies to compensate for
his difficulties; (c) Perhaps we were not picking the right area o f school function to
assess, or (d) Perhaps given his pattern of sensory processing difficulties, he just was
not experiencing any functional difficulties in school.
Another limitation o f this study concerns the differences in a child's behavior
at home and in school. Rules are often more strictly enforced in school and parental
expectations at home may be very different from the teachers’ expectations in the
classrooms. This may result in parents perceiving their children as presenting with
more difficult behaviors while the teachers perceive the same children as compliant
and well behaved. Two teachers o f children with poor sensory processing, while
completing the SFA, commented on this likely difference in behavior and
expectations between home and school.
Lastly, cultural differences should be considered as another potential
limitation o f this pilot study. The criterion cut-off score o f the SFA, used to
determine school functional difficulties o f children in Singapore, was based on an
American population. As mentioned earlier in this chapter, we have questions
regarding the validity o f using a criterion based on American data to determine
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90
difficulties experienced by Singaporean children. Previous literature such as that by
Tobin, Wu and Davidson (1989) described the distinctive differences between three
preschool settings across three different cultures namely Japan, China, and America.
Such evidence suggests that possible differences exist between the American grade
school setting and the Singaporean primary school setting, and needs to be
considered when interpreting results such as those in our study, which used an
American criterion to determine school difficulties experienced in a Singaporean
population.
Interestingly though, despite the fact that the SFA was developed from
American data in an American school culture, the researcher observed that many
teachers who were interviewed liked the SFA and found the questions asked
generally relevant to the daily non-academic tasks performed by the children in
Singapore. However, results of this study still need to be read with caution as the
criterion cut-off points developed on the American population could be significantly
different in the Singaporean population.
Clinical Significance
The ESP is a screening tool that can be useful in helping clinicians identify
sensory processing difficulties in children. Examination of the sensory characteristics
o f the ten children with poor sensory processing showed that although all these
children scored poorly on the ESP, they each presented with unique patterns of
strengths and weaknesses in different sensory domains. This finding implies that
occupational therapists may find it useful to use the ESP to examine the pattern of
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91
behaviors presented by a child (for example, whether a child is over-responsive to
certain sensory input and at the same time seeks other types o f sensations) or to
determine if a child has particular difficulty in processing sensory information in a
certain domain. However, without further research, care should be exercised not to
generalize the use o f a cut-off score such as 277, especially across cultures, to
determine if a child has sensory processing problems. Clinicians using the ESP on
the Singaporean population may want to use the cut off total scores at S'1 1 , 10th and
15* percentiles (see Table 6) to determine how their client scored on the ESP as
compared to a larger Singaporean population.
It was not possible from our small sample size to make conclusions as to
what pattern of sensory processing characteristics resulted in what type o f school
function. Examination o f the individual profiles o f school function and sensory
processing revealed that children with similar sensory processing abilities might
experience difficulties in different areas o f school function (e.g. Case One and Case
Nine). It was also found that children with low total ESP scores may not even have
any school function difficulties that were measurable on the 6 SFA scales used in
this study. This result indicates that clinicians using the ESP should not assume that
all children with similar sensory processing characteristics will experience similar
functional difficulties (e.g. that all children with poor visual processing will have
handwriting problems).
Clinicians should also recognize that there are other factors beyond sensory
processing that may contribute to poor school functioning. Hence, it is important to
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92
always assess the functional performance o f children across various settings such as
home and school. If indicated, other occupational therapy assessments or referrals to
other professionals such as speech and language therapists should be carried out in
order to obtain a foil picture of the child’s functional problems and possible factors
contributing to them. The ESP should not be used as the sole indicator and its ability
to predict functional difficulties in other areas has not yet been demonstrated.
On the other hand, results from this pilot study show that children with
difficulty in the same areas o f school functions may present with different sensory
processing characteristics. Profiles o f individual children from this study showed that
two children (e.g. Case One and Case Three) with exactly the same problems in
school as measured on the SFA may have entirely different sensory characteristics
when assessed using the ESP. It is therefore imperative for clinicians to discover the
unique issues underlying each individual child’s limitations in functional
performance and to address that accordingly. Individual patterns o f sensory
processing need to be considered when planning occupational therapy treatment.
Lastly, in these days o f limited resources, it is essential to demonstrate that
occupational therapy treatments are effective and have an impact on the functional
performance o f our clients. Clinicians should not rely on a bottom-up approach and
provide treatment to a child simply because it was noted that he or she has some
sensory processing difficulties. It should be recognized that this child might not have
any functional problems or difficulties in reaching his or her potential. Nevertheless,
there remains the question o f wellness versus disability. Should we be providing
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93
occupational therapy treatment for this child with poor sensory processing (and no
apparent functional disabilities) if it really does improve his or her quality o f life?
Directions for Future Research
The ESP continues to undergo refinement through research. In view o f the
earlier discussion regarding the limitations in using the ESP in Singapore, and to
facilitate future use of the ESP in Singapore, the ESP may need to be further
modified and its validity and reliability studied on the Singaporean population. An in
depth interview with parents in Singapore, similar to that conducted by Johnson
(1996) in the United States o f America, may be necessary to re-establish its validity
for this population while addressing cultural and language issues. Studies using the
ESP to examine differences between children with and without disabilities in
Singapore are also essential to establish validity data for use of the ESP in Singapore.
Such studies may also be used to establish a new criterion cutoff score for
differentiating sensory processing difficulties in the Singaporean population.
It was the finding o f this study that out o f the 20 children selected for the
second part o f the study, more mothers reported that their children were not doing
well on the ESP while more fathers report their child as doing well on the ESP (see
Chapter III, Table 4). This result is similar to the findings by Chang (1999). In her
study o f the interrater reliability o f the ESP in children in America (N=35), she found
that mean scores for each item on the ESP was lower for children with sensory
integrative dysfunction when they were rated by their mothers rather than their
fathers. However, for children in the typically developing group, mean item scores of
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94
fathers were higher than mothers. Chang suggested that mothers may be more
sensitive to children’s difficulties with sensory processing. This could be the case in
our study. Fathers o f typically developing children in Singapore may also be able to
tolerate a greater variety in their children’s behavior as compared to the mothers, and
hence tend not to be as critical when rating their children on the ESP. Future research
investigating the interrater reliability between parents in Singapore would be useful
and interesting.
In this study, it was also found that out o f the 10 children with the lowest
total ESP scores, there were more boys (n=7) than girls (n=3). O f the 10 children
with the highest total ESP scores, there were an equal number o f male and female
(n=5, n=5). VerMaas Lee (1999) found that certain responses to sensory inputs (e.g.,
proprioceptive seeking behaviors) are more prevalent in boys with autism compared
to girls with autism. However, these differences did not appear to exist in her group
o f typically developing children. Future research utilizing a much larger sample size
will be useful to determine if indeed gender difference only exists in children with
poor sensory processing and if this is also true across disability groups.
The second part o f this study was a pilot study that involved only a small
sample size. This limits the types of statistical analyses that can be conducted and
restrict our exploration o f sensory processing difficulties. Future research utilizing a
larger sample size would enhance the strength o f the findings o f the study, and thus
increase confidence in the results. A larger study examining sensory processing and
school function should be conducted only after the ESP has been studied further with
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95
Singaporean samples to assure its validity with this cultural group. This might serve
to reduce problems such as response set that occurred in our present study.
Future research should continue to include a global measure o f school
function, such as the Participation scale o f the SFA. The Participation scale measures
the “degree to which students can access and actively participate in the opportunities
and roles open to others o f the same age, culture etc.”(Coster, Deeney, Haltiwanger,
& Haley, 1998, p. 4). Results o f this study showed that 6 out of 10 children with poor
sensory processing have difficulties on the Participation scale, and that all the
children who were reported to have difficulties on any scale of the SFA had a low
score on the Participation scale. This finding supported the use of the Participation
scale as a global scale to measure general ability o f children to be involved in school
activities.
It was interesting to note that despite not knowing the children’s ESP scores,
many teachers commented correctly that the children with poor sensory processing
were among the poorest performers in their class. This observation lends further
support to the use of a global scale o f school function such as the Participation scale
on the SFA or a visual analogue scale o f the teacher’s perception of the child’s
overall performance, to determine difficulties in occupational performance.
Future research may also involve other scales o f the SFA and other forms of
instruments to measure occupational performance. Studies that attempt to associate
sensory processing with other areas o f performance such as academic achievement or
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96
self-esteem could also be conducted to examine the effects of sensory processing on
the quality o f lives o f children with sensory processing difficulties.
One other suggestion for future research relates to the measurement o f
sensory processing difficulties and school functional performance. Both the ESP and
the SFA are based on adult perceptions, that is parent's and teacher’s reports. Future
studies may want to consider the use o f home or school observations by the
researcher to explore the qualitative aspect of sensory processing abilities. This and
other type o f direct quantitative measurements may offer to eliminate some o f the
subjectivity o f teacher and parental reports and perhaps a correlation between these
objective measurements and adult reports may further establish the reliability o f the
ESP and the SFA.
It is also hoped that the results o f this study will prompt other researchers to
consider investigating the nature o f sensory processing difficulties and to further
clarify the life problems that children with these difficulties are experiencing. Past
studies (Baranek et al., 1997; Case-Smith & Bryan, 1999; Parush, Sohmer,
Steinberg, & Kaitz, 1997) have mainly focused on examining the presentation o f
sensory processing difficulties in children with known disabilities (such as ADHD,
ASD and learning disabilities). However, this study has shown that there is possibly
o f a large group o f children who are typically developing and experiencing sensory
processing difficulties. Future research might examine further the effects o f sensory
processing difficulties on the lives and daily functioning of these children.
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97
Finally, longitudinal studies that follow the functional development of young
children who were diagnosed as having poor sensory processing would further
clarify the significance o f these difficulties over the course o f a lifespan. Such future
research will aid professionals to consider how, when, and for whom services
addressing sensory problems should be organized and prioritized. Exploring the
point at which sensory processing difficulties constitute a disability versus a wellness
issue is pertinent, especially when considering the appropriateness o f intervention for
children with poor sensory processing.
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98
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APPENDIX A
Introductory Letter and Consent Form to School Principals
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103
use
U N IV E R S IT Y
O F S O U T H E R N
C A L IF O R N IA
Department of
Occupational Science
and Occupational
Therapy
University of
S o u th ern California
C e n te r fo r Health
Professions 133
1540 E ast Alcazar Street
Los A ngeles.
California 90089-9003
Tel 323 442 28SO
fa x : 323 442 1S40
May 23,2001
Dear Principals:
R E Q U E S T F O R C O N S E N T T O C O N D U C T R E S E A R C H S T U D Y
My name is Tan Peng Chian. I am currently completing a master’s degree
program in the Department of Occupational Therapy and Occupational Science at the
University of Southern California, USA. 1 will be conducting a research study as part of
my master thesis and I am seeking your assistance in this research.
The title of my study is “Prevalence of Sensory Processing Difficulties and the
Relationship Between Sensory Processing and School Function in Children in
Singapore". There are two parts to this study. In the first part, we would like to find out
how many primary one children in Singapore has difficulty with processing sensory
information. In order to do this we have selected 8 primary schools in Singapore
through a process of drawing lots. Two classes of primary one children in each of these
8 schools will be given questionnaires for their parents to complete. The questionnaire.
Evaluation of Sensory Processing (ESP) will tell us how the children are processing
sensory information in their daily activities and how many of these children have
difficulties.
In the second part of this study, teachers will use the School Function
Assessment (SFA) questionnaire to assess children who score either very well or very
poorly on the ESP. By comparing the result on the SFA with the ESP, we will be able to
draw conclusions on the relationship between sensory processing and school function of
primary one children in Singapore.
I have enclosed the following in an attempt to explain the detail purpose and
process of the research and to assist you in your decision:
1 . A le tte r fro m th e M in is try o f E d u c a tio n s u p p o r tin g th is re s e a rc h .
2. A complete research proposal for your reference.
Revised date: 05/23/01
Page I of3
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104
3. A copy of the letters, forms and questionnaires to be used in the study:
a) Informed Consent Form for Teachers
b) Cover Letter for Parents and Legal Guardians
c) Information Sheets for Parents and Legal Guardians
d) Description of Participating Student Form
e) The Evaluation of Sensory Processing (ESP)
f) The School Function Assessment (SFA)
If you decide that your teachers and students will be able to participate in this
research, please find two form teachers of primary one classes who are willing to
participate in the study and who meet the following inclusion criteria:
a) the teacher must be spending more than 50% of total weekly hours with his or her
class,
b) the teacher must have taught the class for more than three months, and
c) the teacher must agree to complete the SFA if one of his or her student is selected to
participate in the second part of the study.
The teachers selected by you will then each complete an Informed Consent
Form for Teachers. Please collect both their consent forms, signed at the bottom of this
letter (please make a copy for yourself) and send them in the enclosed self-addressed,
stamped envelope.
Once I have received the consent of you and your teachers, I will be contacting
you regarding the dates for data collection. During data collection, I will require the
teacher to provide me with a list of the names of the students in his or her class.
Subsequently, I will give the teacher sealed packages with the necessary questionnaires.
They will distribute each package to their students and instruct them to bring home to
their parents. I will be collecting the questionnaires from your teachers for 3
consecutive days following the distribution of the questionnaire and again at the end of
one week.
Revised date: O S/23 1 01 Page 2 of 3
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105
Following this first part of the study, some students will be identified for the
second port where approximately half an hour will be required of their form teachers to
meet with myself in order to complete the SFA. No more than 20 students out of the 8
participating schools will be identified for part U of the study. Hence, not all teachers
will be involved in part IL
Your participation in this study will allow us to yield valuable insights into
children, their sensory processing ability and its relationship to school function. If you
have any questions, please feel free to email me at jannneng@singnetcom.sg or contact
me at 97677800. You may also write to me at 2, Hougang Street 92, #12-02, Singapore
538683. Thank you. I look forward to hearing from you.
Sincerely yours, _____ ______________________
Tan, Peng Chian (Ms)
Occupational Therapist
I give my consent to members of my school to participate in the above-mentioned
research.
Form Valid For E nrollm ent From
MAr 2 5 2001 y 0 APR - 4 2002
Institutional Review Board
Name:
Signature: Date:
School:
Email: Tel:
Revised date: 05/23/01 Page 3 o f 3
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APPENDIX B
Informed Consent Form for Teachers
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107
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U N IV E R S IT Y
O F S O U T H E R N
C A L IF O R N IA
Department o<
Occupational Science
and Occupational
Therapy
U rm ertity o f
S outhern California
C en ter fo r H ealth
P io fe sio n s 133
1540 East A lcatar Street
Los Angeles.
California 90089-9003
Tel: 323 442 2850
Fa«. 323 442 1540
INFORMED CONSENT FORM FOR TEACHERS
TITLE OF RESEARCH STUDY:
Prevalence of Sensory Processing Difficulties and the Relations hip Between Sensory
Processing Difficulties and School Function in Children in Singapore
PRINCIPAL INVESTIGATOR: Tan, Peng Chian
TELEPHONE NO.: 65-97677800
CO-PRINCIPAL INVESTIGATOR: L. Diane Parham, PhD, OTR, FAOTA
TELEPHONE NO.: 1-323-442-2879
DEPARTMENT: Occupational Therapy and Occupational Science
24-HOUR TELEPHONE NUMBER: 65-97677800
PURPOSE OF THE STUDY
You are invited to participate in a research study o f sensory processing o f primary one school
children in Singapore. The following information is provided in order to help you make an
informed decision whether or not to participate. We hope to leant how many children in
Singapore have difficulties with processing sensory information and whether or not these
difficulties are related to functioning in schooL
You are invited as a participant in this study because your student is attending primary one in a
Singapore school. About 640 participants will be invited to take part in the first part of this
study and no more than 20 of these children will be identified for the second part of the study.
P R n n - n tiR R S
If you decide to participate, we will ask you to sign this consent form and pass it to your-school
principal to send it back to us. The school you belong has been selected to participate in this
study by a process o f drawing lots. A total of 8 schools have been selected and invited to
participate in this research study. We have instructed each school principal to select two form
teachers o f primary ooe classes who meet the following criteria:
a) the teacher must be spending more than 50% of total weekly hours with his or her class,
b) the teacher must have taught the class for mote than three months, and
c) the teacher must agree to complete the School Function Assessment (SFA) if one of his or
her student is selected to participate in the second part of the study.
A few weeks later, we will be approaching you for a list o f the names o f the students in your
class. This list will help us to assign each student in your class with a study identification
number. We will then prepare a package for each o f your students with their name on it This
package consists of 1) a Cover Letter fbr Parents and Legal Guardians, 2) an Information Sheets
for Patents and Legal Guardians, 3) a “Description of Participating Student" form and 4) an
“Evaluation o f Sensory Processing” (ESP) parent questionnaire and an extra envelope. You will
be requested to hand a package out to each and every student in your class and instruct them to
bring it home to their patents without opening it The parents have a right not to participate in
the study. You are not to instruct the children to ask their parents to complete iL
All the forms in the package will be marked with an individual student identification number
and hence is important that yon give the correct package to the student whose name is marked
on the package. A copy o f these forms has been attached for your reference.
Tbe cover letter and infarmatiao sheet in this package informs (be parents about the purpose and
procedure o f this research study. By completing and returning the questionnaires, the parents of
your students ate giving us information on how their children ate processing sensory
Revised date: O S/23JO I t f i i e y Page 1 of3
k YonS tM ho
Kvad. Data Administn-iio-i I
Adr.iintstraiio;-.
Mi-iistry Cr a T ~
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108
information. We will then be able to examine their answers to the questionnaire and estimate
how many children in Singapore are having difficulties with sensory processing.
As soon as the questionnaires are completed, the parents will seal the questionnaires in the extra
envelope provided and have their child give it bade to you. This envelope and all the
questionnaires to be returned will only have the student identification number written on them
and no names o f any individuals. This helps to protect the identity o f your students and their
family. By signing this informed consent, you have also agreed to respect the confidentiality of
your student and refrain from opening sealed envelopes or leading completed questionnaires.
The principal investigator will collect the sealed envelopes from you every day for 3
consecutive days after distributing the package and once again one-week later. Envelopes
received after one week will not be included in the study and you will return them to the
parents.
From all the children whose parents returned the questionnaires, 10 children with the highest
ESP scores and 10 with the lowest scores will be selected lor the second part o f the research. If
your student is selected, you and your student’s parents will be notified. If a student o f yours is
to take part in the second part o f the research, the principal investigator, Ms Tan Peng Chian,
will contact you to make an appointment to meet up.
During the meeting, the purpose and nature o f the School Function Assesanent (SFA) will be
explained to you. Subsequently, you will be instructed on the method of completion for this
questionnaire and you will complete the questionnaire to your best knowledge o f the particular
student being assessed. The time taken is about half an hour for the assessment of each child. A
copy of the questions that will be asked from the SFA has been attached for your reference,
Subsequently, we will compare the children's scores on the SFA to their scores on the ESP. In
this manner, this research study will be able to draw conclusions on the relationship between
sensory processing difficulties and school function in children in Singapore.
RISKS
There are no known risks involved in distributing the packages to your students and in filling
out the SFA except lot the inconvenience that may occur as your time is being used. The
completion o f the SFA does not reflect your knowledge or your skills. You and your student
will not be examined or observed in any way by the researcher. You will not be informed of
your students’ performance on either the ESP or the SFA.
Despite not disclosing student’s performance to their teachers, there is a likelihood that teachers
may be able to predict their students' ESP and SFA scores and hence; resulting in a snail risk
that the student may be stigmatised or “labelled".
PENEFUS
Y o u 'a n d y o u r stn d c n t m a y re c e iv e n o d ire c t b e n e fit fro m y o u r p a rtic ip a tio n in th is stu d y .
H o w ev er, i t is p o s s ib le th a t in fillin g o u t th e S F A , y o u m a y g a in n e w in sig h ts a b o u t y o u r
stu d e n t. Y o u r p a rtic ip a tio n in th is s tu d y m a y h e lp n s to g a in k n o w le d g e a ix tu t th e p e rc e n ta g e o f
c h ild re n w h o m a y b e h a v in g se n so ry p ro c e ss in g d iffic u ltie s . I t m a y a ls o h e lp u s to u n d e rsta n d
w h e th e r se n so ry p ro c e ssin g is re la te d to c h ild re n ’s f ia c tio n in s c h o o l.
A L T E R N A T IV E T O P A R T IC IP A T IO N
Y o u m a y c h o o s e n o t to p a rtic ip a te in th is stu d y . Y o u r stu d e n ts w ill a u to m a tic a lly n o t b e
in v o lv e d in th e stu d y . ,
Revised date; 05/23/01 Page 2 of 3
m? , Chu:K ^ ^ Y e n s (Mas)
Head. Data Admin.;.,(ration 3
Ad: Centre
•tvution
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OFFER TO ANSWER QUESTIONS
Your participation in this study wilt be supervised by Ms Tan Peng Chian at 65*97677800 who
you may contact with any questions or coocetus regarding your participation. If you have any
questions regarding your rights ss a study subject, you may contact the Institutional Review
Board Office at 001-1323-223-2340 (USA). You will be given a copy o f this form to keep.
In the unlikely event that you or your student should suffer an injury as a result of participation
in the study, the financial responsibility for medical care and other such care will be yours.
CONFIDENTIALITY STATEMENT
Every effort will be made by the principal investigator to keep information that is obtained from
this study strictly confidential to the extent permitted by law. Results o f this study may be
presented at professional conferences and in publication. However, the participating children,
parents and teachers will not be named or otherwise identifiable.
VOLUNTARY PARTICIPATION AND WITHDRAWAL STATEMENT
Your participation in this research study is voluntary. Your derision whether or not to
participate will not interfere your right to health care, educational or other services to which you
are otherwise entitled. You are not waiving any legal claims or rights because of your
participation in this study. If you deride not to participate, you are free to withdraw your
consent and discontinue your participation at any tune.
AORRRMFNT
I have read (or someone has read to me) the information provided above. I have been gives the
opportunity to ask questions and all o f my questions have been answered to my satisfaction. My
signature below indicates that I have decided to participate having read the information
provided above.
Name o f teacher Signature Date signed
Name o f Witness Signature Date signed
Name o f School
Form Valid For Enrollment From
M A Y 2 5 APR "4 an?
Institutional Review Board
Revised date: 05/23/01
Ivy c kliss)
: — i ion 3
Page 3 of3
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110
APPENDIX C
Approval Letter from the M inistry of Education
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Ill
MINISTRY OF EDUCATION
I NORTH BUONA VISTA DRIVE
SINGAPORE 13(675
REPUBLIC O F SINGAPORE
Thr Smfinpore Education Scnice
Robinson Rood P.O. Box 746
Telephone; S721110
Facsim ile: 7753126
CS-fnailbox: GV T 036
Cable:-ED U CA TIO N -
Internet address:
K(tp^/www.moe.edu4|.
Internet Office e*mail address:
contictM O E@ m oe.edu.sg
M OULDING THE FUTURE OF
O U R NATION
Personal e-mail address:
E-mail: lvy_Chua@moe.gov.jg
Kim_Yu@moe. go v.sg
EDUN N32-07-005 Vol. 62 Request No.: RQ/0321
11 April 2001
To: Principals of Primary Schools
STUDY ON “PREVALENCE OF SENSORY PROCESSING DIFFICULTIES AND THE
RELATIONSHIP BETWEEN SENSORY PROCESSING AND SCHOOL FUNCTION
IN CHILDREN IN SINGAPORE”
The Ministry has no objection to the research proposed by Ms Tan Peng Chian, a
Masters student in Department of Occupational Therapy and Occupational Science at
University of Southern California. You may decide whether or not to allow her to conduct the
research in your schools. If you do, please:
i) ensure that the approved research proposal including questionnaire (see attached) is
adhered to;
ii) inform your teachers/pupils that participation in the study is voluntary and they
need not provide any sensitive information (e.g. name and NRIC No.);
iii) record your schools’ participation by completing the form as shown in Annex A.
2 If you require any clarifications, please contact Miss Jacklyn at Tel: 8796069 or myself
at Tel: 8796073. Thank you for your co-operation.
IvyCh ing(Ms)
Head, 1 ustration 3
Data Administration Centre
N320700& *q0321
Public Service for the 21st Century
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112
APPENDIX D
Letter for Parents and Legal Guardians
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113
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U N IV E R S IT Y
O F S O U T H E R N
C A L IF O R N IA
Department of
Occupational Science
and Occupational
Therapy
University of
S o u th ern California
C en ter fo r H ealth
Professions 133
1540 East Alcazar Street
LOS A ngeles.
California 90089*9003
Tel 323 442 28S0
Fa*: 323 442 *540
M a y 2 3 .2 0 0 1
Dear Parents and Legal Guardians:
IN V IT A T IO N T O P A R T IC IP A T E I N R E S E A R C H S T U D Y
My name is Tan Peng Chian. I am currently completing a master’s degree
program in the Department of Occupational Therapy and Occupational Science at the
University of Southern California, USA. I will be conducting a research study as part of
my master thesis and I am seeking your assistance in this research.
The title of my study is “Prevalence of Sensory Processing Difficulties and the
Relationship Between Sensory Processing and School Function in Children in
Singapore”. I would like to find out how many primary one children in Singapore have
difficulty with processing sensory information and whether this difficulty affects their
school function. The detail purpose and process of this research are described in the
following Information Sheets for Parents and Legal Guardians.
If you decide to participate in this research study, please fill out the two
questionnaires in the package: I) Description of Participating Students form and 2)
Evaluation of Sensory Processing questionnaire. When completed, sealed the two forms
back in the extra envelope provided and have your child return them to his or her form
teacher. Remember to seal the envelope, this will prevent the information of your
child from being read by anybody else other than myself
By returning these forms, you will be giving your consent to participate in this
study. Your answers on the Evaluation of Sensory Processing Questionnaire will give
us an idea as to how your child is processing sensory information. This information will
also help us estimate how many primary one children in Singapore have sensory
Revised Due: 05/23/01 Page 1 of 2
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114
processing difficulties. This is the first part o f the study. If your child is found to have
either very good or very poor sensory processing, he or she will be selected for the
second part o f the study. In this second part o f the study, we will have your child’s form
teacher complete a questionnaire in order to find out how your child is doing in school.
In this way, our research study will be able to decide if children’s school function is
related to their sensory processing ability.
If you have any questions, please feel free to contact me at 97677800. Thank
you.
Sincerely yours.
Enclosed:
1) Information Shecu for Parents and Legal Guardians
2) Description of Participating Student Form
3 ) E valuation o f Sensory Processing
4) Envelope for returning questionnaires
Revised Due: 05/23/01 Page 2 of 2
Tan, Peng Chian (Ms)
Occupational Therapist
Form Valid For E nrollm ent From
m 25 a o i T n A P R “ 4 2 0 0 2
Institutional Review Board
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115
APPENDIX E
Information Sheets for Parents and Legal Guardians
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116
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U N IV E K S IT V
O F S O U T H E R N
C A L IF O R N IA
Department of
Occupational Science
and Occupational
Therapy
University o f
S o u th ern California
C e n te r for Health
Professions 133
1540 East A lcazar S treet
lo s A ngeles.
California 90089-9003
Tel: 323 442 2850
Fax: 323 442 1540
INFORMATION SHEETS FOR PARENTS AND LEGAL GUARDIANS
TITLE OF RESEARCH STUDY:
Prevalence or Sensory Processing Difficulties nnd (he Relationship Between Sensory
Processing and School Function in Children in Singapore
PRINCIPAL INVESTIGATOR: Tan, Peng Chinn
TELEPHONE NO.: 65-97677800
CO-PRINCIPAL INVESTIGATOR: L. Diane Parham, PhD, OTR, FAOTA
TELEPHONE NO.: 1-323-442-2879
DEPARTMENT: Occupational Therapy and Occupational Science
24-HOUR TELEPHONE NUMBER: 65-97677800
PURPOSE OF THE STUDY
You are invited to participate in a research study o f sensory processing of primary one school
children in Singapore. The following information is provided in order to help you make an
informed decision whether or not to participate. We hope to I cam how many children in
Singapore have difficulties with processing sensory information and whether or not these
difficulties are related to functioning in school.
You are invited as a possible participant in this study because your child is attending primary
one in a Singapore schooL About 640 participants will be invited to take part in the first part of
this study and about 20 o f these children will be identified for the second part of the study.
PROCEDURES
If you decide to participate, please fill out the “Description o f Participating Student” form
where you will provide us with personal information about you and your child. Next, you will
complete a questionnaire about your child's behavioural responses to various types o f sensory
experiences. This questionnaire is called the “Evaluation of Sensory Processing” or “ESP”. A
tool of about 25 to 30 minutes is expected for completing the questionnaires.
As soon as all the items are completed, you will seal the 2 questionnaires in the extra envelope
provided and have your child give it back to his or her form teacher during the next school day.
Please remember to seal the envelope containing the questionnaires. This will help prevent the
information about your child from being read by people other than the principal investigator,
Ms Tan Peng Chian.
We will only be collecting the sealed envelopes from the teacher up to one-week following
distribution o f these questionnaires. Questionnaires received after one week will not be included
in the study and the teachers will be instructed to return them to you.
You have received these questionnaires because we selected your child’s primary school
through a process of drawing lots. Your child's principal and form teacher have both agreed to
participate in this research. By agreeing to take part in this research, your child’s form teacher
has to pass this package to the students in her class and have them bring it home to their parents.
There are two parts to this study. When you complete the questionnaires m d return them to
your child’s teacher, you have given us information on how your child is processing sensory
information. We will then be able to estimate bow many children in Singapore are having
difficulties with sensory processing. This is the first part o f this study.
Revised date: 05/23/01 Page 1 of 3
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117
When you return the questionnaire*, you are also agreeing to let your child participate in the
second part o f the study. A child may be selected for the second part o f the study if he or she
either score very high or very low on the ESP. You and your child's teacher will be notified if
your child is selected for this part o f the study. In the questionnaires that you complete, you may
choose not to reveal your name, address and contact number. However, we do need to know the
name of your child in case we need to identify him or her for the second part o f the study.
For the second part of the research, your child’s form teacher will be interviewed in order for us
to complete an assessment called the “School Function Assessment”. Children’s score on this
assessment will be compared with their scores on the ESP. In this way, this research study will
be able to know more about the relationship between sensory processing difficulties and school
function in children in Singapore.
RISKS
There are no known risks involved in filling out the questionnaire except for the inconvenience
that may occur as you spend time to complete i t If your child is identified for the second part of
the study, only his or her schoolteacher will be interviewed. Your child will not be examined or
observed in any way by the researcher. Your child’s teacher will not be informed of his or her
performance on the ESP as completed by you.
Despite not disclosing student’s poformance to their teachers, there is a likelihood that teachers
may be able to predict their students' ESP and SFA scores and hence, resulting in a small risk
that the student may be stigmatised or “labelled”.
B E N b rn s
You and your child may receive no direct benefit from your participation in this study.
However, it is possible that in filling out the questionnaire you may gain new insights about
your child Your participation in this study may help us to gain knowledge about the percentage
of children who may be having sensory processing difficulties. It may also help us to understand
whether sensory processing is related to children's function in school.
ALTERNATIVE TO PARTICIPATION
You may choose not to complete the questionnaire. Your child will automatically not be
involved in the study.
OFFER TO ANSWER QUESTIONS
Your participation in this study will be supervised by Ms Tan Peng Chian at 65-97677800 who
you may contact with any questions or concerns regarding your participation. If you have any
questions regarding your rights as a study subject, you may contact the Institutional Review
Board Office at001-1323-223-2340 (USA). This information sheet is for you to keep.
INJURY STATEMENT
In th e u n lik e ly e v e n t th a t y o u o r y o u r c h ild sh o u ld safT er a n in ju ry a s a r e s u lt o f p m tirip a tio a in
th e stu d y , th e fin a n c ia l re s p o n s ib ility f o r m e d ic a l c a re a n d o th e r su c h c a re w ill b e y o u rs.
COHRPEtglALTTY STA TEMENT
E v e ry e ffo rt w ill b e m a d e b y th e p rin c ip a l in v e s tig a to r to k e e p in fo rm a tio n th a t i s o b ta in e d fro m
th is stu d y s tric tly c o n fid e n tia l to th e ex ten t pe rm itte d b y la w . Y o u r p e rs o n a l in fo rm a tio n a n d
y o u r c h ild ’s p e rfo rm a n c e w ill n o t b e d is c lo s e d to a n y p e rso n n e l, in c lu d in g th e sc h o o l a u th o rity .
R e su lts o f th is stu d y m a y b e p re s e n te d a t p ro fe s sio n a l c o n fe re n c e s a n d in p u b lic a tio n . H o w ev er,
th e p a rtia 'p a tin g c h ild re n a n d p a re n ts w ill n o t b e n am ed o r o th e rw ise id e n tifia b le .
Revised date: O S/23A H Page 2 of 3
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118
VOLUNTARY PARTICIPATION AND WITHDRAWAL STATEMENT
Your participation in this research study is voluntary. Your decision whether or not to
participate will not interfere your right to health care, educational or other services to which you
are otherwise entitled. You are not waiving any legal claims or rights because o f your
participation in this study. If you do not decide to participate, you are fe e to withdraw your
consent and discontinue your participation at any tune.
Form Valid For Enrollment From
MAY 2 5 2001 Tn - 4 m
Institutional Review Board
Revised date: 05/23/01 Page 3 of 3
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119
APPENDIX F
Description of Participating Student Form
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120
DESCRIPTION OF PARTICIPATING STUDENT
Form Valid For Enrollment From
MAY 2 5 M U T< * iP n ™
T n A P R - 4 2 0 0 2
Institutional Review Board
Student Identification number____________________________________
Please provide the following information about your child:
♦ Sex: Female / Male
♦ Date of Birth:________________
♦ Ethnicity:___________________
Please circle:
♦ Relationship of person completing questionnaire to student:
Father / mother / grandparents / legal guardians / others:__________________
♦ Highest level of education of person completing questionnaire:
None / primary / secondary / tertiary / not applicable
♦ Approximate annual income of household that child reside in:
1) Less than $12,000 per annum
2) $12,000 to $30,000 per annum
3) $30,000 to $60,000 per annum
4) more than $60,000 per annum
♦ Does your child have any known medical condition (e.g. asthma, diabetes etc.)?
Yes/No.
If yes, please specify:_____________________________________
♦ Does your child have any known developmental disorders (e.g. autism,
developmental delay, chromosomal disorders, attention deficit disorder, cerebral
palsy, muscular dystrophy, spina bifida etc) or traumatic head/spinal cord injury?
Yes/No.
If yes, please specify:_____________________________________
Head. Data Adtnir.ti.retion I
Data Administration Ce.-.:re
o f E dutC i? ;.i
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121
APPENDIX G
Evaluation of Sensory Processing Questionnaire (ESP) (Research Version 4)
(Modified for Singapore Use)
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122
ESP
Evaluation o f Sensory Processing
Version 4
Instructions: Please read each question carefully and answer each as accurately and
honestly as you can. Indicate only one answer for each question by ticking the
appropriate box, using the key below:
A = Always
0»= Often
S = Sometimes
R = Rarely
N = Never
The key is also printed on the first page o f the questionnaire.
Please answer the questions according to what you think your child’s behaviours are like
in the last six months. Your honest answer is very important to us. None of the questions
are intended to be “trick” questions. If you are not sure of the meaning of a particular
item, or if you are unsure of how to answer it, please call the principal investigator, Tan
Peng Chian, at 9-767-7800.
D iu Adr-jinissnvioti Centre
1 . -,:r/ of uducation
Date: 04/23/01
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123
E V A L U A T IO N OF SENSORY PROCESSING
ESP Research Version 4 (modified) A * Always
Student Identification number________ O ■ Often
S * Sometimes
R ■ Rarely
N • Never
ITEM A O S R N
Auditory System
i . D oes your child have trouble understanding w hat other people m ean when they
say som ething?
2. Is your child bothered by sny household o r otritoary sounds, such a s the
vacuum , hairdryer, or toilet flushing?
3. D oes your child respond negatively to loud noises a s in naming away, crying,
o r hofdtog hands over earn?
4. D oes your child appaar to not hear certain sounds?
5. Is your child distracted by sounds not usuaty noticed by other people?
6. Is your ch id frightened of sounds that do not usuafly convey alarm to other
chfldten the sam e age?
•
7. D oes your chid seem to under-read to loud noises?
a. D oes your ch id have trouble interpreting (he m eaning o t sim ple o r common
w onts?
9. Is your child easily detracted by (relevant n oises such a s a grass-cutter
outside, children taking in the back ot the room, crinhflng paper, an air
conditioner, a refrigerator, o r fluorescent lights?
10. D oes your child seem too sensitive to sounds?
Gustatory / Olfactory System
1. D oes your chfld gag, vomit, o r complain o t n au sea when im ekng odors such
a s soap, pethane, or cleaning products?
2. D oes your chfld complain fliat foods a te too bland o r re fta e to e a t bland foods?
3. D o ts yourcKM p fiftfv o y w H y foods?
4 . D oes your chfld M s to taste non-food Rems such a s glue o r paint?
5. D oes your chfld gag whan anticipating an unsppeaflng food such a s century
egg. (ah . o r cooked cabbage o r green leafy vegetables?
O Diane Paitiam and Cheryl Ecfcer
Ivy Giua'fjrtif Ybng (Miss)
Head. CSw Administration 3
D:ns Adr.anirtration Centre
M.-.— ' i o£ Education
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124
ITEM A O s R N
Proprioception System
i . Does your chad grasp objects so tightly that it 1 * difficult to u s* the object?
2. Does your ch id grfcid his/her teeth?
3. Doe* your ch id seem driven 10 seek activities such a s pushing, puMng,
dragging. Citing, and jumping?
4. Does your cM d teem unsure of how far to raise o r lower ttie body during
movement such a s sitting down o r stepping over an object?
S. Does your child grasp objects so loosely that H is difficult to u se (tie object?
6. Does your child seem to exert too m uch pressu re for the task, such a s w aking
heavily, slamming doors, o r pressing loo hard w hen using p endls o r crayons?
7. Does your child jump a lot?
6. D oes your child have dfficutty playing with anim als appropriately, such a s
petting them with too much force?
0. Does your child have difficulty positioning him /herself in a chair?
10. Does your child bump or push other chadren?
11. Ooes your ch id seem generatty weak?
12. D oes your child chew on toys, do ih es, o r other objects mom than other
chadren?
-
Tactile System
i D oes your chad p ul away from being touched kglitty?
2. Does your chad seem to lack the normal aw areness of being touched?
3. Does your child react negatively to the feel of new d othes?
4. D oes your chad show an unusual disiaie for having his/her hair combed,
brushed o r styled?
S. O oes your chad prefer to touch rather than be touched?
e. D oes your chad saem driven to touch different textures?
7. Does your chad refuse to w ear h ats, su nglasses, o r other accessories?
8. D oes R bottler your chid to have his/her linger o r to e n a ls cut?
9. D oes your ch id struggle a g ain st being held?
1 0. D oes your ch id have a tendency to touch things conatanOy?
11. O oss your cM d avoid o r tfsO csptayfngw ttt gritty o r coars+ tsxtured t a g s
such a s sand?
© Diane Parham and Cheryl Ector
|w CkjS'yecfc Yong (ML«1
l^ od T u a® Administration 3
Data AdT.anisintion Centre
Ivtin&ry o f Education
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125
ITEM A 0 s R N
12. D oes your child prefer certain M atures of clothing or particular fabrics?
13. D oes N h o tte r your cM d to hava his/liar faca touched?
14. O oas M bother your ch id to hava his/her face w ashed?
15. O oas your ch8d resist o r dbSke w earing short sleeved shirts o r short p ants?
16. D oes your child dislike eating m essy foods with his/her hands?
17. Does your child avoid foods of certain textures?
18. O oes your child avoid getting his/her hands in finger paM , paste, sand, day,
mud, glue, o r other m essy things?
19. D oes 4 bother your child to have his/her hair cut?
20. O oes your child overreact to m inor b^uries?
21. D oes your chdd have an unusuafy high tolerance for pain?
Vestibular System
1. Does your chad seem excessively fearful of m ovement, a s in going up and
down stairs o r riding swings, seesaw s, sid e s, o r other playground equipm ent?
2. D oes your child dem onstrate d istress w hen he/she is moved o r riding on
moving equipm ent?
3. O oes your chad have poor balance?
4. O oes your ch id avoid balance activities such a s wanting on curbs o r on uneven
ground?
5. O oes your chad Bta fast spinning carnival rides, such a s m efiygo-rounds?
6 . W hen your chad shats his/her body, does he/she fafl out of the chair?
7. Is your chad unable to catch him /herself when falling?
6 . D oes your child seem lo not g et dizzy when others usuaSy do?
9. D oes your chad seem generaty w eah?
10. D oes your chad spin and whiri his/her body m ore «tan other chadren?
11. O oes your chad reck himseNlhersetr when stressed ?
12. O oes your ch id M e to b e inverted o r tipped upside down, o r enjoy doing
acrivtties m at invohra Inversion, such a s hanging upside down o r doing
som ersaults?
13. W hs your cM d fcaiM o f swinging o r boundng a s an M m ?
14. Com pared wMhodier chadren to e sam e ag e, do es your ch id seem to ride
longer o r harrier on certain playground equipm ent, such a s a swing o r merry-
go-round?
© Diane Partwm and ChefylEcfcer A P P R O V E D B Y
Ivy CMZyVyzk
uaia A^i
Ailr.Jnisti
" o f
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126
ITEM A O s R N
19. Dom your chid dem onstrate distress whan his/her head is hi any other
position S u n upright o r vertical a u d i a s having t ie head W ad b a e b w d or
upside down?
Visual System
i. Ooes your child have trouble telling the difference betw een printed figures that
eppear simfier, tbr exam ple, differentiating b with p. or ♦ with *?
2. Is pour ch id sensitive to or bothered by light. e sp e d aiy bright fight (blinks,
squints, cries, or d o se s eyes, etc.)?
3. When looting at pictures, does your cMd focus on patterns or details instead
of the main pictures?
4. Does your chid have difficulty keeping his/her eyes on th e task or activity a t
hand?
5. Ooas your ctdd becom e easfiy detracted by visual stimuli?
6. Does your child have trouble finding an object w hen It is am idst a group of
ia e S d i T i i I I ^
O V W f WnQftr
7.
O oes your ch id d o se one eye and/or tip his/her head back when looking a t
something o r som eone?
a. Does your child have dffficulty with unusual visual environm ents such a s a
bright cotorfvi room or e dimiy lit room?
9. Ooes your child have dttfieulty controlling eye m ovem ent when following
objects ik e a b al with his/her eyes?
10. Does your cM d have dttfieulty naming, dbaim inating. o r matching colore,
shepes o r sizes?
I T your child is 6 y eere o f ag e o r older, p lea se a n sw er th e following
3 q uestions.
11. Oid your child make teversals in w ords o r tatters when writing o r copying or
read words backwards (such a s reading saw for w as) after kindergarten 2?
12. Ooes your chBd lose his/her place on a page w hie reading, copying, solving
problems, or performing m anipulations?
13. In school, does your ch id have dHficutty shitting gaze from the board to the
paper when coating bom the board?
Form Valid For Enrollm ent From
my 2 8 M i T ft A P R - 4 2 0 0 2
Institutional R eview Board
C Diane Paftiam and ChmylEcfcer AFP^O' lD BY
•v.'r Centre
i-n isn y c f ilwJw-uricn
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127
APPENDIX H
Letter of Notification
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128
Dear Parents/Legal Guardians,
Notification of selection into second part of study
Thank you for completing the Evaluation of Sensory Processing
Questionnaire (ESP) a number of weeks ago. By returning the questionnaire, you
have agreed for your child to participate in the second part o f our study on
“Prevalence o f Sensory Processing Difficulties and the Relationship of Sensory
Processing to School Function in Children in Singapore.”
This is to inform you that your child_______________________________
has been selected for the second part of the study. His or her teacher will be asked to
complete a school function assessment. The teacher will answer non-academic
related questions such as “Can your child attend to a class activity?” and “Can the
child copies accurately from the blackboard?”
Your child will NOT be observed at anytime. This is a notification only. You do
not have to reply.
If you have any questions, you may contact me at 97677800.
Yours sincerely,
Tan Peng Chian (Ms)
Occupational Therapist.
University o f Southern California (USA)
KK Women’s and Children’s Hospital (Singapore)
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

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Asset Metadata

Creator Tan, Peng Chian (author)

Core Title Prevelance of sensory processing difficulties and the relationship between sensory processing and school function in children in Singapore

Degree Master of Arts

Degree Program Occupational Therapy

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag education, educational psychology,health sciences, rehabilitation and therapy,OAI-PMH Harvest,psychology, developmental

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-296352

Unique identifier UC11337772

Identifier 1411809.pdf (filename),usctheses-c16-296352 (legacy record id)

Legacy Identifier 1411809.pdf

Dmrecord 296352

Document Type Thesis

Rights Tan, Peng Chian

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA